Impact of Urinary Catheterization on Postoperative Outcomes After Roux-En-Y Gastric Bypass Surgery in Propensity-Matched Cohorts.

BACKGROUND: The impact of urinary catheter avoidance in bariatric enhanced recovery after surgery (ERAS) protocols is yet to be established. The purpose of the current study is to determine whether urinary catheter use in patients undergoing Roux-en-Y gastric bypass (RYGB) procedures has an effect on postoperative outcomes. METHODS: An institutional database was utilized to identify adult patients undergoing primary minimally invasive RYGB surgery. Outcomes included incidence of urinary tract infection (UTI) within 30 days postoperatively, 30-day readmission rates, proportion of patients discharged after postoperative day 1 (delayed discharge), length of stay (LOS), and operating room time. These were compared between propensity-matched groups with and without urinary catheter placement. RESULTS: There were no significant differences in postoperative UTI's (2.2% for both cohorts, P = .593) or 30-day readmission rates for patients with and without urinary catheters (6.6% and 4.4%, respectively, P = .260). Mean LOS (1.7 vs. 1.5 days, P = .001) and the proportion of patients having a delayed discharge (47.3% vs. 33.7%, P = .001) was greater in patients with a catheter. Operating room time was longer in the urinary catheter group (221.8 vs. 207.9 minutes, P = .002). DISCUSSION: Avoidance of indwelling urinary catheters in RYGB surgical patients decreased delayed discharges and LOS without affecting readmission or reoperation rates. Therefore, we recommend that avoidance of urinary catheters in routine RYGB surgery be considered for inclusion into standardized ERAS protocols. Urinary catheters should continue to be utilized in select cases, however, as these were not shown to affect rate of UTIs.

Outcomes of Bariatric Surgery in Patients on Chronic Opioids: Can Bariatric Surgery Assist with Decreasing Long-term Opioid Utilization?

PURPOSE: The aim of our study was to assess long-term opioid use following bariatric surgery in patients on preoperative narcotics. METHODS: We evaluated patients utilizing preoperative opioids (OP) who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2020. Patients were propensity-matched to those without preoperative opioid use (NOP) by demographics and comorbidities. Our objectives were to compare opioid use at 1 and 3 years after surgery and evaluate perioperative outcomes. RESULTS: A total of 806 patients, matched 1:1 were evaluated, with 82.7% being females. Mean age was 46.5 years in the OP and 45.6 years in the NOP (p = 0.0018), preoperative BMI was 45.8 in the OP and 46.1 in the NOP (p = 0.695). All patients were followed up for 1 year. In the OP, 156 (38.7%) patients were taking opioids 1 year after surgery as opposed to 27 (6.7%) in the NOP (p < 0.0001). Three years after surgery, 74 (37.5%) patients in the OP and 27 (14.4%) in the NOP were taking outpatient opioids (p < 0.0001). There was no statistically significant difference between OP and NOP groups in terms of readmissions (9.4% vs. 5.7% p = 0.06), reinterventions (3.7 vs. 1.7% p = 0.13), reoperations (3.5% vs. 1.5% p = 0.11), or emergency room visits (8.9% vs. 7.2% p = 0.44). There were no mortalities. CONCLUSION: Most patients requiring preoperative opioids can be weaned off after bariatric surgery. Enhanced recovery pathways are key to obtaining these results. Preoperative opioid use is not associated with increased complications compared to opioid-naïve patients.

Asymptomatic Cholelithiasis and Bariatric Surgery: a Comprehensive Long-Term Analysis of the Risks of Biliary Disease in Patients Undergoing Primary Roux-en-Y Gastric Bypass.

PURPOSE: Currently, there is little consensus on management of the in situ gallbladder of patients undergoing gastric bypass. Our aim was to evaluate outcomes of selective concomitant cholecystectomy (CCY) and long-term biliary outcomes after Roux-en-Y gastric bypass (RYGB). MATERIALS AND METHODS: We performed a retrospective analysis of patients undergoing laparoscopic RYGB (LRYGB) between 2008 and 2018. Chi-square, Fisher's exact, or Wilcoxon rank-sum tests were used to compare outcomes. Concomitant CCY was performed on a selective basis. RESULTS: Three thousand and four patients underwent a RYGB (LRYGB n = 2458, open RYGB n = 546). Fifty-two percent (n = 1670) of patients had undergone CCY at any stage. Thirty-one percent of patients (n = 933) had CCY prior to RYGB, 13% (n = 403) had a concomitant CCY and 13% (n = 214) of the remainder required interval CCY. In the LRYGB subgroup, 29.9% (n = 735) had a prior CCY; 12.9% (n = 202) of those with an in situ gallbladder required interval CCY. Those who underwent concomitant CCY/LRYGB (n = 328) were compared with LRYGB alone (n = 1231). The concomitant CCY group was significantly older and had higher percentage of females, higher preoperative BMI, higher Charlson Comorbidity Index, and a higher medication count. There was no significant difference in BMI nadir, length of stay, complications, or mortality. Interval CCY had a higher incidence of CCY-related complications. CONCLUSION: Our study suggests a higher percentage of bariatric patients with in situ gallbladders will undergo interval CCY than documented in recently published guidelines. Concomitant CCY can be performed without an increase in length of stay or complications. Interval CCY may be associated with a higher complication rate.

First assistant impact on early morbidity and mortality in bariatric surgery.

BACKGROUND: The future of bariatric surgery depends largely on how effectively residents and fellows are trained. The challenge is to assure patient safety during training. Our study compares the impact of first assistants on patient outcomes after Roux-en-Y gastric bypass and sleeve gastrectomy. METHODS: A retrospective review of primary, elective Roux-en-Y gastric bypass and sleeve gastrectomy procedures performed in 2015 and 2016 from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant user files was performed. Patient cohorts were categorized by the level of training of the surgical first assistant (FA). Multivariate regression models were developed to determine the impact of the FA level on patient outcomes, adjusting for patient demographic characteristics and co-morbid conditions. RESULTS: Compared with an attending weight loss surgeon as FA, minimally invasive surgery fellows and general surgery residents were more likely to have an unplanned admission to the intensive care unit (ICU) within 30 days (odds ratio [OR] 1.422, 95% confidence interval [CI] 1.196-1.691; OR 1.206, 95% CI 1.034-1.406, respectively, P < .0001) and were more likely to have a 30-day hospital readmission (OR 1.143, 95% CI 1.056-1.236; OR 1.127, 95% CI 1.055-1.204, respectively, P < .0001). Compared with having a weight loss surgeon as FA, operative duration was significantly longer for all other assistant levels, or no assistant (P < .0001). CONCLUSION: The training level of the FA does not impact early patient mortality or reoperation rates after Roux-en-Y gastric bypass or sleeve gastrectomy. However, unplanned intensive care unit admissions and readmissions within 30 days were significantly associated with surgical resident or minimally invasive surgery fellow FAs. Further analysis is needed to understand this cause and effect; however, these data provide direction to redesign residency and fellowship training.

Equivalent Peri-Operative Outcomes for Laparoscopic Roux-En-Y Gastric Bypass Patients Discharged on Post-Operative Day One.

BACKGROUND: Previous studies have evaluated the safety of post-operative day one (POD #1) discharge after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Few studies, however, have evaluated the impact of a standardized POD #1 discharge pathway on peri-operative outcomes. This study aims to evaluate peri-operative outcomes after implementation of an enhanced recovery pathway for RYGB patients. METHODS: Data from a prospectively maintained database identified 2,049 patients (pre-implementation n = 904; post-implementation n = 1,144) who underwent LRYGB between 2008 and 2016. The POD1 discharge pathway was implemented in July 2011. Patient demographics and outcomes before and after implementation of the POD1 pathway were compared using univariate analysis and propensity matching. RESULTS: A propensity-matched group of all patients (n = 714) and POD #1 candidates (n = 490) pre- and post-pathway implementation were analyzed. Successful POD #1 discharges were significantly increased after introduction of the pathway (54.3 vs 17.8%, p < 0.0001). The post-implementation groups demonstrated no differences in mortality, Emergency department (ED) visits, readmissions, reoperations, and major or minor complications. CONCLUSIONS: Early discharge after bariatric surgery has a significant impact on the cost effectiveness of surgery, patient comfort, potential reduction of medical errors, and exposure to hospital-acquired infections. Our results demonstrate that a standardized POD #1 discharge pathway can be safely implemented and in turn, reduce hospital LOS without negatively affecting peri-operative morbidity, mortality, ED visit, readmission, or reoperation rates.

Multimodal Postoperative Pain Control Is Effective and Reduces Opioid Use After Laparoscopic Roux-en-Y Gastric Bypass.

BACKGROUND: Opioids have been the mainstay for postoperative pain relief for many decades. Recently, opioid-related adverse events and death have been linked to postoperative dependency. Multimodal approaches to postoperative pain control may be part of the solution to this health care crisis. The safety and effectiveness of multimodal pain control regimens after laparoscopic Roux-en-Y gastric bypass (LRYGB) has not been well studied. The primary aim of our study was to determine if an evidence-based, multimodal pain regimen during hospitalization could decrease the total oral morphine equivalent (TME) use after LRYGB. STUDY DESIGN: We conducted a retrospective cohort study comparing outcomes prior to the implementation of a multimodal pain protocol (December 2010-December 2012) to those after implementation (April 2013-July 2015). The protocol utilized oral celecoxib and scheduled oral acetaminophen for pain control, with opioids used only as needed for breakthrough pain. Data was extracted from an electronic medical record and an institutionally maintained database of all patients undergoing bariatric surgery at a single center. RESULTS: Compared to controls, the multimodal pain regimen significantly reduced TME used and maximum pain scores with no change in mean pain scores. Multimodal pain protocol patients had a shorter length of stay with no increase in bleeding complications or marginal ulcer rates. CONCLUSIONS: An opioid-sparing multimodal pain regimen adequately controls pain while reducing TME use. The regimen appears to be safe and was associated with a reduced length of stay in patients undergoing LRYGB.

Laparoscopic paraesophageal hernia repair is safe in elderly patients.

BACKGROUND: Paraesophageal hernias (PEHs) occur frequently in the elderly. Patients may not be referred for repair due to age or concern for high operative morbidity and mortality. The aim of this study was to compare outcomes of PEH repair based on age. METHODS: Adult patients undergoing PEH repair between 2003 and 2012 at a tertiary referral center were included. Patients were divided by age (Y < 69, YO 70-79 and VO > 80). Body mass index (BMI), Charlson comorbidity index, operative time, estimated blood loss, length of stay, recurrence, Quality of Life in Reflux and Dyspepsia Questionnaire (QOLRAD) scores, morbidity and mortality were analyzed. RESULTS: Two hundred and sixty-seven patients were included: Group Y N = 140 (median age 58.5); Group YO N = 82 (median age 75.0); and Group VO N = 45 (median age 83.0). Group Y had a significantly lower age-adjusted Charlson score compared to the older groups. Group VO had significantly lower BMIs compared to Groups Y and YO. Both groups had similar operative times, intraoperative blood loss and rates of Collis gastroplasty. Group Y had significantly less acute presentations compared to the elderly groups YO 12.2 %, p = 0.028, and VO 22.2 %, p = <0.001. Group Y had a smaller percentage of intrathoracic stomach (55.7 %) as compared to Groups YO (65.1 %; p = 0.001) and VO (74.3 %; p = < 0.001). There were no significant differences in mortalities between all three groups. The mean length of hospital stay was significantly shorter in Group Y (2.45) than in both Group YO (3.12; p = 0.001) and Group VO (5.13; p = <0.001). Major morbidity was significantly lower in the younger group 3.6 % when compared to Group VO (17.8 %; p = 0.001). All groups demonstrated significant improvement in QOLRAD scores. CONCLUSION: The decision to perform laparoscopic paraesophageal hernia repair (LPEHR) in elderly patients remains challenging. LPEHR can be done safely and effectively in elderly patients at experienced centers.

Laparoscopic transhiatal esophagectomy for esophageal adenocarcinoma identified at laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: More than one third of Americans are obese. Obesity is a risk factor for gastroesophageal reflux disease (GERD) and esophageal adenocarcinoma (EA). The only durable treatment for morbid obesity and its comorbid conditions is bariatric surgery. There is no consensus among bariatric surgeons, however, regarding the role of preoperative screening upper endoscopy in bariatric surgery. PRESENTATION OF CASE: Two cases of incidental EA were identified by completion EGD following laparoscopic Roux-en-Y gastric bypass (LRYGB). EGD was done for anastomotic surveillance and provocative leak testing. Esophageal masses were identified and biopsies demonstrated adenocarcinoma. In both cases a laparoscopic transhiatal esophagectomy (LTHE) was completed using the gastric remnant as conduit; the biliopancreatic limb was divided proximal to the jejunojejunostomy and anastomosed to the proximal roux limb to complete the reconstruction. DISCUSSION: Obesity is a risk factor for GERD and EA. The role of EGD prior to bariatric surgery is unclear. Studies have demonstrated routine EGD prior to bariatric surgery may diagnose foregut pathology; however, few of the findings alter the planned treatment. The cost effectiveness of this strategy is questionable. There are reports of EA developing after bariatric surgery; however, we found no previous case reports of EA identified at LRYGB. CONCLUSION: Our institution has opted for selective preoperative endoscopy in patients with preoperative gastrointestinal symptoms. In post gastric bypass patients LTHE can be performed with good results.