Enhanced recovery after bariatric surgery (ERABS) in a high-volume bariatric center.

BACKGROUND: The growing demand for bariatric surgery has been accompanied by an expensive technological evolution and the need to contain healthcare costs and to increase the quality of care. The enhanced recovery after surgery (ERAS) protocols applied to the bariatric setting can be the answer to all these different issues. OBJECTIVES: Feasibility and safety of ERAS protocol in a single, high-volume bariatric center. SETTING: Humanitas Research Hospital, Rozzano MI, Italy. METHODS: Our ERAS bariatric protocol is based on the following 3 steps: (1) preoperative: optimization of all co-morbidities, counseling patients and family with information and education, and shortening fasting times (clear fluids up to 2 hr and solids up to 4 hr before induction of anesthesia); (2) intraoperative: premedication, parallel team work, awake patient positioning, standardized multimodal anesthesia and analgesia, noninvasive monitoring, video-laryngoscopy in reverse Trendelenburg position, short-acting anesthetic agents, and standardized laparoscopic surgery avoiding the nasogastric tube, catheter, and drain; and (3) postoperative: analgesia, early mobilization, early oral fluid, thromboprophylaxis, discharge planning, and follow-up telephone call. Clinical pathways were established and outcomes were retrospectively collected. RESULTS: Comparison between conventional care and ERAS protocol reveals a reduction of the length of hospital stay (from 4.7 to 2.1 d) and a low morbidity rate. From July 2015 to July 2018, a total of 2400 consecutive patients underwent primary or revisional bariatric surgery (2122 sleeve gastrectomies and 278 Roux-en-Y gastric bypasses [RYGB]). Mean body mass index was 44.9 kg/m2, mean age was 41.9 years, and the male to female ratio was 1:2.5. Total mean operative time was 85 minutes, with a surgical time of 65 minutes and an anesthesiologic/patient induction time of 4 minutes. Early complication rate was 3.5% with no perioperative mortality. Mean hospital stay was 2.1 days and the rate of readmission was .9%. CONCLUSIONS: This study demonstrates that our ERAS protocol is safe, feasible, and efficient. Patient preparation and multidisciplinary/parallel team work are crucial points.

Laparoscopic sleeve gastrectomy in a patient with situs viscerum inversus totalis: is the life easy upside-down?

INTRODUCTION: Obesity is an epidemic on the rise [1]. The number of bariatric procedures has increased worldwide. Laparoscopic sleeve gastrectomy (LSG) is a valid therapeutic option, leading to a sustained weight loss with a low complication rate [2]. Situs viscerum inversus totalis (SIT) is the complete transposition of all the abdominal organs, occurring in about 1 in 10,000 people [3]. Laparoscopic approach in SIT is challenging due to the mirror image anatomy. MATERIALS AND METHODS: We present the case of a 41-year-old man with a body mass index of 46.4 kg/m2 (131 kg; 1.68 m) previously diagnosed with SIT who has undergone LSG. RESULTS: In this video, we show a LSG performed in a patient with SIT. There were no changes in the technique compared to the "standard anatomy." The patient was placed on the operative table in anti-trendelenburg position with legs abducted. The surgeon stood between the legs while the assistant was on the right side of the patient and the scrub nurse on the opposite side. A 12-mm trocar was inserted with a direct technique in the right lateral flank. Carbon dioxide insufflation was done under vision. Other three trocars (12, 10, and 5 mm) were positioned in the left lateral flank, supraumbilical, and subxiphoid areas, respectively. Gastroepiploic dissection started at 5 cm from the pylorus up to the right crus. After the insertion of a 36-Fr boogie, an accurate stapling of the stomach was performed. The proximal side of the sleeve was reinforced with a non-absorbable suture. Titanium clips were placed leading to a complete haemostasis. The procedure lasted 45 min. The patient followed a "fast-track" protocol afterwards, with no changes in the perioperative workup compared to "standard anatomy" patients. He was discharged on day 2 postoperatively and no complication occured in the perioperative period. CONCLUSION: SIT is a rare condition leading to a mirror image that can be challenging for a laparoscopic surgeon. LSG is feasible and safe also for morbidly obese patients with SIT, not requiring any change in the surgical technique and perioperative management, as long as the surgeon is well beyond the learning curve.

Crohn disease obstruction of the biliopancreatic limb in a patient operated for biliopancreatic diversion for morbid obesity.

Although rare, patients with biliopancreatic diversion for morbid obesity will be subject to obstruction of the biliopancreatic limb. This condition is commonly due to postoperative adhesions and intussusception and usually presents with misleading clinical and radiographic features that can delay the diagnosis and the treatment. We recently encountered a patient with obstruction of the biliopancreatic limb due to involvement from Crohn disease. We report this case to highlight the clinical and imaging findings of this rare condition.

Specific effects of biliopancreatic diversion on the major components of metabolic syndrome: a long-term follow-up study.

OBJECTIVE: Gastric bypass and biliopancreatic diversion (BPD) are known to have a beneficial effect on glucose metabolism superior to that of the other bariatric operations. Thanks to its excellent weight loss results and to its specific actions, BPD has proven able to guarantee permanent normalization of serum glucose, triglyceride, and cholesterol levels in the vast majority, if not the totality, of operated patients. However, clinical studies on the duration of these effects in large patient populations are still lacking. RESEARCH DESIGN AND METHODS: The files of 312 BPD obese patients with type 2 diabetes operated on from June 1984 to January 1993 were examined. Pre- and postoperative serum glucose, triglyceride, and cholesterol levels, along with arterial pressure measurements, were considered. RESULTS: After BPD, fasting serum glucose concentration fell within normal values in all but two of the operated subjects and remained in the physiological range in all but six up until 10 years. Serum triglyceride and total cholesterol steadily normalized in all subjects with abnormally high preoperative values, and arterial hypertension disappeared in the vast majority of the preoperatively hypertensive patients. CONCLUSIONS: BPD proved able to reverse all the major components of the metabolic syndrome in nearly all the operated subjects, with results being strictly maintained over a 10-year follow-up period. This outcome, which far exceeds those following similar weight loss at short or long term obtained by any other means, confirms the existence of specific actions of BPD on the major components of metabolic syndrome.

Thirteen years of follow-up in patients with adjustable silicone gastric banding for obesity: weight loss and constant rate of late specific complications.

BACKGROUND: Despite its simplicity, safety and good short-term results, progressive weight regain and a high incidence of complications have been reported after the adjustable silicone gastric banding (ASGB). The aim of this study is to evaluate the long-term results of this operation in our patient population. METHODS: Between 1990 and 1996, 45 morbidly obese patients underwent insertion of an ASGB. The trend of the patients' BMI over time was studied using a linear mixed effect model adjusted for the preoperative BMI. So as to estimate the cumulative probability of band removal and the cumulative hazard function, Lambda(t) Kaplan-Meier analysis was used. RESULTS: 1 year after the operation, the average BMI was 79% of its preoperative value, which then increased linearly over time. The slope of the regression line was estimated at beta =0.42, indicating an average increase of 0.42 BMI units per year. 27 bands (60%) were removed because of specific late complications. The cumulative risk of band removal increased linearly with time. The hazard rate was estimated to be lambda =0.008 events/patient/month, corresponding to 0.1 events/patient/year. CONCLUSIONS: ASGB yielded good short-term results, but the progressive weight regain and constant risk of complications in the long term tend to nullify the optimism.

Radiology of patients with vertical banded gastroplasty.

BACKGROUND: The authors evaluated the usefulness of routine traditional radiology in the management of patients submitted to VBG. METHODS: Radiological findings in 65 subjects who had undergone VBG were evaluated. Post-surgical clinical and radiological examinations were performed 3 days, 1, 4 and 12 months after surgery. Upper GI symptoms, gastroesophageal imaging and 80% solid meal pouch emptying time were recorded. RESULTS: The routine postoperative study, in the absence of clinical symptoms, showed no unsuspected complication in any patient, both in the early and in the late postoperative period. There was no significant correlation at 4 and 12 months between emptying time and duration of satiation, emptying time and percent excess weight loss (%EWL), and duration of satiation and %EWL. CONCLUSIONS: Traditional radiological studies can be safely omitted from both the immediate postoperative period and from the long-term follow-up in asymptomatic VBG patients. The studies were not helpful in understanding functional changes leading to weight loss after VBG.