Increasing utilization of laparoscopic gastric banding in the adolescent: data from academic medical centers, 2002-2009.

Bariatric surgery in the adolescent continues to be a controversial topic. This study compared the utilization and perioperative outcomes of adolescent bariatric surgery performed at academic centers from 2002 to 2006 versus 2007 to 2009. We obtained data from the University HealthSystem Consortium for all adolescent patients (ages 12-18 years) who underwent bariatric surgery for the treatment of morbid obesity between 2002 and 2009. Outcomes including type of procedure, characteristics, length of stay, 30-day readmission, morbidity, and in-hospital mortality were compared between the two time periods. From 2007 to 2009, 340 adolescents underwent bariatric surgery at 63 academic hospitals. The mean number of adolescent bariatric procedures performed/year increased from 61.8 in 2002 to 2006 to 113.3 procedures/year in 2007 to 2009. There was an increase in utilization of laparoscopic gastric banding from 29 per cent to 50 per cent with a decrease in utilization of gastric bypass from 62 per cent to 48 per cent, respectively. For 2007 to 2009, the overall morbidity was 2.9 per cent with a 30-day readmission of 1.5 per cent and an in-hospital mortality of 0 per cent. Within the context of academic medical centers, adolescent bariatric surgery is associated with low morbidity and no mortality. Compared with 2002 to 2006, there has been an increase in the number of adolescent bariatric operations with increase in utilization of the laparoscopic gastric banding.

Improved bariatric surgery outcomes for Medicare beneficiaries after implementation of the medicare national coverage determination.

OBJECTIVE: To compare the outcomes of Medicare beneficiaries who underwent bariatric surgery within 18 months before and after implementation of the national coverage determination (NCD) for bariatric surgery. DESIGN: Analysis of the University HealthSystem Consortium database from October 1, 2004, through September 31, 2007. SETTING: A total of 102 academic medical centers and approximately 150 of their affiliated hospitals, representing more than 90% of the nation's nonprofit academic medical centers. PATIENTS: Medicare and Medicaid patients who underwent bariatric surgery to treat morbid obesity. MAIN OUTCOME MEASURES: Demographics, length of stay, 30-day readmission, morbidity, observed-to-expected mortality ratio, and costs. RESULTS: A total of 3196 bariatric procedures were performed before and 3068 after the NCD. After the implementation of the NCD, the volume of gastric banding doubled and the proportion of laparoscopic gastric bypass increased from 60.0% to 77.2%. Patients who underwent bariatric surgery after the NCD benefited from a shorter length of stay (3.5 vs 3.1 days, P < .001) and lower overall complication rates (12.2% vs 10.0%, P < .001), with no significant differences in the in-hospital mortality rates (0.28% vs 0.20%). Among Medicare patients, there was a 29.3% reduction in the number of bariatric procedures performed within the first 2 quarters after the NCD. However, the number of procedures returned to baseline volume within 1 year and exceeded baseline volume after 2 years of the NCD. CONCLUSION: The bariatric surgery NCD resulted in improved outcomes for Medicare beneficiaries without limiting access to care for individuals with medical disability.

Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients.

BACKGROUND: Findings have shown that single-incision laparoscopic cholecystectomy (SILC) is feasible and reproducible. The authors have pioneered a two-trocar SILC technique at the University of Texas Southwestern. Their results for 100 patients are presented. METHODS: From January 2008 to March 2009, 100 patients with symptomatic gallbladder disease underwent SILC through a 1.5- to 2-cm umbilical incision using a two-port (5-mm) technique. For nearly all the patients, a 30 degrees angled scope was used. The gallbladder was retracted, with two or three sutures placed along the gallbladder. These sutures were either fixated internally or placed through the abdominal wall to obtain a critical view of Calot's triangle. The SILC procedure was performed using standard technique with 5-mm reticulating or conventional laparoscopic instruments. The cystic duct and artery were well visualized, clipped, and divided. Cholecystectomy was completed with electrocautery, and the specimen was retrieved through the umbilical incision. RESULTS: In this series, 80 women (85%) and 15 men (15%) with an average age of 33.8 years (range, 17-66 years) underwent SILC. Their mean BMI was 29.8 kg/m(2) (range, 17-42.5 kg/m(2)), and 39% of these patients had undergone previous abdominal surgery. The mean operative time was 50.8 min (range, 23-120 min). The mean estimated blood loss was 22.3 ml (range, 5-125 ml), and 5% of the patients had an intraoperative cholangiogram. There were no conversions of the SILC technique. A two-trocar technique was feasible for 87% of the patients. For the remaining patients, either a three-channel port or three individual trocars were required. A SILC technique was used for 5% of the patients to manage acute cholecystitis or gallstone pancreatitis. CONCLUSION: The SILC technique with a two-trocar technique is safe, feasible, and reproducible. The operating times are reasonable and can be lessened with experience. Even complex cases can be managed with this technique. Excellent exposure of the critical view was obtained in all cases. The SILC procedure is becoming the standard of care for most of the authors' elective patients with gallbladder disease. Clinical trials are warranted before the SILC technique is adopted universally.

Improvement of restrictive and obstructive pulmonary mechanics following laparoscopic bariatric surgery.

BACKGROUND: Morbidly obese patients often have impaired respiratory mechanics leading to restrictive and obstructive lung diseases. Weight loss after bariatric surgery has been shown to improve or resolve many obesity-related comorbidities. However, few studies have examined long-term changes in pulmonary mechanics after bariatric surgery. We hypothesize that pulmonary function improves after surgically induced weight loss. METHODS: We examined the pulmonary function of 104 morbidly obese patients who underwent laparoscopic gastric bypass or gastric banding. Pulmonary studies, including forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC), peak expiratory flow (PEF), and forced expiratory volume at midexpiratory phase (FEV(25-75%)) were measured preoperatively and at 3-month intervals. All results are expressed as a percentage of the baseline values. RESULTS: There were 80 females and 24 males with a mean age of 41 years. The mean body mass index was 48 kg/m(2). The mean percentage of excess body weight loss at 12 months was 54%. At 12 months postoperatively, restrictive pulmonary mechanics significantly improved as demonstrated by an increase in the FEV(1) to 112% of baseline value, increase in the FVC to 109% of baseline value, increase in the PEF to 115% of baseline value, and increase in the FEV(25-75%) to 130% of baseline value. Additionally, the percentage of patients with obstructive lung pattern (FEV(1)/FVC ratio less than 0.8) decreased from 9.6% preoperatively to 1.9% postoperatively (p=0.03). CONCLUSIONS: Weight loss after laparoscopic gastric bypass significantly improves restrictive and obstructive respiratory mechanics. The improvements were observed as early as 3 months postoperatively.

Polyester composite mesh for laparoscopic paraesophageal hernia repair.

Recent evidence supports the use of prosthetic reinforcement material during laparoscopic hiatal hernia repair; however, the search for appropriate prosthetic materials is still under investigation. In this article, the technical feasibility and the short-term outcomes of the use of polyester composite mesh for crural reinforcement was determined. A small series of patients with large paraesophageal hiatal hernias underwent laparoscopic repair with mesh (5 males; mean age = 62 +/- 10 years; mean body mass index = 29 +/- 1 kg/m2, and mean American Society of Anesthesiologists = 3 +/- .4). There were no postoperative complications, deaths, or evidence of hernia recurrence documented by barium study at a median follow-up of 9 months. The use of the polyester composite mesh is technically feasible, has excellent intracorporeal handling characteristics, and holds suture readily. The short-term outcomes of the use of the polyester composite mesh for paraesophageal hernia repair reinforcement appeared to be favorable and are encouraging.

Laparoscopic gastric ischemic conditioning prior to esophagogastrectomy: technique and review.

Esophagectomy can be associated with significant peri-operative morbidity such as leaks and strictures. Gastric ischemia as a result of gastric devascularization is one of the several contributing factors that may play a role in development of these complications. In an attempt to improve gastric tissue perfusion, a technique of gastric ischemic conditioning was proposed. For patients with esophageal cancer and at the time of laparoscopic staging, partial gastric devascularization is achieved by division of the left gastric vessels. Esophagectomy is subsequently performed several days after the gastric ischemic conditioning procedure. Our experience showed that preoperative ligation of left gastric vessels prior to esophagogastrectomy is technically feasible and safe and may decrease ischemic complications such as leaks and strictures.

Laparoscopic surgery is associated with a lower incidence of venous thromboembolism compared with open surgery.

BACKGROUND: Although laparoscopy now plays a major role in most general surgical procedures, little is known about the relative risk of venous thromboembolism (VTE) after laparoscopic compared with open procedures. OBJECTIVE: To compare the incidence of VTE after laparoscopic and open surgery over a 5-year period. PATIENTS AND INTERVENTIONS: Clinical data of patients who underwent open or laparoscopic appendectomy, cholecystectomy, antireflux surgery, and gastric bypass between 2002 and 2006 were obtained from the University HealthSystem Consortium Clinical Database. The principal outcome measure was the incidence of venous thrombosis or pulmonary embolism occurring during the initial hospitalization after laparoscopic and open surgery. RESULTS: During the 60-month period, a total of 138,595 patients underwent 1 of the 4 selected procedures. Overall, the incidence of VTE was significantly higher in open cases (271 of 46,105, 0.59%) compared with laparoscopic cases (259 of 92,490, 0.28%, P < 0.01). Our finding persists even when the groups were stratified according to level of severity of illness. The odds ratio (OR) for VTE in open procedures compared with laparoscopic procedures was 1.8 [95% confidence interval (CI) 1.3-2.5]. On subset analysis of individual procedures, patients with minor/moderate severity of illness level who underwent open cholecystectomy, antireflux surgery, and gastric bypass had a greater risk for developing perioperative VTE than patients who underwent laparoscopic cholecystectomy (OR: 2.0; 95% CI: 1.2-3.3; P < 0.01), antireflux surgery (OR: 24.7; 95% CI: 2.6-580.9; P < 0.01), and gastric bypass (OR: 3.4; 95% CI: 1.8-6.5; P < 0.01). CONCLUSIONS: Within the context of this large administrative clinical data set, the frequency of perioperative VTE is lower after laparoscopic compared with open surgery. The findings of this study can provide a basis to help surgeons estimate the risk of VTE and implement appropriate prophylaxis for patients undergoing laparoscopic surgical procedures.

Surgical site infections after colorectal surgery: do risk factors vary depending on the type of infection considered?

BACKGROUND: The purpose of this study was to compare risk factors for the development of incisional versus organ/space infections in patients undergoing colorectal surgery. METHODS: An institutional review board-approved retrospective review was performed examining a 4-year period (January 2002 to December 2005). Patients were included if they had undergone abdominal operations (open or laparoscopic) in which the colon/rectum was surgically manipulated. Patients were excluded if the surgical wound was not closed primarily. A standardized definition of incisional and organ/space infection was employed. RESULTS: A total of 428 operations were performed. Overall, 105 infections were identified (25%); 73 involved the incision and 32 were classified as organ/space. Multivariate analysis suggested that incisional infection was independently associated with body mass index (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.02-1.11) and creation/revision/reversal of an ostomy (OR, 2.2; 95% CI, 1.3-3.9). Organ/space infection was independently associated with perioperative transfusion (OR, 2.3; 95% CI, 1.1-5.5) and with previous abdominal surgery (OR, 2.5; 95% CI, 1.2-5.3). CONCLUSIONS: Factors associated with infection differed based on the type of surgical site infection being considered. The lack of overlap between factors associated with incisional infection and organ/space infection suggests that separate risk models and treatment strategies should be developed.

Use and outcomes of laparoscopic versus open gastric bypass at academic medical centers.

BACKGROUND: A large outcome study of laparoscopic gastric bypass has not been done because of difficulty in differentiating between open and laparoscopic procedures in the absence of a specific ICD-9 procedural code for the laparoscopic operation. The University HealthSystem Consortium (UHC) clinical database recently added a specific procedural code for laparoscopic gastric bypass. The goal of this study was to compare the use and outcomes of laparoscopic versus open gastric bypass at academic centers. STUDY DESIGN: Using ICD-9 diagnosis and procedure codes, we obtained data from the UHC clinical database for all patients who underwent laparoscopic or open Roux-en-Y gastric bypass for treatment of morbid obesity between 2004 and 2006 (n = 22,422). The main outcomes measures were demographics, comorbidities, length of hospital stay, 30-day readmission, morbidity, observed and expected (risk-adjusted) mortality, and costs. RESULTS: There were 16,357 patients who underwent laparoscopic gastric bypass and 6,065 patients who underwent open gastric bypass. Laparoscopic gastric bypass patients had a shorter length of hospital stay (2.7 days versus 4.0 days, p < 0.01); lower overall complications (7.4% versus 13.0%, p < 0.01); lower rates of pneumonia, venous thrombosis, leak, wound infection, and pulmonary complications; costs were also lower. The observed-to-expected in-hospital mortality ratio was similar between groups (1.0 versus 1.0). CONCLUSIONS: This nationwide analysis of academic medical centers between 2004 and 2006 showed that bariatric surgery has shifted to a predominately laparoscopic approach. In addition, laparoscopic gastric bypass is as safe as open gastric bypass and is considerably associated with a lower 30-day morbidity.

Laparoscopic and thoracoscopic Ivor Lewis esophagectomy after Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass is a commonly performed procedure for the treatment of morbid obesity. Esophagectomy in patients with a history of Roux-en-Y gastric bypass presents a difficult technical challenge for the surgeon. In this report we describe a technique of minimally invasive Ivor Lewis esophagogastrectomy in a patient who had had an open Roux-en-Y gastric bypass. Minimally invasive esophagectomy was performed with resection of the Roux limb using the gastric remnant as the conduit for gastrointestinal reconstruction.

Resolution of hyperlipidemia after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Hyperlipidemia is an established risk factor for development of coronary artery disease. The aim of our study was to examine the changes in serum lipid profiles of morbidly obese patients complicated by hyperlipidemia, who underwent laparoscopic gastric bypass. STUDY DESIGN: We retrospectively reviewed the charts of 95 morbidly obese patients with documented hyperlipidemia who underwent laparoscopic gastric bypass. Mean duration of hyperlipidemia was 44+/- 56 months. Hyperlipidemia was defined as an elevated level of triglycerides (> 150 mg/dL) or total cholesterol (> 200 mg/dL). Changes in lipid profile of a subset of patients with subnormal levels of high-density lipoprotein cholesterol ( 130 mg/dL), and very-low-density lipoprotein cholesterol (> 40 mg/dL) were also examined. Fasting lipid profiles were measured preoperatively and at 3-month intervals. RESULTS: There were 68 women (72%) with a mean age of 43 +/- 10 years. Mean body mass index was 47+/- 5 kg/m2. Mean percentage of excess body weight loss at 12 months postoperatively was 66%. One year after gastric bypass, mean total cholesterol levels decreased by 16%; triglyceride levels decreased by 63%; low-density lipoprotein cholesterol levels decreased by 31%; very-low-density lipoprotein cholesterol decreased by 74%; total cholesterol/high-density lipoprotein cholesterol risk ratio decreased by 60%, and high-density lipoprotein cholesterol levels increased by 39%. Also, within 1 year, 23 of 28 (82%) patients requiring lipid-lowering medications preoperatively were able to discontinue their medications. CONCLUSIONS: Weight loss after laparoscopic gastric bypass substantially improves lipid profiles in morbidly obese patients who have hyperlipidemia. Improvement in lipid profiles was observed as early as 3 months postoperatively and was sustained at 1 year. Improvement of lipid profiles after laparoscopic gastric bypass can reduce health risks associated with high levels of atherogenic lipoproteins.