Enhanced Recovery After Surgery Protocol in Bariatric Surgery Leads to Decreased Complications and Shorter Length of Stay.

PURPOSE: Enhanced recovery after surgery (ERAS) programs have been shown in some specialties to improve short-term outcomes following surgical procedures. There is no consensus regarding the optimal perioperative care for bariatric surgical patients. The purpose of this study was to develop a bariatric ERAS protocol and determine whether it improved outcomes following surgery. MATERIALS AND METHODS: An IRB-approved prospectively maintained database was retrospectively reviewed for all patients undergoing bariatric surgery from October 2018 to January 2020. Propensity matching was used to compare post-ERAS implementation patients to pre-ERAS implementation. RESULTS: There were 319 patients (87 ERAS, 232 pre-ERAS) who underwent bariatric operations between October 2018 and January 2020. Seventy-nine patients were kept on the ERAS protocol whereas 8 deviated. Patients who deviated from the ERAS protocol had a longer length of stay when compared to patients who completed the protocol. The use of any ERAS protocol (completed or deviated) reduced the odds of complications by 54% and decreased length of stay by 15%. Furthermore, patients who completed the ERAS protocol had an 83% reduction in odds of complications and 31% decrease in length of stay. Similar trends were observed in the matched cohort with 74% reduction in odds of complications and 26% reduction in length of stay when ERAS was used. CONCLUSIONS: ERAS protocol decreases complications and reduces length of stay in bariatric patients.

Enhanced recovery after surgery (ERAS) decreases complications and reduces length of stay in foregut surgery patients.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programs provide a framework for optimal perioperative care to improve post-operative outcomes following surgical procedures. However, there is no consensus regarding an ERAS protocol following foregut surgery. The purpose of this study was to develop an ERAS protocol for these patients and determine whether they improved outcomes. METHODS: An IRB approved prospectively maintained database was retrospectively reviewed for all patients undergoing benign minimally invasive foregut surgery from October 2018 to January 2020. All patients were entered into the ACS risk calculator to determine their predicted rate of complications and length of stay for comparison between the ERAS and control groups. Propensity matching was used to compare post-ERAS implementation to pre-ERAS implementation patients. Firth logistic and Poisson regression analysis were used to assess the rate of complications and length of stay among the different groups of patients. RESULTS: There were 255 patients (60 Post-ERAS, 195 Pre-ERAS) who underwent foregut operations and met inclusion criteria. ERAS was implemented, and patients were then subdivided based on those who completed ERAS (44) and those who deviated from the protocol (16). Propensity matching analysis was performed to compare the different cohorts and showed ERAS patients had 41% decreased odds of complications and 33% reduction in length of stay compared to pre-ERAS patients. Completion of the ERAS protocol resulted in even further reductions in odds of complication and length of stay compared to patients who deviated from the protocol. CONCLUSIONS: ERAS has shown to improve perioperative outcomes, but there is limited literature supporting the use of ERAS in foregut surgery. Usage of an ERAS protocol can decrease complications and reduce the length of stay in patients.

Nutritional Support and Duration of Drainage Recommendations for Endoscopic Internal Drainage: Review of the Literature and Initial Experience.

INTRODUCTION: Anastomotic leaks following foregut surgery pose a difficult scenario for surgeons. While definitive surgical options are more invasive and may result in diversion requiring subsequent surgeries, endoscopic management of these leaks has been shown to work as an alternative platform for management. An evolving option is endoscopic internal drainage. We have reviewed our experience using endoscopic internal drainage and report our outcomes. MATERIALS AND METHODS: An institution review board approved prospectively gathered database was used to identify all patients undergoing endoscopic internal drainage following esophageal and gastric leaks. Patient demographics, sentinel operation causing the leak, and outcomes of therapy were collected. The rate of healing and complications with the drainage catheter in place were the primary endpoints. RESULTS: Sixteen patients were identified (5 male, 11 female) that underwent endoscopic internal drainage with a mean age of 48 and mean BMI of 30.8. Overall success rate was 69% (11/16), where 4 patients required a definitive surgery, and one healed with endoluminal vacuum therapy. Of the 4 failures, 1 patient required esophagojejunostomy, 2 patients required a fistulojejunostomy, and one required a partial gastrectomy. A total of 12 patients (75%) had a prior endoscopic procedure that was unsuccessful. The mean duration of drainage catheter in place was 48 days. While the catheter was in place, 4 patients were allowed minimal PO intake in conjunction with total parenteral nutrition or tube feeds. The rest of the patients were strict NPO with other means of nutrition. There were no complications with the drainage catheters and no deaths. CONCLUSION: Leaks following esophagogastric surgery are difficult to manage; however, endoscopic internal drainage has been shown to be effective. Duration of the technique should be around 6 to 8 weeks with nutritional support guided by the comfort of the managing clinician.

Complications Following Robotic Hiatal Hernia Repair Are Higher Compared to Laparoscopy.

BACKGROUND: The use of robotic platforms in surgery is becoming increasingly common in both practice and residency training. In this study, we compared the perioperative outcomes between robotic platforms and traditional laparoscopy in paraesophageal hernia repair. METHODS: A retrospective population-based analysis was performed using the National Inpatient Sample for the period of 2010-2015. Adult patients (≥18 years old) who underwent laparoscopic or robotic paraesophageal hernia repairs were included. Weighted multivariable random intercept linear and logistic regression models were used to assess the effects of robotic surgery on patient outcomes. RESULTS: A total of 168,329 patients were included in the study. The overall adjusted rate of complications was significantly higher in patients who underwent robotic paraesophageal hernia (PEH) repair compared to laparoscopic PEH OR (95% CI) = 1.17 (1.07, 1.27). Specifically, respiratory failure OR (95% CI) = 1.68 (1.37, 2.05) and esophageal perforation OR (95% CI) = 2.19 (1.42, 3.93) were higher in robotic PEH patients. A subset analysis was performed looking at high-volume centers (>20 operations per year), and, although the risk of complications was lower in the high volume centers compared to intermediate volume centers, complication rates were still significantly higher in the robotic surgery group compared to laparoscopic. Overall charges per surgery were significantly higher in the robotic group. CONCLUSION: Robotic PEH repair is associated with significantly more complications compared to laparoscopic paraesophageal hernia repair even in high-volume centers.

Endoscopic sleeve gastroplasty requiring emergent partial gastrectomy.

Bariatric surgery has become an accepted and effective treatment for morbid obesity. Laparoscopic sleeve gastrectomy is the most common weight loss procedure, in which patients on average lose 60% of their excess body weight. Recently, a completely endoscopic approach was developed that takes advantage of an endoscopic suturing device to plicate the greater curvature of the stomach into sleeve-like anatomy. The endoscopic sleeve gastroplasty has been shown to be safe with minimal complications and good weight loss outcomes. We present a case of a rare and dangerous complication of endoscopic sleeve gastroplasty that required emergent surgical intervention.

Objectively Confirmed Gastroesophageal Reflux Disease Following Per Oral Endoscopic Myotomy Higher in Obese Patients (BMI>30).

INTRODUCTION: Per oral endoscopic myotomy (POEM) is a promising minimally invasive therapy in the treatment of achalasia and other esophageal motility disorders. A concern surrounding POEM is the development of gastroesophageal reflux disease (GERD) postoperatively. This study was designed to report outcomes and identify risk factors for the development of postoperative GERD. METHODS: Patients who underwent POEM between January 1, 2015 and December 12, 2019 were prospectively followed in an Institutional Review Board approved database. All patients were invited for a full comprehensive workup 6 months post-POEM including symptom scores, pH testing, manometry and esophagogastroduodenoscopy. In a retrospective review of this database, those who developed postoperative GERD were compared with those who did not. RESULTS: There were 82 patients that met study criteria (median age 59). Indications for POEM include 35 type I achalasia, 16 type II achalasia, 21 type III achalasia and other spastic esophageal motility disorders, and 10 esophagogastric junction outflow obstruction. Mean Eckardt scores post-POEM were 2.67 compared with 6.79 pre-POEM (P<0.05). Mean integrated relaxation pressure improvement decreased from 27 to 13.1 (P<0.05). The presence of postoperative GERD was defined as an abnormal DeMeester score (>14.7) with pH testing off-medications or the presence of Grade C/D esophagitis on endoscopy. Thirty-five percent (29/82) of patients developed postoperative GERD following POEM. Negative predictive factors for the development of postoperative GERD include myotomy length and normal body mass index (BMI). Obesity (BMI>30) was a positive predictive risk factor in the development of GERD (P=0.029). CONCLUSIONS: POEM provides symptomatic relief and reduced Eckardt scores in patient with achalasia and other esophageal motility disorders. Patients who undergo POEM are at risk for developing gastroesophageal reflux disease especially in obese patients.

Endoscopic Per-oral Pyloromyotomy for Gastroparesis: Initial Experience and Postoperative Comparison to Predicted Complications Following Laparoscopic Pyloromyotomy as Calculated by the ACS Risk Calculator.

INTRODUCTION: Per-oral endoscopic pyloromyotomy (POP) is a promising new therapy in the treatment of gastroparesis, where the pyloric muscle is cut using an endoscopic tunneling technique. This study was designed to report outcomes from our initial experience and compare the rate of complications to the laparoscopic equivalent using the American College of Surgeons (ACS) risk calculator. METHODS: Patients who underwent POP between August 2018 to May 2019 were prospectively followed in a database approved by the institutional review board. Preoperatively, patients were evaluated objectively with a 4-hour gastric emptying study (GES). Following POP, all patients were invited for repeat GES 3 months postoperatively. The same cohort was entered into the ACS risk calculator using laparoscopic pyloromyotomy (LPM) as the selected procedure. Complication risk of LPM was then compared with the actual complication rate of POP. RESULTS: There were 11 patients that met study criteria (median age 52). Sixty-four percent (7/11) of patients agreed to do repeat GES postoperatively. Of those, 6 of 7 (86%) had normal GES (<10% emptying at 4 h) and the mean improvement was 36.4%. All patients were entered into the ACS risk calculator in which LPM (CPT code 43800) was used as a control. The postoperative complication rate was less than the median predicted risk of LPM in all categories including overall complications (0% vs. 10.05%), return to the operating room, (0% vs. 2.68%), and sepsis (0% vs. 1.42%). The rate of readmission (9% vs. 6.29%, P=0.65) was higher in the POP group than LPM predicted. Length of stay for all patients was significantly shorter than predicted (1.8 vs. 4.6 d, P<0.001). CONCLUSIONS: All POP patients had objective improvement in their GES and 86% had normal GES following this procedure. POP had significantly lower morbidity and reduced length of stay compared with that predicted of the laparoscopic equivalent using the ACS risk calculator.