First modified Delphi consensus statement on robotic-assisted da Vinci sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is the most commonly performed metabolic and bariatric surgery (MBS) procedure. Technical considerations related to the performance of SG are well established and reported in the literature but not in relation to robotic-assisted (RA) SG. We report the results of the first modified Delphi consensus-building exercise addressing technical considerations of RA da Vinci (dV) SG. OBJECTIVES: Develop best practices for the performance of robotic-assisted da Vinci sleeve gastrectomy. SETTING: Survey based consensus statement. METHODS: A consensus building committee (CBC) was created comprising 10 experts in the field of RA surgery and MBS based on strict selection criteria. The CBC developed 49 consensus statements which were then shared with 240 experts in RA surgery. Our stopping criterion was stability in responses (≤15%). The consensus cut point was 70%. RESULTS: The overall response rate was 49%. In the first round of voting, there was consensus agreement on 25 statements (51%), consensus disagreement on 14 (28%), and no consensus on the remaining statements (21%). In the second round of voting, we reached agreement on 3 additional statements. Experts recommended the use of the number of pauses generated by the stapler to guide choice of staple height (91.2%) and to upsize the staple height when using buttressing (92%). There was also consensus (81.4%) that the use of the closed staple height of 1.00 mm (white) is acceptable and that stapling of the antrum using a 1.5-mm staple (blue load) is also acceptable (73%). CONCLUSIONS: Collective expert opinion structured through a modified Delphi consensus statement presents a practical guide for surgeons interested in performing dV-SG.

International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical approach, but 1 that has seen a surge in popularity because of its perceived technical simplicity, feasibility, and good outcomes. An international expert panel was convened in Coral Gables, Florida on March 25 and 26, 2011, with the purpose of providing best practice guidelines through consensus regarding the performance of LSG. The panel comprised 24 centers and represented 11 countries, spanning all major regions of the world and all 6 populated continents, with a collective experience of >12,000 cases. It was thought prudent to hold an expert consensus meeting of some of the surgeons across the globe who have performed the largest volume of cases to discuss and provide consensus on the indications, contraindications, and procedural aspects of LSG. The panel undertook this consensus effort to help the surgical community improve the efficacy, lower the complication rates, and move toward adoption of standardized techniques and measures. The meeting took place at on-site meeting facilities, Biltmore Hotel, Coral Gables, Florida. METHODS: Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed >500 cases. The topics for consensus encompassed patient selection, contraindications, surgical technique, and the prevention and management of complications. The responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement). RESULTS: Full consensus was obtained for the essential aspects of the indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 69 key questions. CONCLUSION: The present consensus report represents the best practice guidelines for the performance of LSG, with recommendations in the 3 aforementioned areas. This report and its findings support a first effort toward the standardization of techniques and adoption of working recommendations formulated according to expert experience.

Mechanical prophylaxis to prevent venous thromboembolism in surgical patients: a prospective trial evaluating compliance.

PURPOSE: Sequential compression devices (SCDs) and venous foot pumps (VFPs) are used to prevent venous thromboembolism in surgical patients, but compliance is presumed to be poor. We evaluated compliance with these devices, compared compliance between intensive care unit (ICU) and non-ICU patients, and identified factors associated with better compliance. MATERIALS AND METHODS: Compliance was prospectively evaluated twice daily from admission until discharge, ambulation, or device discontinuation. A compliance score was determined by dividing the number of compliant evaluations by the total number of assessments. Compliance was compared between ICU and non-ICU patients, and predictors for compliance were identified. RESULTS: There were 150 patients evaluated. Overall compliance was 73 +/- 29. Compliance was higher in ICU patients compared to non-ICU patients (82 +/- 22 vs 62 +/- 32; P < .001). Admission to the ICU (odds ratio [OR], 2.21 [1.04-4.65]; P = .038) and SCD use (as opposed to VFP) (OR, 2.94 [1.36-6.37]; P = .006) were independent predictors for better compliance. CONCLUSIONS: Compliance with mechanical prophylaxis is suboptimal particularly in non-ICU patients. Strategies to improve compliance or alternative prophylaxis should be considered in those patients.

Limitations of a standardized weight-based nomogram for heparin dosing in patients with morbid obesity.

BACKGROUND: Confusion exists when dosing heparin using a weight-based nomogram in the obese population. At 2 affiliated community teaching hospitals, we compared the activated partial thromboplastin time (aPTT) values in morbidly obese and nonmorbidly obese patients using a standardized nomogram and determined factors associated with achieving a supratherapeutic aPTT value. METHODS: This was a retrospective study that included patients who had received intravenous heparin according to a standardized weight-based nomogram for >or=12 hours. The exclusion criteria were age <18 years, pregnancy, and insufficient data. Patients were stratified into morbidly obese (body mass index [BMI] >or=40 kg/m(2)) and nonmorbidly obese (BMI <40 kg/m(2)) groups. The aPTT values were compared and predictors for a supratherapeutic aPTT values were identified. RESULTS: A total of 101 patients were included in the study. Greater aPTT values were noted at 6 hours (155 +/- 37 versus 135 +/- 44, P = .020) and 12 hours (141 +/- 45 versus 117 +/- 45, P = .012) for patients with morbid obesity than for those without it, respectively. Increasing BMI (odds ratio = 1.06, 95% confidence interval 1.02-1.1; P = .003) and age (odds ratio 1.05, 95% confidence interval 1.02-.09; P = .001] were independent predictors of supratherapeutic aPTT values. CONCLUSION: Heparin dosing with a weight-based nomogram will yield greater aPTT values in morbidly obese patients. Consideration of BMI and age can help identify those patients at risk of supratherapeutic aPTTs. Alternative strategies, such as a dose cap should be considered in patients with morbid obesity.

Primary breast lymphoma: the role of mastectomy and the importance of lymph node status.

OBJECTIVE: To construct and analyze a database comprised of all reported cases of primary breast lymphoma (PBL) that include treatment and follow-up information published during the last 3 decades. SUMMARY BACKGROUND DATA: PBL accounts for 0.4% of breast malignancies and 2% of extranodal lymphomas. Surgical therapy has varied from biopsy to radical mastectomy. Chemotherapy and radiation therapy have been used as adjuvant or primary therapy. A standard consensus treatment of PBL is not available. METHODS: We reviewed all published PBL reports from June 1972 to March 2005. A database was compiled by abstracting individual patient information, limiting our study to those reports that contained specific treatment and outcome data. Patient demographics such as survival, recurrence, and time to follow-up were recorded, in addition to surgical, radiation, and/or chemotherapy treatment(s). RESULTS: We found 465 acceptable patients reported in 92 publications. Age range was 17 to 95 years (mean, 54 years). Mean tumor size was 3.5 cm. Diffuse large cell (B) lymphoma was the most common histologic diagnosis (53%). Disease-free survival was 44.5% overall. Follow-up ranged from one to 288 months (mean, 48 months). Treatment by mastectomy offered no survival benefit or protection from recurrence. Treatment that included radiation therapy in stage I patients (node negative) showed benefit in both survival and recurrence rates. Treatment that included chemotherapy in stage II patients (node positive) showed benefit in both survival and recurrence rates. Histologic tumor grade predicted survival. CONCLUSIONS: Mastectomy offers no benefit in the treatment of PBL. Nodal status predicts outcome and guides optimal use of radiation and chemotherapy.

A double-blinded, prospective randomized controlled trial of intraperitoneal bupivacaine in laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Intraperitoneal local anesthetics have been investigated in several laparoscopic procedures that demonstrate improved postoperative pain control and reduced length of hospital stay. No published studies to date address the effectiveness of IP local anesthetics in laparoscopic gastric bypass patients (LRYGB). STUDY DESIGN: Between October 2004 and March 2005, 133 patients were prospectively studied to evaluate the efficacy of IP bupivacaine (IPB) in LRYGB. Patients were randomized to receive either bupivacaine (study group) or saline (control group), which was administered over the esophageal hiatus before dissection and bypass. All procedures were performed in a University-affiliated community-based hospital by three experienced laparoscopic gastric bypass surgeons. Outcomes variables included postoperative pain and narcotic use, length of stay, antiemetic use, cost, and pulmonary function. RESULTS: There were 65 patients within the study group and 68 control patients, with equivalent patient demographics (p > 0.05). A statistically significant decrease in oral narcotic (hydrocodone/acetaminophen, Lortab Elixir, UCB) use was seen in the experimental group relative to the control group (23.8 +/- 2.2 mL versus 33.7 +/- 3.0 mL). Material cost was greater by $0.36 per patient in the study group. All other outcomes variables (ie, length of stay, postoperative IV narcotic use, incentive spirometer volumes, visual analog pain scale, and antiemetic use) showed no considerable differences. CONCLUSIONS: IPB use during LRYGB revealed a statistically significant difference only in postoperative oral narcotic use. Possibly, the IPB can limit or prevent peritoneal irritation and reduce the need for longer narcotic use. Clinical significance was not demonstrated by our outcomes variables.

Multifocal primary breast lymphoma.

Primary breast lymphoma (PBL) is a rare condition, accounting for only 0.04 to 0.5% of breast malignancies and less than 2% of extranodal lymphomas. Clinical presentation and imaging may suggest a benign condition. Reports of treatment vary widely. Surgical therapy has been reported to include only biopsy or extend to partial mastectomy, total mastectomy, or even radical mastectomy. Chemotherapy with various agents is often used. Radiotherapy has been used in the adjuvant setting or as primary local therapy. Immunotherapy and radioimmunotherapy have shown some promise in other lymphomas and may be useful here as well. There is no standard or consensus of treatment for PBL. This report describes a case of multifocal PBL in a 45-year-old female and discusses the physical findings, diagnosis, and treatment options for this condition.

The science of stapling and leaks.

Staple-line leaks represent an unwanted, yet seemingly unavoidable, complication of stapling associated with bariatric surgery. Although, "folk legends" abound as to precluding leaks, little has been written based on basic research and understanding of stapling mechanics. This article reviews the history of stapling and discusses the implications of understanding the biomechanics of stapling living tissue. Finally, three leak studies evaluating ways to optimize staple-line strength are presented, and a large bariatric clinical series is reviewed.

A randomized trial of endoscopic and fluoroscopic placement of postpyloric feeding tubes in critically ill patients.

BACKGROUND: Early postpyloric feeding is considered the accepted method of nutrition support in critically ill patients. Endoscopic and fluoroscopic techniques are associated with the highest percentage of successful placement. The purpose of this study was to compare endoscopic vs fluoroscopic placement of postpyloric feeding tubes in critically ill patients. METHODS: This is a randomized prospective clinical trial. Forty-three patients were randomized to receive feeding tubes by endoscopic or fluoroscopic technique. All procedures were performed at the bedside in the critical care unit. A soft small-bore nonweighted feeding tube was used in all cases. Successful placement was confirmed by either an abdominal x-ray for endoscopic technique or a fluoroscopic radiograph for fluoroscopic technique. RESULTS: Postpyloric feeding tubes were successfully placed in 41 of 43 patients (95%). The success rate using endoscopic technique was 96% (25 of 26), whereas the rate using fluoroscopy was 94% (16 of 17). The average time of successful placement was 15.2 +/- 2.9 (mean +/- SEM) minutes for endoscopic placement and 16.2 +/- 3.2 minutes for fluoroscopic placement, which was not statistically significant (p > .05). CONCLUSIONS: Endoscopic and fluoroscopic placement of postpyloric feeding tubes can safely and accurately be performed at the bedside in critically ill patients. Our results showed no significant difference in the success rate or time of placement between endoscopic vs fluoroscopic placement of postpyloric feeding tubes.