Can Risk-Based Thromboprophylaxis Practice Guidelines be Safely Used in Esophagectomy Cases? Experience of an Academic Health System.

BACKGROUND: Venous thromboembolism (VTE) occurs in 3-11% of esophagectomy patients and is associated with increased mortality and morbidity. The use of validated VTE risk assessment tools and compliance with recommended practice guidelines remains unclear. In this study, we seek to determine the use of Caprini guideline indicated VTE prophylaxis and its effect on VTE and bleeding complications following esophagectomy. METHODS: Esophagectomy cases were identified from the Mayo Clinic electronic health records. Caprini score and VTE prophylaxis regimen received were determined retrospectively. VTE prophylaxis was identified as appropriate or inappropriate based on the Caprini score and prophylaxis received preoperative, during hospitalization, and after hospital discharge. Study cohorts were compared by Pearson Chi-square test, Fisher's Exact test, Kruskal-Wallis test, and logistic regression models. Stata/MP 16.1 was used for analysis. Odds ratios and 95% confidence intervals were reported for logistic regression models. A p-value < 0.05 was considered significant. RESULTS: Four hundred and fifty-six esophagectomy cases were analyzed. The median Caprini score was thirteen. Appropriate prophylaxis resulted in a 6.9-fold reduction in inpatient VTE. All 30- and 90-day post-discharge VTEs occurred in those not receiving Caprini guideline-indicated VTE prophylaxis. Inpatient, 30- and 90-day post-discharge bleeding rates were 7.68%, 0.91%, and 2.11%, respectively; however, bleeding was not increased with receipt of appropriate prophylaxis. CONCLUSION: In this esophagectomy cohort, Caprini guideline indicated VTE prophylaxis resulted in reduced inpatient VTE events without increasing bleeding complications. Risk-based VTE prevention measures should be considered in this patient cohort known to be at heightened risk for postoperative VTE.

Factors Associated with Weight Loss After Metabolic Surgery in a Multiethnic Sample of 1012 Patients.

BACKGROUND: Metabolic surgery is the most effective method for weight loss in the long-term treatment of morbid obesity and its comorbidities. The primary aim of this study was to examine factors associated with percent total weight loss (%TWL) after metabolic surgery among an ethnically diverse sample of patients. METHODS: A retrospective review was performed on 1012 patients who underwent either a sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) at our institution between January 2008 and June 2015. RESULTS: African Americans had a lower %TWL than non-Hispanic/Latino Whites at 6, 9, 12, 18, and 48 months. At all timeframes, there was a negative association between pre-surgery TWL and %TWL after surgery. Female sex was negatively associated with %TWL at 3 months only. Higher initial BMI was also associated with greater post-operative %TWL at 18, 24 and 36 months. Older patients had lower %TWL at 6, 9, 12 and 24 months post-surgery. Patients who received RYGB had greater %TWL than those who received SG at 3, 6, 9, 12, 24 and 36 months. CONCLUSIONS: African Americans had a lower %TWL than non-Hispanic/Latino Whites at most time points; there were no other significant race/ethnicity or sex differences. BMI (greater initial BMI), age (lower) and RYGB were associated with a greater post-operative %TWL at certain post-surgery follow-up time points. A limitation of this study is that there was missing data at a number of time points due to lack of attendance at certain follow-up visits.

Outcomes of Robot-Assisted Roux-en-Y Gastric Bypass as a Reoperative Bariatric Procedure.

BACKGROUND: We evaluate the outcomes of robot-assisted Roux-en-Y gastric bypass (RRYGB) as a reoperative bariatric procedure (RBP). METHODS: A retrospective analysis was done from 2007 to 2014, and all the patients who underwent RRYGB as a RBP at a teaching university hospital were included. RESULTS: A total of 32 patients underwent RRYGB as a reoperation from adjustable gastric band (AGB n = 16) or sleeve gastrectomy (SG n = 11) or previous gastric bypass (n = 5). Twenty patients underwent conversion to RRYGB due to weight loss failure, either after AGB (n = 13) or SG (n = 7). Twelve patients underwent reoperation because of complications of index procedure. Mean preoperative weight was 109.7 ± 29.5 kg, and BMI was 40 ± 10.6 kg/m(2). The mean operative time for RRYGB was 226 ± 45.3 min with a blood loss of 20 ± 15.9 ml. Average length of stay was 3 days. In two cases, pin point leaks were detected intraoperatively during check gastroscopy, and they were repaired with sutures. There were no postoperative anastomotic leaks or hemorrhage or gastrojejunostomy strictures. None of the patients required a blood transfusion or reoperation within perioperative period. In the patients who underwent RRYGB for weight loss failure (n = 20), the mean excess weight loss (EWL) was 39.2% at 6 months (n = 11), 53.8% at 1 year (n = 13), and 60.7% at 2 years (n = 6). CONCLUSIONS: RRYGB is safe and effective to be used as a revisional bariatric procedure. The weight loss outcomes and complication rates compare favorably with the published results of laparoscopic technique, although the small sample size may not be enough to reach definite conclusions.

Indocyanine green (ICG) fluorescent cholangiography during robotic cholecystectomy: results of 184 consecutive cases in a single institution.

BACKGROUND/AIM: Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy. METHODS: A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case. RESULTS: No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively. CONCLUSIONS: ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy.

Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience.

BACKGROUND: Use of robotic surgery has gained increasing acceptance over the last few years. There are few reports, however, on advanced pancreatic robotic surgery. In fact, the indication for robotic surgery in pancreatic disease has been controversial. This paper retrospectively reviews one surgeon's experience with robotic surgery to treat pancreatic disease, and analyzes its indications and outcomes, as well as the controversy that exists. METHODS: A retrospective review of the charts of all patients who underwent robotic surgery for pancreatic disease by a single surgeon at two different institutions was carried out. RESULTS: From October 2000 to January 2009, 134 patients underwent robotic-assisted surgery for different pancreatic pathologies. All procedures were performed using the da Vinci robotic system. Of the 134 patients, 83 were female. The average age of all patients was 57 years (range 24-86 years). Mean operating room (OR) time was 331 min (75-660 min). There were 14 conversions to open surgery. Mean length of stay was 9.3 days (3-85 days). Length of stay for patients with no complications was 7.9 days (3-15 days). The postoperative morbidity rate was 26% and the mortality rate was 2.23% (three patients). Among the procedures performed were 60 pancreaticoduodenectomies, 23 spleen-preserving distal pancreatectomies, 23 splenopancreatectomies, 3 middle pancreatectomies, 1 total pancreatectomy, and 3 enucleations. Another 21 patients underwent different surgical procedures for treatment of acute and chronic pancreatitis. Two cases of pancreaticoduodenectomy were performed in outside institutions and are not included in this series. CONCLUSIONS: This is the largest series of robotic pancreatic surgery presented to date. Robotic surgery enables difficult technical maneuvers to be performed that facilitate the success of pancreatic minimally invasive surgery. The results in this series demonstrate that it is feasible and safe. Complication and mortality rates are comparable to those of open surgery but with the advantages of minimally invasive surgery.