Auto-diuresis Predicts Return of Bowel Function.

PURPOSE: Feeding a ventral hernia repair (VHR) patient before the return of bowel function (ROBF) can lead to distention and emesis. Many patients spontaneously diurese after surgery. We hypothesized that this auto-diuresis would signal ROBF. MATERIALS AND METHODS: A total of 395 patients who underwent open, laparoscopic, or mixed VHR were evaluated for correlation between fluid status and ROBF or discharge. ROBF within 24 hours and discharge within 24 hours or 48 hours were used as outcome measures. RESULTS: Patients remained an average 3.59 days after surgery in the hospital and the average ROBF was on day 2.99. The first shift of ≥700 mL of urine predicted ROBF ( P =0.03) and discharge ( P =0.04) within 24 hours. The first shift output of ≥500 mL predicted discharge within 48 hours ( P =0.02). CONCLUSION: Auto-diuresis after surgery is correlated to ROBF and discharge. Accurate fluid measurement can predict bowel function and allow early diet and discharge.

Epidural anesthesia for post-operative pain is associated with a higher incidence of complications following open ventral hernia repair.

INTRODUCTION: Ventral/incisional hernia repair is a common procedure. Epidural anesthesia for post-operative pain control has been used to attempt to limit opioids. The complications associated with epidural anesthesia are starting to be recognized in open ventral hernia repair patients. METHODS: Data were abstracted from the National Surgical Quality Improvement Program (NSQIP) participant use data file for 2015. Adult patients with an open ventral hernia repair were identified. In an effort to identify complex hernias, patients who required the implantation of mesh and remained inpatient for 2 or more days were included. Patients with epidural anesthesia and general anesthesia (epidural group) were compared to those with general anesthesia alone (non-epidural). Descriptive statistics and complications were recorded and compared. RESULTS: A total of 1943 patients met inclusion criteria: 1009 patients (51.9%) in the non-epidural group and 934 (48.1%) in the epidural group. There were fewer clean cases in the epidural group (63.2%) than the non-epidural group (68.8%, p = 0.007). Otherwise, there was no difference in gender, age, body mass index, American Society of Anesthesiologists physical status, and current smoking status. There were more pulmonary emboli in the epidural group (1.39%) compared to the non-epidural group (0.50%, p = 0.04). Urinary tract infection was also significantly higher in the epidural group (3.10%) compared to the non-epidural group (1.59%, p = 0.03). Transfusions were also administered to more of the epidural patients (5.14%) compared to non-epidural patients (2.78%, p = 0.007). The rates of other post-operative complications were not statistically significant between the two groups. Total length of stay in the hospital was also greater in the epidural group (6.7 vs. 5.0 days, p < 0.0001). CONCLUSIONS: This is an association with the use of epidural anesthesia in open ventral hernia repairs and an increased incidence of pulmonary emboli, transfusions, and urinary tract infections, as well as an increased length of stay.

Primary care providers' attitudes and knowledge of bariatric surgery.

BACKGROUND: Despite the increasing obesity prevalence among American adults, relatively few qualified patients proceed to bariatric surgery. Suggested explanations include referral barriers for weight loss management at primary care provider (PCP) visits. This study aims to assess the referral and practice patterns of PCPs treating patients with obesity. Our goal is to understand treatment barriers in order to implement targeted interventions that enhance quality of care. METHODS: A 39-question electronic survey was emailed to PCPs at a single academic institution with community physicians. Questions explored providers' demographics, referral patterns, and knowledge of pathophysiologic obesity mechanisms and bariatric surgery qualifications. Frequency and univariate analyses were performed and compared providers' demographics, positions, and BMIs between referring providers and non-referring providers. RESULTS: Of 121 surveys distributed, we achieved a 33.9% response rate (n = 41). 78.0% stated that > 15% of their patients in the preceding year were classified as obese. PCPs indicated initiating weight loss management conversations < 50% of the time with 48.8% of patients. Provider-identified barriers to discussing weight loss surgery included being unsure if patient's insurance would cover the procedure or if patients would qualify (24.4% vs. 19.5%). In addition, 43.9% of providers felt that the risks of bariatric surgery outweigh the benefits. CONCLUSION: Despite a large percentage of patients cared for by PCPs being classified as obese, few providers initiate discussions on weight loss options with potentially eligible surgical candidates. The barriers identified indicate an opportunity for improved education on patient qualifications, strategies for streamlining conversations and referrals, and reinforcement of the safety of surgical weight loss. Providers' desire for this education demonstrates an opportunity to work toward minimizing the referral gap by increasing patient conversations about these topics.

Buyer's remorse: what predicts post-decision dissonance after bariatric surgery?

BACKGROUND: Bariatric surgery continues to be the most effective long-term treatment for obesity and its associated co-morbidities. Despite the benefits, not all patients may repeat the decision to undergo bariatric surgery based on their postoperative experience (postdecision dissonance). OBJECTIVES: In this study, we explore the predictors of postdecision dissonance following bariatric surgery. SETTING: Accredited bariatric center at an academic medical center. METHODS: Patients at an accredited Bariatric Center who underwent bariatric surgery between 2011 and 2017 were surveyed to determine factors predictive of postdecision dissonance, as well as expectations, well-being, and overall satisfaction. RESULTS: A total of 591 patients were sent surveys, of whom 184 (31.1%) responded. Of the 184 responders, 20 (10.9%) patients would not choose to undergo bariatric surgery if they had it do to over again (postdecision dissonance). There was no difference in the time since surgery, age, sex, or type of bariatric surgery among groups. Dissonant patients were less likely to be married and privately insured. Dissonant patients were more likely to feel they had inadequate preoperative education on postoperative expectations (P < .001). These patients also had significantly greater postoperative weight regain, failed weight loss expectations, depression, and dissatisfied body image. CONCLUSION: Postdecision dissonance is driven in part by a patient's perceived inadequacy of preoperative preparation for postoperative outcomes coupled with postoperative weight regain, depression, dissatisfied body image, and failed weight loss expectations. This highlights the importance of preoperative counseling on managing expectations and outcomes after surgery, as well as the need for continued postoperative engagement with a bariatric program to address weight regain and provide mental health support.

Practice patterns regarding post-discharge chemoprophylaxis for venous thromboembolism following bariatric surgery in the United States.

BACKGROUND: There is no consensus regarding the optimal venous thromboembolism (VTE) prevention strategy following bariatric surgery. Post-discharge chemoprophylaxis is frequently recommended for high-risk patients with little supporting data. OBJECTIVES: To define practices related to post-discharge chemoprophylaxis in the United States. SETTING: United States. METHODS: From the Truven Health MarketScan Research database we identified patients age 18 to 64 years undergoing laparoscopic sleeve gastrectomy and gastric bypass (2009-2015). Use of post-discharge low-molecular-weight or unfractionated heparin, vitamin K antagonists, Factor Xa inhibitors, or direct thrombin inhibitors was determined, as was the occurrence of VTE events from discharge to 90 days. Patients with VTE during the index admission were excluded to focus on chemoprophylaxis after discharge (versus treatment). Multivariate logistic regression was used to evaluate the association between VTE and anticoagulant usage. RESULTS: Of 105,246 patients, .8% with VTE prior to discharge were excluded. The study cohort was 78.1% female, with a median age of 44 years. Hypercoagulable disorder was present in .9%. Post-discharge chemoprophylaxis rates were 11.3% and varied from state to state (.5%-37.4%). VTE rates varied from state to state (.4%-2.6%). VTE after discharge occurred in 1.3%. On multivariate analysis, hypercoagulable disorder (odds ratio [OR] 14.0; 95% confidence interval [CI] 11.6-16.9, P < .001), age ≥60 years (OR 2.3; 95% CI 1.0-5.3; P = .047), and male sex (female OR .8; 95% CI .7-.9, P < .001) increased the risk for VTE. Post-discharge chemoprophylaxis was associated with increased VTE risk (OR 2.1; 95% CI 1.8-2.4; P < .001). CONCLUSIONS: Post-discharge chemoprophylaxis following laparoscopic bariatric surgery is employed in 11.3% of patients. Variation in VTE rates and prophylaxis strategies exist nationally.

Preoperative functional health status is a predictor of short-term postoperative morbidity and mortality after bariatric surgery.

BACKGROUND: Functional health status (FHS) is the ability to perform activities of daily living without caregiver assistance. OBJECTIVES: The primary aim of this study was to determine the impact of impaired preoperative FHS on morbidity and mortality within 30 days of bariatric surgery. SETTING: Academic medical center in the United States. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 data set was queried for primary minimally invasive bariatric procedures. The demographic characteristics and perioperative details of patients who were functionally independent were compared with patients with impaired FHS. Multivariable logistic regression analysis was performed to determine the odds of developing a perioperative complication or death for patients with impaired functional health. RESULTS: Of patients, 1515 (1.0%) were reported as having impaired FHS and 147,195 patients (99.0%) were independent before surgery. Patients with impaired FHS experienced significantly longer length of hospital stays (2.4 versus 1.8 d; P < .0001), a higher morbidity (adjusted odds ratio 1.5; P <0.0001), and higher mortality (adjusted odds ratio 2.1; P < .0001). Impaired FHS resulted in significantly increased rate of unplanned admissions to the intensive care unit, interventions, reoperations, and readmissions within 30 days of surgery. CONCLUSIONS: Patients with impaired FHS preoperatively have a significantly increased risk of short-term morbidity and mortality after bariatric surgery. The results of this study highlight the importance of establishing quality initiatives focused on improving short-term outcomes for patients with impaired functional health status.

Linear vs. circular-stapled gastrojejunostomy in Roux-en-Y gastric bypass.

BACKGROUND: Various surgical techniques exist to create the gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (LRYGB). Linear-stapled anastomosis (LSA) and circular-stapled anastomosis (CSA) are two commonly employed techniques. We hypothesized that CSA is associated with an increased rate of surgical site infection (SSI) and gastrojejunostomy stenosis when compared to LSA. METHODS: This study is a retrospective review of patients who underwent LRYGB for morbid obesity at a single institution between 2012 and 2016. Three bariatric surgeons contributed patients to this series. Clinical information and perioperative outcomes were collected through 90 days after surgery. RESULTS: 171 patients met the inclusion criteria. Two patients did not complete 90-day follow-up and were excluded from the analysis (88 patients CSA, 81 LSA; 99% 90-day follow-up). Patient demographics did not differ between groups. The LSA technique was associated with a significantly reduced rate of SSI (0 (0%) vs. 6 (6.8%), p = 0.02) and stenosis (2 (2.5%) vs. 17 (19.3%), p < 0.01). The CSA technique demonstrated a greater number of endoscopic dilations per stenotic event (1.5 ± 0.8 vs. 1.0 ± 0, p = 0.03). CONCLUSION: In our experience, a gastrojejunostomy constructed with an LSA technique was associated with a significantly reduced rate of stenosis and SSI compared to the CSA technique. LSA is currently our anastomotic technique of choice in LRYGB.

Peri-operative, intravenous clindamycin may improve the resolution rate of hypertension after Roux-en-Y gastric bypass in morbidly obese patients.

BACKGROUND: Recent studies have suggested that potential aberrant alterations in the gastrointestinal microbiome contribute to the development of cardiovascular disease, specifically hypertension. Bariatric surgery produces significant sustained weight loss and hypertension resolution likely through multiple mechanisms which includes beneficial changes in the gut microbiome. We hypothesized that the type of prophylactic antibiotic given for bariatric surgery could impact the resolution rate of hypertension by altering the post-operative gastrointestinal microflora. METHODS: A retrospective analysis of adult bariatric patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2012 and 2016 was conducted. The standard antibiotic prophylaxis was cefazolin, or clindamycin in patients with a penicillin allergy. Univariate analyses were performed comparing the differing peri-operative antibiotic treatments with resolution of hypertension at 2-week (± 1 week), 6-week (± 2 weeks), 3-month (± 2 weeks), 6-month (± 6 weeks), and 1-year (± 2 months) follow-up appointments. The criterion for resolution of hypertension was no longer requiring medication at time of follow-up. RESULTS: In total, 123 RYGB and 88 SG patients were included. No significant differences were found between cefazolin and clindamycin regarding hypertension resolution rates after SG. However, patients who underwent RYGB and received clindamycin had a significantly higher rate of hypertension resolution compared to cefazolin. This effect started at 2 weeks post-operatively (52.4% vs. 23.5% respectively, p = 0.008) and persisted up to the 1-year (57.9% vs. 44.0% respectively, p = 0.05). CONCLUSION: Prophylactic peri-operative, intravenous clindamycin was associated with significantly increased resolution of post-operative hypertension compared to cefazolin. This finding was not observed in SG patients. Future studies are needed to confirm the mechanism of action for this novel finding is due to the differing modifications of the gastrointestinal microflora after RYGB resulting from the specific peri-operative antibiotic administered.

Perioperative blood transfusion increases risk of surgical site infection after bariatric surgery.

BACKGROUND: Surgical site infection (SSI) is an important marker of postoperative morbidity and overall quality of care. Transfusion-related immunomodulation can lead to weakened immunity in response to blood transfusion and predispose patients to SSIs. OBJECTIVES: The aim of this study was to determine the impact of perioperative blood transfusions on SSIs in bariatric surgery patients. SETTING: National data set. METHODS: The American College of Surgeons National Surgical Quality Improvement Program data sets were queried for laparoscopic and open bariatric operations between 2012 and 2014. Univariate analyses identified perioperative variables associated with postoperative SSIs. Multivariate regression analyses determined the effect of perioperative blood transfusions on postoperative SSI. RESULTS: The study cohort included 59,424 patients: 480 (8.1%) biliopancreatic diversions, 28,268 (44.2%) gastric bypasses, 30,258 (50.9%) sleeve gastrectomies, and 418 (7.0%) bariatric revisions. Of the patients, 1107 (1.9%) developed a SSI: 662 (1.1%) superficial, 89 (0.1%) deep, and 356 (.6%) organ space. Patients receiving a perioperative blood transfusion were more likely to develop any type of SSI, organ space being most prevalent (Fig. 1). Among organ space SSIs, 198 (55.6%) were gastric bypasses and 125 (35.1%) were sleeve gastrectomies. CONCLUSIONS: Bariatric surgery patients who receive a perioperative blood transfusion are at higher risk of developing SSIs, particularly organ space. The majority of organ space SSIs occur after gastric bypass, likely secondary to infected intra-abdominal hematomas. Close monitoring of postoperative signs of infection in these patients is important to determine if additional interventions are warranted.

C-Reactive protein as a predictor of post-operative complications in bariatric surgery patients.

BACKGROUND: The primary objective of this study was to evaluate the utility of CRP in early identification of post-operative complications after bariatric surgery. The ability of this marker to acutely predict post-operative complications in bariatric surgery patients has not been determined. METHODS: A retrospective chart review was conducted of adult patients who underwent a primary and revisional laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) between 2013 and 2017 at a single institution. Patients were identified using the prospective Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. CRP levels were drawn on post-operative day one per standard protocol. Univariate analyses were performed to determine the predictive impact of CRP levels on post-operative complications, readmissions, and reoperations. RESULTS: There were 275 patients who underwent bariatric surgery, 222 primary and 53 revisional. Of the 275 patients, 36 (13.1%) had a complication. Bariatric surgery patients with a post-operative complication had higher CRP levels compared to those who did not (4.8 ± 4.6 vs. 2.9 ± 2.0; p = 0.02). A CRP ≥ 5 mg/dL had a sensitivity for a complication of 27% and a specificity of 88%. There was no difference in CRP levels for patients with a 30-day reoperation or readmission. There were no mortalities. CONCLUSIONS: Bariatric surgery patients with elevated post-operative CRP levels are at increased risk for 30-day complications. The low sensitivity of a CRP ≥ 5 mg/dL suggests that a normal CRP level alone does not rule out the possibility of a post-operative complication. However, with its high specificity, there should be an elevated clinical suspicion of a post-operative complication in patients with a CRP ≥ 5 mg/dL.

Retro-rectus placement of bio-absorbable mesh improves patient outcomes.

BACKGROUND: There is little consensus on the ideal anatomical placement of bio-absorbable mesh. We hypothesized that retro-rectus placement of bio-absorbable mesh would significantly reduce recurrence rates when compared to intraperitoneal mesh placement. METHODS: A retrospective review was conducted of patients who underwent open complex ventral hernia repair using bio-absorbable mesh (Bio-A, Gore, Flagstaff, AZ). Patient demographics and Centers for Disease Control wound type were collected. RESULTS: A total of 81 patients were included. Seventy-four (91.4%) of these hernia repairs had mesh in the retro-rectus position, while 7 (8.6%) had intraperitoneal mesh placement. Patient demographics, including preoperative comorbidities, did not differ between groups. The retro-rectus group trended to have larger hernia defects (156.2 cm2) compared to the intraperitoneal group (63.9 cm2) (p = 0.058). Overall complications (e.g., dehiscence, wound drainage, cellulitis, sepsis) were also similar in both groups of patients. Recurrence rates in the retro-rectus and intraperitoneal group were 8.1% and 42.9%, respectively (p = 0.005). When evaluating only patients with CDC class 1 wounds, the recurrence rate in the retro-rectus group was 8.2% and the intraperitoneal group was 50% (p = 0.02). Overall, the average patient follow-up was 22 months and did not differ between groups. Both the retro-rectus and intraperitoneal groups indicated a significant (p < 0.05) improvement in quality of life from baseline. No long-term (> 7 days) antibiotics were used and no mesh implants were removed during the study. CONCLUSION: Patients who underwent open complex ventral hernia repairs with bio-absorbable mesh in the retro-rectus position experienced lower overall complication rates than those with intraperitoneal mesh placement. Despite a larger hernia defect in the retro-rectus group, recurrence rates were significantly reduced with retro-rectus placement of mesh compared to intraperitoneal placement. In addition, recurrence rates using bio-absorbable mesh in clean wounds are comparable to previously published recurrence rates with permanent mesh.

Metabolic Syndrome Is a Significant Predictor of Postoperative Morbidity and Mortality Following Bariatric Surgery.

INTRODUCTION/PURPOSE: Metabolic syndrome is commonly demonstrated in patients with morbid obesity undergoing bariatric surgery. The purpose of this study was to determine the effect of metabolic syndrome on morbidity and mortality following bariatric surgery. MATERIALS AND METHODS: The National Surgical Quality Improvement Program (NSQIP) dataset was queried for patients who underwent bariatric surgical procedures between 2012 and 2014. Patient demographics, comorbid conditions, bariatric procedure type, and postoperative complications were analyzed. Metabolic syndrome was defined as having a body mass index > 30 kg/m2 in the presence of the comorbid conditions of hypertension and diabetes. Regression analysis was used to determine the relationship between metabolic syndrome and postoperative morbidity and mortality. RESULTS: During the study interval, 59,404 patients underwent bariatric surgery (Roux-en-Y gastric bypass = 28,263, sleeve gastrectomy = 30,239, revision = 422, and biliopancreatic diversion = 480). The mean body mass index was 45.9 kg/m2, and the mean age was 45 years. Of the cohort, 30,104 (50.6%) patients had a diagnosis of hypertension, 16,558 (27.8%) had diabetes mellitus, and 12,803 (21.5%) met the criteria for metabolic syndrome. Patients with metabolic syndrome were more likely to have Roux-en-Y gastric bypass procedure, a history of congestive heart failure, severe COPD, renal failure, and diminished functional status (p < 0.0001). Morbidity was greater for patients with metabolic syndrome (7.5% vs. 5%; p < 0.0001), and patients in this subset also had a 3.2-fold increased risk of mortality (p < 0.0001). DISCUSSION: Metabolic syndrome is prevalent in patients who undergo bariatric surgery. We have demonstrated that patients with the constellation of comorbid conditions defining metabolic syndrome are at an increased risk of morbidity and mortality following bariatric surgery. Patients and surgeons should be informed of the potential increased risk in this patient population.

Very Early Versus Early Readmissions in General Surgery Patients.

BACKGROUND: Hospital readmission rates are an important quality metric. A readmission very soon after discharge may be related to a different cause than readmissions that occur later in the first 30 d. MATERIALS AND METHODS: The National Surgical Quality Improvement Program data sets from 2014 to 2015 were used to identify patients undergoing general surgery procedures. Demographics, comorbidities, and morbidity were analyzed. Stepwise regression was used to determine statistical predictors for any readmission. The final model variables were a combination of selected clinical variables and statistically significant variables. Multinomial logistic regression was then used with these variables to develop models for "very early" (days 0-3 after discharge) and "early" (days 4-30) readmissions. RESULTS: A total of 744,492 patients were included with 5.9% readmitted within 30 d and 1.5% readmitted within 3 d of discharge (26.1% of all readmissions). Significant risk factors for any readmission included ≥3 comorbidities, major surgery (operative time >1 h, length of stay greater >2 d), and American Society of Anesthesiologists class ≥3. When examining "very early" readmissions, the greatest risk factor was experiencing a severe complication (≥Grade III) before discharge. CONCLUSIONS: Readmissions within 3 d of discharge constitute a large portion of all 30 d readmissions. The greatest risk factor for "very early" readmission was a severe complication before discharge. Better understanding of the reason for this association is needed to develop effective prevention strategies.

The impact of preoperative anemia and malnutrition on outcomes in paraesophageal hernia repair.

BACKGROUND: Patients with a paraesophageal hernia may experience gastroesophageal reflux symptoms and/or obstructive symptoms such as dysphagia. Some patients with large and complex paraesophageal hernias unintentionally lose a significant amount of weight secondary to difficulty eating. A subset of patients will develop Cameron's erosions in the hernia, which contribute to anemia. Given the heterogeneous nature of patients who ultimately undergo paraesophageal hernia repair, we sought to determine if patients with anemia or malnutrition suffered from increased morbidity or mortality. METHODS: The American College of Surgeons National Surgical Quality Improvement Program datasets from 2011 to 2015 were queried to identify patients undergoing paraesophageal hernia repair. Malnutrition was defined as preoperative albumin < 3.5 g/dL. Preoperative anemia was defined as hematocrit less than 36% for females and 39% for males. Thirty-day postoperative outcomes were assessed. RESULTS: A total of 15,105 patients underwent paraesophageal hernia repair in the study interval. Of these patients, 7943 (52.6%) had a recorded preoperative albumin and 13.9% of these patients were malnourished. There were 13,139 (87%) patients with a documented preoperative hematocrit and 23.1% met criteria for anemia. Both anemia and malnutrition were associated with higher rates of complications, readmissions, reoperations, and mortality. This was confirmed on logistic regression. The average postoperative length of stay was longer in the malnourished (6.1 vs. 3.1 days when not malnourished, p < 0.0001) and anemic (4.1 vs. 2.8 days without anemia, p < 0.0001). CONCLUSION: Malnutrition and anemia are associated with increased morbidity and mortality in patients undergoing paraesophageal hernia repair, as well as a longer length of stay. This information can be used for risk assessment and perhaps preoperative optimization of these risk factors when clinically appropriate.

Predictors of Postoperative Urinary Tract Infection After Bariatric Surgery.

BACKGROUND: In bariatric surgery patients, urinary tract infections (UTIs) are one of the most common postoperative infections. In this study, we sought to determine if preoperative patient factors and perioperative processes contribute to an increased risk of UTI. METHODS: A retrospective analysis was performed of patients who underwent bariatric surgery at a single institution between March 2012 and May 2016. Standard protocol was antibiotic prophylaxis with cefazolin. Patients with a penicillin allergy received clindamycin. Urinary catheters were placed selectively. A univariate and multivariate analyses were performed to determine risk factors for patients who developed a UTI within 30 days postoperatively. RESULTS: Six hundred ninety-four patients (82.7% female) underwent bariatric surgery in the study interval. UTIs were more common in females (4.9 vs. 1.7%, p = 0.12). On univariate analysis age, operative time, length of stay, urinary catheter placement, clindamycin prophylaxis, and revisional surgery were significantly correlated with UTI. A multivariate logistic regression model revealed the risk of UTI increased 5.38-fold [95% confidence interval (CI) 2.41-12.05] with clindamycin use, 6.37-fold [95% CI 2.22-18.18] with revision surgery, and 1.25-fold [95% CI 1.05-1.49] for every 5 years gained in age. CONCLUSIONS: Older age, clindamycin prophylaxis, and revisional procedures are significantly associated with an increased rate of UTI following bariatric surgery. Several identified variables are modifiable risk factors and targets for a quality improvement initiative to decrease the rate of UTI in bariatric surgery patients.

Improved immediate postoperative pain following laparoscopic inguinal herniorrhaphy using self-adhering mesh.

BACKGROUND: Several synthetic meshes are available to reinforce the inguinal region following laparoscopic hernia reduction. We sought to compare postoperative pain of patients who underwent laparoscopic inguinal herniorrhaphy using self-adhering polyester mesh to those who had non-adhering, synthetic mesh implanted using absorbable tacks. MATERIALS AND METHODS: This study is a retrospective review of patients who underwent primary laparoscopic inguinal herniorrhaphy at the Medical College of Wisconsin between October 2012 and July 2014. Clinical information and perioperative pain scores using the visual analog scale (VAS) were obtained to evaluate immediate pre and postoperative pain. RESULTS: A total of 98 patients (88 male) underwent laparoscopic inguinal herniorrhaphy during the study interval. Forty-two patients received self-adhering mesh and 56 patients received mesh secured with tacks. Patient demographics and comorbidities did not differ significantly between the two groups. There was no difference in preoperative VAS scores between groups. The self-adhering mesh patients had a lower mean VAS change score (less pain). Postoperative complications did not differ between groups apart from a higher observed incidence of seroma in the self-adhering mesh group (p = 0.04). No hernias recurred in either group during the study interval. CONCLUSIONS: Self-adhering mesh in laparoscopic inguinal herniorrhaphy resulted in less immediate postoperative pain than tacked mesh as demonstrated by VAS score. Postoperative complications were similar between the two groups. The results of this study demonstrate that laparoscopic inguinal herniorrhaphy using self-adhering mesh is comparable to tacked mesh in regards to short-term complication rates, but show a favorable advantage in regards to immediate postoperative pain.

Increased glycine-amidated hyocholic acid correlates to improved early weight loss after sleeve gastrectomy.

BACKGROUND: Bile acids (BAs) are post-prandial hormones that play an important role in glucose and lipid homeostasis as well as energy expenditure. Total and glycine-amidated BAs increase after sleeve gastrectomy (SG) and correlate to improved metabolic disease. No specific bile acid subtype has been shown conclusively to mediate the weight loss effect. Therefore, the objective of this study was to prospectively evaluate the comprehensive changes in meal-stimulated BAs after SG and determine if a specific change in the BA profile correlates to the early weight loss response. METHODS: Patients were prospectively enrolled at the University of Nebraska Medical Center who were undergoing a SG for treatment of morbid obesity. Primary and secondary plasma bile acids and their amidated (glycine, G-, or taurine, T-) subtypes were measured at fasting, 30 and 60 min after a liquid meal performed pre-op, and at 6 and 12 weeks post-op. Area under the curve (AUC) was calculated for the hour meal test for each bile acid subtype. BAs that were significantly increased post-op were correlated to body mass index (BMI) loss. RESULTS: Total BA AUC was significantly increased at 6 (p < 0.01) and 12 weeks post-op (p < 0.01) compared to pre-operative values. The increase in total BA AUC was due to a statistically significant increase in G-BAs. Nine different BA AUC subtypes were significantly increased at both 6 and 12 weeks post-op. Increased total and G-chenodeoxycholic acid AUC was significantly correlated to the 6 week BMI loss (p = 0.03). Increased G-hyocholic acid was significantly correlated to increased weight loss at both 6 (p = 0.05) and 12 weeks (p = 0.006). CONCLUSIONS: SG induced an early and persistent post-prandial surge in multiple bile acid subtypes. Increased G-hyocholic consistently correlated with greater early BMI loss. This study provides evidence for a role of BAs in the surgical weight loss response after SG.

Robotic skills can be aided by laparoscopic training.

BACKGROUND: General Surgery is currently the fastest growing specialty with regards to robotic surgical system utilization. Contrary to the experience in laparoscopy, simulator training for robotic surgery is not widely employed partly because robotic surgical simulators are expensive. We sought to determine the effect of a robotic simulation curriculum and whether robotic surgical skills could be derived from those psychomotor skills attained in laparoscopic training. METHODS: Twenty-seven trainees with no prior robotic experience and limited laparoscopy exposure were randomly assigned to one of three training groups: no simulator training, training on a fundamentals of laparoscopic surgery (FLS™) standard box trainer, and training on a robotic computer based simulator (da Vinci Skills Simulator™). Baseline robotic surgical skills were assessed on the clinical robot docked to a standard FLS trainer box on two tasks-intracorporeal knot tying and peg transfer. Subjects subsequently underwent four 1-h long training sessions in their assigned training environment over a course of several weeks. Robotic surgical skills were reassessed on the robot on the same two tasks used to assess skills prior to training. RESULTS: FLS training resulted in a greater score improvement than no training for both knot and peg scores. FLS training was also determined to result in greater score improvement than robotic simulator training for knot tying. There was no significant difference in peg transfer or knot tying scores when comparing robotic simulator training and no training. CONCLUSIONS: Robotic surgical skills can be in part derived from psychomotor skills developed in a laparoscopic trainer, especially for complex skills such as intracorporeal knot tying. Acquisition of robotic surgical skills may be enhanced by practice on a laparoscopic simulator using the FLS curriculum. This may be especially helpful when a robotic simulator is not available or is poorly accessible.

Perioperative bleeding and blood transfusion are major risk factors for venous thromboembolism following bariatric surgery.

BACKGROUND: Morbidly obese patients are at increased risk for venous thromboembolism (VTE) after bariatric surgery. Perioperative chemoprophylaxis is used routinely with bariatric surgery to decrease the risk of VTE. When bleeding occurs, routine chemoprophylaxis is often withheld due to concerns about inciting another bleeding event. We sought to evaluate the relationship between perioperative bleeding and postoperative VTE in bariatric surgery. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) dataset between 2012 and 2014 was queried to identify patients who underwent bariatric surgery. Gastric bypass (n = 28,145), sleeve gastrectomy (n = 30,080), bariatric revision (n = 324), and biliopancreatic diversion procedures (n = 492) were included. Univariate and multivariate regressions were used to determine perioperative factors predictive of postoperative VTE within 30 days in patients who experience a bleeding complication necessitating transfusion. RESULTS: The rate of bleeding necessitating transfusion was 1.3%. Bleeding was significantly more likely to occur in gastric bypass compared to sleeve gastrectomy (1.6 vs. 1.0%) (p < 0.0001). For all surgeries, increased age, length of stay, operative time, and comorbidities including hypertension, dyspnea with moderate exertion, partially dependent functional status, bleeding disorder, transfusion prior to surgery, ASA class III/IV, and metabolic syndrome increased the perioperative bleeding risk (p < 0.05). Multivariate analysis revealed that the rate of VTE was significantly higher after blood transfusion [Odds Ratio (OR) = 4.7; 95% CI 2.9-7.9; p < 0.0001). Predictive risk factors for VTE after transfusion included previous bleeding disorder, ASA class III or IV, and COPD (p < 0.05). CONCLUSIONS: Bariatric surgery patients who receive postoperative blood transfusion are at a significantly increased risk for VTE. The etiology of VTE in those who are transfused is likely multifactorial and possibly related to withholding chemoprophylaxis and the potential of a hypercoagulable state induced by the transfusion. In those who bleed, consideration should be given to reinitiating chemoprophylaxis when safe, extending treatment after discharge, and screening ultrasound.