Early postoperative hemorrhage after open and laparoscopic roux-en-y gastric bypass.

BACKGROUND: Early postoperative hemorrhage is an infrequent complication of both laparoscopic and open Roux-en-Y gastric bypass (RYGBP). The objective of our study is to review the incidence and management of this complication and identify contributing clinical and technical risk factors. METHODS: Over a 3-year period, 1,025 patients underwent RYGBP at our institution. The medical records of patients who required postoperative blood transfusions were reviewed for clinical presentation, diagnostic evaluation and management. These patients were matched for surgical approach (open vs. laparoscopic) in a 1:3 ratio and compared to a random group of patients who underwent RYGBP during the same time period. RESULTS: Thirty-three patients (3.2%) were diagnosed with postoperative hemorrhage, 17 (51.5%) of which were intraluminal. The incidence of hemorrhage was higher in the laparoscopic group (5.1% vs. 2.4%, p = 0.02). Comparing bleeders to nonbleeders, the average BMI, gender distribution, gastro-jejunostomy anastomotic technique (stapled vs. hand sewn) and the postoperative administration of ketorolac were not significantly different. The bleeding group was older (47.5 vs. 42.8, p = 0.02), had a longer hospital stay (4.9 vs. 3 days, p = 0.0001) and was more likely to have received low molecular weight heparin (LMWH) preoperatively (p = 0.03). Hemorrhage occurred earlier (13.8 vs. 25.9 h, p = 0.039) and was more severe (4.1 vs. 2.3 transfused blood units, p = 0.007) in the patients who required surgical reexploration (n = 9). CONCLUSIONS: A laparoscopic approach and the preoperative administration of LMWH may increase the incidence of early hemorrhage after RYGBP. This complication frequently requires surgical reexploration and significantly prolongs the hospital stay.

Post discharge prophylactic anticoagulation in gastric bypass patient-how safe?

BACKGROUND: It is becoming an increasingly common practice to discharge gastric bypass (GBP) patients on prophylactic anticoagulation. This is because pulmonary embolism (PE) is a common cause of mortality postoperatively. This study was undertaken to: (1) determine the incidence of major bleeding in GBP patients discharged on prophylactic low molecular weight heparin (LMWH)-enoxaparin and, (2) correlate the bleeding risk to the dose used. METHODS: Retrospective chart review of all open GBP operation from June 2004 to August 2005. One hundred and twenty seven patients were sent home on LMWH for 2 weeks. INDICATIONS: Body mass index (BMI) > or =50 kg/m(2) with chronic venous stasis and/or obstructive sleep apnea, previous history of PE or deep vein thrombosis (DVT) or BMI > or =60 kg/m(2). The study group was divided into two subgroups: 40 mg twice daily (bid) and 60 mg bid LMWH. Statistical analysis was done with the chi-square. The primary outcome measure was major bleeding; defined as bleeding during the period of LMWH use associated with symptomatic decrease in hematocrit (HCT), necessitating stopping LMWH administration before the end of the study period (2 weeks), bleeding-related readmission, blood transfusion, or intervention. Excluded were patients on warfarin or treated with therapeutic LMWH. RESULTS: The groups were similarly matched for age, body mass index, and risk factors. No episode of major bleeding after discharge occurred in either group. CONCLUSION: The use of low molecular weight heparin for prophylactic anticoagulation after open gastric bypass is not associated with risk of major bleeding.

How do family practitioners perceive surgery for the morbidly obese?

BACKGROUND: Little is known about the level of knowledge and comfort with bariatric surgery among family practice physicians. METHODS: Surveys were sent to all family practitioners in Connecticut querying the practice type and knowledge of bariatric surgery. The results were analyzed for the prevalence of opinion. RESULTS: Of 620 surveys sent out, 129 (21%) were completed. Of the 129 respondents, 73% were men, aged 31-79 years, and 92% were board certified, with an average of 19 years' experience. The average body mass index of respondents was 26 kg/m2 (range 16-40). Only 4% of respondents had a body mass index >30 kg/m2. Physicians reported a patient obesity rate of 43%. Of the 129 respondents, 88% believed obesity was difficult to control with diet and exercise alone. Only 6% thought obesity was best controlled surgically. Also, 85% of respondents had referred a patient for gastric bypass, although only 57% were comfortable explaining the procedure. The most common reason for refusal to refer was fear of complications and death. Additionally, 55% correctly listed a body mass index of 40 kg/m2 as qualifying for bariatric surgery without comorbidities; 48% identified the mortality rate of surgery as <1%, with 4% of respondents reporting >10%; and 84% were familiar with gastric bypass, 66% with LapBand, 33% with vertical banded gastroplasty, and 5% with duodenal switch. The respondents believed that nausea was the most common side effect, followed by anemia and fatigue. Finally, 53% believed bowel obstruction was common. CONCLUSIONS: The results of our study have shown that misconceptions about bariatric surgery exist in the family practice community despite the increasing frequency of these procedures. Educational programs need to be designed to assist family practitioners in treating and referring obese patients.

Natural history of morbid obesity without surgical intervention.

BACKGROUND: To study the mortality among morbidly obese patients qualifying for bariatric surgery. Mortality from bariatric surgery for morbid obesity has been widely reported; however, little is known about the mortality in morbidly obese patients who defer surgery. METHODS: Consecutive patients evaluated for bariatric surgery with an initial encounter between 1997 and 2004 were identified. The Social Security Death Index and office records were used to identify mortality through 2006. We conducted telephone interviews to determine whether the 305 patients who did not undergo bariatric surgery at our institution had undergone the surgery elsewhere. Using Cox proportional hazards models, we compared the mortality in patients undergoing surgery with that of those who did not. To evaluate bias resulting from missing data, we conducted analyses assuming that all patients with missing data had (1) undergone surgery and (2) not undergone surgery. RESULTS: A total of 908 patients underwent bariatric surgery (880 patients at our institution and 28 patients elsewhere). A total of 112 patients did not undergo surgery. Data regarding surgery on 165 patients could not be obtained. The mortality in those patients who did not undergo surgery was 14.3% compared with 2.9% for those who did undergo surgery. Adjusting for age, gender, and body mass index, patients who had undergone surgery had an 82% reduction in mortality (hazard ratio 0.18, 95% confidence interval 0.09-0.35, P <.0001). Sensitivity analysis, assuming that all patients with missing data received surgery resulted in an 85% mortality reduction (P <.001) and assuming that patients did not receive surgery resulted in a 50% mortality reduction (P = .04). CONCLUSIONS: Mortality among morbidly obese patients without surgery was 14.3% during the study period. Surgical intervention offered a 50%-85% mortality reduction benefit.

Clinical pulmonary embolus after gastric bypass surgery.

BACKGROUND: Pulmonary embolus (PE) is one of the most common causes of death for patients undergoing gastric bypass surgery. The risk of developing PE has been associated with increased age, greater body mass index (BMI), and chronic venous stasis disease. METHODS: Between 1998 and 2003, 1225 patients underwent open Roux-en-Y gastric bypass (RYGBP) surgery (258 men and 967 women) for the treatment of morbid obesity and its related disorders. The medical records for morbidly obese patients diagnosed with PE after RYGBP were identified. The presenting signs and symptoms were reviewed, and the known risk factors were analyzed. We compared the age and BMI of these patients with those of a randomly selected RYGBP control group. The Mann-Whitney U test was used to analyze the statistical significance of the results. RESULTS: During the study period, 11 patients were diagnosed with PE (0.9%). Six patients were men and five were women, for a gender-specific incidence of PE of 2.3% in men and 0.5% in women. The average BMI was 62.5 kg/m(2) in the men and 59.1 kg/m(2) in the women, much greater than in the control group (men 53 kg/m(2) and women 52 kg/m(2); P <0.005 and P <0.05, respectively). All male patients were super-obese (BMI >50 kg/m(2)). The total number of super-obese patients undergoing RYGBP during the study period was 147, for an incidence of PE in super-obese men of 4%. Nine of the 11 patients developed PE after discharge from the hospital within an average of 10 days. CONCLUSION: The super-obese male patient is at a much greater risk of developing PE than other RYGBP patients (relative risk 4.4). The risk extends to several weeks after discharge. Therefore, extending PE prophylaxis to several weeks after surgery may be warranted.

Effects of delaying appendectomy for acute appendicitis for 12 to 24 hours.

OBJECTIVE: To determine whether delaying appendectomy for 12 hours to avoid disturbing the operating room schedule and to minimize the number of operations during the night negatively affects the outcome of patients with acute appendicitis. DESIGN: Retrospective study. SETTING: Large teaching community hospital. PATIENTS: The medical records of 380 patients who underwent appendectomies between January 1, 2002, and December 31, 2004, were reviewed. Patients proven to have an inflamed appendix on the pathological report were divided into 2 groups. The early group comprised patients who had undergone appendectomies within 12 hours of presentation to the emergency department, including patients with generalized sepsis. The late group comprised patients who had undergone appendectomies more than 12 to 24 hours after presentation. MAIN OUTCOME MEASURES: Length of stay, operative time, and the rate of perforations and complications. INTERVENTIONS: Laparoscopic or open appendectomies. RESULTS: There were 309 patients included in our study. There were no statistically significant differences between the early and late groups in the length of stay, operative time, the percentage of advanced appendicitis, or the rate of complications. CONCLUSIONS: In selected patients, delaying appendectomies for acute appendicitis for 12 to 24 hours after presentation does not significantly increase the rate of perforations, operative time, or length of stay. It decreases the use of the nursing staff, anesthesia team, and surgical house staff during the night shifts, and it decreases the interruption of the regular operating room schedule.