Cost-savings of short stay sleeve gastrectomy and walk-in hydration clinic versus conventional inpatient care.

OBJECTIVE: We aim to evaluate the cost-saving of the short stay ward (SSW) versus conventional inpatient care following sleeve gastrectomy (LSG). We also compared the readmission rates pre- and post-inception of the intravenous hydration clinic and analyzed the cost-savings. METHODS: Patients who underwent LSG between December 2021 to March 2022 with SSW care were compared with standard inpatient care. Total costs were analyzed using univariate analysis. With a separate cohort of patients, 30-day readmission rates in the 12-months preceding and following implementation of the IV hydration clinic and associated cost-savings were evaluated. RESULTS: After matching on the propensity score to within ± 0.1, 20-subjects pairs were retained. The total cost per SSW-subject was significantly lower at $13,647.81 compared to $15,565.27 for conventional inpatient care (p = 0.0302). Lower average ward charges ($667.76 vs $1371.34, p < 0.0001), lower average daily treatment fee per case ($235.68 vs $836.54, p < 0.0001), and lower average laboratory investigation fee ($612.31 vs $797.21, p < 0.0001) accounted for the difference in costs between the groups. Thirty-day readmission rate reduced from 8.9 to 1.8% after implementation of the hydration clinic (p < 0.01) with decreased 30-day readmission cost (S$96,955.57 vs. S$5910.27, p < 0.01). CONCLUSION: SSW for LSG is cost-effective and should be preferred to inpatient management. Walk-in hydration clinics significantly reduced readmission rates and result in tremendous cost-savings.

Laparoscopic resectional oesophago-gastroplasty: a novel technique for minimally invasive treatment of large high gastric lesser curve GIST involving gastroesophageal junction.

A paramount factor in selecting the operative approach for gastric gastrointestinal stromal tumours (GIST) is tumour location. Tumours located high along the lesser curve of the stomach pose a challenge in laparoscopic resection. A 56-year-old lady presented with per rectal bleeding and loss of weight. Endoscopic and radiological investigations revealed a large gastric GIST located over the lesser curve with proximal margin <1 cm from the gastroesophageal junction (GEJ). We present the steps of a novel technique for laparoscopic resectional oesophago-gastroplasty to resect large high gastric lesser curve GIST involving the GEJ.

Five-year long-term clinical outcome after bariatric metabolic surgery: A multi-ethnic Asian population in Singapore.

Bariatric surgery is an effective treatment for morbid obesity and its metabolic related comorbidities; type 2 diabetes, hypertension and hyperlipidaemia.1 However, the literature is scarce regarding the long-term outcome after bariatric surgery, especially among multi-ethnic Asian populations. Considering the growing number of bariatric metabolic surgeries in Asia, we have attempted to provide a regional perspective on 5-year long-term clinical outcomes post bariatric surgery in Singapore. Between 2010 and 2016, all bariatric operative cases were included, and these comprised: laparoscopic sleeve gastrectomy (LSG), 393; laparoscopic Roux-En-Y gastric bypass (RYGB), 125; laparoscopic mini-gastric bypass (MGB), 43. The primary outcome measure was the percentage of excess weight loss (% EWL) at 6 months, 1, 2, 3, 4 and 5 years, with % remission of type 2 diabetes mellitus (T2DM) at 1 year following LSG (49.7%, 61.2%, 56.1%, 47.8%, 40.8% and 47.3%; 82.2%), RYGB (60.2%, 62.1%, 57.6%, 50.1%, 48.7% and 47.7%; 86.9%) and MGB (58%, 68.1%, 62.7%, 66.2%, 64.0%, 65.2%; 71.9%). In conclusion, MGB and RYGB showed the greatest % EWL at 5 years and are recommended for moderate T2DM. LSG is an effective bariatric operation with a high % EWL up to 2 years, and a high remission rate of mild T2DM. The remission rate of T2DM was equally high in all 3 surgical groups, independent of ethnic differences.

Leaks in fixed-ring banded sleeve gastrectomies: a management approach.

BACKGROUND: The use of a Fobi ring to prevent pouch dilation is sometimes used in Roux-en-Y gastric bypass (RYGB). Recently, it has been extrapolated to laparoscopic sleeve gastrectomy (LSG) procedures by placing a fixed-ring band a few centimeters below the gastroesophageal junction (GEJ). OBJECTIVES: What is the consequence if a patient develops a leak? SETTING: Tertiary metropolitan referral center, Australia. METHODS: Over 18 months, all patients with either a conventional LSG or a fixed-ring banded sleeve gastrectomy (BLSG) who presented with a proven leak complication were included. The management approaches along with the surgical, endoscopic, and percutaneous procedures used were examined. RESULTS: Six patients had a BLSG leak and 6 had a LSG leak. All patients had leak resolution. There was no significant difference in body mass index (BMI), time to leak, initial white cell count (WCC), and C-reactive protein (CRP) levels between the 2 groups. LSG patients required a median of 2 endoscopic procedures (range: 1-3). Stents were deployed in 3 patients. All BLSG patients required a single surgical intervention with laparoscopic washout, drainage, removal of band±feeding jejunostomy. One stent was deployed in 1 BLSG patient. BLSG leak resolution was found at 34±12 days versus 85±12 days in the LSG group (P< .05). CONCLUSION: The BLSG is a new modification of the sleeve gastrectomy procedure. This study presents a management strategy for leak resolution employed in BLSG patients. The presence of a foreign body as a persistent nidus of infection mandates band removal.

Trans-thoracic peri-oesophageal adjustable band for intractable reflux.

INTRODUCTION: Gastric bands for obesity have the beneficial side-effect of improving reflux symptoms in patients; however placement of these on patients with multiple prior abdominal surgeries can be challenging. PRESENTATION OF CASE: We present two cases where gastric bands were placed in a peri-oesophageal position via a left thoracotomy due to multiple previous abdominal surgeries in an attempt to treat their intractable reflux. DISCUSSION: At three month follow up, both patients have reported improvement in their symptoms of GORD. CONCLUSION: A peri-oesophageal position adjustable gastric band is a possible solution for patients with intractable reflux and hostile abdomens.

A bleeding esophagopulmonary fistula: rare complication of stasis ulcer in refractory achalasia.

Achalasia refractory to Heller cardiomyotomy is a rare problem. Complications arising from long-standing achalasia include perforation because of stasis ulcers and malignancy. Here, we report a case of refractory achalasia presenting with recurrent hematemesis because of a perforated stasis ulcer leading to a bleeding esophagopulmonary fistula.

Prospective audit of laparoscopic cholecystectomy experience at a secondary referral centre in South australia.

BACKGROUND: Laparoscopic cholecystectomy is now the gold standard procedure for symptomatic gallstone disease. Nevertheless, there are still several controversies such as the need for routine intraoperative cholangiogram (IOC), the indications for and results of early laparoscopic cholecystectomy in the setting of acute cholecystitis and the use of endoscopic retrograde cholangiopancreatography versus laparoscopic common bile duct (CBD) exploration for intraoperatively detected choledocholithiasis. The aim of this study was to investigate some of these controversies. METHODS: All laparoscopic cholecystectomies carried out at our institution, a secondary referral centre in Adelaide, South Australia, over a 9-month period were prospectively audited. Data were collected regarding indications for surgery, rate of conversion to open operation, use of IOC, rate of choledocholithiasis and complication rate. RESULTS: There were 202 patients, of whom 152 were women and 50 men. Age range was 15-83 years. Sixty-one per cent of emergency operations were for acute cholecystitis. The conversion rate for emergency operations was 20.6% and for elective procedures was 4.2% (P = 0.003). One hundred and eighty-four patients had an IOC performed. Twelve of these patients had choledocholithiasis. Six of these 12 patients had both normal preoperative ultrasound and liver function tests. Four of the patients went on to postoperative endoscopic retrograde cholangiopancreatography, four had successful laparoscopic CBD exploration, two had open CBD exploration and two had their distal CBD filling defects flushed away with normal saline. There was no morbidity associated with performance of the IOC. There were three patients with postoperative bile leak and one with a bile duct injury. CONCLUSION: Selective IOC would miss a proportion of patients with choledocholithiasis. Early laparoscopic cholecystectomy for acute cholecystitis is associated with a higher conversion rate than elective laparoscopic cholecystectomy. Overall complication rate is low, with 95% of patients having no complications. Laparoscopic CBD exploration is feasible with a reasonable success rate. This can all be achieved at a secondary referral centre staffed by general surgeons.