Safety culture and complications after bariatric surgery.

OBJECTIVE: To assess relationships between safety culture and complications within 30 days of bariatric surgery. BACKGROUND: Safety culture refers to the quality of teamwork, coordination, and communication, as well as responses to error in health care settings. Although safety culture is thought to be an important determinant of surgical outcomes, few studies have examined this empirically. METHODS: We surveyed staff from 22 Michigan hospitals participating in a statewide bariatric surgery collaborative. Each safety culture survey item was rated on a 1 to 5 Likert scale with lower scores representing better patient safety culture. These data were linked to clinical registry data for 24,117 bariatric surgery patients between 2007 and 2010. We used negative binomial regression to calculate incidence rates and incidence rate ratios measuring the increase in hospitals' rate of complications per unit increase in safety culture (individual items as well as hospital and operating room-specific subscales), controlling for patient risk factors, procedure mix, and bariatric procedure volume. RESULTS: All 22 hospitals participated in this study, submitting safety culture ratings from 53 surgeons, 102 nurses, and 29 operating room administrators. Rates of serious complications were significantly lower among hospitals receiving an overall safety rating of excellent from nurses (1.5%), compared with those receiving a very good (2.6%) or acceptable (4.6%) rating (P = <0.0001). Surgeons' overall safety ratings were also associated with rates of serious complications (2.1% excellent, 2.6% very good, 4.7% acceptable, P = 0.011). Nurses' ratings of the hospital-specific subscale (P = 0.002) and surgeons' ratings of the operating room-specific subscale (P = 0.045) were also associated with rates of serious complications. Of the individual items, those related to coordination and communication between hospital units were the most strongly associated with rates of complications. Operating room administrator ratings of safety culture were not related to rates of complications for any of the domains of safety culture studied. CONCLUSIONS: Safety culture is associated with rates of serious surgical complications in bariatric surgery. Although nurses provide better information about hospital safety culture, surgeons are better judges of safety culture in the operating room. Interventions targeting safety culture, particularly coordination and communication, seem to be important for quality improvement.

The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity.

OBJECTIVE: To evaluate the comparative effectiveness of sleeve gastrectomy (SG), laparoscopic gastric bypass (RYGB), and laparoscopic adjustable gastric banding (LAGB) procedures. BACKGROUND: Citing limitations of published studies, payers have been reluctant to provide routine coverage for SG for the treatment of morbid obesity. METHODS: Using data from an externally audited, statewide clinical registry, we matched 2949 SG patients with equal numbers of RYGB and LAGB patients on 23 baseline characteristics. Outcomes assessed included complications occurring within 30 days, and weight loss, quality of life, and comorbidity remission at 1, 2, and 3 years after bariatric surgery. RESULTS: Matching resulted in cohorts of SG, RYGB, and LAGB patients that were well balanced on baseline characteristics. Overall complication rates among patients undergoing SG (6.3%) were significantly lower than for RYGB (10.0%, P < 0.0001) but higher than for LAGB (2.4%, P < 0.0001). Serious complication rates were similar for SG (2.4%) and RYGB (2.5%, P = 0.736) but higher than for LAGB (1.0%, P < 0.0001). Excess body weight loss at 1 year was 13% lower for SG (60%) than for RYGB (69%, P < 0.0001), but was 77% higher for SG than for LAGB (34%, P < 0.0001). SG was similarly closer to RYGB than LAGB with regard to remission of obesity-related comorbidities. CONCLUSIONS: With better weight loss than LAGB and lower complication rates than RYGB, SG is a reasonable choice for the treatment of morbid obesity and should be covered by both public and private payers.

The Normohormonal Primary Hyperparathyroidism; a surgical dilemma pre and intra-operatively.

INTRODUCTION: Normohormonal Primary Hyperparathyroidism (NPHPT), poses a dilemma for surgeons; first in deciding when to operate where the PTH is normal and second at what level should the drop in intra-operative PTH (ioPTH) be considered a successful operation. MATERIALS & METHODS: A retrospective evaluation of all parathyroidectomies performed by a single surgeon from 2009 to 2019 was conducted. RESULTS: In 33 of 349 (9%) parathyroidectomies the indication was NPHPT. Negative pre-operative nuclear localization was found in 17(52%) patients. Intra-operative findings were: 27(82%) single-adenoma, 3(9%) double-adenomas and 3(9%) hyperplasia. In patients with single-adenomas the ioPTH dropped from 57 ± 8 to 23 ± 10 pg./ml. The average size of the adenomas was 403 ± 360 mg. CONCLUSION: NPHPT is uncommon where the disease is diagnosed in its early stages. Over 50% has negative pre-operative nuclear localization test requiring 4-gland surgical exploration. The intra-operative drop in PTH below 30 pg./ml can be utilized as an indicator of a successful operation.

Can lower preoperative 48-hour pH score predict reflux resolution after sleeve gastrectomy.

BACKGROUND: Morbidly-obese patients with reflux who are undergoing sleeve gastrectomy (SG) may experience resolution, or persistent reflux. We studied factors associated with reflux resolution after SG. METHOD: We evaluated baseline weight, body mass index, and DeMeester score (DMS) in patients with reflux undergoing SG. Outcome measure was resolution of reflux post-operatively. RESULTS: Study group included 70 patients; 33 (47.1%) patients reported resolution of reflux (RR group) after surgery; 37 (52.9%) patients didn't have resolution (NR group). Pre-operative weight, body mass index, percent excess BMI loss and presence of ≤2 cm hiatal hernia (HH) were similar between the two groups. Males and lower pre-operative DMS were associated with resolution of reflux (18.4 ± 13 vs. 29.1 ± 26, p = 0.03). CONCLUSION: Lower pre-SG DeMeester score tend to imply ability to resolve reflux in morbidly-obese patients thus, SG may still be offered, without repair of ≤2 cm HH if present. Unfortunately, it can't be used as the only factor.

Lack of efficacy of dual intragastric balloon therapy on weight loss and patient dissatisfaction.

BACKGROUND: Dual intragastric balloon (DIGB) therapy is a non-surgical, restrictive method of weight loss. We evaluated weight loss and patient satisfaction after DIGB removal. METHODS: Between 2016 and 2019, 35 patients had DIGB therapy. A retrospective review of weight loss at balloon removal and follow-up, adverse events during DIGB therapy, and patient satisfaction was performed. RESULTS: At follow-up after balloon removal (22.3 ± 10.5 months), mean percent excess weight loss (%EWL) was significantly decreased compared to %EWL at removal (4.7 ± 42.7% vs 32.4 ± 38.8%, p = .001). Weight regain occurred in 22/31 (71%) patients. Adverse events during DIGB therapy included: nausea, abdominal pain, reflux, pancreatitis, and gastric outlet obstruction. Twenty-five (71.4%) patients completed a satisfaction questionnaire. Only 3/25 (12%) patients were satisfied, and 92% would not choose DIGB for weight loss. CONCLUSION: Weight loss achieved from DIGB on average was not maintained after balloon removal. Most patients were not satisfied and would not choose DIGB again.

Laparoscopic Ligamentum Teres cardiopexy to the rescue; an old procedure with a new use in managing reflux after sleeve gastrectomy.

BACKGROUND: Severe reflux after sleeve-gastrectomy (SG) often requires conversion to Roux-en-Y-Gastric Bypass (RYGB). We performed laparoscopic Ligamentum Teres Cardiopexy (LLTC) as an alternative operation. MATERIALS & METHODS: Ten patients had LLTC between June 2019-June 2020. Pre-operative work-up included Barium swallow, upper endoscopy with pH monitoring. The percent excess body mass index (%EBMI) loss before LLTC was 70 ± 0.2%. RESULTS: Pre-operative DeMeester score was 69 ± 50 (normal = 14.72). All patients underwent repair of hiatal hernia and gastric plication in addition to LLTC. The average operative-time was 110 ± 26 min. The follow up was 7 ± 3 months. Eight patients had resolution of their reflux. Two patients resumed medication for recurrent mild reflux. CONCLUSION: LLTC is a safe technique and may be considered a rescue operation in lieu of conversion to RYGB in managing severe reflux after SG. Long term results are needed to confirm its durable effectiveness.

Hospital complication rates with bariatric surgery in Michigan.

CONTEXT: Despite the growing popularity of bariatric surgery, there remain concerns about perioperative safety and variation in outcomes across hospitals. OBJECTIVE: To assess complication rates of different bariatric procedures and variability in rates of serious complications across hospitals and according to procedure volume and center of excellence (COE) status. DESIGN, SETTING, AND PATIENTS: Involving 25 hospitals and 62 surgeons statewide, the Michigan Bariatric Surgery Collaborative (MBSC) administers an externally audited, prospective clinical registry. We evaluated short-term morbidity in 15,275 Michigan patients undergoing 1 of 3 common bariatric procedures between 2006 and 2009. We used multilevel regression models to assess variation in risk-adjusted complication rates across hospitals and the effects of procedure volume and COE designation (by the American College of Surgeons or American Society for Metabolic and Bariatric Surgery) status. MAIN OUTCOME MEASURE: Complications occurring within 30 days of surgery. RESULTS: Overall, 7.3% of patients experienced perioperative complications, most of which were wound problems and other minor complications. Serious complications were most common after gastric bypass (3.6%; 95% confidence interval [CI], 3.2%-4.0%), followed by sleeve gastrectomy (2.2%; 95% CI, 1.2%-3.2%), and laparoscopic adjustable gastric band (0.9%; 95% CI, 0.6%-1.1%) procedures (P < .001). Mortality occurred in 0.04% (95% CI, 0.001%-0.13%) of laparoscopic adjustable gastric band, 0 sleeve gastrectomy, and 0.14% (95% CI, 0.08%-0.25%) of the gastric bypass patients. After adjustment for patient characteristics and procedure mix, rates of serious complications varied from 1.6% (95% CI, 1.3-2.0) to 3.5% (95% CI, 2.4-5.0) (risk difference, 1.9; 95% CI, 0.08-3.7) across hospitals. Average annual procedure volume was inversely associated with rates of serious complications at both the hospital level (< 150 cases, 4.1%; 95% CI, 3.0%-5.1%; 150-299 cases, 2.7%; 95% CI, 2.2-3.2; and > or = 300 cases, 2.3%; 95% CI, 2.0%-2.6%; P = .003) and surgeon level (< 100 cases, 3.8%; 95% CI, 3.2%-4.5%; 100-249 cases, 2.4%; 95% CI, 2.1%-2.8%; > or = 250 cases, 1.9%; 95% CI, 1.4%-2.3%; P = .001). Adjusted rates of serious complications were similar in COE and non-COE hospitals (COE, 2.7%; 95% CI, 2.5%-3.1%; non-COE, 2.0%; 95% CI, 1.5%-2.4%; P = .41). CONCLUSIONS: The frequency of serious complications among patients undergoing bariatric surgery in Michigan was relatively low. Rates of serious complications are inversely associated with hospital and surgeon procedure volume, but unrelated to COE accreditation by professional organizations.

Laparoscopic Cholecystectomy in a Patient with Situs Inversus Totalis: Port Placement and Dissection Techniques.

BACKGROUND Situs inversus is a rare congenital condition. Since 1991, more than 60 cases of laparoscopic cholecystectomy have been reported in patients with situs inversus. There are many different port placement techniques depending on the surgeon's preference. The fact that some of the critical dissection is easier performed by the left hand poses technical difficulty for right-handed surgeons. CASE REPORT A 56-year-old woman with known situs inversus totalis and extensive past surgical history presented with acute cholecystitis. A Veress needle was used to enter the abdomen at Palmer's point. Visiport was used to place the first 5-mm port at the left mid-clavicular line. The dissection was performed in a mirror image to the usual dissection through the epigastric port. CONCLUSIONS There have been several techniques described in the literature to facilitate the dissection in laparoscopic cholecystectomy in patients with situs inversus totalis. We argue that the first port should be placed at the mid-clavicular line with Visiport. The other ports should be placed in mirror image of the normally placed ports, including a 12-mm epigastric port, 5-mm or 11-mm paraumbilical port, and 5-mm port at the left anterior axillary line. For dissection, we argue that it is preferable to have 2 assistants with 1 retracting the gallbladder and the other holding the camera. This allows the primary surgeon to use the dominant hand during critical dissection in this unfamiliar anatomy.

Laparoscopic placement of the LINX® system in management of severe reflux after sleeve gastrectomy.

BACKGROUND: Management of severe reflux after sleeve gastrectomy (SG) is often done by conversion to Roux-en-Y gastric bypass (RYGB). The LINX® system could be an alternative treatment. METHOD: Between 2015 and 2017, 13 patients had LINX® system placed to manage their reflux after SG. Pre-operative evaluation included a barium swallow, endoscopy with pH monitor and esophageal motility. RESULTS: Ten females and three males with mean age of 49 ±â€¯13 years were evaluated. Their mean weight before placing the LINX® system was 193 ±â€¯45 lbs. and mean BMI of 33 ±â€¯6 kg/m2. The mean time between SG and placing the LINX® system was 43 ±â€¯19 months. The mean Bravo score was 46 ±â€¯26 (normal 14.7). One patient developed severe dysphagia post-operatively requiring removal of the LINX® after 18 days and one patient was lost to follow up. The mean follow-up in the remaining 11 patients was 26 ±â€¯12 months. The mean GERD-HRQL score dropped significantly from 47/75 ±â€¯17/75 to 12/75 ±â€¯14/75 (p = .0003). CONCLUSION: The LINX® system may be used as an alternative to RYGB conversion in managing refractory post-SG reflux.

Association of Race With Bariatric Surgery Outcomes.

Importance: The outcomes of bariatric surgery vary considerably across patients, but the association of race with these measures remains unclear. Objective: To examine the association of race on perioperative and 1-year outcomes of bariatric surgery. Design, Setting, and Participants: Propensity score matching was used to assemble cohorts of black and white patients from the Michigan Bariatric Surgery Collaborative who underwent a primary bariatric operation (Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding) between June 2006 and January 2017. Cohorts were balanced on baseline characteristics and procedure. Conditional fixed-effects models were used to evaluate the association of race on outcomes within hospitals and surgeons. Data analysis occurred from June 2006 through August 2018. Main Outcomes and Measures: Thirty-day complications and health care resource utilization measures, as well as 1-year weight loss, comorbidity remission, quality of life, and satisfaction. Results: In each group, 7105 patients were included. Black patients had a higher rate of any complication (628 [8.8%] vs 481 [6.8%]; adjusted odds ratio, 1.33 [95% CI, 1.17-1.51]; P = .02), but there were no significant differences in the rates of serious complications (178 [2.5%] vs 135 [1.9%]; adjusted odds ratio, 1.32 [95% CI, 1.05-1.66]; P = .29) or mortality (5 [0.10%] vs 7 [0.10%]; adjusted odds ratio, 0.73 [95% CI, 0.23-2.31]; P = .54). Black patients had a greater length of stay (mean [SD], 2.2 [3.0] days vs 1.9 [1.7] days; adjusted odds ratio, 0.30 [95% CI, 0.20-0.40]; P < .001), as well as a higher rate of emergency department visits (541 [11.6%] vs 826 [7.6%]; adjusted odds ratio, 1.60 [95% CI, 1.43-1.79]; P < .001) and readmissions (414 [5.8%] vs 245 [3.5%]; adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P < .001). At 1 year, black patients had lower mean total body weight loss and as a percentage of weight (32.0 kg [26%]; vs 38.3 kg [29%]; P < .001) and this held true across procedures. Remission of hypertension was lower for black patients (564 [40.0%] vs 1096 [56.0%]; P < .001), but the rate of sleep apnea remission (467 [62.6%] vs 615 [56.1%]; P = .005) and gastroesophageal reflux disease (309 [78.6%] vs 453 [75.4%]; P = .049) were higher. There were no significant differences in remission of diabetes with insulin dependence, diabetes without insulin dependence,or hyperlipidemia hyperlipidemia. Fewer black patients than white patients reported a good or very good quality of life (1379 [87.2%] vs 2133 [90.4%]; P = .002) and being very satisfied with surgery (1908 [78.4%] vs 2895 [84.2%]; P < .001) at 1 year. Conclusions and Relevance: Black patients undergoing bariatric surgery in Michigan had significantly higher rates of 30-day complications and resource utilization and experienced lower weight loss at 1 year than a matched cohort of white patients. While sleep apnea and gastroesophageal reflux disease remission were higher and hypertension remission lower in black patients, comorbidity remission was otherwise similar between matched cohorts. Racial and cultural differences among patients should be considered when designing strategies to optimize outcomes with bariatric surgery.

Laparoscopic management of severe reflux after sleeve gastrectomy using the LINX® system: Technique and one year follow up case report.

INTRODUCTION: Management of severe reflux after sleeve gastrectomy (SG) usually requires converting to Roux-en-y gastric bypass (RYGB). We present a case of managing this problem using the LINX® system. PRESENTATION OF CASE: In February 2015, we performed a laparoscopic placement of LINX® system to treat severe reflux after sleeve gastrectomy on a 25-year-old female. The operative time was 47min. There were no intra or postoperative complications. The hospital stay was one day. The postoperative UGI showed no reflux. Ten days after surgery her Quality of life score (QOL) changed from 64/75 to 7/75 after the LINX® placement. One year later the patient continued to enjoy no reflux and stayed off medication. DISCUSSION: Reflux after sleeve gastrectomy is usually managed by conversion to RYGB by most surgeons. This case report opens the door for an alternative management of this problem while maintaining the original sleeve gastrectomy. This technique is reasonably easy to perform in comparison to the conversion to RYGB with less potential post-operative complications. A one year follow up showed good control of reflux without medication. CONCLUSION: Laparoscopic placement of the LINX® system to correct severe reflux after sleeve gastrectomy is a safe alternative procedure to conversion to a RYGB.

Total laparoscopic live donor nephrectomy: a 6-year experience.

BACKGROUND: Since the introduction of the laparoscopic live donor nephrectomy in 1995, attempts have been made to depart from the total laparoscopic approach to the hand-assisted approach to decrease surgical time and complications. We present our 6-year experience with the total laparoscopic approach. METHODS: Between December 1998 and November 2004 there were 168 total laparoscopic live donor nephrectomies performed at our institution. There were 163 left nephrectomies and 5 right nephrectomies. RESULTS: The procedure was performed in a systematic approach. The surgical time deceased from an average of 2:27 hours in the first year to 1:34 hours in the last year of the study. The overall average warm ischemia time was 3.5 minutes. Major bleeding requiring conversion to an open procedure occurred in 2 (1.2%) donors. Minor bleeding that was controlled laparoscopically occurred in 9 (5.4%) donors. Degloving of the renal capsule occurred in 2 (1.2%) donors with no consequences. Minor mesenteric rent occurred in 7 (4.2%) donors. All mesenteric complications were recognized and repaired laparoscopically. No ureteral or bowel injuries occurred. There were no mortalities. Eighty-three percent of donors were discharged the next day. CONCLUSIONS: Total laparoscopic live donor nephrectomy is safe. It was performed successfully in 98.8% of donors with a short surgical time, low morbidity, and 0% mortality.

Degloving of the renal capsule: a rare complication of laparoscopic live donor nephrectomy.

Laparoscopic live donor nephrectomy is becoming the procedure of choice for kidney procurement. In the course of 172 laparoscopic procurements, degloving of the renal capsule, a rare complication believed to be related to the method of extraction of the kidney, was encountered in 2 patients (1.2%). The complication was noted after revascularization of the kidney. A capsulotomy was performed to evacuate the subcapsular hematoma. No adverse effect was noted in the postoperative period in the transplanted kidneys.

The incidence of cholelithiasis after sleeve gastrectomy and its association with weight loss: A two-centre retrospective cohort study.

INTRODUCTION: Gallstones commonly develop after Roux-en-Y gastric bypass and other bariatric surgery; however, incidence of gallstone development after SG has not been adequately studied. METHODS: We conducted a retrospective cohort study of patients who underwent SG at two institutions from January 1, 2011 to December 31, 2012. Patients with previous cholecystectomy, preexisting gallstones, gallbladder polyps, or the absence of preoperative abdominal imaging were excluded. Follow-up abdominal ultrasonography was performed once the patients achieved 80-lb weight loss, became symptomatic, or reached one-year post-surgery. The incidence of gallstones and symptomatic gallstones and/or bile sludge was calculated. Different parameters of early and late postoperative weight loss were compared between the patients who developed gallstones and those who did not. RESULTS: During the study period, 253 underwent laparoscopic sleeve gastrectomy. Ultimately, 96 patients met inclusion criteria and were evaluated. The incidence of gallstone formation was 47.9% (46/96), and the incidence of symptomatic gallstones was 22.9% (22/96). None of the weight loss parameters during the early and late postoperative period were significantly different between the patients who developed gallstones and those who did not. CONCLUSION: Gallstones are a common complication after rapid weight loss from SG. Our data suggest that gallstone formation during the weight loss period is not associated with amount or rate of weight loss both during the early or late postoperative period.

Do gallstones found before sleeve gastrectomy behave the same as those formed after surgery due to weight loss?

BACKGROUND: Gallstone formation is prevalent in the bariatric population and after weight loss. We believe that gallstones found preoperatively behave differently and may not cause significant complications as those developing after weight loss. Thus, prophylactic cholecystectomy before or during sleeve gastrectomy (SG) may not be necessary. METHODS: Patients undergoing SG from January 2011 to May 2012 were evaluated for the presence of gallstones and development of symptoms or need for cholecystectomy postoperatively. RESULTS: Group 1 (n = 18) had gallstones preoperatively. Group 2 (n = 29) developed gallstones after weight loss. Both groups' demographics were similar. Symptomatic gallstones occurred in 1 patient (5.6%) in group 1 and in 9 patients (31.0%) in group 2 (P = .19). Percent excess body mass index loss (%EBL) was 58 ± 24% vs 70 ± 22% (P = .11) with a mean follow-up of 8.9 ± 6.2 and 14.7 ± 3.9 months for group 1 and group 2, respectively (P = .005). CONCLUSIONS: Asymptomatic gallstones found before SG tend to have less risk of becoming symptomatic than those formed after weight loss. There was no statistical significant difference because of small sample. Prophylactic cholecystectomy, however, may not be warranted in these patients.

Can morbidly obese patients with reflux be offered laparoscopic sleeve gastrectomy? A case report of 40 patients.

BACKGROUND: The incidence of reflux in obesity can reach greater than 35%. Most surgeons recommend Roux-en-y gastric bypass to patients with pre-existing reflux. One alternative to Roux-en-y gastric bypass is the addition of anterior fundoplication (AF) with posterior crural approximation (pCA) to laparoscopic sleeve gastrectomy (LSG) in patients with documented reflux. METHODS: Between February 2011 and April 2013 we reviewed data from the bariatric registry on weight loss, resolution of symptoms, and quality of life presurgery and postsurgery for all patients who consented to participate in the registry and underwent LSG with AF/pCA. RESULTS: Forty patients met inclusion criteria; 78% (31) were female. The mean initial weight was 298 ± 64 lbs. with mean BMI of 49 ± 8 kg/m(2). The mean DeMeester score was 36 ± 27 (normal <14.7). Nine (22.5%) patients had esophagitis. Thirty-six (90%) patients had hiatal hernia. There were no intraoperative complications. The mean operative time was 84 ± 20 minutes and the mean hospital stay was 1.6 ± .9 days. Postoperative complications included 1 fluid collection, 1 narrowing, 4 admissions for nausea and dehydration, 1 for pancreatitis, and 1 for deep vein thrombosis . Thirty-eight (95%) patients had immediate resolution of reflux, whereas 2 (5%) patients complained of worsening symptoms. On short-term follow-up of 24 ± 6 months, 55% of patients responded to the gastroesophageal reflux disease-health related quality of life questionnaire with improvement in their median score from 31/75 interquartile range (IQR 25) preoperatively to 0/75 (IQR 6.5) postoperatively (P < .0001). Their %excess body mass index loss was 69 ± 27%. CONCLUSIONS: Morbidly obese patients with documented reflux can be offered LSG with the addition of AF/pCA.

Laparoscopic Management of Severe Reflux After Sleeve Gastrectomy, in Selected Patients, Without Conversion to Roux-en-Y Gastric Bypass.

BACKGROUND: Treatment of severe reflux after laparoscopic sleeve gastrectomy (LSG) may require conversion to Roux-en-Y gastric bypass (RYGB). We conducted a pilot study to evaluate the feasibility and effectiveness of performing laparoscopic anterior fundoplication with posterior crura approximation (LAF/pCA), in selected patients, to correct the reflux without conversion to RYGB. PATIENTS AND METHODS: From October 2012 to April 2013, 6 patients with confirmed severe de novo reflux after LSG were treated with LAF/pCA. RESULTS: All patients were females with a mean age of 41.5±14.2 years. All patients had lost weight after initial LSG. The percentage excess body mass index (BMI) loss (%EBL) was 61.2±33.2%. The mean time from the initial LSG to LAF/pCA was 33.2±12.5 months. Four patients had reduction of gastric fundus size. One patient required resleeving. Reflux resolved immediately in all patients with a follow-up of 18.5±2.7 months. All patients continued to lose weight, with %EBL reaching 75.5±22.9% and a mean BMI of 32±7.3 kg/m(2). CONCLUSIONS: LAF/pCA with reduction of gastric fundus size, when needed, may be considered an alternative option to correct severe reflux after LSG in selected patients.

Early effects of bougie size on sleeve gastrectomy outcome.

BACKGROUND: When performing sleeve gastrectomy, a bougie (32 to 60 French) is used. We evaluated 2 different bougie sizes on early postoperative outcomes and long-term weight loss. METHODS: A 1-year prospective study was conducted on patients undergoing sleeve gastrectomy. In the first 6 months, patients had 32-French bougies (Group 1); in the second 6 months, they had 36-French bougies (Group 2). RESULTS: We evaluated 131 patients. No intraoperative complications or mortality occurred. Postoperatively, Group 1 (n = 72) had a longer hospital stay (1.6 ± .8 vs 1.3 ± .5 days, P = .04) and used more Ondansetron for nausea than Group 2 (n = 59) (6.7 ± 8.0 vs 5.3 ± 4.5 mg, P = .2, respectively). Ten (14%) patients in Group 1 returned to the emergency department compared with 5 (9%) in Group 2. One-year percent excess weight loss was similar (73.0 ± 20.6% vs 71.1 ± 20.9%, P = .73, respectively). CONCLUSIONS: The smaller bougie resulted in a longer hospital stay, with tendency toward increased nausea, more emergency department visits, and readmissions. Long-term weight loss was not affected.