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1.
Surg Endosc ; 38(8): 4604-4612, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-38886234

RESUMEN

BACKGROUND: Patients undergoing sleeve gastrectomy (SG) experience transformative changes in eating-related experiences that include eating-related symptoms, emotions, and habits. Long-term assessment of these endpoints with rigorous patient-reported outcome measures (PROMs) is limited. We assessed patients undergoing SG with the Body-Q Eating Module PROMs. METHODS: All patients evaluated at the Emory Bariatric Center were given the Body-Q Eating Modules questionnaire at preoperative/postoperative clinic visits. Rasch scores and prevalence of relevant endpoints were assessed across six time-points of interest: preoperatively, post-operative months 0-6, 7-12, 12-24, 24-36, and over 36. Student's t-test and Chi-square test were used for analysis. RESULTS: Overall, 1,352 questionnaires were completed pre-operatively and 493 postoperatively. Survey compliance was 81%. Compared to the pre-operative group, the post-operative group had lower BMI (39.7 vs. 46.4, p < 0.001) and higher age (46.3 vs. 44.9, p = 0.019). Beginning one year after SG, patients experience more frequent eating-related pain, nausea and constipation compared to pre-operative baseline (p < 0.05). They also more frequently experience eating-related regurgitation and dumping syndrome-related symptoms beginning post-operative year two (p < 0.05). In the first year after SG, patients more rarely feel eating-related embarrassment, guilt, and disappointment compared to pre-operative baseline (p < 0.05). These improvements disappear one year after SG, after which patients more frequently experience feeling out of control, unhappy, like a failure, disappointed, and guilty (p < 0.05). In the first year after SG, patients experience an increased frequency in positive eating behaviors (ate healthy foods, showed self-control, stopped before full; (p < 0.05). Only two eating-related behavior improvements persist long-term: feeling in control and eating the right amount (p < 0.05). CONCLUSIONS: Patients undergoing SG may experience more frequent eating-related symptoms, distress, and behavior in the long-term. These findings can enhance the pre-operative informed consent and guide development of a more tailored approach to postoperative clinical management such as more frequent visits with the dietician.


Asunto(s)
Gastrectomía , Obesidad Mórbida , Medición de Resultados Informados por el Paciente , Humanos , Gastrectomía/métodos , Gastrectomía/psicología , Femenino , Masculino , Estudios Transversales , Adulto , Persona de Mediana Edad , Obesidad Mórbida/cirugía , Obesidad Mórbida/psicología , Conducta Alimentaria/psicología , Encuestas y Cuestionarios , Cirugía Bariátrica/psicología , Trastornos de Alimentación y de la Ingestión de Alimentos/psicología
2.
Surg Obes Relat Dis ; 20(1): 72-79, 2024 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-37684191

RESUMEN

BACKGROUND: Metabolic and bariatric surgery (MBS) venous thromboembolism (VTE) prescribing practices vary widely. Our institutional VTE prophylaxis protocol has historically been unstandardized. OBJECTIVES: To create a standardized MBS VTE prophylaxis protocol, track protocol compliance, and identify barriers to protocol compliance and address them with Plan-Do-Study-Act (PDSA) cycles. SETTING: Single Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited academic hospital. METHODS: We conducted a retrospective study for all patients undergoing MBS (January 2019 to September 2022). A multidisciplinary group of bariatric clinicians reviewed literature and developed the following standardized VTE prophylaxis protocol: 5000 units preoperative subcutaneous (SC) heparin within 60 minutes of anesthesia induction and postoperative 40 mg SC low molecular weight heparin (LMWH) within 24 hours of surgery. This protocol was distributed to relevant clinical stakeholders. We assessed monthly compliance rates through chart review. Goal compliance was ≥90%. We identified sources of noncompliance and addressed them with PDSA methodology. RESULTS: A total of 796 patients were included. Preoperative heparin administration increased from a mean of 47% (107/228) preintervention to 96% (545/568) postintervention (P < .0001), and postoperative LMWH administration increased from 71% (47/66) to 96% (573/597, P = .0002). These compliance rates were sustained for 3 years. Barriers to protocol noncompliance included order set timing errors (n = 45), surgeon error (n = 44), surgeon discretion (n = 40), and nursing error (n = 20). No change in bleeding or VTE rates was observed. CONCLUSIONS: Developing a standardized VTE prophylaxis protocol, monitoring process measures, and engaging relevant stakeholders in PDSA cycles resulted in drastic and durable improvement in VTE prophylaxis compliance rates.


Asunto(s)
Cirugía Bariátrica , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & control , Heparina de Bajo-Peso-Molecular/uso terapéutico , Estudios Retrospectivos , Anticoagulantes/uso terapéutico , Heparina/uso terapéutico , Centros Médicos Académicos , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/tratamiento farmacológico
3.
Surg Endosc ; 37(10): 7940-7946, 2023 10.
Artículo en Inglés | MEDLINE | ID: mdl-37433914

RESUMEN

BACKGROUND: It is critical to ensure appropriate and consistent sleeve size and orientation during laparoscopic sleeve gastrectomy (LSG). Various devices are used to achieve this, including weighted rubber bougies, esophagogastroduodenoscopy (EGD), and suction calibration systems (SCS). Prior reports suggest that SCSs may decrease operative time and stapler load firings but are limited by single-surgeon experience and retrospective design. We performed the first randomized controlled trial comparing SCS against EGD in patients undergoing LSG to investigate whether the SCS decreases the number of stapler load firings. METHODS: This was a randomized, non-blinded study from a single MBSAQIP-accredited academic center. Appropriate LSG candidates ≥ 18 years of age were randomized to EGD or SCS calibration. Exclusion criteria included prior gastric or bariatric surgery, detection of hiatal hernia before surgery, and intraoperative hiatal hernia repair. A randomized block design was employed controlling for body mass index, gender, and race. Seven surgeons employed a standardized LSG operative technique. The primary endpoint was the number of stapler load firings. Secondary endpoints were operative duration, reflux symptoms, and change in total body weight (TBW). Endpoints were analyzed via t-test. RESULTS: A total of 125 LSG patients (84% female) underwent study enrollment, with an average age of 44 ± 12 years and average BMI of 49 ± 8 kg/m2. Overall, 117 patients were randomized to receive EGD (n = 59) or SCS (n = 58) calibration. No significant differences in baseline characteristics were identified. The mean number of stapler load firings for EGD and SCS groups were 5.43 ± 0.89 and 5.31 ± 0.81, respectively (p = 0.463). The mean operative times for EGD and SCS groups were 94.4 ± 36.5 and 93.1 ± 27.9 min, respectively (p = 0.83). There were no significant differences in post-operative reflux, TBW loss, or complications. CONCLUSION: Use of EGD and SCS resulted in a similar number of LSG stapler load firings and operative duration. Additional research is needed to compare LSG calibration devices in different patients and settings to optimize surgical technique.


Asunto(s)
Laparoscopía , Obesidad Mórbida , Humanos , Femenino , Adulto , Persona de Mediana Edad , Masculino , Obesidad Mórbida/cirugía , Tempo Operativo , Calibración , Estudios Retrospectivos , Succión , Laparoscopía/métodos , Gastrectomía/métodos , Resultado del Tratamiento
4.
Surg Obes Relat Dis ; 19(8): 808-816, 2023 08.
Artículo en Inglés | MEDLINE | ID: mdl-37353413

RESUMEN

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of 30-day mortality after metabolic and bariatric surgery (MBS). Multiple predictive tools exist for VTE risk assessment and extended VTE chemoprophylaxis determination. OBJECTIVE: To review existing risk-stratification tools and compare their predictive abilities. SETTING: MBSAQIP database. METHODS: Retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed (2015-2019) for primary minimally invasive MBS cases. VTE clinical factors and risk-assessment tools were evaluated: body mass index threshold of 50 kg/m2, Caprini risk-assessment model, and 3 bariatric-specific tools: the Cleveland Clinic VTE risk tool, the Michigan Bariatric Surgery Collaborative tool, and BariClot. MBS patients were deemed high risk based on criteria from each tool and further assessed for sensitivity, specificity, and positive predictive value. RESULTS: Overall, 709,304 patients were identified with a .37% VTE rate. Bariatric-specific tools included multiple predictors: procedure, age, race, gender, operative time, length of stay, heart failure, and dyspnea at rest; operative time was the only variable common to all. The body mass index cutoff and Caprini risk-assessment model had higher sensitivity but lower specificity when compared with the Michigan Bariatric Surgery Collaborative and BariClot tools. While the sensitivity of the tools varied widely and was overall low, the Cleveland Clinic tool had the highest sensitivity. The bariatric-specific tools would have recommended extended prophylaxis for 1.1%-15.6% of patients. CONCLUSIONS: Existing MBS VTE risk-assessment tools differ widely for inclusion variables, high-risk definition, and predictive performance. Further research and registry inclusion of all significant risk factors are needed to determine the optimal risk-stratified approach for predicting VTE events and determining the need for extended prophylaxis.


Asunto(s)
Cirugía Bariátrica , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & control , Mejoramiento de la Calidad , Estudios Retrospectivos , Complicaciones Posoperatorias/etiología , Anticoagulantes/uso terapéutico , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/métodos , Factores de Riesgo
5.
Surg Endosc ; 37(2): 1449-1457, 2023 02.
Artículo en Inglés | MEDLINE | ID: mdl-35764842

RESUMEN

BACKGROUND: Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations. METHODS AND PROCEDURES: An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student's t-tests. RESULTS: Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (P < 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4-80.8% post-implementation (P < 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes. CONCLUSION: Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.


Asunto(s)
Cirugía Bariátrica , Recuperación Mejorada Después de la Cirugía , Humanos , Proyectos Piloto , Atención Perioperativa/métodos , Tiempo de Internación , Estudios Retrospectivos
6.
J Gastrointest Surg ; 26(9): 1830-1837, 2022 09.
Artículo en Inglés | MEDLINE | ID: mdl-35715643

RESUMEN

BACKGROUND: Although revisions account for 17% of cases performed at bariatric centers of excellence, scarce data exists on whether index operation type influences outcomes after secondary operations. OBJECTIVE: We designed a study investigating the effect of primary procedure type on weight loss and perioperative complications after conversion bariatric surgery. SETTING: Tertiary Referral Hospital, USA. METHODS: We performed a retrospective review of patients undergoing conversion from sleeve gastrectomy (SG) or adjustable gastric band (AGB) to Roux-en-Y gastric bypass (RYGB) from 2009 to 2019. Post-operatively, we measured short- and medium-term complications and changes in body weight at various time points. Univariate and regression analyses were performed. RESULTS: Forty-two (SG) patients and 116 (AGB) patients underwent conversion to RYGB, most commonly for GERD (57.1%) in SG patients vs. weight regain (77.6%) in AGB patients. Mean pre-conversion BMI was 36.7 kg/m2 (SG) vs 43.8 kg/m2 (AGB). Mean time to conversion (months) was 52.9 (SG) vs 94.7 (AGB). Complication rate was 9.5% (SG) vs 6% (AGB) at 30 days (p = 0.48) and 31%(SG) vs 14.5% (AGB) (p = 0.02) at 2 years. Mean post conversion %TWL was 11.6% (SG) vs 24.6% (AGB) in patients with GERD/dysphagia (p = 0.014) and 20.7% (SG) vs 27.6% (AGB) in patients converted for weight-related reasons (p = 0.027) at 1 year. Overall mean %TWL was 13.2% (SG) vs 24.7% (AGB) at 2 years (p < 0.0035). CONCLUSION: After conversion to RYGB, patients with AGB experience better short- and medium-term weight loss than those with SG, even after accounting for conversion indications. SG to RYGB conversions have a higher resolution of reflux disease.


Asunto(s)
Cirugía Bariátrica , Derivación Gástrica , Reflujo Gastroesofágico , Obesidad Mórbida , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/métodos , Gastrectomía/efectos adversos , Gastrectomía/métodos , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Reflujo Gastroesofágico/etiología , Reflujo Gastroesofágico/cirugía , Humanos , Obesidad Mórbida/complicaciones , Obesidad Mórbida/cirugía , Reoperación/efectos adversos , Estudios Retrospectivos , Resultado del Tratamiento , Pérdida de Peso
7.
Surg Laparosc Endosc Percutan Tech ; 32(4): 466-471, 2022 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-35583523

RESUMEN

INTRODUCTION: Patients undergoing bariatric surgery with body mass index (BMI) >50 kg/m 2 are at a higher risk of surgical morbidity when compared with less obese patients, however, there is limited data correlating surgical risk and efficacy with increasing BMI in patients with severe obesity. We hypothesize that regardless of the degree above 50 kg/m 2 their BMI, patients with severe obesity respond similarly to bariatric surgery. MATERIALS AND METHODS: We performed a retrospective analysis of patients with BMI >50 kg/m 2 who underwent biliopancreatic diversion with duodenal switch, Roux-en-Y gastric bypass, or sleeve gastrectomy at a single institution. Outcomes were compared in patients with a BMI between 50 and 60 kg/m 2 to patients with a BMI >60 kg/m 2 and included percent total weight loss as well as early and late complications. Statistical analyses were performed using logistic regression, univariate, and multivariate models. RESULTS: There were 571 patients with BMI >50 kg/m 2 who underwent bariatric surgery at our center, 170 (29.8%) had a BMI >60 kg/m 2 . Percent total weight loss was statistically significant between the BMI 50 and 60 kg/m 2 and BMI >60 kg/m 2 groups at 24 months ( P =0.047) but not at 60 months ( P =0.54). No significant difference was found in the incidence of early complications in a univariate ( P =0.46) or a multivariate ( P =0.06) analysis. The BMI >60 subgroup was associated with a higher rate of late complications in univariate analysis (heart rate=2.37; 1.03-5.47, P =0.04), but not in multivariate analysis ( P =0.78). CONCLUSIONS: Efficacy and complication rates of bariatric surgeries are similar in patients with BMI 50 to 60 kg/m 2 and >60 kg/m 2 , providing evidence supporting similar management of patients despite specific subgroups.


Asunto(s)
Cirugía Bariátrica , Derivación Gástrica , Laparoscopía , Obesidad Mórbida , Índice de Masa Corporal , Gastrectomía/efectos adversos , Derivación Gástrica/efectos adversos , Humanos , Obesidad Mórbida/complicaciones , Obesidad Mórbida/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Pérdida de Peso
8.
Surg Endosc ; 36(7): 4946-4955, 2022 07.
Artículo en Inglés | MEDLINE | ID: mdl-34731300

RESUMEN

INTRODUCTION: Bariatric surgery is the most effective modality to stably reduce weight and related comorbidities in patients suffering from class II and III obesity. Data comparing long-term safety and efficacy of the three most effective bariatric operations are limited in patients with BMI ≥ 50 kg/m2, which complicate shared surgeon-patient decision making regarding optimal procedure selection. METHODS: A retrospective analysis was performed on all patients with BMI ≥ 50 kg/m2 who underwent biliopancreatic diversion with duodenal switch (BPD/DS), Roux-en-Y gastric bypass (RYGB), or sleeve gastrectomy (SG) at our institution between 2009 and 2019. Data collected from patients' electronic medical records included operative details as well as BMI and presence and resolution of obesity-related comorbidities at 0, 6, 12, 24, 48, and 60 months post-operatively. RESULTS: Among 537 patients with BMI ≥ 50 kg/m2 who had a primary bariatric procedure, 93 patients underwent BPD/DS (17.3%), 341 patients underwent RYGB (63.5%), and 103 patients underwent SG (19.2%). BMI decreased by 23.7 kg/m2 in BPD/DS, 14.7 kg/m2 in RYGB, and 13.6 kg/m2 in SG cohorts at 60 months post-operatively (p < 0.0001). The greatest %TWL occurred in BPD/DS cohort (38.4%) followed by the RYGB (26.3%) and SG (23.6%) cohorts (p < 0.0001). The thirty-day complication rate was 12.9% for BPD/DS, 4.7% for RYGB, and 8.7% for SG (p = 0.015). CONCLUSIONS: Our study demonstrated that the BPD/DS is the most effective operation at long-term reduction of BMI and achieved highest %TWL while SG and RYGB had similar results at 60 months post-op. BPD/DS is associated with increased early and late surgical complications compared to RYGB and SG.


Asunto(s)
Desviación Biliopancreática , Derivación Gástrica , Obesidad Mórbida , Desviación Biliopancreática/métodos , Índice de Masa Corporal , Gastrectomía/métodos , Derivación Gástrica/métodos , Humanos , Obesidad/cirugía , Obesidad Mórbida/complicaciones , Obesidad Mórbida/cirugía , Estudios Retrospectivos , Pérdida de Peso
9.
J Am Coll Surg ; 221(6): 1057-66, 2015 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-26453260

RESUMEN

BACKGROUND: Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency. We aimed to evaluate patient and surgeon acceptance of online postoperative care after elective general surgical operations. STUDY DESIGN: A prospective pilot study within an academic general surgery service compared online and in-person postoperative visits from May to December 2014. Included patients underwent elective laparoscopic cholecystectomy, laparoscopic ventral hernia repair, umbilical hernia repair, or inguinal hernia repair by 1 of 5 surgeons. Patients submitted symptom surveys and wound pictures, then corresponded with their surgeons using an online patient portal. The primary outcome was patient-reported acceptance of online visits in lieu of in-person visits. Secondary outcomes included detection of complications via online visits, surgeon-reported effectiveness, and visit times. RESULTS: Fifty patients completed both online and in-person visits. Online visits were acceptable to most patients as their only follow-up (76%). For 68% of patients, surgeons reported that both visit types were equally effective, while clinic visits were more effective in 24% and online visits in 8%. No complications were missed via online visits, which took significantly less time for patients (15 vs 103 minutes, p < 0.01) and surgeons (5 vs 10 minutes, p < 0.01). CONCLUSIONS: In this population, online postoperative visits were accepted by patients and surgeons, took less time, and effectively identified patients who required further care. Further evaluation is needed to establish the safety and potential benefit of online postoperative visits in specific populations.


Asunto(s)
Colecistectomía Laparoscópica , Herniorrafia , Internet , Cuidados Posoperatorios , Telemedicina , Adulto , Actitud del Personal de Salud , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Proyectos Piloto , Estudios Prospectivos
10.
Am Surg ; 81(7): 679-86, 2015 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-26140887

RESUMEN

Classification of ventral hernias (VHs) into categories that impact surgical outcome is not well defined. The European Hernia Society (EHS) classification divides ventral incisional hernias by midline or lateral location. This study aimed to determine whether EHS classification is associated with wound complications after VH repair, indicated by surgical site occurrences (SSOs). A retrospective cohort study of patients who underwent VH repair at a tertiary referral center between July 1, 2005 and May 30, 2012, was performed. EHS classification, comorbidities, and operative details were determined. Primary outcome was SSO within two years, defined as an infection, wound dehiscence, seroma, or enterocutaneous fistula. There were 538 patients included, and 51.5 per cent were female, with a mean age of 54.2 ± 12.4 years and a mean body mass index of 32.4 ± 8.6 kg/m(2). Most patients had midline hernias (87.0%, n = 468). There were 47 patients (8.7%) who had a lateral hernia, and 23 patients (4.3%) whose repair included both midline and lateral components. Overall rate of SSO was 39 per cent (n = 211) within two years. The rate of SSO by VH location was: 39 per cent (n = 183) for midline, 23 per cent (n = 11) for lateral, and 74 per cent (n = 17) for VHs with midline and lateral components (P = <0.001). Patients whose midline hernia spanned more than one EHS category also had a higher rate of SSOs (P = 0.001). VHs are often described by transverse dimension alone, but a more descriptive classification system offers a richness that correlates with outcomes.


Asunto(s)
Hernia Ventral/clasificación , Hernia Ventral/cirugía , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Comorbilidad , Femenino , Hernia Ventral/epidemiología , Humanos , Fístula Intestinal/epidemiología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Seroma/epidemiología , Dehiscencia de la Herida Operatoria/epidemiología
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