Mid-term Results of an ERAS Program of Bariatric Surgery in a Tertiary Referral Center.

BACKGROUND: To identify preoperative risk factors for discharge failure beyond postoperative day two (POD-2) in bariatric surgery ERAS program in a tertiary referral center. METHODS: all consecutive patients who underwent laparoscopic bariatric treated in accordance with ERAS protocol between January 2017 and December 2019 were included. Two groups were identified, failure of early discharge (> POD-2) (ERAS-F) and success of early discharge (≤ POD-2) (ERAS-S). Overall postoperative morbidity, unplanned readmission rates were analyzed at POD-30 and POD-90, respectively. Multivariate logistic regression was performed to determine the independent risk factors for LOS > 2 days (ERAS-F). RESULTS: A total of 697 consecutive patients were included, 148 (21.2%) in ERAS-F group and 549 (78.8%) in ERAS-S group. All postoperative complications at POD 90, whether medical or surgical were significantly more frequent in ERAS-F group than in ERAS-S group. Neither readmission nor unplanned consultations rates at POD 90 were significantly different between both groups. History of psychiatric disorder (p = 0.01), insulin-dependent diabetes (p < 0.0001), use of anticoagulants medicine (p < 0.00001), distance to the referral center > 100 km (p = 0.006), gallbladder lithiasis (p = 0.02), and planned additional procedures (p = 0.01) were independent risk factors for delayed discharge beyond POD-2. CONCLUSIONS: One in five patients with bariatric surgery failed to discharge earlier despite the ERAS program. Knowledge of these preoperative risk factors would allow us to identify patients who need more recovery time and a tailored approach to the ERAS protocol.

Are Geographical Health Accessibility and Socioeconomic Deprivation Associated with Outcomes Following Bariatric Surgery? A Retrospective Study in a High-Volume Referral Bariatric Surgical Center.

PURPOSE: Few studies have evaluated the association between non-clinical determinants (socioeconomic status and geographic accessibility to healthcare) and the outcomes of bariatric surgery, with conflicting results. This study aimed to evaluate this association. METHODS: The medical records of 1599 consecutive patients who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between June 2005 and December 2017 were retrieved. All relevant data, including patient characteristics, biometric values before and after surgery, related medical problems, surgical history, medications, and habitus, for each patient were prospectively collected in a database. Logistic regressions were used to assess the influence of non-clinical determinants on surgical indications and complications. Multilevel linear or logistic regression was used to evaluate the influence of non-clinical determinants on long-term %TWL and the probability to achieve adequate weight loss (defined as a %TWL > 20% at 12 months). RESULTS: Analysis of the 1599 medical records revealed that most geographically isolated patients were more likely to have undergone laparoscopic Roux-en-Y gastric bypass (odds ratio: 0.97; 95% confidence interval: 0.94 to 0.99; P = 0.018) and had a greater likelihood of adequate weight loss (ß: 0.03; 95% CI: 0.01 to 0.05; P = 0.021). Conversely, socioeconomic status (measured by the European Deprivation Index) did not affect outcomes following bariatric surgery. CONCLUSION: Geographical health isolation is associated with a higher probability to achieve adequate weight loss after 1 year of follow-up, while neither health isolation nor socioeconomic deprivation is associated with post-operative mortality and morbidity. This results suggests that bariatric surgery is a safe and effective tool for weight loss despite socioeconomic deprivation.

Is laparoscopic bariatric surgery as safe and effective before and after age 60? Results from a propensity-score analysis.

BACKGROUND: Patients over 60 years old undergoing bariatric surgery is still increasing. OBJECTIVES: First, to assess the impact of age (>60 years) on the 90-day morbidity and mortality of both laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG), and second, to determine the effectiveness of surgical weight loss and resolution of obesity-related comorbidities for patients 60 years of age and older over a 2-year period. SETTING: Bicentric study from University Hospital of Caen and Memorial Hospital of Saint Lô, France. METHODS: This is a retrospective review of a prospectively maintained database of patients with morbid obesity undergoing laparoscopic bariatric surgery from October 2005 to April 2019. Patients 60 years of age and older were defined as cases (elderly group [EG], n = 137), and patients younger than 60 years of age were defined as controls (young group [YG], n = 1544). The primary endpoint of the study was the prevalence of severe postoperative complications within 90 days of surgery determined by a propensity-score-matching (PSM) analysis. RESULTS: The PSM population included 133 patients in the EG who were matched 1:2 with 266 patients in the YG. There was no mortality in either group. Although not significant (with an absolute difference of 4.5% between the EG and the YG), the odds of severe postoperative complications were 2.5 times higher in the EG than in the YG (7.5% versus 3.0%, P = .053). At 90 days postoperatively, the prevalences of overall morbidity (31.6% versus 22.9%, P = .044), leakage (5.3% versus 1.1%, P = .026), and reoperation (5.3% versus 1.1%, P = .026) were significantly higher in the EG than in the YG. CONCLUSION: This propensity-matched study suggests that laparoscopic bariatric surgery is probably an effective treatment in obese elderly patients (EPs) in terms of weight loss and resolution of comorbidities. However, the EP should be warned of the increased risk of severe postoperative complications within 90 days, including leakage and reoperation rates, especially after RYGB.

Development of the "OS-SEV90 Score" to Predict Severe Postoperative Complications at 90 Days Following Bariatric Surgery.

BACKGROUND: Bariatric surgery may be associated with severe postoperative complications (SPC). Factors associated with the risk of SPC have not been fully investigated. OBJECTIVES: This study aimed to identify preoperative risk factors of SPC within 90 days and to develop a risk prediction model based on these factors. METHODS: We conducted a retrospective single-center cohort study based on a prospectively maintained database of obese patients undergoing laparoscopic bariatric surgery from October 2005 to May 2019. All SPC occurring up to the 90th postoperative day were recorded according to the Dindo-Clavien classification. Associations between potential risk factors and SPC were analyzed using a logistic regression model, and the risk prediction ("OS-SEV90 score") was computed. Based on the OS-SEV90 score, the patients were grouped into 3 categories of risk: low, intermediate, and high. RESULTS: Among 1963 consecutive patients, no patient died and 82 (4.2%) experienced SPC within 90 days. History of gastric or esophageal surgery (adjusted odds ratio (aOR) 3.040, 95% confidence interval; CI 1.78-5.20, p< 0.0001), past of thromboembolic event aOR 2.26, 95%; CI 1.12-4.55, p = 0.0225), and surgery performed by a junior surgeon (aOR 1.99, 95%; CI 1.26-3.13, p = 0.003) were all independently associated with risk for SPC, adjusting for ASA physical status system (ASA) score ≥ 3, severe OSA, psychiatric disease, asthma, a history of abdominal surgery, alcohol, cardiac disease, and dyslipidemia. "the OS-SEV90 score" based on these factors was constructed to classify patients into 3 risk groups: low (≤2), intermediate (3-4), and high (≥5). According to "the OS-SEV90 score," SPC increased significantly from 2.9% in the low-risk group, 7.7% in the intermediate-risk group, and 23.3% in the high-risk group. CONCLUSIONS: A predictive model of SPC within 90 days "the OS-SEV90 score" has been developed using 9 baseline risk factors. The use of the OS-SEV90 score may help the multidisciplinary team to identify the specific risk of each patient and inform them about and optimize the comorbidities before the surgery. Further studies are warranted to validate this score in a new independent cohort before using it in clinical practice.

Malignancy in bariatric surgery patients: a French multisite cohort.

BACKGROUND: Bariatric surgery is associated with decreased cancer-related mortality. An indefinite proportion of patients that undergo bariatric surgery have a history of malignancy or will develop cancer. In these patients, weight loss and oncologic evolution needed to be assessed. The aim of this study was to report the results of patients diagnosed with malignancy before and after bariatric surgery in a French multisite cohort. METHODS: We conducted a retrospective cohort study of all patients who underwent bariatric surgery in six university centers. Patients were divided in two groups: patients with a preoperative history of malignancy and patients diagnosed with malignancy during the follow-up. Both groups were compared with control groups of patients that underwent surgery during the same period. RESULTS: From 2008 to 2018, 8927 patients underwent bariatric surgery. In patients with a history of malignancy (n = 90), breast and gynecologic cancers were predominant (37.8%). Median interval between malignancy and surgery was 60 (38-118) months. After a follow-up of 24 (4-52) months, 4 patients presented with cancer recurrence. Comparative analysis demonstrated equivalent weight loss one year after surgery. In patients with postoperative malignancy (n = 32), breast and gynecologic cancers were also predominant (40.6%). Median interval between surgery and malignancy was 22 (6-109) months. In the comparative analysis, weight loss was similar at 2 years. CONCLUSIONS: History of malignancy should not be considered as an absolute contraindication for bariatric surgery. Gynecological cancer screening should be reinforced before and after surgery. The development of malignancy postoperatively does not seem to affect mid-term bariatric outcomes.

Comparison of sleeve gastrectomy and Roux-en-Y gastric bypass after failure of gastric banding: a two-center study with a propensity score-matched analysis.

BACKGROUND: Few studies on series comparing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) after failure of gastric banding (GB) are available. The objective of this study was to compare the short- and medium-term outcomes of SG and RYGB after GB. MATERIALS AND METHODS: Between January 2006 and December 2017, patients undergoing SG (n = 186) or RYGB (n = 107) for failure of primary GB were included in this two-center study. Propensity-score matching was performed based on preoperative factors with a 2:1 ratio. Primary endpoint was the weight loss at 2 years between the SG and RYGB groups. Secondary endpoints were overall mortality and morbidity, reoperation, correction of comorbidities and the rate of adverse events at 2 years follow-up. RESULTS: In our propensity score matching analysis, operative time was significantly less in the SG group (95 min vs. 179 min; p < 0.001). Post-operative complications were lower in the SG group (9.5% vs. 35.4%; p = 0.003). At 2 years follow-up, the mean EWL was similar as same as comorbidities. There was a significant difference in favor of SG concerning the rate of adverse events at 2 years follow-up (p < 0.001). CONCLUSION: Revision of GB by SG or RYGB is feasible, with a higher rate of early post-operative complications for RYGB. Weight loss at 2 years follow-up is similar; however, RYGB appears to result in a higher rate of adverse events than SG.

Does the Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines Improve Outcomes of Bariatric Surgery? A Propensity Score Analysis in 464 Patients.

BACKGROUND: The aim of this study was to investigate whether the implementation of enhanced recovery after surgery (ERAS) guidelines according to Thorell and co. in our tertiary referral bariatric center might improve post-operative outcomes. METHODS: ERAS program was introduced in our center since January 1, 2017. Retrospective review of a prospectively collected database identified patients who underwent laparoscopic primary and revisional bariatric surgeries from October 2005 to January 2018. Patients exposed to ERAS program ("ERAS group") were matched in a 1:1 ratio with patients exposed to conventional care (control group) using a propensity score based on age, gender, preoperative body mass index (BMI), diabetes mellitus, and the type of procedures. The primary outcome was total hospital length of stay (LOS) and the secondary outcomes included the post-operative complications and readmission rates. RESULTS: During the study period, 464 patients were included, 232 in each group. Implementation of the ERAS protocol was significantly associated with a reduction of LOS (2.47 ± 1.7 vs 5.39 ± 1.9 days, p < 0.00001). One-third of patients was discharged (77/232, 33%) on the first postoperative day (POD) and more than three quarter of patients on POD 2 (182/232, 77%). At the opposite, no patients of the control group were discharged on POD 2. Overall 30-day and 90-day morbidity and readmission rates were the same in both groups. There was no death in each group. CONCLUSIONS: This large case-matched study using a propensity score analysis suggests that implementation of ERAS program significantly reduced length of hospital stay without significant increases on overall morbidity, and readmission rates.

Revisional Roux-en-Y Gastric Bypass: a Safe Surgical Opportunity? Results of a Case-Matched Study.

OBJECTIVE: To evaluate the safety and efficacy of revisional Roux-en-Y gastric bypass (RYGB) after adjustable gastric banding (AGB) or sleeve gastrectomy (SG) compared with primary RYGB, in regard to early and late morbidity, weight, and resolution of obesity-related comorbidities. METHODS: The group of patients undergoing revisional RYGB was matched in a 1:1 ratio with control patient who underwent a primary RYGB, based on age, gender, American Society of Anesthesiologist (ASA) score, preoperative body mass index (BMI), and diabetes mellitus. Demographics, anthropometrics, preoperative work-up, and perioperative data were retrieved. RESULTS: One hundred fifteen patients (16 males and 99 females) with a mean age of 45.5 ± 1.5 years underwent revisional RYGB following either LAGB in 82 patients (71.3%) or laparoscopic sleeve gastrectomy (LSG) in 33 patients (28.7%). There was no conversion and no mortality in either group. Revisional RYGB was associated with similar early (16.5 vs 15.6%, ns) and late (42.6% vs 32.2%, ns) morbidity rates with a mean follow-up of 25.3 ± 16.6 months compared to primary laparoscopic Roux-en-Y gastric bypass. The revisional RYGB group had significantly less weight loss (mean %EWL 67.4 ± 20.7 vs 72.7 ± 22.9, p = 0.023 and mean %EBMI 68.1 ± 22 vs 78.3 ± 25.7, p = 0.01) at the time of 1 year. Improvement of comorbidities including hypertension (62.5 vs 70.5%; p > 0.05), diabetes (73.7 vs 79%; p > 0.05), and obstructive sleep apnea syndrome (100 vs 97%; p > 0.05) was similar. CONCLUSION: This large case-matched study suggests that conversion of SG or AGB to RYGB is feasible with early and late comparable morbidity in an accredited center; even weight results might be inferior.

F18-choline PET/CT guided surgery in primary hyperparathyroidism when ultrasound and MIBI SPECT/CT are negative or inconclusive: the APACH1 study.

PURPOSE: To evaluate the sensitivity of F18-choline (FCH) PET/CT for parathyroid adenoma detection prior to surgery in patients with primary hyperparathyroidism and negative or inconclusive cervical ultrasound and Tc99m-sestaMIBI SPECT/CT. METHODS: We conducted a prospective bicentric study (NCT02432599). All patients underwent FCH PET/CT. The result was scored positive, inconclusive or negative. The number of uptakes and their sites were recorded. The FCH PET/CT result guided the surgical procedure (minimally invasive parathyroidectomy, bilateral cervical exploration, or other in case of multiple or ectopic foci). FCH PET/CT results were compared to the surgical and pathological findings and the follow-up. RESULTS: Twenty-five patients were included. Mean calcium and PTH levels prior to surgery were 2.76 ± 0.17 mmol/l and 94.8 ± 37.4 ng/l. Nineteen (76%) FCH PET/CTs were scored positive, 3 (12%) inconclusive and 3 (12%) negative, showing 21 cases of uniglandular disease, including 1 ectopic localization and 1 case of multiglandular (3 foci) disease. Mean lesion size was 13.1 ± 8.6 mm. Twenty-four patients underwent surgery. FCH PET/CT guided surgery in 22 (88%) patients, allowing for 17 minimally invasive parathyroidectomies, 1 bilateral cervical exploration for multifocality and 4 other surgical procedures. Two patients with negative FCH-PET/CT underwent bilateral cervical exploration. When dichotomizing the FCH PET/CT results, thereby classifying the inconclusive FCH PET/CT results as positive, the per lesion and per patient sensitivities were 91.3% (95%CI: 72.0-98.9) and 90.5% (95%CI: 69.6-98.8) and the corresponding positive predictive values were 87.5% (95%CI: 67.6-97.3) and 86.4% (95%CI: 65.1-97.1), respectively. Twenty-one (88%) patients were considered cured after surgery. Their mean calcium level after surgery was 2.36 ± 0.17 mmol/l. CONCLUSIONS: Preoperative FCH PET/CT has a high sensitivity and positive predictive value for parathyroid adenoma detection in patients with primary hyperparathyroidism and negative or inconclusive conventional imaging results. Bilateral cervical exploration could be avoided in the majority (75%) of patients.

Esophagopericardial fistula: an unexpected dreaded complication of treatment of leak following revisional sleeve gastrectomy by endoscopic internal drainage.

Esophagopericardial fistula (EPF) is an uncommon but life-threatening complication of upper gastrointestinal tract surgery or endoscopy, which is related to anastomotic breakdown, chronic infection or esophageal traumatism. We first describe the first case of an EPF secondary to double pigtail drain migration: an endoscopic internal approach for the treatment of leak following revisional sleeve gastrectomy.

Indications and mid-term results of conversion from sleeve gastrectomy to Roux-en-Y gastric bypass.

Sleeve gastrectomy (SG) is currently considered as a primary bariatric surgery. This is because of its relative simplicity and satisfactory results. As observed with other bariatric procedures, surgeons are confronted with insufficient weight loss or weight regain, insufficient resolution of metabolic disorders, and intractable severe reflux. A retrospective analysis of conversion from SG to Roux-en-Y gastric bypass (RYGBP) was performed to assess weight loss, diabetes resolution, and relief of reflux symptoms. The mean interval between the two procedures was almost 24 months. Eighteen patients underwent conversion from SG to RYGBP for insufficient weight loss (n = 9), severe reflux (n = 6), and persistence of type 2 diabetes mellitus (T2DM) (n = 3). The median follow-up was 15.5 months. Weight loss was significantly improved with a mean percentage of excess of body mass index loss at 64.6 % after conversion versus 47.1 % before conversion. All reflux symptoms were immediately relieved without any medication at the end of the follow-up. The three patients who had an operation for persistence of T2DM are now free of medication. Only one postoperative complication was observed as a small bowel injury, which was treated surgically. Conversion from SG to RYGBP is safe. Severe reflux is definitely treated and is an incontestable indication with this procedure. Additionally, weight loss and diabetes are clinically improved. Our results appear to be similar to those with a primary RYGBP.

Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study.

CONTEXT: Surgical site infections prolong hospital stays, are among the leading nosocomial causes of morbidity, and a source of excess medical costs. Clinical studies comparing the risk of nosocomial infection after different hand antisepsis protocols are scarce. OBJECTIVE: To compare the effectiveness of hand-cleansing protocols in preventing surgical site infections during routine surgical practice. DESIGN: Randomized equivalence trial. SETTING: Six surgical services from teaching and nonteaching hospitals in France. PATIENTS: A total of 4387 consecutive patients who underwent clean and clean-contaminated surgery between January 1, 2000, and May 1, 2001. INTERVENTIONS: Surgical services used 2 hand-cleansing methods alternately every other month: a hand-rubbing protocol with 75% aqueous alcoholic solution containing propanol-1, propanol-2, and mecetronium etilsulfate; and a hand-scrubbing protocol with antiseptic preparation containing 4% povidone iodine or 4% chlorhexidine gluconate. MAIN OUTCOME MEASURES: Thirty-day surgical site infection rates were the primary end point; operating department teams' tolerance of and compliance with hand antisepsis were secondary end points. RESULTS: The 2 protocols were comparable in regard to surgical site infection risk factors. Surgical site infection rates were 55 of 2252 (2.44%) in the hand-rubbing protocol and 53 of 2135 (2.48%) in the hand-scrubbing protocol, for a difference of 0.04% (95% confidence interval, -0.88% to 0.96%). Based on subsets of personnel, compliance with the recommended duration of hand antisepsis was better in the hand-rubbing protocol of the study compared with the hand-scrubbing protocol (44% vs 28%, respectively; P =.008), as was tolerance, with less skin dryness and less skin irritation after aqueous solution use. CONCLUSIONS: Hand-rubbing with aqueous alcoholic solution, preceded by a 1-minute nonantiseptic hand wash before each surgeon's first procedure of the day and before any other procedure if the hands were soiled, was as effective as traditional hand-scrubbing with antiseptic soap in preventing surgical site infections. The hand-rubbing protocol was better tolerated by the surgical teams and improved compliance with hygiene guidelines. Hand-rubbing with liquid aqueous alcoholic solution can thus be safely used as an alternative to traditional surgical hand-scrubbing.