Revisional Bariatric/Metabolic Surgery: What Dictates Its Indications?

Bariatric/metabolic surgery is currently the only effective long-term treatment for morbid obesity- and obesity-related diseases such as diabetes, heart disease, hypertension, obstructive sleep apnea, and dyslipidemia. In addition, bariatric/metabolic surgery has been shown to significantly reduce the incidence of diabetes and cancer and prolong life when compared to non-surgical therapies. However, as obesity is a chronic disease, recidivism of weight and comorbid conditions can occur. In addition, the surgical construct can lead to long-term consequences such as marginal ulceration, bowel obstruction, reflux, and nutritional deficiencies. Despite these drawbacks, prospective randomized controlled studies and long-term longitudinal population-based comparative studies greatly favor surgical intervention as opposed to traditional lifestyle, diet, and exercise programs. Revisional surgery can be quite complex and technically challenging and may offer the patient a wide variety of solutions for treatment of weight recidivism and complications after primary operations. Given the paucity of high quality published data, we have endeavored to provide indications for revisions after bariatric surgery.

Prophylactic Fresh Frozen Plasma Infusion is Ineffective in Reversing Warfarin Anticoagulation and Preventing Delayed Intracranial Hemorrhage After Falls.

BACKGROUND: Elderly patients, with considerable fall risk, are increasingly anticoagulated to prevent thromboembolic disease. We hypothesized that a policy of prophylactic fresh frozen plasma (FFP) infusion in patients having falls would reverse vitamin K antagonists (VKAs) and that reversal would decrease delayed intracranial hemorrhage (ICH). METHODS: A retrospective review of patients with trauma admitted to a level 2 community trauma center was performed from January 2010 until November 2012. Inclusion criteria were: ground level fall (GLF) with suspected head trauma, on VKA, an international normalized ratio (INR) of >1.5, and a negative head computed tomography (CT). Patients were transfused with FFP to a goal INR of <1.5 while observed. Patients were classified as reversed (REV) if the lowest INR achieved within 4 to 24 hours after initial INR was <1.5 or unreversed (NREV) if lowest INR achieved was >1.5. Chi-square and logistic regression were performed. RESULTS: A total of 194 patients met the criteria. In all, 43 (22%) patients were able to be REV, and 151 (78%) patients remained NREV. Unreversed patients were male and younger (P < .05). There was no difference in mean FFP received. Unreversed patients had a higher initial INR of 3.0 compared to REV patients (2.5; P = .018). One patient developed a delayed ICH and belonged to the REV group. CONCLUSION: The incidence of delayed hemorrhage was 0.5%. A strategy of prophylactic FFP infusion was ineffective in VKA reversal. We recommend against prophylactic infusion of FFP during a period of observation for patients on VKA with suspected head trauma and a negative initial CT.

Periprosthetic Anesthetic for Postoperative Pain After Laparoscopic Ventral Hernia Repair: A Randomized Clinical Trial.

IMPORTANCE: Laparoscopic ventral hernia repair (LVHR) using mesh is a well-established intervention for ventral hernia, but pain control can be challenging. OBJECTIVE: To determine whether instillation of a long-acting local anesthetic between the mesh and the peritoneum after LVHR reduces pain or narcotic requirements. DESIGN, SETTING, AND PARTICIPANTS: A prospective, double-blind, randomized clinical trial with data collection during a brief hospital stay in a tertiary care, community teaching hospital over 3 years between December 15, 2011, and March 28, 2014. Of 120 screened patients undergoing LVHR in this intention-to-treat analysis, 99 eligible patients were randomized. Forty-two patients received the study drug, and 38 patients received placebo. Patients with a history of chronic narcotic use were excluded. INTERVENTION: After mesh placement, a long-acting local anesthetic (bupivacaine hydrochloride, 0.50%) or placebo (0.9% normal saline) was injected between the mesh and the peritoneum. MAIN OUTCOMES AND MEASURES: Postoperative pain (on a standard scale ranging from 0 to 10), and narcotic medication use (intravenous morphine equivalents). There were no adverse events. RESULTS: Baseline and operative characteristics were similar except that the treatment group was older (61.8 vs 52.3 years, P = .001). After surgery, pain scores in the recovery room (3.2 vs 4.7, P = .003), interval total narcotic use (6.7 vs 12.5 mg, P = .003 at <4 hours and 0 vs 2.7 mg, P = .01 at 8-12 hours), and total intravenous narcotic use (9.2 vs 17.2 mg of morphine sulfate equivalents, P = .03) were significantly less in the treatment group. CONCLUSIONS AND RELEVANCE: Administration of a long-acting local anesthetic between the mesh and the peritoneum significantly reduces postoperative pain and narcotic use after LVHR. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01530815.

Laparoscopic Versus Open Bowel Resection in Emergency Small Bowel Obstruction: Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: Small bowel obstruction (SBO) is commonly encountered by surgeons and has traditionally been handled via an open approach, especially when small bowel resection (SBR) is indicated, although recent series have shown improved outcomes with a laparoscopic approach. In this retrospective study, we sought to evaluate outcomes and identify risk factors for adverse events after emergency SBR for SBO with an emphasis on surgical approach. MATERIALS AND METHODS: In this retrospective review using American College of Surgeons National Surgical Quality Improvement Program data, 1750 patients were identified who had emergency SBR with the principal diagnosis of SBO from 2006 to 2011. Mortality and postoperative adverse events were evaluated. RESULTS: Of 1750 patients who had emergency SBR, 51 (2.9%) had laparoscopic bowel resection (LBR). There was no difference in surgery duration (open bowel resection [OBR] versus LBR, 100 minutes versus 92 minutes; P=.38). Compared with the LBR group, the OBR group had a higher rate of baseline cardiac comorbidities and postoperative complications, and their length of stay was longer (10 versus 8 days; P<.001). Using multivariate analysis, perioperative variables of age >70 years, pulmonary, renal, neurological, and cardiac comorbidities, preoperative sepsis, steroid use, and body mass index of <30 kg/m(2) were associated with increased odds of mortality. OBR was associated with overall increased odds of morbidity (2.8; P=.003) and postoperative wound (2.9; P=.018) and respiratory (6.5; P=.011) infections. CONCLUSIONS: LBR was associated with equivalent operative time, shorter length of stay, less morbidity, and equivalent mortality compared with OBR. Although therapy for SBO secondary to adhesive disease remains controversial, our study shows numerous benefits to the laparoscopic approach to SBOs and thus should be considered a first-line treatment option for the management of this common surgical problem.

Model Point-of-Care Ultrasound Curriculum in an Intensive Care Unit Fellowship Program and Its Impact on Patient Management.

Objectives. This study was designed to assess the clinical applicability of a Point-of-Care (POC) ultrasound curriculum into an intensive care unit (ICU) fellowship program and its impact on patient care. Methods. A POC ultrasound curriculum for the surgical ICU (SICU) fellowship was designed and implemented in an urban, academic tertiary care center. It included 30 hours of didactics and hands-on training on models. Minimum requirement for each ICU fellow was to perform 25-50 exams on respective systems or organs for a total not less than 125 studies on ICU. The ICU fellows implemented the POC ultrasound curriculum into their daily practice in managing ICU patients, under supervision from ICU staff physicians, who were instructors in POC ultrasound. Impact on patient care including finding a new diagnosis or change in patient management was reviewed over a period of one academic year. Results. 873 POC ultrasound studies in 203 patients admitted to the surgical ICU were reviewed for analysis. All studies included were done through the POC ultrasound curriculum training. The most common exams performed were 379 lung/pleural exams, 239 focused echocardiography and hemodynamic exams, and 237 abdominal exams. New diagnosis was found in 65.52% of cases (95% CI 0.590, 0.720). Changes in patient management were found in 36.95% of cases (95% CI 0.303, 0.435). Conclusions. Implementation of POC ultrasound in the ICU with a structured fellowship curriculum was associated with an increase in new diagnosis in about 2/3 and change in management in over 1/3 of ICU patients studied.

Incidence of intracranial hemorrhage and outcomes after ground-level falls in geriatric trauma patients taking preinjury anticoagulants and antiplatelet agents.

Antiplatelet and anticoagulant medication increases the risk of intracranial hemorrhage (ICH) after a fall in geriatric patients. We sought to determine whether there were differences in ICH rates and outcomes based on type of anticoagulant or antiplatelet agent after a ground-level fall (GLF). Our institutional trauma registry was used to identify patients 65 years old or older after a GLF while taking warfarin, clopidogrel, or aspirin over a 2-year period. Rates and types of ICH and patient outcomes were evaluated. Of 562 patients who met inclusion and exclusion criteria, 218 (38.8%) were on warfarin, 95 (16.9%) were on clopidogrel, and 249 (44.3%) were on aspirin. Overall ICH frequency was 15 per cent with no difference in ICH rate, type of ICH, need for craniotomy, mortality, or intensive care unit or hospital length of stay between groups. Patients with ICH were more likely to present with abnormal Glasgow Coma Score, history of hypertension, and/or loss of consciousness.

Accuracy of national surgery quality improvement program models in predicting postoperative morbidity in patients undergoing colectomy.

BACKGROUND: The National Surgery Quality Improvement Program (NSQIP) is the standard for assessment of acuity-adjusted outcomes in surgery. The validity of NSQIP has not been well established in colorectal surgery. Technical and process variables, which NSQIP may not consider, affect morbidity rate. OBJECTIVE: A retrospective observational study was undertaken to determine the accuracy of NSQIP models in predicting morbidity for patients undergoing laparoscopic or open colectomy. METHODS: NSQIP participant use files for 2005 to 2008 were obtained. Data were selected using Current Procedural Terminology coding for open or laparoscopic colectomy. NSQIP-generated predicted morbidities were used to create area under the receiver operator curves (AUROCs). RESULTS: AUROCs demonstrated an accurate predictive model if the value was above 0.8 and indicated a marginal predictor mode if below 0.7. The AUROC for the general NSQIP model was 0.817 (confidence interval [CI] = 0.815-0.819, p < 0.001). AUROC for the combined laparoscopic and open colectomy group was 0.703 (CI = 0.698-0.709, p value < 0.001). AUROCs for the individual laparoscopic and open colectomy groups were 0.627 (CI = 0.615-0.640, p < 0.001) and 0.701 (CI = 0.695-0.707, p < 0.001). CONCLUSION: This study demonstrates that although NSQIP-generated morbidities used to create AUROCs are accurate for patients in an overall surgical model, predictive models for morbidity are marginal for laparoscopic and open abdominal colectomies. NSQIP risk models tend to emphasize comorbidities rather than intraoperative details or technical aspects of colonic resections.

Predictors of critical care-related complications in colectomy patients using the National Surgical Quality Improvement Program: exploring frailty and aggressive laparoscopic approaches.

BACKGROUND: Colectomy patients experience a broad set of adverse outcomes. Complications requiring critical care support are common in this group. We hypothesized that as frailty increases, the risk of Clavien class IV and V complications will increase in colectomy patients. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) participant use files for 2005-2009, we identified patients who underwent laparoscopic and open colectomies by Current Procedural Terminology code. Using the Clavien classification for postoperative complications, we identified NSQIP data points most consistent with Clavien class IV requiring intensive care unit (ICU) care or class V complications (death). We used a modified frailty index with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index and existing NSQIP variables. Logistic regression was performed to acuity adjust the findings. RESULTS: A total of 58,448 colectomies were identified. As frailty index increased from 0 to 0.55, the proportion of those experiencing Clavien class IV or V complications increased from 3.2% at baseline to 56.3%. Variables found to be significant by logistic regression (odds ratio) were frailty index (14.4; p = 0.001), open procedure (2.35; p < 0.001), and American Society of Anesthesiologists class 4 (3.2; p = 0.038) or 5 (7.1; p = 0.001) while emergency operation and wound classification 3 or 4 were not. CONCLUSIONS: Complications requiring ICU care represent a significant morbidity in the colectomy patient population. Frailty index seems to be an important predictor of ICU-level complications and death, and laparoscopy seems to be protective.

Getting back to zero with nucleated red blood cells: following trends is not necessarily a bad thing.

BACKGROUND: The presence of nucleated red blood cells (NRBCs) has been identified as a poor prognostic indicator. We investigated the relationship of NRBC trends in patients with and without trauma. METHODS: We retrospectively reviewed surgical intensive care unit admissions over 4 years, categorizing trauma and nontrauma patients and subdividing them into 3 groups: group A, all-zero NRBC; group B, positive NRBC value returning to zero; and group C, positive NRBC value that did not return to zero. We analyzed all groups for outcomes of length of stay and mortality. RESULTS: Group A was the largest and had the shortest length of stay and least mortality. Group C had the highest mortality rate. No statistical difference was observed with mortality. CONCLUSIONS: Any positive NRBC was associated with poor outcome, and increasing NRBC was associated with increasing mortality. Trends in NRBC values showed that returning to zero was protective.

A comparative study of handsewn versus stapled gastrojejunal anastomosis in laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The two basic techniques available in which to perform the gastrojejunal (GJ) anastomosis during a laparoscopic Roux-en-Y gastric bypass (LRYGBP) are stapled and handsewn. Few outcomes differences have been noted between the two to recommend one as a superior approach. We present our findings in comparison of the two methods. METHODS: This is a retrospective review of all patients who underwent LRYGBP at a single institution during a 3-year period. The two different techniques that were used were a linear stapled and handsewn anastomosis with an anastomotic diameter of 18 mm. The groups were compared for postoperative complications, including stricture, anastomotic leak, and the need for early reoperation. All patients were followed up for a minimum period of 8 months. RESULTS: A total of 222 patients were analyzed after excluding 4 patients: 3 for revisional surgery and 1 for conversion to open. There were 99 patients in the stapled group and 123 in the handsewn group. In both groups, patients were predominantly female. The average age was 42.63 in the stapled group and 44.33 in the handsewn group (P = 0.218). Body mass index was 48.23 in the stapled group and 47.91 in the handsewn group (P = 0.733). Stricture rate in the stapled group was 10.1% (10/99) and 4.1% (5/123) in the handsewn group (P = 0.076). Four patients from the stapled group (4.08%) and six from the handsewn group (4.88%) needed early reoperation. One patient in each group had a GJ anastomotic leak (0.9%). There were no deaths. CONCLUSIONS: The incidence of anastomotic stricture tends to be lower with a handsewn technique with lower operative time. No difference was appreciated in the anastomotic leak or reexploration rate with either technique.

Disproportionate Acidosis After Traumatic Bladder Rupture: A Case-Control Study.

BACKGROUND: Traumatic bladder injury is rare and often missed on initial evaluation. We sought to identify early markers of bladder injury with a high sensitivity. METHODS: A retrospective review from 1999 to 2008. RESULTS: There were 28 patients diagnosed with traumatic bladder injury. The most common mechanism was car accidents with pelvic fractures. 93% (26) of the patients presented with significant metabolic acidosis, without evidence of hemorrhagic shock. For intra- and extraperitioneal bladder ruptures, the mean hemoglobin level on arrival was 12.4 + 2.0 (range 9.0-16.0) and 11.4 + 1.9 (range 8.2-14.7). The average pH on arrival for intraperitoneal ruptures was 7.22 + 0.16 (range 6.86-7.37) and for extraperitoneal ruptures, 7.22 + 0.16 (range 6.85-7.37). The pH improved in all patients with intraperitoneal rupture after surgical repair, up to a mean of 7.27 + 0.11 (range 7.06-7.36, p = 0.5) within 12 h. Extraperitoneal ruptures recovered more quickly with a pH after catheter drainage of 7.34 + 0.04 (range 7.27-7.37, p = 0.1) within 12 h. The ISS for intraperitoneal and extraperitoneal ruptures were similar, 30 + 12 (range 13-57) and 32 + 13 (range 13-57, p = 0.7). A cohort of trauma patients, matched by ISS, age, and pelvic fracture, but without bladder rupture, was used for comparison. Their mean ISS was 30 + 10 (range 14-57). The average pH for this group on arrival was 7.33 + 0.11 (range 7.16-7.42), and 47% of these patients had a normal pH. There was a significant difference between the pH on arrival in the ruptured compared to the nonruptured cohort (intraperitoneal pH 7.22, p = 0.008, extraperitoneal pH 7.22, p = 0.02). Three patients died (mortality 10.7%). CONCLUSIONS: Disproportionate acidosis in the trauma patient is a sensitive indicator of bladder injury, especially with a pelvic fracture or hematuria. Fully resuscitated patients with persistent acidosis and an appropriate mechanism should be evaluated for bladder injury.