Laparoscopic pyloroplasty versus endoscopic per-oral pyloromyotomy for the treatment of gastroparesis.

BACKGROUND: Gastroparesis is a debilitating functional disorder of the stomach characterized by delayed gastric emptying absent an obstructive etiology. Surgical or endoscopic disruption of the pylorus has been utilized to treat this disease, but there is little evidence comparing laparoscopic pyloroplasty (LP) with endoscopic per-oral pyloromyotomy (POP). Herein we describe our experience at our institution using a propensity-matched cohort study to compare outcomes between these procedures. METHODS: All patients who underwent LP for the treatment of gastroparesis from October 2014 through September 2017 at our institution were retrospectively reviewed. Propensity scoring was used to match these patients 1:1 to patients undergoing POP during this time period based on gender, age, and etiology of gastroparesis. Symptom scores using the Gastroparesis Cardinal Symptom Index (GCSI), scintigraphic gastric emptying studies (GES), and perioperative outcomes were compared between matched cohorts. Thirty patients underwent LP for gastroparesis during the study period which were matched 1:1 with patients undergoing POP. The etiology of gastroparesis was 63.3% idiopathic (n = 19), 20.0% post-surgical (n = 6), and 16.7% diabetic (n = 5) in both cohorts. RESULTS: Patients who underwent LP had a longer average length of stay (4.6 vs. 1.4 days, p = 0.003), operative time (99.3 vs. 33.9 min, p < 0.001), and estimated blood loss (12.9 vs. 0.4 mL, p < 0.001). There were more complications in the LP cohort (16.7 vs. 3.3%, p = 0.086), which included surgical site infection (6.7 vs. 0%, p = 0.153), pneumonia (6.7 vs. 0.0%, p = 0.153), and unplanned ICU admission (10.0 vs. 0.0%, p = 0.078). LP and POP both resulted in similar, significant improvements in both in GCSI scores and objective gastric emptying. CONCLUSIONS: Per-oral endoscopic pyloromyotomy (POP) is safe and effective for the treatment of medical refractory gastroparesis. POP has less perioperative morbidity compared to LP with comparative functional outcomes.

Per-oral Pyloromyotomy (POP) for Medically Refractory Gastroparesis: Short Term Results From the First 100 Patients at a High Volume Center.

OBJECTIVE: For patients with gastroparesis, temporary pyloric disruption has been shown to improve symptoms and gastric emptying. Per-oral pyloromyotomy (POP) is an innovative endoscopic procedure to divide the pylorus from within a submucosal tunnel, as a corollary to surgical pyloromyotomy. Here we evaluate subjective and objective outcomes 12-weeks after POP at a high volume center. METHODS: The first 100 consecutive patients undergoing POP were included, with procedure dates between January 2016 and October 2017. Patients were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and 4-hour solid-phase scintigraphic gastric emptying studies (GES) prior to procedure and at 90 days post-POP RESULTS:: The study cohort was 85% female with a mean age of 45.0 ±â€Š14.6 years. Gastroparesis etiologies were divided among idiopathic (56%), diabetic (21%), postsurgical (19%), and other in 4%. There were 67% of the patients who had previous endoscopic or surgical interventions for gastroparesis. Most POP procedures were performed in the operating room (97%) and were completed in an average of 33 minutes. Ten patients incurred complications (10%), which included 1 diagnostic laparoscopy and 2 cases of gastrointestinal bleeding. Overall GCSI improved from a preoperative mean of 3.82 ±â€Š0.86 to 2.54 ±â€Š1.2 (P < 0.001). The improvement in each GCSI subscore was also highly statistically significant. Among the patients with postoperative GES available, 78% had objectively better 4-hour emptying with a mean improvement in retention by 23.6% (P < 0.001). This included 57% of patients with normal gastric emptying post-POP. CONCLUSION: For patients with medically refractory gastroparesis, POP results in both subjective and objective improvement in the majority of patients. Prior intervention does not obviate POP as a therapeutic option. POP should be included along the treatment algorithm for patients with gastroparesis as an organ-sparing procedure.

Upper gastrointestinal endoscopy is safe and feasible in the early postoperative period after Roux-en-Y gastric bypass.

BACKGROUND: Surgeons may be reluctant to perform upper gastrointestinal (UGI) endoscopy in the early post-operative period due to concern for anastomotic disruption. The aim of this study was to determine the safety and feasibility of early (≤ 30 days) post-operative UGI endoscopy after roux-en-y gastric bypass (RYGB). METHODS: A retrospective data analysis of a prospectively maintained database was completed between May 2002 and March 2015 for patients that had undergone UGI endoscopy within 30 days of their RYGB. Data analysis included baseline patient demographics, Charlson Comorbidity Index, perioperative parameters, indications for endoscopy; indications for any further endoscopic evaluation, interventions performed, and post-endoscopy complications. RESULTS: 190 patients underwent early postoperative UGI endoscopy after RYGB during the study period. Nineteen patients (10 %) had undergone revisional surgeries. The median duration to postoperative endoscopy was 22 days [IQR 16-26]. The most common indications included dysphagia (n = 74, 39%), abdominal pain (n = 53, 28%), nausea (n = 55, 29%), and vomiting (n = 47, 25%). Therapeutic interventions were performed in 79 patients (42%). These included balloon dilation (n = 66, 84%), feeding tube placement (n = 7, 9%), evacuation of clot (n = 2, 3%), epinephrine injection (n = 2, 3%) and coagulation of bleeding (n = 1, 1%). There were no post-UGI endoscopy anastomotic disruptions or leaks. CONCLUSION: Endoscopy is helpful for the diagnosis and management of complications after RYGB. Despite the perceived risks, our study demonstrated no complications for both diagnostic and therapeutic endoscopy when performed in the early postoperative period.

Utilization and outcome of laparoscopic versus robotic general and bariatric surgical procedures at Academic Medical Centers.

BACKGROUND: Robotic-assisted general and bariatric surgery is gaining popularity among surgeons. The aim of this study was to analyze the utilization and outcome of laparoscopic versus robotic-assisted laparoscopic techniques for common elective general and bariatric surgical procedures performed at Academic Medical Centers. METHODS: We analyzed data from University HealthSystem Consortium clinical database from October 2010 to February 2014 for all patients who underwent laparoscopic versus robotic techniques for eight common elective general and bariatric surgical procedures: gastric bypass, sleeve gastrectomy, gastric band, antireflux surgery, Heller myotomy (HM), cholecystectomy (LC), colectomy, rectal resection (RR). Utilization and outcome measures including demographics, in-hospital mortality, major complications, 30-day readmission, length of stay (LOS), and costs were compared between techniques. RESULTS: 96,694 laparoscopic and robotic procedures were analyzed. Utilization of the robotic approach was the highest for RR (21.4%), followed by HM (9.1%). There was no significant difference in in-hospital mortality or major complications between laparoscopic versus robotic techniques for all procedures. Only two procedures had improved outcome associated with the robotic approach: robotic HM and robotic LC had a shorter LOS compared to the laparoscopic approach (2.8 ± 3.6 vs. 2.3 ± 2.1; respectively, p < 0.05 for HM and 2.9 ± 2.4 vs. 2.3 ± 1.7; respectively, p < 0.05 for LC). Costs were significantly higher (21%) in the robotic group for all procedures. A subset analysis of patients with minor/moderate severity of illness showed similar results. CONCLUSION: This national analysis of academic centers showed a low utilization of robotic-assisted laparoscopic elective general and bariatric surgical procedures with the highest utilization for rectal resection. Compared to conventional laparoscopy, there were no observed clinical benefits associated with the robotic approach, but there was a consistently higher cost.

Body mass index is predictive of higher in-hospital mortality in patients undergoing laparoscopic gastric bypass but not laparoscopic sleeve gastrectomy or gastric banding.

High body mass index (BMI) has been shown to be a factor predictive of increased morbidity and mortality in several single-institution studies. Using the University HealthSystem Consortium clinical database, we examined the impact of BMI on in-hospital mortality for patients who underwent laparoscopic gastric bypass, sleeve gastrectomy, and gastric banding between October 2011 and February 2014. Outcomes were examined within each procedure according to BMI groups of 35 to 49.9, 50.0 to 59.9, and 60.0 kg/m(2) or greater. Outcome measures included in-hospital mortality, major complications, length of hospital stay, 30-day readmission, and cost. A total of 40,102 bariatric procedures were performed during this time period. For gastric bypass, there was an increase of in-hospital mortality (0.01 and 0.02 vs 0.34%; P < 0.01) and major complications (0.93 and 0.99 vs 2.62%; P < 0.01) in the BMI 60 kg/m(2) or greater group. In contrast, sleeve gastrectomy and gastric banding had no association between BMI and rates of mortality and major complications. Cost increased with increasing BMI groups for all procedures. A strong association was found between BMI 60 kg/m(2) or greater and higher in-hospital mortality and major complication rates for patients who underwent laparoscopic gastric bypass but not in patients who underwent sleeve gastrectomy or gastric banding.

Changes in high-sensitivity C-reactive protein levels after laparoscopic gastric stapling procedures versus laparoscopic gastric banding.

Obesity, hypertension, diabetes, and hyperlipidemia are risk factors for the development of coronary artery disease. High-sensitivity C-reactive protein (hs-CRP) is an inflammatory biomarker that has been shown to be an independent predictor for cardiovascular risk. The aim of the current study was to examine the changes in cardiovascular risk profile in morbidly obese patients who underwent laparoscopic gastric stapling procedures (bypass and sleeve) compared with laparoscopic gastric banding. Levels of hs-CRP were measured preoperatively and at 12 to 24 months postoperatively. Based on hs-CRP levels, cardiovascular risk was categorized as low (less than 1 mg/L), moderate (1 to 3 mg/L), or high (greater than 3 mg/L). A total of 52 patients underwent gastric stapling procedures and 49 underwent gastric banding and both had preoperative and postoperative hs-CRP levels measured. There were no significant differences in age, gender, or preoperative body mass index (BMI) between groups. At baseline, 48.0 per cent of patients undergoing gastric stapling and 38.8 per cent of patients undergoing gastric banding had moderate or high cardiovascular risk. BMI at 24 months was significantly lower in the gastric stapling compared with the gastric banding group (30.4 ± 5.4 vs 36.1 ± 5.5 kg/m(2), respectively, P < 0.01). Of the patients with elevated cardiovascular risk, 64.0 per cent of gastric stapling versus 57.8 per cent of gastric banding patients had a reduction in risk category at 12 to 24 months follow-up, whereas 1.9 per cent of patients undergoing gastric stapling versus 4.1 per cent of patients undergoing gastric banding had an increase in risk category. The mean reduction in hs-CRP level for patients with elevated cardiovascular risk was greater for gastric stapling compared with gastric banding procedures (-1.10 ± 0.94 mg/L vs -0.67 ± 0.82 mg/L, respectively, P < 0.05). Cardiovascular risk improved in the majority of patients after bariatric surgery, but a more pronounced improvement occurred in patients who underwent gastric stapling procedures.

Motor impairment rehabilitation post acquired brain injury.

OBJECTIVE: We sought to investigate the efficacy of treatment strategies used to manage motor impairments following acquired brain injury (ABI) in order to provide guidance for clinical practice based on the best available evidence. METHODS AND MAIN OUTCOMES: A systematic review of the literature from 1980-2005 was conducted focusing on pharmacological, non-pharmacological, and exercise interventions available for motor impairments post ABI. The efficacy of a given intervention was classified as strong (supported by two or more randomized controlled trials (RCTs)), moderate (supported by a single RCT), or limited (supported by other types of studies in the absence of RCTs). RESULTS: Thirty-six studies examining a variety of treatment approaches for motor impairments and activity limitations following ABI were evaluated. The majority of interventions are only supported by limited evidence. However, there is strong evidence that serial casting does reduce ankle plantar contractures due to spasticity of cerebral origin, and strong evidence also suggests that partial body weight supported gait training does not provide any added benefit over conventional gait training. There is also moderate evidence to support the use of functional fine motor control retraining to improve motor coordination, tizanidine for upper and lower extremity spasticity, and specific sit-to-stand training to improve functional ability. There is also moderate evidence that casting alone is as effective as casting and Botulinum toxin injections for plantar contractures. CONCLUSIONS: Although there are a variety of treatment strategies to manage motor impairments and activity limitations following ABI, most are only supported by limited evidence pointing to the need for studies of improved methodological quality in this area.

Post-traumatic seizure disorder following acquired brain injury.

OBJECTIVE: The present study aimed to evaluate the effectiveness of prophylactic anticonvulsant pharmacological strategies for the prevention of seizure disorders following acquired brain injury (ABI) to provide guidance for clinical practice based on the best available evidence. METHODS AND MAIN OUTCOMES: A systematic review of the literature from 1980-2005 was conducted focusing on treatment interventions available for post-traumatic seizures following ABI. The evidence for the efficacy of a given intervention was ranked as strong (supported by at least two randomized controlled trials (RCTs), moderate (supported by a single RCT), or limited (supported by other types of studies in the absence of RCTs). RESULTS: Based on a previous meta-analysis and the findings of this review, there is strong evidence that prophylactic anticonvulsant therapy decreases the occurrence of early seizures but only within the first week post-injury. Moreover, the evidence indicates that prophylactic anticonvulsant therapy does not decrease the incidence of seizure onset more than one week post-injury. In children, there is moderate evidence that prophylactic phenytoin does not reduce the incidence of early or late seizures. The efficacy of anticonvulsants after the development of seizures has not been specifically studied in ABI. CONCLUSIONS: Prophylactic anti-convulsants are effective in reducing seizures in the first week post-injury in adults. However, they do not reduce the occurrence of seizures after the first week.

Community reintegration following acquired brain injury.

OBJECTIVE: To evaluate the interventions and strategies used to enable transition from acute care or post-acute rehabilitation to the community following brain injury. METHODS AND MAIN OUTCOMES: A systematic review of the literature from 1980-2005 was conducted focusing on ABI rehabilitation. Five major aspects of community reintegration, including: independence and social integration, caregiver burden, satisfaction with quality of life, productivity and return to driving were considered. RESULTS: With the exception of one, the majority of interventions are supported by only limited evidence, denoting an absence of randomized controlled trials (RCTs) in the literature. Of 38 studies evaluated for this review, only one RCT was found. That RCT provided moderate evidence that behavioural management, coupled with caregiver education, did not help to improve caregiver burden. CONCLUSIONS: Further research, using an interventional approach, is required to advance the evidence base of reintegration into the community following brain injury.