Propensity score matched analysis of laparoscopic revisional and conversional sleeve gastrectomy with concurrent hiatal hernia repair.

INTRODUCTION: The primary aim of this study was to evaluate outcomes associated with concurrent hiatal hernia repair (CHHR) when performing a conversional or revisional vertical sleeve gastrectomy (VSG). CHHR is often necessary during VSG due to potential gastroesophageal reflux disease (GERD) development or obstructive symptoms. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement (MBSAQIP) participant use file was assessed for the years 2015-2020 for revisional/conversional VSG procedures. The presence of CHHR was used to create two groups. Propensity score matching (PSM) was performed with E-analysis. RESULTS: There were 33,909 patients available, with 5986 undergoing the VSG procedure with CHHR. In the unmatched analysis, there was an increased frequency of patients being female (85.72 vs 83.30%; p < 0.001), having a history of GERD (38.01 vs 31.25%; p < 0.001), and being of older age (49.59 ± 10.97 vs 48.70 ± 10.83; p < 0.001). Patients undergoing VSG with CHHR experienced decreased sleep apnea (25.00 vs 28.84%; p < 0.001) and diabetes (14.27 vs 17.80%; p < 0.001). PSM yielded 5986 patient pairs. Matched patients with CHHR experienced increased operative time (115 min ± 53 vs 103 min ± 51; p < 0.001), increased risk of postoperative pneumonia (0.45 vs 0.15%; p = 0.005) and readmission (4.69 vs 3.58%; p = 0.002) within thirty days. However, patients undergoing CHHR with revisional or conversional VSG did not experience increased risk of death, postoperative bleeding, postoperative leak, or reoperations. CONCLUSION: Despite a small association with increased postoperative pneumonia, the rate of complications in patients undergoing laparoscopic revisional/conversional VSG and CHHR are low. CHHR is a safe option when combined with the laparoscopic revisional/conversional VSG procedure in the early postoperative period.

Concurrent paraesophageal hernia repair in revisional/conversional laparoscopic Roux-en-Y gastric bypass: propensity score-matched analysis of the MBSAQIP database.

BACKGROUND: Patients requiring concurrent paraesophageal hernia repair (CPHR) have been shown to have favorable outcomes in primary bariatric surgery. However, patients requiring revisional or conversional surgery represent a group of patients with higher perioperative risk. Currently, few reports on concurrent paraesophageal hernia repair utilizing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database are available. The primary aim of this study was to determine perioperative complications associated with CPHR and the Roux-en-Y gastric bypass (RYGB) as a revisional/conversional operation. METHODS: In this study, patients undergoing revisional/conversional RYGB between 2015 and 2020 were accessed via the MBSAQIP database. Patients were categorized based on the presence of a paraesophageal hernia as a concurrent procedure. Patients who underwent revisional/conversional surgery without additional procedures were utilized for controls. A propensity score-matched cohort was generated and E-analysis utilized to assess unmeasured confounding. RESULTS: After exclusions, 35,698 patients were available. Patients receiving CPHR were more likely to be female (90.79% vs 87.37%; p < 0.001) and have increased frequency of gastroesophageal reflux disease (69.20% vs 51.69%; p < 0.001). However, these patients had lower frequencies of sleep apnea (24.12% vs 30.13%; p < 0.001), hypertension requiring medication (38.51% vs 42.59%; p < 0.001), and decreased frequency of hyperlipidemia (19.44% vs 21.60%;p < 0.001). After matching, 6,231 patient pairs were developed and showed that patients undergoing CPHR were at increased risk of readmission (9.44% vs 7.58%; p < 0.001), intervention (3.56% vs 2.79%; p = 0.018), increased requirement for outpatient dehydration treatment (5.87% vs 4.67%;p = 0.004), and overall increased operation time (169.3 min ± 76.0 vs 153.5 ± 73.3; p < 0.001). However, there were no significant increases in the rates of reoperation, death, postoperative leak complications, or bleeding complications after CPHR. CONCLUSION: Patients undergoing revisional/conversional RYGB with CPHR may be at higher risk for a small number of rare postoperative complications. CPHR is a safe procedure in patients undergoing revisional/conversional RYGB in the short-term postoperative period.

Current practices in biliary surgery: Do we practice what we teach?

INTRODUCTION: Since the widespread adoption of laparoscopic techniques in biliary surgery, the incidence of bile duct injures (BDI) has not significantly declined despite increased operative experience and recognition of the critical view of safety (CVS) method for anatomic identification. We hypothesized that operative approaches in clinical practice may vary from well-described technical recommendations. The objective of this study was to access how practicing surgeons commonly identify anatomy during laparoscopic cholecystectomy (LC). METHODS: We performed a cohort study assessing practices in biliary surgery among current practicing surgeons. Surgeons belonging to the Midwest Surgical Association and the Society of American Gastrointestinal and Endoscopic Surgeons were surveyed. Items surveyed include preferred methods for cystic duct identification, recognition of the CVS, and use of intraoperative imaging. RESULTS: In total, 374 of 849 surgeons responded. The CVS was not correctly identified by 75 % of surgeons descriptively and by 21 % of surgeons visually. 56 % of surgeons practiced the infundibular method for identification of the cystic duct; 27 % practiced the CVS method. Intraoperative cholangiography was used by 16 % and laparoscopic ultrasound by <1 %. CONCLUSION: A majority of surgeons preferably do not use the CVS method of identification during LC. A large percentage of practicing surgeons are unable to describe or visually identify the CVS. These results suggest an urgent need to reexamine the tenets of how LC is being taught and disseminated and present a clear target for improvement to reduce BDI.

Robotic Repair of a Paraesophageal Hernia After an Open Nissen Fundoplication: Case Presentation and Clinical Discussion.

We present a female in her sixties with a recurrent paraesophageal hernia status post open Nissen fundoplication and multiple esophageal dilations who underwent a robotic paraesophageal hernia repair, with extensive lysis of adhesions. The stomach and esophagus were dissected off the crura and the previous wrap was undone. Once the entirety of the stomach and esophagus were freed from their surrounding structures, the hernia sac was able to be excised. The crural defect was closed and gastropexy was performed. The patient had an uneventful postoperative course and was discharged home. This case is presented to provide evidence that robotic repair presents a viable option in the reoperation of patients following an open Nissen fundoplication as well as provide an overview of the types of hiatal hernias and the indications and options for surgical intervention.

Appendiceal Vaginal Fistula: A Rare Complication of Nonoperative Appendicitis Management.

Appendicitis is one of the most common conditions encountered in emergency surgical practice. An appendico-cutaneous fistula is a rare complication of appendicitis. An appendico-vaginal fistula is extremely rare. To our knowledge, based on a thorough review of the literature using PubMed, MEDLINE, and Google Scholar, only three other cases of an appendico-vaginal fistula have been reported. We present one such case in a 43-year-old female with a history of partial hysterectomy, recurrent abscesses that had failed to respond to repeated drainage and antibiotic treatment, and nonoperative treatment of appendicitis.

The role of preoperative toxicology screening in patients undergoing bariatric surgery.

BACKGROUND: Some programs and insurers may require patients to undergo toxicology screening despite lack of evidence that this practice affects postoperative outcomes. OBJECTIVES: To understand the prevalence of screening positive on toxicology testing in the bariatric surgical population and to examine the association between testing positive and important surgical outcomes. METHODS: We performed a retrospective review of patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from an academic health system from 2017-2020. We described the rate of preoperative toxicology positivity as determined by serum and urine testing. We examined the association between toxicology positivity and outcomes of preoperative length, 30-day complications (bleeding, venous thromboembolism, leak, wound infection, pneumonia, urinary tract infection, and myocardial infarction), readmissions, and 1-year weight loss using chi-square and t-test analysis. RESULTS: Of 1057 patients, there were 134 patients (12.7%) who had positive toxicology testing. Of these, 37 (28%) were positive for opiates and 21 (16%) were positive for cotinine. Mean preoperative length was 381.8 days (standard deviation [SD], 222.5) for patients with positive testing versus 287.8 days (SD, 151.5; P = 1.00) for negative testing. Toxicology positivity was not associated with readmissions (5.2% versus 4.3%, X2 = 0.22; P = .64). The loss to follow-up at 1 year was 32.5%. There was no association with 1-year mean change in body mass index (mean of loss 12.23kg/m2 [SD, 5.61]) versus mean of loss 12.74 (SD, 6.44; P = .20)]. CONCLUSIONS: Our study is the first to describe preoperative toxicology positivity rates. We found no association between toxicology positivity and preoperative length, readmissions, or weight loss. Given its lack of impact on outcomes, toxicology testing prior to bariatric surgery may be an unnecessary burden on patients and healthcare, with regard to cost and wait times.

Outcomes in complex ventral hernia repair with anterior component separation in class III obesity patients.

BACKGROUND: Consensus guidelines recommend against elective ventral hernia repair (VHR) in patients with BMI >30 kg/m2 without preoperative weight loss intervention. We aim to compare hernia recurrence and perioperative complications in VHR utilizing anterior component separation (CS) in patients with class III obesity (BMI >40 kg/m2). METHODS: A retrospective review of patients undergoing VHR with CS was performed. The primary endpoint was hernia recurrence; secondary endpoints were wound complications, postoperative medical complications, mortality and length of stay. RESULTS: 185 consecutive patients were identified from 2008 to 2016. There were no significant differences between groups: hernia recurrence (6.9% BMI >40 kg/m2, 2.4% BMI <39.9 kg/m2, p = 0.21), wound complications (58.6% BMI >40 kg/m2, 47.2% BMI <39.9 kg/m2, p = 0.16), postoperative complications (39.7% BMI >40 kg/m2, 26% BMI <39.9 kg/m2, p = 0.08), mortality (1.6% BMI >40 kg/m2, 3.4% BMI <39.9 kg/m2, p = 0.59), and length of stay (10.6 days BMI >40 kg/m2, 11.2 days BMI <39.9 kg/m2, p = 0.5). CONCLUSION: This study demonstrates similar outcomes in class III obesity patients undergoing elective VHR compared to patients with BMI <39.9 kg/m2.