Analysis of perioperative outcomes, length of hospital stay, and readmission rate after gastric bypass.

BACKGROUND: Hospital lengths of stay (LOS) and readmission rates often are used by third parties to measure quality of outcomes despite only a few published series that analyze risk-adjusted data and predictors of these events. METHODS: Single-institution retrospective multivariable analysis of consecutive Roux-en-Y gastric bypass (RYGB) patients was performed to determine variables that may influence LOS and the readmission rate. RESULTS: Between 2006 and 2010, 1,065 consecutive RYGB procedures were analyzed. The mean initial body mass index (BMI) of the patients was 48.4 kg/m(2) (range 35-108 kg/m(2)), and their mean age was 42 years (range 15-75 years). Of these patients, 42% were black and 31% were either Medicare or Medicaid beneficiaries. The average LOS was 1.8 days (range 1-59 days; median, 2 days). The hospital discharged 48% of these patients on postoperative day (POD) 1, 85% on POD 2, and 96% on POD 3. According to multivariable Poisson regression, the independent predictors of a longer LOS included longer procedure time, surgeon, BMI, black race, older age, and status as a Medicare/Medicaid beneficiary (all P < 0.01). Gender and measured comorbidities were not associated with LOS. However, this model was poorly predictive of LOS due to substantial unexplained variance (R (2) = 0.10). Complications were significantly associated with Medicare/Medicare status (odds ratio [OR] 2.0), older age (OR 1.03), and longer procedure time (OR 1.02) (P < 0.05). According to logistic regression, a 30-day readmission rate was predicted only by a LOS longer than 3 days for the primary procedure (P < 0.0005). CONCLUSIONS: Early discharge on postoperative day 1 is possible but nonmodifiable, and random patient factors challenge predictable discharge planning. Reliable discharge on postoperative day 1 is not likely with current technologies.

Multidisciplinary management of adult cloacal exstrophy complications: A challenging case of nephrolithiasis and abdominal wall extrusion of a catheterizable ileal pouch.

Cloacal exstrophy is a rare congenital syndrome which comprises multiple genitourinary, gastrointestinal and musculoskeletal anomalies. The long-term effects following childhood cloacal exstrophy management is poorly characterized in living adults. In this report, a 42-year-old female born with cloacal exstrophy presented after numerous prior surgical reconstructions with abdominal extrusion of a catheterizable ileal pouch and bilateral staghorn calculi. We review the steps in surgical management of this uncommon scenario with a goal of improving the patient's quality of life.

Analysis of leukopenia and anemia after gastric bypass surgery.

BACKGROUND: Although anemia is a well-described complication after Roux-en-Y gastric bypass (RYGB) in association with iron deficiency, no studies have been published regarding changes in the white blood cell count. METHODS: Mixed longitudinal models were used to follow the changes in white blood cell count, platelet count, and hematocrit over time after RYGB. RESULTS: A total of 590 patients, who had undergone RYGB from 2006 to 2010, inclusively, had laboratory studies available. The mean follow-up was 398 days (range 30-1484). The incidence of leukopenia (white blood cell count ≤4000 cm(3)) increased significantly from 2.0% (12 of 590) before surgery to 14.6% (86 of 590) afterward (P < .0005). A lower white blood cell count was independently predicted by greater weight loss, longer time after surgery, a lower hematocrit, and a lower platelet count (P < .0005). No patient developed neutropenia. The incidence of pre-existing anemia was ∼17% for both men and women. After surgery, the incidence of anemia substantially increased only in premenopausal women (from 16% to 33%). Anemia occurred independently of the degree of weight loss. The platelet counts decreased by a clinically insubstantial, although statistically significant, amount (281,000-250,000; P < .0005). CONCLUSION: RYGB is associated with a generalized decrease in the white blood cell and platelet counts. These decreases do not seem clinically important, unlike the substantial decrease in red blood cell mass in premenopausal women. A generalized suppression of hematopoiesis might occur after RYGB.

Longitudinal analysis of cardiovascular parameters after gastric bypass surgery.

BACKGROUND: Identifying the predictors of co-morbidity improvement after gastric bypass surgery (Roux-en-Y gastric bypass) might give insight into disease pathophysiology. METHODS: We performed an observational study of 949 patients undergoing primary RYGB from 2005 to 2010. Multivariate mixed models were used to determine the predictors of change in hemoglobin A1c (HbA1c), lipids, systemic blood pressure, and C-reactive protein. RESULTS: Greater weight loss, decreased severity of initial disease, and a greater initial body mass index predicted a significantly greater likelihood of improvement in nearly all measured parameters. Male gender predicted greater improvement in diastolic blood pressure and low-density lipoprotein and triglyceride levels. Younger patients had a greater improvement in blood pressure. Improvement in the lipid profile was independent of weight loss, and improved glycemic control was strongly dependent on weight loss. Of the 949 patients, 33% had diabetes before RYGB. A mean of 388 days after RYGB, 66% of these patients had an HbA1c of <6.5, with their mean HbA1c decreasing from 8.0 to 5.9. A greater decrease in HbA1c was also seen in patients who initially were only treated with oral hypoglycemic agents compared with those receiving insulin. The low-density lipoprotein cholesterol levels decreased significantly from a mean of 108 to 87 mg/dL. High-density lipoprotein increased by a mean of 10 mg/dL in both men and women. Also, 15% of the patients had a triglyceride level of ≥ 200 mg/dL before RYGB and only 1.1% did so afterward. The mean C-reactive protein level decreased from 5.0 to 1.6 mg/dL. We measured a 20% reduction in patients with measured hypertension after RYGB. CONCLUSION: RYGB resulted in dramatic improvement in cardiovascular risk factors, with several significant predictors of outcome.

Laparoscopy in Crohn's disease.

Crohn's disease represents a challenging operative dilemma. The nature of the disease increases the technical complexity of operations, their morbidity, and the likelihood of multiple operations. In this setting, the advantages of laparoscopic surgery, including shorter hospital stays, less adhesion formation, fewer wound complications, and faster recovery of bowel function, are particularly beneficial to the patient. Patients with Crohn's disease requiring operations in the elective and semi-elective setting can all be approached initially laparoscopically. The surgeon's skill set should include extensive experience in advanced laparoscopic bowel surgery as well as open management of Crohn's disease and its complications. Strict adherence to the basic tenet of bowel preservation is imperative. The operations most commonly performed for Crohn's disease include diagnostic laparoscopy, stricturoplasty, small bowel resection, ileocolic resection, colectomy, repair of fistulae, and gastrojejunostomy for bypass of gastric or duodenal disease. Postoperative management includes resumption of steroids, typically without the need for "stress-dosing," bowel rest for a short period, and pain control, which is also less than that experienced with a laparotomy.