Efficacy of a Required Preoperative Weight Loss Program for Patients Undergoing Bariatric Surgery.

The efficacy of mandatory medically supervised preoperative weight loss (MPWL) prior to bariatric surgery continues to be a controversial topic. The purpose of this observational study was to assess the efficacy of a MPWL program in a single institution, which mandated at least 10% excess body weight loss before surgery, by comparing outcomes of patients undergoing primary bariatric surgery with and without a compulsory preoperative weight loss regimen. We analyzed our database of 757 patients who underwent primary bariatric surgery between March 2008 and January 2015. Patients were placed into two cohorts based on their participation in a MPWL program requiring at least 10% excess weight loss (EWL) prior to surgery. Patients were evaluated at 3, 6, 12, and 24 months after surgery for weight loss, comorbidity resolution, and the occurrences of hospital readmissions. A total of 717 patients met the inclusion criteria of whom 465 underwent surgery without a preoperative weight loss requirement and 252 participated in the MPWL program. One year after surgery, 67.1% of non-participants and 62.5% of MPWL participants showed a resolution of at least one of five associated comorbidities (p = 0.45). Non-participants showed an average of 58.6% EWL, while MPWL participants showed 59.1% EWL at 1 year postoperatively (p = 0.84). Readmission rates, excluding those which were ulcer-related, at 30 days (3.4 vs. 6.40%, p = 0.11) and 90 days (9.9 vs. 7.5%, p = 0.29) postoperatively were not significantly different between the non-participants and MPWL patients, respectively. A mandatory preoperative weight loss program prior to bariatric surgery did not result in significantly greater %EWL or comorbidity resolution 1 year after surgery compared to patients not required to lose weight preoperatively. Additionally, the program did not result in significantly lower 30- or 90-day readmission rates for these patients. The value of a MPWL program must be weighed against the potential loss of bariatric surgery candidates. Patients who fail to lose 10% excess weight preoperatively are thus ineligible for a procedure from which they would otherwise benefit. Our data suggest these patients will have similar positive outcomes.

Modified laparoscopic Sugarbaker repair decreases recurrence rates of parastomal hernia.

BACKGROUND: Parastomal hernia (PH) is a frequent complication of stoma formation, and recurrence after repair is common. A laparoscopic modified Sugarbaker technique (SB) may decrease the recurrence of PH compared with other methods. METHODS: A retrospective review, approved by the institutional review board, of patients who underwent PH repair between 2004 and 2014 was performed. Demographics, factors for ostomy formation, hernia risk factors, intraoperative and postoperative information, and recurrence data were compared among SB and other techniques. Time to recurrence was compared between SB versus other techniques with the Kaplan-Meier method and adjusted Cox proportional hazards regression modeling. RESULTS: Sixty-two PH repairs were performed: 39 (61%) paraileostomy and 23 (39%) paracolostomy. Repairs included 25 laparoscopic modified SB and 37 from other techniques. There was no difference in demographics. Postoperative complication rate was lesser in SB versus all other groups (40% vs 76%, P = .02). Recurrence rates were lesser for SB versus all others (16% vs 60%, P < .001). Follow-up was similar among all groups. After adjustment, SB was found to be protective of recurrences (hazard ratio = .28, 95% confidence interval = 0.09-0.82). CONCLUSION: A laparoscopic modified SB technique provides decreased rates of recurrence and postoperative complications compared with other approaches.

Peroral endoscopic myotomy: A short-term comparison with the standard laparoscopic approach.

BACKGROUND: We report our short-term experience with peroral endoscopic myotomy (POEM) and compare perioperative outcomes with laparoscopic Heller myotomy (LHM) for achalasia. METHODS: Patients from an institutional review board-approved protocol underwent POEM and were followed prospectively. Comparisons were made, in a prospective esophageal database, with patients who underwent LHM over the same period. RESULTS: We studied 18 patients who underwent POEM and compared them to 21 who underwent LHM. Demographics, preoperative Eckardt scores, motility data, and prior intervention history were comparable. Operative time, myotomy length, and complication rates (1 perforation in each group) were equal. Postoperative pain was significantly different by visual analogue score (POEM 3.9 ± 0.6 versus LHM 5.7 ± 0.4, P = .02) and analgesic use (POEM 26.0 ± 13.7 versus LHM 90.0 ± 48.5 mg morphine, P = .02). Return to activities of daily living was significantly faster in the POEM group (2.2 ± 0.6 vs 6.4 ± 1.0 days, P = .03). Postoperative dysphagia and Eckardt scores were equally successful in both groups. CONCLUSION: POEM results in similar relief of dysphagia with less postoperative pain and quicker return to normal activities.