Gastrojejunal Anastomotic Stricture Following Roux-en-Y Gastric Bypass: an Analysis of Anastomotic Technique at a Single Institution.

PURPOSE: Patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) are at risk of developing strictures of the gastrojejunal anastomosis (GJA). Several variables can affect this, one of which may be the method of anastomosis. Between 2010 and 2014, our institution utilized three different anastomotic techniques for creating the GJA (25 mm end-to-end circular-stapled (CS), linear-stapled (LS), and robotic hand sewn (HS)). Our objectives were to compare the method of GJA relative to the subsequent development of anastomotic stricture. METHODS: We queried our electronic health record for all patients who underwent an upper endoscopy (EGD) after RYGB (2010-2014). Patient charts were retrospectively reviewed for type of GJA, weight loss, complications, interventions, and revisions of the GJA. RESULTS: In total, 1112 RYGB were performed at our institute, and 17.4% of patients (194/1112) had an upper endoscopy (EGD). Overall, 3.1% (34/1112) were found to have a stricture of the GJA. Patients undergoing a CS, LS, and HS anastomosis had GJA stricture rates of 4.9%, 0.5%, and 1.2% respectively (CS to LS (p < 0.05), p = NS among CS vs. HS, and LS vs. HS). The rate of GJA revision was 1.5%, 0.5%, and 0.1% (p = NS). In patients who had an EGD, excess BMI loss was 57.4%, 64.6%, and 59.2% (p = NS). In patients symptomatic from strictures, excess BMI loss was 69.4%, 83%, and 63.5% respectively (p = NS). CONCLUSION: The anastomotic technique for creating of the GJA may impact the formation of strictures. Based on our experience, gastrojejunostomies created with a 2-mm EEA-stapling technique are at higher risk of strictures.

Impacts of Gastrojejunal Anastomotic Technique on Rates of Marginal Ulcer Formation and Anastomotic Bleeding Following Roux-en-Y Gastric Bypass.

BACKGROUND: Marginal ulceration (MU) and bleeding are possible complications following laparoscopic Roux-en-Y gastric bypass (RYGB). Our institution utilizes three techniques for performing the gastrojejunal anastomosis (GJA), providing a means to compare postoperative MU and bleeding as it relates to GJA technique. OBJECTIVES: We sought to analyze the incidence of MU and bleeding between the 25-mm end-to-end anastomosis (EEA) stapler, linear stapler (LS), and robotic hand-sewn (RHS) GJA techniques. METHODS: Electronic health records for all patients who had an upper endoscopy (EGD) after RYGB were queried (2010-2014). Charts were retrospectively reviewed for type of GJA, complications, endoscopic interventions, and smoking and NSAID use. RESULTS: Out of 1112 RYGBs, the GJA was created using an EEA, LS, or RHS approach in 58.6%, 33.6%, and 7.7% of patients, respectively. 17.4% had an EGD (19.9% EEA, 13.9% LS, and 14.0% RHS). Incidence of MU was 7.3% (9.3% EEA, 4.8% LS, and 5.8% RHS). Rates of EGD and MU were significantly higher after EEA vs. LS GJA (p<0.05). The bleeding rate was 1.5%, [1.1% EEA, 2.1% LS, and 2.3% RHS (p=NS)]. MU within 90 days of RYGB occurred in 4.1%, 0.8%, and 4.7%, respectively (p<0.05 for EEA vs LS only). NSAID and cigarette use were identified in 29.3%, 38.9%, and 60% and 17.2%, 22.2%, and 20%, respectively, for the EEA, LS, and RHS GJA (p=NS). CONCLUSION: The method of GJA has an impact on rate of MU formation. A GJA fashioned with a 25-mm EEA stapler tends to have higher rates of EGD and MU.

Postoperative sepsis after primary bariatric surgery: an analysis of MBSAQIP.

BACKGROUND: Identifying patients at higher risk of postoperative sepsis (PS) may help to prevent this life-threatening complication. OBJECTIVES: This study aimed to identify the rate and predictors of PS after primary bariatric surgery. SETTING: An analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015-2017. METHODS: Patients undergoing elective sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were included. Exclusion criteria were revisional, endoscopic, and uncommon, or investigational procedures. Patients were stratified by the presence or absence of organ/space surgical site infection (OS-SSI), and patients who developed sepsis were compared with patients who did not develop sepsis in each cohort. Logistic regression was used to identify independent predictors of PS. RESULTS: In total, 438,752 patients were included (79.4% female, mean age 44.6±12 years). Of those, 661 patients (.2%) developed PS of which 245 (37.1%) developed septic shock. Out of 892 patients with organ/space surgical site infections (OS-SSI), 298 (45.1%) developed sepsis (P <.001). Patients who developed PS had higher mortality (8.8% versus .1%, P < .001), and this was highest in patients without OS-SSI (11.8% versus 5%, P = .002). The main infectious complications associated with PS in patients without OS-SSI were pneumonia and urinary tract infection. Independent predictors of PS in OS-SSI included RYGB versus SG (OR, 1.8), and age ≥50 years (OR, 1.4). Independent predictors of PS in patients without OS-SSI were conversion to other approaches (OR, 6), operation length >2 hours (OR, 5.7), preoperative dialysis (OR, 4.1), preoperative therapeutic anticoagulation (OR, 2.8), limited ambulation most or all of the time (OR, 2.4), preoperative venous stasis (OR, 2.4), previous nonbariatric foregut surgery (OR, 2), RYGB versus SG (OR, 2), hypertension on medication (OR, 1.5), body mass index ≥50 kg/m2(OR, 1.4), age ≥50 years (OR, 1.3), obstructive sleep apnea (OR, 1.3). CONCLUSION: Development of OS-SSI after primary bariatric surgery is associated with sepsis and increased 30-day mortality. Patients without OS-SSI who develop PS have a significantly higher mortality rate compared with patients with OS-SSI who develop PS. Early identification and intervention in patients with PS, including those without OS-SSI, may improve survival in this high-risk group.

Outcomes of Bariatric Surgery in African Americans: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Data Registry.

BACKGROUND: The incidence of obesity is disproportionally high in African Americans (AA) in the United States. This study compared outcomes for AA patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with non-AA patients. METHODS: The MBSAQIP database was reviewed for RYGB and SG patients (2015-2017). Patients were identified as AA or non-AA and grouped to RYGB or SG. Combined and univariate analyses were performed on unmatched/propensity matched populations to assess outcomes. RESULTS: After applying exclusion criteria, 75,409 AA and 354,305 non-AA patients remained. Univariate analysis identified AA-RYGB and AA-SG patients were heavier and younger than non-AA patients. Overall, AA patients tended to have fewer preoperative comorbidities than non-AA patients with the majority of AA comorbidities related to hypertension and renal disease. Analysis of propensity matched data confirmed AA bariatric surgery patients had increased cardiovascular-related disease incidence compared with non-AA patients. Perioperatively, AA-RYGB patients had longer operative times, increased rates of major complications/ICU admission, and increased incidence of 30-day readmission, re-intervention, and reoperation, concomitant with lower rates of minor complications/superficial surgical site infection (SSI) compared with non-AA patients. For SG, AA patients had longer operative times and higher rates of major complications and 30-day readmission, re-intervention, and mortality, coupled with fewer minor complications, superficial/organ space SSI, and leak. CONCLUSION: African American patients undergoing bariatric surgery are younger and heavier than non-AA patients and present with different comorbidity profiles. Overall, AAs exhibit worse outcomes following RYGB or SG than non-AA patients, including increased mortality rates in AA-SG patients.

Predictors of mortality after elective ventral hernia repair: an analysis of national inpatient sample.

PURPOSE: Deciding between surgery and non-operative management of a non-obstructive ventral hernia (VH) in a high-risk patient often poses a clinical challenge. The aim of this study is to evaluate a national series of open and laparoscopic ventral hernia repair (VHR), and to assess predictors of mortality after elective VHR. METHODS: A retrospective analysis of 2008-2014 data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample was performed. All patients with a primary diagnosis of abdominal wall hernia were included. Inguinal, femoral, or diaphragmatic hernias were excluded. Patients were stratified by elective versus emergent repair. Factors associated with mortality after elective VHR were analyzed. RESULTS: 103,635 patients were studied, including 14,787 (14.3%) umbilical, 63,685 (61.5%) incisional, and 25,163 (24.3%) other ventral hernias. Operative procedures included 59,993 (57.9%) elective and 43,642 (42.1%) emergent VHR. 21.3% elective VHRs were laparoscopic versus 13% in emergent cases (P < 0.001). Mesh was used in 52,642 (87.7%) elective versus 27,734 (63.5%) emergent VHR (P < 0.001). Median (interquartile range) length of stay was 2(3) days in laparoscopic and 3(3) days in open group (P < 0.001). Mortality was 0.2% (n = 135) in elective and 0.6% (n = 269) in emergent group (P < 0.001). In elective group, mortality rates were equal among laparoscopic and open VHR (0.2%), while in emergent group, it was lower in laparoscopic VHR (0.4% vs 0.6%, P = 0.028). Multivariate analysis of elective VHR showed that the following factors were associated with mortality during hospitalization: age > 50 years [Odds ratio (OR) = 1.96], male gender (OR = 2.37), congestive heart failure (OR = 2.15), pulmonary circulation disorders (OR = 5.26), coagulopathy (OR = 3.93), liver disease (OR = 1.89), fluid and electrolyte disturbances (OR = 8.66), metastatic cancer (OR = 4.66), neurological disorders (OR = 2.31), and paralysis (OR = 5.29). CONCLUSIONS: VHR has a low mortality, especially when performed laparoscopically. In patients undergoing elective VHR, higher age and some comorbidities are predictors of mortality. These include congestive heart failure, pulmonary circulation disorders, coagulopathy, liver disease, metastatic cancer, neurological disorders, and paralysis. Conservative management should be considered for these high-risk subgroups in context of the overall clinical presentation.