Clinical significance of perioperative hyperglycemia in bariatric surgery: evidence for better perioperative glucose management.

BACKGROUND: Uncontrolled hyperglycemia in patients undergoing surgery has been shown to be a risk factor for postoperative complications. OBJECTIVE: To assess the clinical significance of perioperative hyperglycemia on infectious complications and clinical outcomes in patients undergoing bariatric surgery. SETTING: Single academic center. METHODS: Retrospective chart review of all patients who underwent primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between 2013 and 2016 was performed. The association between any elevated perioperative glucose value (hyperglycemia: ≥126 mg/dL) and level of elevation (≥126 or ≥200 mg/dL) with 30-day infectious complications, reoperation, length of hospital stay, and readmission was assessed. Patients who developed early complications (within 3 d of surgery), which could potentially lead to immediate postoperative hyperglycemia, were not included in the analysis. Outcomes of patients with and without diabetes were separately analyzed. RESULTS: A cohort of 1981 patients was studied, including Roux-en-Y gastric bypass (n = 1171, 59%) and sleeve gastrectomy (n = 810, 41%) patients. In patients with diabetes (n = 751, 38%), perioperative hyperglycemia was independently associated with higher composite infectious complications (defined as presence of any of 6 infectious complications; odds ratio [OR] 3.1, 95% confidence interval [CI] 1.2-8.2, P = .018) and higher readmission rate (OR 2.2, 95% CI 1.1-4.6, P = .027). In patients without diabetes (n = 1230, 62%), 19.2% had perioperative hyperglycemia (≥126 mg/dL). Perioperative hyperglycemia in patients without diabetes was associated with higher composite infectious complications (OR 2.6, 95% CI 1.1-5.5, P = .018) and prolonged length of stay (OR 3.0, 95% CI 1.5-5.9, P = .001). CONCLUSIONS: An elevated perioperative glucose value is adversely associated with infectious complications and key clinical outcomes after bariatric surgery. The increased risk is correlated with the extent of glucose elevation (dose-response relationship). Our findings highlight the importance of glucose control during the perioperative period in bariatric surgical patients.

Local parastomal hernia repair with biological mesh is safe and effective.

PURPOSE: The goal of this study was to evaluate the efficacy, morbidity and safety of local parastomal hernia repair using biological mesh. PATIENTS AND METHODS: A retrospective analysis of a prospectively maintained database was performed for parastomal hernia repairs. All patients who underwent local parastomal hernia repair with biological mesh between July 2006 and July 2015 were included in the study. Non-local (laparoscopic or midline incision) procedures were excluded. The type of repair, incision used, mesh placement and morbidity were analyzed. Time to recurrence was measured as an independent variable. RESULTS: 58 procedures with a median follow up of 3.8 years were analyzed. The majority (91%) of repairs were performed on an elective basis. Underlay technique was used in 24 patients (39%), overlay in 4 (7%) and both overlay and underlay (sandwich technique) in 33 (54%) of the cases. Overall, 11 patients (18.1%) experienced recurrence. Recurrence occurred in 8 patients in the underlay group (33%), 1 in the overlay group (25%), with 2 recurrences identified in the sandwich technique group (6%; p = 0.02). There was one occurrence of 30-day morbidity in our study population (0.016%). No difference was observed for recurrence or morbidity according to the type of biologic mesh used (human, bovine, or porcine). CONCLUSION: Our results demonstrate that local parastomal hernia repairs are associated with moderate recurrence rates, very low morbidity and consistent with the current literature. The sandwich technique was found to have a significantly lower recurrence rate compared to underlay or overlay techniques. Keyhole incisions were associated with less recurrence than traditional circular incisions. Our findings further reveal biologic mesh type was not associated with any difference in outcomes. Local parastomal hernia repair with biologic mesh is a safe procedure with very low morbidity and acceptable recurrence rate, especially using the sandwich repair technique.

A Comparative Study of Outcomes Between Single-Site Robotic and Multi-port Laparoscopic Cholecystectomy: An Experience from a Tertiary Care Center.

BACKGROUND: The aim of this study was to compare the outcomes of single-site robotic cholecystectomy with multi-port laparoscopic cholecystectomy within a high-volume tertiary health care center. METHODS: A retrospective analysis of prospectively maintained data was conducted on patients undergoing single-site robotic cholecystectomy or multi-port laparoscopic cholecystectomy between October 2011 and July 2014. A single surgeon performed all the surgeries included in the study. RESULTS: A total of 678 cholecystectomies were performed. Of these, 415 (61%) were single-site robotic cholecystectomies and 263 (39%) were multi-port laparoscopic cholecystectomies. Laparoscopic patients had a greater mean BMI (30.5 vs. 29.0 kg/m2; p = 0.008), were more likely to have undergone prior abdominal surgery (83.3 vs. 41.4%; p < 0.001) and had a higher incidence of preexisting comorbidities (76.1 vs. 67.2%; p = 0.014) as compared to the robotic group. There was no statistical difference in the total operative time, rate of conversion to open procedure and mean length of follow-up between the two groups. The mean length of hospital stay was shorter for patients within the robotic group (1.9 vs. 2.4 days; p = 0.012). Single-site robotic cholecystectomy was associated with a higher rate of wound infection (3.9 vs. 1.1%; p = 0.037) and incisional hernia (6.5 vs. 1.9%; p = 0.006). CONCLUSION: Multi-port laparoscopic cholecystectomy should remain the gold standard therapy for gallbladder disease. Single-site robotic cholecystectomy is an effective alternative procedure for uncomplicated benign gallbladder disease in properly selected patients. This must be carefully balanced against a high rate of surgical site infection and incisional hernia, and patients should be informed of these risks.