Impact of Enhanced Recovery After Surgery (ERAS) Combined with Bariatric Surgery Targeting Opioid Prescriptions (BSTOP) Protocol on Patient Outcomes, Length of Stay and Opioid Prescription After Bariatric Surgery.

BACKGROUND: Evidence shows that 14.2% of opioid-naive patients have long-term opioid dependence after bariatric surgery. Enhanced recovery after surgery (ERAS) protocols are widely used in bariatric surgery, while bariatric surgery targeting opioid prescriptions (BSTOP) protocols were recently introduced. We will investigate the combined impact of ERAS and BSTOP protocols after bariatric surgery. METHODS: We conducted a retrospective review for patients who underwent either a sleeve gastrectomy or Roux-en-Y gastric bypass at a tertiary care center. Pre-intervention and post-intervention data were compared. Primary outcomes were length of stay (LOS), 30-day readmission, 30-day complications, and discharge on opioids. Multivariate Poisson regression with robust standard error was used to analyze LOS. RESULTS: There was no significant difference in 30-day emergency room visits (3.3% vs. 4.0%; p value = 0.631), 30-day readmission (4.4% vs. 5.4%; p value = 0.577) or 30-day complication rate (4.2% vs. 6.4%; p value = 0.199). LOS was significantly lower in the post-intervention group; mean (interquartile range) 2 (1-2) days vs. 1 (1-2) day, p value < 0.001. On multivariate analysis, the post-intervention group had 0.74 (95% confidence interval 0.65-0.85; p value < 0.001) times lower LOS as compared to pre-intervention group. Patients with DM had a significantly longer LOS (relative risk: 1.22; p = 0.018). No other covariates were associated with LOS (p value < 0.05 for all). BSTOP analysis found a significant difference between the two groups. Discharge on opioids decreased from 40.6% pre-intervention to 7.1% post-intervention. CONCLUSION: ERAS and BSTOP protocols reduced length of stay and opioid need at discharge without an increase in complication or readmission rates.

Robotic-assisted completion cholecystectomy with repair of cholecystoduodenal fistula.

Post-cholecystectomy syndrome (PCS) is a well-documented complication of incomplete cholecystectomy. The etiology is often post-surgical chronic inflammation from unresolved cholelithiasis, which is secondary to anatomical abnormalities, including a retained gallbladder or a large cystic duct remnant (CDR). An exceedingly rare consequence is retained gallstone fistulization into the gastrointestinal tract. We present a case of a 70-year-old female with multiple comorbidities 4 years status-post incomplete cholecystectomy, who developed PCS with cholecystoduodenal fistula secondary to retained gallstone in the remnant gallbladder, with CDR involvement, treated via robotic-assisted surgery. Reoperation in PCS has been traditionally performed via laparoscopic approach with recent advances made in robotic-assisted surgery. However, we report the first documented case of PCS complicated by bilioenteric fistula repaired with robotic-assisted surgery. This highlights the value of robotic-assisted surgery in complicated cases, where one must contend with post-surgical anatomic abnormalities and visualization difficulties. Subsequent investigation is necessary to objectively quantify the safety and reproducibility of our approach.

A prospective comparative study of the functional results associated with the use of Björk flap tracheostomy versus standard tracheostomy.

BACKGROUND: Placement of a tracheostomy for patients requiring prolonged mechanical ventilation (PMV) improves patients' comfort, decreases dead space ventilation, allows superior airway hygiene, and reduces the incidence of ventilator-associated pneumonia. Controversy still exists regarding the role of standard tracheostomy (ST) as opposed to the less frequently done Björk flap tracheostomy (BFT). This study compares the functional outcomes of these two techniques. STUDY DESIGN: Seventy-nine patients receiving tracheostomy in a 12-month period: 38 BFT vs. 41 ST. Data included demographics, indications for PMV, ventilator days before tracheostomy, time to and a number of patients who passed the fiberoptic endoscopic evaluation of swallowing (FEES), time to and a number of patients decannulated. RESULTS: Indications in both groups were PMV from trauma (18/38 vs 15/41), pneumonia (13/38 vs 13/41), and ARDS (7/38 vs 11/4), respectively (p > 0.05). Patients in both groups did not differ with regard to age, sex, GCS, duration of PMV before tracheostomy, the time to and a number of patients who passed the 1st FEES. However, the number of days and the number of FEES required before the next successful FEES in the 20 BFT and 21 ST patients who failed the 1st was 9 (4) vs. 16 (5), and 2 (1) vs. 4 (1), respectively (p < 0.05). Additionally, the number of intraoperative complications in aggregate were 0/38 in the BFT as opposed to 6/41 in the ST group (p < 0.05). CONCLUSION: We conclude that BFT may be associated with an overall shorter time to restoration of normal swallowing when compared to ST.

Crossing borders to change lives: Surgical mission amidst the COVID-19 pandemic.

INTRODUCTION: During the COVID pandemic, elective global surgical missions were temporarily halted for the safety of patients and travelling healthcare providers. We discuss our experience during our first surgical mission amidst the pandemic. We report a safe and successful treatment of the patients, detailing our precautionary steps and outcomes. METHODS: Retrospective manual chart review and data collection of patients' charts was conducted after IRB approval. We entail our experience and safety steps followed during screening, operating and postoperative care to minimize exposure and improve outcomes during a surgical mission in an outpatient setting during the pandemic. The surgical mission was from February 8 to February 12, 2022. RESULTS: A total of 60 patients who were screened. 33 patients underwent surgical intervention. One patient required postoperative hospitalization for a biliary duct leak. No patient or healthcare provider tested positive for COVID at the end of the mission. The average age of patients was 46.9 years. The average operative time was 116 min, and all patients had local nerve blocks. It included 45 health work providers. CONCLUSIONS: It is safe to perform outpatient international surgery during the pandemic while following pre-selected precautions.

Retrospective observational study correlating traumatic pelvic fractures and their associated injuries according to the Tile classification.

INTRODUCTION: Pelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification. METHODS: Retrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016. RESULTS: A total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P = .032), and Tile B with sacral fractures (P = .033) and visceral injuries (P = .049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock. CONCLUSIONS: Tile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.

Outcomes in Obese vs Non-Obese Injured Patients at a Level 1 Trauma Center and Bariatric Surgery Center of Excellence.

BACKGROUND: We hypothesized that the outcomes of trauma patients with a body mass index (BMI) equal to or greater than 30 compared to patients with BMI less than 30 would not differ at a level 1 trauma center that is also a Metabolic and Bariatric Surgery Center of Excellence in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP). STUDY DESIGN: Patients equal to and greater than 18 years old treated between 1/1/2018 and 12/31/2020 were included. Demographics, BMI, comorbidities, and outcomes (hospital-LOS, ICU-LOS, blood products used, and mortality) were compared between 2 groups: obese (BMI ≥30) vs non-obese (BMI <30). RESULTS: Of the 4192 patients identified, 3821 met the inclusion criteria; 3019 patients had a BMI <30, and 802 had a BMI ≥30. There was a statistically significant difference between the 2 groups with respect to gender (females: 57% vs 47%, P < .0001) and age (median: 80 [IQR: 63-88] vs 69 [IQR: 55-81], P < .0001). When adjusted for age, sex, DM, dementia, ISS, and ICU admission, there was no statistically significant difference in hospital-LOS (4.30 [95% CI: 4.10, 4.52] vs 4.48 [95% CI: 4.18, 4.79]) or mortality. No statistical differences were seen between the 2 groups in blood product use. CONCLUSIONS: Obesity did not correlate with poorer outcomes at an ACS-verified level 1 Trauma Center and Bariatric Surgery Center of Excellence. Further studies are needed to determine whether outcomes vary at hospitals without both designations.

Obstrucción intestinal por vólvulo de ciego en paciente con malrotación intestinal asociado a situs ambiguous / Intestinal obstruction due to volvulus of the cecum in a patient with intestinal malrotation associated with situs ambiguous

Introducción. La oclusión intestinal, completa o incompleta, es uno de los cuadros de abdomen agudo más frecuentes. Constituye entre 20 % y 35 % de los ingresos urgentes en las áreas quirúrgicas hospitalarias. Caso clínico. Se presenta el caso de un paciente con antecedente de carcinoma de próstata, que consultó con un cuadro de obstrucción intestinal y abdomen agudo. Se le diagnosticó vólvulo de ciego, mal rotación intestinal y situs ambiguous. El tratamiento quirúrgico del paciente fue exitoso. Conclusión. El conocimiento de estas condiciones patológicas es imprescindible para poder brindarle un correcto tratamiento quirúrgico y disminuir la mortalidad que pueden acarrear

Introduction. Complete or incomplete intestinal obstruction is one of the most frequent acute abdomen conditions. It constitutes between 20% and 35% of the urgent admissions of hospital surgical areas. Clinical case. We present a case of a patient with a history of prostate carcinoma, who began with clinical symptoms of intestinal obstruction and acute abdomen. He was diagnosed with volvulus of the cecum, intestinal malrotation, and situs ambiguous. Surgical treatment of the patient was successful. Conclusion. Knowledge of these pathological conditions is essential to be able to provide correct surgical treatment and reduce the mortality that these can lead to

Improved Morbidity, Mortality, and Cost with Minimally Invasive Colon Resection Compared to Open Surgery.

Background and Objectives: Despite the growth of minimally invasive surgery (MIS) in many specialties, open colon surgery is still routinely performed. The purpose of this study was to compare outcomes and costs between open colon and minimally invasive colon resections. Methods: We analyzed outcomes between January 1, 2016 and December31, 2018 using the Vizient® clinical database. Demographics, hospital length of stay, readmissions, complications, mortality, and costs were compared between patients undergoing elective open and minimally invasive colon resections. For bivariate analysis, Wilcoxon rank-sum test was used for continuous variables and χ2 test was used for categorical variables. Multiple Logistic and Quintile regression were used for multivariable analyses. Results: A total of 88,405 elective colon resections (open: 56,599; minimally invasive: 31,806) were reviewed. A significantly larger proportion of patients undergoing minimally invasive surgery were obese (body mass index > 30) compared to those undergoing open surgery (71.4% vs. 59.6%; p < 0.0001). As compared to minimally invasive colectomy, open colectomy patients had: a longer median length of stay [median (range): 7 (4-13) days vs. 4 (3 - 6) days, p < 0.0001], higher 30-day readmission rate [n = 8557 (15.1%) vs. 2815 (8.9%), p < 0.0001], higher mortality [n = 2590 (4.4%) vs. 107 (0.34%), p < 0.0001], and a higher total direct cost [median (range): $13,582 (9041-23,094) vs. $9013 (6748 - 12,649), p < 0.0001]. Multivariable models confirmed these findings. Conclusion: Minimally invasive colon surgery has clear benefits in terms of length of stay, readmission rate, mortality and cost, and the routine use of open colon resection should be revaluated.

Gastric Banding with Previous Roux-en-Y Gastric Bypass (Band over Pouch): Not Worth the Weight.

Background and Objectives: Revisional bariatric surgery continues to increase. Laparoscopic adjustable gastric banding (LAGB) after previous Roux-en-Y gastric bypass (RYGB), known colloquially as "band-overpouch" has become an option despite a dearth of critically analyzed long-term data. Methods: Our prospectively maintained database was retrospectively reviewed for patients who underwent band-overpouch at our Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence in a 18-year period ending October 31, 2021. We evaluated: demographics, comorbidities, operative procedures, and outcomes (30-day and > 30-day). Results: During the study period, of 4,614 bariatric procedures performed, 42 were band-overpouch with 39 (93%) being women. Overall, mean age was 49.8 years (range 26-75), a mean weight 251 pounds (range 141-447), and mean body mass index 42.4 (range 26-62). Comorbidities included: hypertension (n = 31; 74%), diabetes (n = 27; 64%), obstructive sleep apnea (n = 26; 62%), gastroesophageal reflux disease (n = 26; 62%), and osteoarthritis (n = 25; 60%). All procedures were performed laparoscopically with no conversions to open. Mean length of stay was 1.2 days (range 1-3). Mean follow-up time was 4.2 years (range 0.5-11). Mean excess weight loss was 14.9%, 24.3%, and 28.2% at 6 months, 1 year and ≥ 3 years, respectively. There was one 30-day trocar-site hematoma requiring transfusion. Long-term events included: 1-year (1 endoscopy for retained food; 1 internal hernia), 3-year (1 LAGB erosion; 1 LAGB explant), 4-year (1 anastomotic ulcer), 6-year (1 LAGB explant and Roux-en-Y revision), and 8-year (1 LAGB erosion). One 5-year mortality occurred (2.4%), in association with hospitalization for chronic illness and malnutrition. Band erosions were successfully treated surgically without replacement. Conclusion: Band-overpouch is associated with moderate excess weight loss and has good short-term safety outcomes.

Missed traumatic abdominal injury with challenging management: report of 12-year follow-up.

Despite well-established clinical guidelines and use of radiologic imaging for diagnosis, challenges are faced when accurate decisions must be made within seconds. Patients with life-threatening injuries represent 10-15% of all hospitalized trauma patients. In fact, 20% of abdominal injuries will require surgical intervention. In abdominal trauma, it is important to distinguish the difference between surgical intervention, which includes damage control procedures and definitive treatment. The main objective of damage control surgery is to control the bleeding, reduce the contamination and delay additional surgical stress at a time of physiological vulnerability of the patient, along with abdominal containment, visceral protection and avoiding aponeurotic retraction in situations where primary abdominal closure is not possible. However, this technique has high morbidity and comes with a myriad of complications, including development of catastrophic abdomen and formation of enterocutaneous fistulas.

Correlation of brain flow variables and metabolic crisis: a prospective study in patients with severe traumatic brain injury.

INTRODUCTION: Current treatment guidelines for patients with severe TBI (sTBI) are aimed at preventing secondary brain injury targeting specific endpoints of intracranial physiology to avoid the development of metabolic crisis. We sought to identify factors contributing to development of metabolic crisis in the setting of a Multi-modality Monitoring and Goal-Directed Therapy (MM&GDTP) approach to patients with severe TBI. METHODS: Prospective monitoring of sTBI patients was performed, with retrospective data analysis. MM&GDTP was targeted to intracranial pressure (ICP) ≤ 20 mmHg, cerebral perfusion pressure (CPP) ≥ 60 mmHg, brain tissue oxygen pressure (PbtO2) ≥ 20 mmHg, and cerebral oxygen extraction measured by bi-frontal Near infrared Spectroscopy (NIRS) > 55%. Brain flow abnormality was defined by one of the following combinations: CPP < 60 mmHg with NIRS < 55% (Type 1), CPP < 60 mmHg with PbtO2 < 20 mmHg (Type 2), or PbtO2 < 20 mmHg with NIRS < 55% (Type 3). Cerebral micro-dialysate was analyzed hourly for glucose, lactate, pyruvate, glutamate, glycerol, and lactate/pyruvate ratio (LPR). Statistical analysis was performed with student t-test, chi-square and Pearson's tests as applicable. RESULTS: A total of 109,474 consecutive minutes of recorded multimodality monitoring was available for analysis. There was a significant difference in the number of minutes of brain flow abnormalities between survivors and non-survivors: 0.8% (875) versus 7.49% (8,199), respectively (p < 0.05). The duration of Type 1-3 flow abnormality per patient was higher in non-survivors (5.7 ± 2.5 h) compared to survivors (0.7 ± 0.6 h) as well as the duration of metabolic crisis, namely, 5.2 ± 2.2 versus 0.6 ± 1.0 h per patient. The occurrence of severe metabolic crisis was associated with a Type 2 flow abnormality (CPP < 60 mmHg and PbtO2 < 20 mmHg), r = 0.97, p < 0.001, but not with Type 1 and 3. CONCLUSIONS: Metabolic crisis can occur despite a MM&GDTP approach aimed at optimizing cerebral blood flow. Severe metabolic crisis is associated to failure to maintain CPP and PbtO2 above 60 and 20 mmHg, respectively. The occurrence of severe metabolic crisis portends a poor prognosis in patients with sTBI.

Safety of Bariatric Surgery in Patients With Congestive Heart Failure: Results of an 11-Year Retrospective Study.

INTRODUCTION: Congestive heart failure (CHF) is a known risk factor for increased postoperative morbidity. However, the safety in patients with CHF has not been well established. The objective of this study was to assess the safety of surgery in patients with a history of CHF undergoing bariatric surgical procedures. METHODS: Retrospective review of a prospectively maintained Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Center of Excellence database. Patients with known CHF undergoing bariatric procedures over an 11-year period were reviewed. RESULTS: Over the 11-year period, 4470 total bariatric surgeries were performed, of which 41 (.92%) patients had known CHF. Twenty-one patients were men (51.2%) with a mean age of 55.8 years and mean body mass index (BMI) of 51.9. Comorbidities included hypertension (87.8%), obstructive sleep apnea (80.5%), osteoarthritis (63.4%), gastroesophageal reflux disease (56%), and diabetes (53.7%). Surgical procedures included 16 sleeve gastrectomies (SGs) (39%), 11 Roux-en-Y gastric bypasses (RYGBs) (26.8%), 10 laparoscopic adjustable gastric bands (LAGBs) (24.4%), 1 removal of a gastric band and conversion to SG (2.4%), 1 removal of a gastric band to RYGB (2.4%), 1 gastric band over RYGB pouch (2.4%), and 1 gastric band replacement (2.4%). All cases were performed minimally invasively (73.2% laparoscopic and 26.8% robotic). Mean LOS was 2.53 days. Thirty-day complications included 2 readmissions (4.9% [1 small bowel obstruction and 1 pulmonary edema]), 1 reoperation (2.4% [small bowel obstruction]), and 1 mortality (2.4%) on postoperative day 30 unrelated to the surgery. CONCLUSIONS: Bariatric surgery can be performed safely in patients with CHF.

Smartphone application alerts for early trauma team activation: Millennial technology in healthcare.

BACKGROUND: Data access through smartphone applications (apps) has reframed procedure and policy in healthcare, but its impact in trauma remains unclear. Citizen is a free app that provides real-time alerts curated from 911 dispatch data. Our primary objective was to determine whether app alerts occurred earlier than recorded times for trauma team activation and emergency department arrival. METHODS: Trauma registry entries were extracted from a level one urban trauma center from January 1, 2018 to June 30, 2019 and compared with app metadata from the center catchment area. We matched entries to metadata according to description, date, time, and location then compared metadata timestamps to trauma team activation and emergency department arrival times. We computed percentage of time the app reported traumatic events earlier than trauma team activation or emergency department arrival along with exact binomial 95% confidence interval; median differences between times were presented along with interquartile ranges. RESULTS: Of 3,684 trauma registry entries, 209 (5.7%) matched app metadata. App alerts were earlier for 96.1% and 96.2% of trauma team activation and emergency department arrival times, respectively, with events reported median 36 (24-53, IQR) minutes earlier than trauma team activation and 32 (25-42, IQR) minutes earlier than emergency department arrival. Registry entries for younger males, motor vehicle-related injuries and penetrating traumas were more likely to match alerts (P < .0001). CONCLUSION: Apps like Citizen may provide earlier notification of traumatic events and therefore earlier mobilization of trauma service resources. Earlier notification may translate into improved patient outcomes. Additional studies into the benefit of apps for trauma care are warranted.

Incidence and effects of deep vein thrombosis on the outcome of patients with coronavirus disease 2019 infection.

BACKGROUND: Deep vein thrombosis (DVT) has been reported to occur at different rates in patients with coronavirus disease 2019 (COVID-19). Limited data exist regarding comparisons with non-COVID-19 patients with similar characteristics. Our objective was to compare the rates of DVT in patients with and without COVID-19 and to determine the effect of DVT on the outcomes. METHODS: We performed a retrospective, observational cohort study at a single-institution, level 1 trauma center comparing patients with and without COVID-19. The 573 non-COVID-19 patients (age, 61 ± 17 years; 44.9% male) had been treated from March 20, 2019 to June 30, 2019, and the 213 COVID-19 patients (age, 61 ± 16 years; 61.0% male) had been treated during the same interval in 2020. Standard prophylactic anticoagulation therapy consisted of 5000 U of heparin three times daily for the medical patients without COVID-19 who were not in the intensive care unit (ICU). The ICU, surgical, and trauma patients without COVID-19 had received 40 mg of enoxaparin daily (not adjusted to weight). The patients with COVID-19 had also received enoxaparin 40 mg daily (also not adjusted to weight), regardless of whether treated in the ICU. The two primary outcomes were the rate of deep vein thrombosis (DVT) in the COVID-19 group vs that in the historic control and the effect of DVT on mortality. The subgroup analyses included patients with adult respiratory distress syndrome (ARDS), pulmonary embolism (PE), and intensive care unit patients (ICU). RESULTS: The rate of DVT and PE for the non-COVID-19 patients was 12.4% (71 of 573) and 3.3% (19 of 573) compared with 33.8% (72 of 213) and 7.0% (15 of 213) for the COVID-19 patients, respectively. Unprovoked PE had developed in 10 of 15 COVID-19 patients (66.7%) compared with 8 of 497 non-COVID-19 patients (1.6%). The 60 COVID-19 patients with ARDS had had an incidence of DVT of 46.7% (n = 28). In contrast, the incidence of DVT for the 153 non-COVID-19 patients with ARDS was 28.8% (n = 44; P = .01). The COVID-19 patients requiring the ICU had had an increased rate of DVT (39 of 90; 43.3%) compared with the non-COVID-19 patients (33 of 123; 33.3%; P = .01). The risk factors for mortality included age, DVT, multiple organ failure syndrome, and prolonged ventilatory support with the following odd ratios: 1.030 (95% confidence interval [CI], 1.002-1.058), 2.847 (95% CI, 1.356-5.5979), 4.438 (95% CI, 1.973-9.985), and 5.321 (95% CI, 1.973-14.082), respectively. CONCLUSIONS: The incidence of DVT for COVID-19 patients receiving standard-dose prophylactic anticoagulation that was not weight adjusted was high, especially for ICU patients. DVT is one of the factors contributing to increased mortality. These results suggest a reevaluation is necessary of the present standard-dose thromboprophylaxis for patients with COVID-19.