Reconstruction options following pancreaticoduodenectomy after Roux-en-Y gastric bypass: a systematic review.

BACKGROUND: Obesity is a risk factor for pancreatic cancer which may be treated with Roux-en-Y gastric bypass and represents an increasing morbidity. Post-RYGB anatomy poses considerable challenges for reconstruction after pancreaticoduodenectomy (PD), a growing problem encountered by surgeons. We characterize specific strategies used for post-PD reconstruction in the RYGB patient. METHODS: PubMed search was performed using MeSH terms "Gastric Bypass" and "Pancreaticoduodenectomy" between 2000 and 2018. Articles reporting cases of pancreaticoduodenectomy in post-RYGB patients were included and systematically reviewed for this study. RESULTS: Three case reports and five case series (25 patients) addressed PD after RYGB; we report one additional case. The typical post-gastric bypass PD patient is a woman in the sixth decade of life, presenting most commonly with pain (69.2%) and/or jaundice (53.8%), median 5 years after RYGB. Five post-PD reconstructive options are reported. Among these, the gastric remnant was resected in 18 cases (69.2%), with reconstruction of biliopancreatic drainage most commonly achieved using the distal jejunal segment of the pre-existing biliopancreatic limb (73.1%). Similarly, in the eight cases where the gastric remnant was spared (30.8%), drainage was most commonly performed using the distal jejunal segment of the biliopancreatic limb (50%). Among the 17 cases reporting follow-up data, median was 27 months. CONCLUSION: Reconstruction options after PD in the post-RYGB patient focus on resection or preservation gastric remnant, as well as creation of new biliopancreatic limb. Insufficient data exists to make recommendations regarding the optimal reconstruction option, yet surgeons must prepare for the possible clinical challenge. PD reconstruction post-RYGB requires evaluation through prospective studies.

Robotic-Assisted Surgery Results in a Shorter Hospital Stay Following Revisional Bariatric Surgery.

BACKGROUND: Revisional surgery is rapidly growing within the field of bariatric surgery. The use of robotic assisted surgery, considered controversial by many, may offer advantages in revisional bariatric surgery (RBS). There are few studies comparing laparoscopic and robotic-assisted RBS. The aim of this study is to compare the safety and outcome of laparoscopic and robotic RBS in a single accredited center. METHODS: A retrospective analysis of data collected prospectively on patients undergoing either laparoscopic (L-RBS) or robotic (R-RBS) RBS between January 1, 2017 and December 31, 2019 was performed. The primary outcomes included length of stay (LOS), 30-day major and minor complication rates, readmission rates, and mortality rates. RESULTS: A total of 167 patients were included in our analysis. Fifty-two patients underwent R-RBS (31%), and 115 underwent L-RBS (69%). Thirty-day major and minor complication rates for R-RBS and L-RBS were 1.9% and 5.8% vs 5.2% and 5.2%, respectively (p > .05). There was no difference in readmission rates (3.8% vs 8.7%, p > 0.05) or intraoperative blood loss (35.5 mL vs 37.4 mL, p > .05) between R-RBS and L-RBS. R-RBS resulted in a shorter length of stay when compared with L-RBS (40.2 h vs 62.6 h, p < .05). CONCLUSIONS: R-RBS has a decreased, albeit non-significant, rate of 30-day major complications with no difference in minor complications, readmission rates, or intraoperative blood loss when compared with L-RBS. R-RBS resulted in a decreased length of stay when compared with L-RBS. Randomized clinical trials are needed to better elucidate our findings.

Outcomes of robotic surgery in revisional bariatric cases: a propensity score-matched analysis of the MBSAQIP registry.

In recent years, there has been a significant increase in the number of Revisional Bariatric Surgery (RBS) cases performed to address complications and weight recidivism. The use of the da Vinci robotic platform, considered controversial by many, may offer advantages in RBS. The objective of our study is to compare the outcomes of Robotic RBS (R-RBS) to Laparoscopic RBS (L-RBS). Using the 2015-2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we selected all RBS and we matched R-RBS to L-RBS using a propensity score matching system to create balanced groups. Our primary outcomes were 30-day Serious Adverse Events (SAE), 30-day Organ Specific Infection (OSI), 30-day reoperation and 30-day interventions. Our secondary outcomes included length of operation and 30-day readmission. We conducted separate Mann-Whitney rank sums tests or chi-square tests and Fisher exact test. R-RBS and L-RBS included 220 patients each. The overall incidence of 30-day SAEs, 30-day OSIs, 30-day reoperations, 30-day interventions were lower for R-RBS (6.4%, 0.9%, 2.7% and 2.3%, respectively) compared L-RBS (7.7%, 1.4%, 3.6% and 3.6%, respectively). Subgroup analysis showed that R-RBS had a lower rate of complications for the Gastric Bypass procedure but not for Sleeve gastrectomy cases. However, 30-day readmission was higher for R-RBS compared to L-RBS (9.1% vs 6.4% respectively). None of the analyses reached statistical significance. R-RBS took significantly longer compared to L-RBS (169 min vs 138 min, p < 0.05). Our study shows that R-RBS has lower complication rate albeit non-significant as compared to L-RBS.

Thirty-Day Outcomes of Bariatric Surgery in Adolescents: a First Look at the MBSAQIP Database.

INTRODUCTION: Bariatric surgery is the only effective treatment of severe obesity. The number of adolescents undergoing bariatric surgery is increasing. However, bariatric surgery in adolescents is controversial. OBJECTIVE: The purpose of this study is to evaluate the outcomes of bariatric surgery in adolescents based on the MBSAQIP database (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project). METHODS: We analyzed the 2015-2017 MBSAQIP database; patients ≤ 19 years of age were included in our analysis. Primary outcomes were 30-day serious adverse events (SAEs), organ space infection (OSI), re-intervention, and re-operation rates. Secondary outcomes included operation length, hospital stay, and re-admission rates. We conducted separate Mann-Whitney rank sums tests, chi-square, or Fisher's exact tests as appropriate, with p < .05 denoting statistical significance. RESULTS: A total of 1983 adolescent patients were included in our analysis. The average age and BMI were 18.1 and 47.5, respectively. Of adolescent patients, 21.7% underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) and 78.3% underwent laparoscopic sleeve gastrectomy (LSG). The 30-day SAE and readmission rates were significantly lower for LSG compared with LRYGB (2.9% and 2.6% vs 6.5% and 5.6%, respectively; p < 0.05). The 30-day reoperation rate was also lower for LSG compared with LRYGB albeit not significant (1.1% and vs 2.3%; p = 0.05). The 30-day intervention rate for LSG was significantly lower, however, compared with LRYGB (1.2% vs 3%; p < 0.05). Compared with adult patients, > 19 years old (n = 353,726), we found no difference in our outcomes. However, adolescents had significantly shorter operation length. CONCLUSION: In adolescents, LSG had fewer SAE, re-intervention, and readmission rates compared with LRYGB. There was no difference in outcomes between adolescents and adults.

RETRACTED: Robotic surgery results in better outcomes following Roux-en-Y gastric bypass: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program analysis for the years 2015-2018.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted in accordance with the Committee on Publication Ethics (COPE) Retraction Guidelines because of the author's (Maher el Chaar) failure to comply with SOARD guidelines for appropriate disclosure of conflict of interest with industry as well as flawed research design and analytical errors that resulted in biased conclusions considered to be misleading to patients and readers.

Cost Analysis of Robotic Roux-en-Y Gastric Bypass in a Single Academic Center: How Expensive Is Expensive?

BACKGROUND: Although the use of da Vinci robotic platforms in bariatric surgery is gaining momentum, it is still controversial because of financial concerns. OBJECTIVES: The objective of our study is to evaluate the cost of robotically assisted Roux-en-Y gastric bypass (R-RYGB) versus conventional laparoscopic Roux-en-Y gastric bypass (L-RYGB). METHODS: We analyzed consecutive primary bariatric patients who underwent R-RYGB and compared them with patients who underwent L-RYGB during the same time period. Primary outcomes were overall cost for length of stay, operating time, and supplies. Direct cost data was generated using the StrataJazz reporting module, which is fed daily from EPIC, our electronic health record system, and contains hospital-based data only. Secondary outcomes were 30-day rates of complications, reoperations, and readmissions. RESULTS: We found no difference in primary or secondary outcomes following R-RYGB and L-RYGB. The overall cost for R-RYGB and L-RYGB was not statistically different (median total cost for R-RYGB and L-RYBG was $6431.34 and $6349.09, P > 0.05, respectively). Operating time cost was significantly higher for R-RYGB compared with L-RYGB ($2248.51 versus $19,836.29, respectively, P < 0.0001, respectively). R-RYGB had lower cost of supplies as well as a shorter length of stay compared with L-RYGB (mean 1.5 versus 1.7 days, respectively). CONCLUSIONS: Our study revealed no cost difference between R-RYGB and L-RYGB, with a decreased cost of supplies and trend toward lower hospital stay favoring R-RYGB. Further studies are needed to evaluate the outcomes of R-RYGB compared with L-RYGB; however, the cost of robotic surgery may not be a prohibitive factor.

Worsening head bleeds in elderly blunt head trauma patients taking antithrombotics: Delayed CT head fails to change management.

BACKGROUND: Most elderly trauma patients suffer blunt head injury and many utilize antithrombotic (AT) medications. The utility of delayed CT-head (D-CTH) in neurologically intact elderly patients using AT who have an intracranial hemorrhage (ICH) on presentation is unknown. We hypothesized that D-CTH would not alter clinical management and aimed to evaluate the role of D-CTH in this population. METHODS: A retrospective cohort study was performed. Patients ≥65 years sustaining blunt head injuries from January 2010 to July 2017 were identified using our level 1 trauma center database. AT-patients presenting with ICH who underwent D-CTH were included. Patients with worsened ICH were compared to those with stable to improved ICH on D-CTH. AT-patients were compared to a cohort of non-AT patients. Fisher's Exact and Mann-Whitney U tests were utilized and a power analysis conducted. RESULTS: 137 A T and 34 non-AT patients were identified. There was no difference in hemorrhage progression or appearance of new ICH. No patient had a change in management from D-CTH in either cohort. AT-patients were slightly older (p < 0.001), but cohorts were otherwise similar. 50 AT-patients with worsened ICH were compared to 87 with stable ICH. There was no difference in cohort demographics. Hemorrhage progression did not vary with type of AT used but did increase if multiple types of synchronous ICH were present (p < 0.001). CONCLUSIONS: Our data supports abstaining from routine D-CTH of elderly ICH patients with an intact neurologic examination who are utilizing aspirin, clopidogrel or warfarin. Conclusions cannot be drawn regarding new oral anticoagulants (NOACs) given low enrollment. Further multicenter study is required to provide adequate power and detect small levels of management change.

Aspectos críticos contextuales de un hospital de alta complejidad / Critical contextual aspects of a highly complex hospital / Aspectos críticos contextuais de um hospital de alta complexidade

Este artículo presenta los resultados parciales de un análisis FODA realizado en el Instituto Nacional del Tórax, con el fin de generar información sobre los aspectos críticos que afectan la gestión estratégica de un hospital público de alta complejidad, y abrir una reflexión ética sobre tales procesos. Para su determinación se usaron focus group, entrevistas en profundidad, propuestas por el equipo Directivo del Hospital y discusiones en torno al ámbito contextual. Las entrevistas individuales y grupales tuvieron una duración de una hora y veinte minutos aproximadamente y se realizaron en dependencias del hospital. La conceptualización de los datos, se hizo desde la Teoría Fundamentada. El estudio muestra, de acuerdo con la percepción de los entrevistados, que hay aspectos contextuales, tales como reglas del juego, stakeholders y cultura país, cuya tensión ética con la organización, afectan el quehacer del Instituto Nacional del Tórax, en cuanto hospital público de alta complejidad.

This article presents the partial results of a SWOT analysis at the National Chest Institute, in order to generate information on critical issues affecting the strategic management of a public hospital of high complexity, and open an ethical reflection on such processes. For their determination were used: focus groups, interviews, proposed by the management team of the Hospital and discussions on the contextual level. The Individual and group interviews lasted about an hour and twenty minutes and were performed at hospital units. The conceptualization of the data was made from Grounded Theory. The study shows, according to the perception of the interviewees, their contextual issues such as rules, stakeholders and cultural country, whose ethical tension with the organization, affect the work of the National Chest Institute as a high complexity public hospital.

objetivo: Este artigo apresenta resultados parciais de uma análise FOFA realizada no Instituto Nacional de Tórax do Chile, com a finalidade de gerar informações sobre os aspectos críticos que afetam a gestão estratégica de um hospital público de alta complexidade, e gerar uma reflexão ética sobre tais processos. Método: para sua determinação fora utilizado o focus group, entrevistas em profundidade propostas pela equipe de gestão do hospital e discussões acerca do escopo contextual. A conceitualização dos dados, foi feita a partir da Teoria Fundamentada. Conclusões: o estudo demonstra que, de acordo com a percepção dos entrevistados, há aspectos contextuais, tais como as regras do jogo, stakeholders e a cultura do país, cuja tensão ética com a organização afetam o trabalho do Instituto Nacional do tórax, enquanto hospital público de alta complexidade.