Laparoscopic versus open inguinal hernia repair in patients with obesity: an American College of Surgeons NSQIP clinical outcomes analysis.

INTRODUCTION: The laparoscopic approach to inguinal hernia repair (IHR) has proven beneficial in reducing postoperative pain and facilitating earlier return to normal activity. Except for indications such as recurrent or bilateral inguinal hernias, there remains a paucity of data that specifically identities patient populations that would benefit most from the laparoscopic approach to IHR. Nevertheless, previous experience has shown that obese patients have increased wound morbidity following open surgical procedures. The aim of this study was to investigate the effect of a laparoscopic versus open surgical approach to IHR on early postoperative morbidity and mortality in the obese population using the National Surgical Quality Improvement Program (NSQIP) database. METHODS: All IHRs were identified within the NSQIP database from 2005 to 2013. Obesity was defined as a body mass index ≥30 kg/m2. A propensity score matching technique between the laparoscopic and open approaches was used. Association of obesity with postoperative outcomes was investigated using an adjusted and unadjusted model based on clinically important preoperative variables identified by the propensity scoring system. RESULTS: A total of 7346 patients met inclusion criteria; 5573 patients underwent laparoscopic IHR, while 1773 patients underwent open IHR. On univariate analysis, obese patients who underwent laparoscopic IHR were less likely to experience a deep surgical site infection, wound dehiscence, or return to the operating room compared with those who underwent an open IHR. In both the adjusted and unadjusted propensity score models, there was no difference in outcomes between those who underwent laparoscopic versus open IHR. CONCLUSIONS: The laparoscopic approach to IHR in obese patients has similar outcomes as an open approach with regard to 30-day wound events. Preoperative risk stratification of obese patients is important to determining the appropriate surgical approach to IHR. Further studies are needed to investigate the long-term effects of the open and laparoscopic approaches to IHR in the obese population.

Imaging evaluation of laparoscopic greater curvature plication: preliminary observations.

OBJECTIVE: The purpose of this article is to assess normal imaging findings and complications after laparoscopic greater curvature plication on luminal upper gastrointestinal studies and CT. MATERIALS AND METHODS: This was a retrospective chart review of 24 adults who underwent laparoscopic greater curvature plication between 2008 and 2011. Seventeen patients (70.8%) underwent postoperative luminal upper gastrointestinal studies, and four (16.7%) underwent postoperative CT. Normal imaging features and complications were recorded. The percentage of intraluminal gastric diameter occupied by the plicated segment and the percentage of greater curvature involved on postoperative upper gastrointestinal luminal studies were determined. RESULTS: A multilobular intraluminal filling defect reflecting the surgical plication occupied the proximal third of the greater curvature in 16 of 17 patients (94%), extending to the mid portion in 10 of 17 patients (59%) and to the distal third in one of 17 patients (6%). There was luminal narrowing of 50-75% in 14 of 17 patients (82%) and narrowing of 25-50% in two patients (12%). In 14 of 17 patients (82%), the plication involved 50-75% of the greater curvature length and 25-50% in the remaining three patients (18%). In four patients who underwent CT, a central low-attenuation stripe accompanied the plication. Five of 24 patients (21%) had complications, including extraluminal gastric leak (n = 1), gastric outlet obstruction (n = 2), and plication suture failure (n = 2). CONCLUSION: Laparoscopic greater curvature plication is seen as multilobular filling defects most commonly along the proximal greater curvature with 50-75% narrowing of the gastric lumen. A linear low-attenuation stripe accompanies the filling defect on CT.

An apoptosis panel for nonalcoholic steatohepatitis diagnosis.

BACKGROUND & AIMS: The extrinsic death receptor-mediated pathway of apoptosis is involved in nonalcoholic steatohepatitis (NASH) development. Our aims were to create and validate a noninvasive prediction model for NASH diagnosis based on specific circulating markers of apoptosis. METHODS: Our initial cohort consisted of 95 consecutive patients undergoing a liver biopsy for clinically suspected NASH. Blood was obtained from each patient at the time of liver biopsy. Plasma caspase 3 generated cytokeratin-18 fragments (CK-18), soluble Fas (sFas), and soluble Fas ligand (sFasL) were measured. Histology was assessed by an experienced hepatopathologist. The validation cohort consisted of 82 consecutive patients that underwent liver biopsy at the time of bariatric surgery. RESULTS: Patients with NASH had significantly higher levels of CK-18 and sFas than patients in the "not NASH" group [median (25th, 75th percentile): 508 (280, 846) U/L versus 176 (131, 224) U/L (p<0.001), and 11.8 (7.8, 12.5) ng/ml versus 5.9 (4.8, 8.3) ng/ml (p<0.001), respectively]. A significant positive correlation was revealed between the apoptosis markers and liver histopathology independent of other metabolic factors. A prediction model was generated including CK-18 fragments and sFas levels that showed an AUC of 0.93 and 0.79 in the initial and validation cohorts, respectively. A cutoff value using this model predicted NASH with a sensitivity and specificity of 88% and 89%, respectively. CONCLUSIONS: Quantification of circulating levels of two apoptotic markers accurately predicts the presence of NASH, supporting the potential usefulness of these markers in clinical practice for noninvasive diagnosis of NASH.

Joint international consensus statement for ending stigma of obesity.

People with obesity commonly face a pervasive, resilient form of social stigma. They are often subject to discrimination in the workplace as well as in educational and healthcare settings. Research indicates that weight stigma can cause physical and psychological harm, and that affected individuals are less likely to receive adequate care. For these reasons, weight stigma damages health, undermines human and social rights, and is unacceptable in modern societies. To inform healthcare professionals, policymakers, and the public about this issue, a multidisciplinary group of international experts, including representatives of scientific organizations, reviewed available evidence on the causes and harms of weight stigma and, using a modified Delphi process, developed a joint consensus statement with recommendations to eliminate weight bias. Academic institutions, professional organizations, media, public-health authorities, and governments should encourage education about weight stigma to facilitate a new public narrative about obesity, coherent with modern scientific knowledge.

Comparative Outcomes of Bariatric Surgery in Patients with Impaired Mobility and Ambulatory Population.

PURPOSE: This study aims to characterize complications, metabolic improvement, and change in ambulation status for patients with impaired mobility undergoing bariatric surgery. MATERIAL AND METHODS: Individuals undergoing primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from February 2008 to December 2015 were included. Impaired mobility (WC) was defined as using a wheelchair or motorized scooter for at least part of a typical day. The WC group was propensity score matched to ambulatory patients (1:5 ratio). Comparisons were made for 30-day morbidity and mortality and 1-year improvement in weight-related comorbidities. RESULTS: There were 93 patients in the WC group matched to 465 ambulatory controls. The median operative time (180 vs 159 min, p = 0.003) and postoperative length of stay (4 vs 3 days, p ≤ 0.001) was higher in the WC group. There were no differences in readmission or all-cause morbidity within 30 days. The median percent excess weight loss (%EWL) at 1 year was similar (WC group, 65% available, 53% EWL vs AMB group, 73% available, 54% EWL); however, patients with impaired mobility were less likely to experience improvement in diabetes (76 vs 90%, p = 0.046), hypertension (63 vs 82%, p < 0.005), and obstructive sleep apnea (53 vs 71%, p < 0.001). Within the WC group, 62% had improvement in their mobility status, eliminating dependence on wheelchair or scooter assistance. CONCLUSION: Patients with both obesity and impaired mobility experience similar rates of perioperative morbidity and weight loss at 1 year compared to ambulatory controls. However, improvement in weight-related comorbidities may be less likely with impaired mobility.

Primary Inadequate Weight Loss After Roux-en-Y Gastric Bypass Is not Associated with Poor Cardiovascular or Metabolic Outcomes: Experience from a Single Institution.

BACKGROUND: It is well accepted that bariatric surgery has cardiovascular and metabolic effects independent of weight loss. METHODS: Weight loss outcomes of patients undergoing Roux-en-Y gastric bypass (RYGB) at a high volume referral center were collected at 1 year postoperatively. Patients with failed primary weight loss were identified. Primary inadequate weight loss was defined as total body weight loss less than 15 %. Changes in hypertension (HTN), dyslipidemia, type 2 diabetes mellitus (T2DM), and metabolic syndrome profiles were investigated using Student's t test. RESULTS: A total of 2500 patients underwent RYGB from the years 2001-2013 at our institution. One hundred five (4.2 %) patients had primary inadequate weight loss. Within this cohort, 81 (77.1 %) patients had hypertension, 67 (63.8 %) had dyslipidemia, 53 (50.5 %) had type 2 diabetes mellitus, and 66 (62.9 %) patients had metabolic syndrome. At 1 year postoperatively, all metabolic parameters were significantly improved. Measures of metabolic disease included high-density lipoprotein (HDL) (46.3 ± 11.6 versus 54.1 ± 12.7 mg/dL, p < 0.01), low-density lipoprotein (LDL) (103.6 ± 35.8 versus 89.2 ± 30.0 mg/dL, p < 0.01), triglycerides (177.3 ± 139.1 versus 117.6 ± 59.3 mg/dL, p < 0.01), mean plasma glucose (128.9 ± 55.3 versus 102.7 ± 27.3 mg/dL, p < 0.01), and hemoglobin A1C (7.3 ± 1.9 versus 6.1 ± 1.0 %, p < 0.01). HTN was noted to improve in 27 (33.3 %) patients based on a decrease in the number of anti-hypertensives used (1.7 ± 1.0 versus 1.3 ± 1.3, p < 0.01), and 21 (31.8 %) patients had resolution of their metabolic syndrome. CONCLUSION: Improvement in cardiometabolic comorbidities still occurs despite suboptimal weight loss following RYGB.

Should recent smoking be a contraindication for sleeve gastrectomy?

BACKGROUND: One of the ultimate goals of bariatric and metabolic surgery is to decrease cardiovascular morbidity and mortality. Obese individuals who smoke tobacco are at an increased risk of cardiovascular events and may benefit the most by positive effects of bariatric surgery on cardiometabolic risk factors. The safety profile of sleeve gastrectomy in patients who smoke has not yet been characterized. OBJECTIVES: To investigate the independent effect of smoking on early postoperative morbidity and mortality of laparoscopic sleeve gastrectomy. SETTING: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. METHODS: All patients undergoing primary laparoscopic sleeve gastrectomy from 2010 to 2014 were identified within the NSQIP database. Thirty-day postoperative outcomes for smokers, defined as patients who smoked within the year before surgery, were compared with nonsmokers. RESULTS: A total of 33,714 people underwent sleeve gastrectomy; 30,418 (90.2%) patients were nonsmokers, whereas 3296 (9.8%) patients smoked within a year before surgery. Among the 17 examined individual adverse events, patients who smoked were more likely to experience an unplanned reintubation (odds ratio [OR] = 1.88, 95% confidence interval [CI]: 1.01-3.50). Patients in the smoking group were significantly more likely to experience a composite morbidity event (4.3% versus 3.7%, P = .04), serious morbidity event (.9% versus .6%, P = .003), and 30-day mortality (0.2% versus .1%, P = .0004). The length of hospital stay, unplanned readmission, and readmission rates were comparable between the 2 groups. These differences in the composite morbidity event, serious morbidity event, and mortality persisted even when those patients with chronic obstructive pulmonary disease, used as a surrogate for end-stage pulmonary effects of smoking, were excluded from the analysis. CONCLUSION: Sleeve gastrectomy is a well-tolerated procedure in nonsmokers and smokers. However, patients who have smoked within a year before sleeve gastrectomy are at an increased, albeit still very low, risk for 30-day morbidity and mortality compared with nonsmokers. Additional studies are needed to determine if long-term improvement in co-morbidities can offset this initial modest increased perioperative risk.

Laparoscopic Three-Port Sleeve Gastrectomy: A Single Institution Case Series.

BACKGROUND: Further minimization of abdominal wall trauma during laparoscopic bariatric surgery is a topic of great interest. Reducing the number of trocars may provide superior cosmetic results with less pain and shorter length of stay (LOS). However, it remains unclear if this approach compromises safety or effectiveness of weight loss. The aim of this study is to report initial safety and feasibility results using a three-port minimally invasive sleeve gastrectomy technique. MATERIALS AND METHODS: A retrospective review of patients who underwent laparoscopic three-port sleeve gastrectomy (3PSG) at our institution was conducted. Patient demographics, intraoperative parameters, and perioperative outcomes were extracted and analyzed. Postoperative data were obtained from routine follow-up history and physical examination. RESULTS: From May 2013 to April 2014, 45 morbidly obese patients underwent 3PSG. The cohort had a male-to-female ratio of 20:25, mean age of 47.4 ± 11.6 years, and a mean preoperative body mass index (BMI) of 47.6 ± 9.7 kg/m(2). The mean number of comorbidities was 4 (range 0-8), and the mean American Society of Anesthesiologists score was 2.82 (range 1-4). Mean procedural duration and blood loss were 165 ± 31.9 minutes and 27.0 ± 31.8 mL, respectively. Eight patients (17%) required one additional trocar. Two cases (4.4%) had an intraoperative complication (staple line bleeding and splenic capsule laceration). Two (4.4%) postoperative complications were encountered (wound infection and axillary vein thrombosis). The mean LOS was 2.7 (range 2-7) days. At a mean follow-up of 5 (range 0.4-11.7) months, the cohort had a mean BMI of 40.0 ± 9.26 kg/m(2), which corresponded to a mean excess weight loss of 36.0% ± 18.1%. There were no trocar site hernias. All patients were highly satisfied with the final cosmetic result. CONCLUSION: Laparoscopic 3PSG appears to be a safe and feasible technique for performing sleeve gastrectomy. While further long-term research is needed, it appears to have significant benefits, mainly patient satisfaction and potentially less pain.

Is Laparoscopic Bariatric Surgery a Safe Option in Extremely High-Risk Morbidly Obese Patients?

INTRODUCTION: Age, superobesity, and cardiopulmonary comorbidities define patients as high risk for bariatric surgery. We evaluated the outcomes following bariatric surgery in extremely high-risk patients. MATERIALS AND METHODS: Among 3240 patients who underwent laparoscopic bariatric surgery at a single academic center from January 2006 through June 2012, extremely high-risk patients were identified using the following criteria: age ≥ 65 years, body mass index (BMI) ≥ 50 kg/m(2), and presence of at least two of six cardiopulmonary comorbidities, including hypertension, ischemic heart disease, congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and history of venous thromboembolism. Perioperative and intermediate-term outcomes were assessed. RESULTS: Forty-four extremely high-risk patients underwent laparoscopic Roux-en-Y gastric bypass (n = 23), adjustable gastric banding (n = 11), or sleeve gastrectomy (n = 10). Patients had a mean age of 67.9 ± 2.7 years, a mean BMI of 54.8 ± 5.5 kg/m(2), and a median of two (range, two to five) cardiopulmonary comorbidities. There was no conversion to laparotomy. Thirteen (29.5%) 30-day postoperative complications occurred; only six were major complications. Thirty-day postoperative re-admission, re-operation, and mortality rates were 15.9%, 2.3%, and 0%, respectively. Within a mean follow-up time of 24.0 ± 18.4 months, late morbidity and mortality rates were 18.2% and 2.3%, respectively. The mean percentage total weight and excess weight losses after at least 1 year of follow-up were 26.7 ± 12.0% and 44.1 ± 20.6%, respectively. CONCLUSIONS: Laparoscopic bariatric surgery is safe and can be performed with acceptable perioperative outcomes in extremely high-risk patients. Advanced age, BMI, and severe cardiopulmonary comorbidities should not exclude patients from consideration for bariatric surgery.

The incidence of hiatal hernia and technical feasibility of repair during bariatric surgery.

PURPOSE: To evaluate the incidence and outcomes of hiatal hernias (HH) that are repaired concomitantly during bariatric surgery. METHODS: We identified patients who had concomitant HH repair during bariatric surgery from 2010 to 2014. Data collected included baseline demographics, perioperative parameters, type of HH repair, and postoperative outcomes. RESULTS: A total of 83 underwent concomitant HH during study period. The male-to-female ratio was 1:8, mean age was 57.2 ± 10.0 years, and mean body mass index was 44.5 ± 7.9 kg/m(2). A total of 61 patients had laparoscopic Roux-en-Y gastric bypass, and 22 had laparoscopic sleeve gastrectomy. HH was diagnosed before bariatric surgery in 32 (39%) subjects, whereas 51 (61%) were diagnosed intraoperatively. Primary hernia repair was performed with anterior reconstruction in 45 (54%) patients, posterior in 21 (25%), and additional mesh placement in 7 (8%). A total of 24 early minor postoperative symptoms were reported. At 12 month follow-up, mean body mass index improved to 30.0 ± 6.2 kg/m(2), and anti-reflux medication was decreased from 84% preoperatively to 52%. Late postoperative complications were observed in 3 patients. A comparative analysis with a matched 1:1 control group displayed no significant differences in operative time (P = .07), duration of stay (P = .9), intraoperative complications, or early (P = .09) and late post-operative symptoms (P = .3). In addition, no differences were noted in terms of weight-loss outcomes. CONCLUSION: The true incidence of HH may be underestimated before bariatric surgery. Combined repair of HH during bariatric surgery appears safe and feasible.