A predictive model for patients with median arcuate ligament syndrome.

BACKGROUND: Due to the rarity of median arcuate ligament (MAL) syndrome, patient selection for surgery remains difficult. This study provides a predictive model to optimize patient selection and predict outcomes following a MAL release. METHODS: Prospective data from patients undergoing a MAL release included demographics, radiologic studies, and SF-36 questionnaires. Successful postoperative changes in SF-36 was defined as an improvement > 10% in the total SF-36 score. A logistic regression model was used to develop a clinically applicable table to predict surgical outcomes. Celiac artery (CA) blood flow velocities were compared pre- and postoperatively and Pearson correlations were examined between velocities and SF-36 score changes. RESULTS: 42 patients underwent a laparoscopic MAL release with a mean follow-up of 28.5 ± 18.8 months. Postoperatively, all eight SF-36 scales improved significantly. The logistic regression model for predicting surgical benefit was significant (p = 0.0244) with a strong association between predictors and outcome (R2 = 0.36). Age and baseline CA expiratory velocity were significant predictors of improvement and predicted clinical improvement. There were significant differences between pre- and postoperative CA velocities. Postoperatively, the bodily pain scale showed the most significant increase (64%, p < 0.0001). A table was developed using age and preoperative CA expiratory velocities to predict clinical outcomes. CONCLUSIONS: Laparoscopic MAL produces significant symptom improvement, particularly in bodily pain. This is one of the first studies that uses preoperative data to predict symptom improvement following a MAL release. Age and baseline CA expiratory velocity can be used to guide postoperative expectations in patients with MAL syndrome.

Median arcuate ligament syndrome in athletes.

BACKGROUND: Exercise-related transient abdominal pain (ETAP) is a common entity in young athletes. Most occurrences are due to a "cramp" or "stitch," but an uncommon, and often overlooked, etiology of ETAP is median arcuate ligament syndrome (MALS). The initial presentation of MALS typically includes postprandial nausea, bloating, abdominal pain, and diarrhea, but in athletes, the initial presentation may be ETAP. METHODS: We present a case series of three athletes who presented with exercise-related transient abdominal pain and were ultimately diagnosed and treated for MALS. Unlike other patients with median arcuate ligament syndrome, these athletes presented with exercise-induced pain, rather than the common postprandial symptoms. These symptoms persisted despite conservative measures. Work-up of patients with suspected MALS include a computed tomography or magnetic resonance angiography showing compression of the celiac artery with post-stenotic dilation, or a celiac artery ultrasound demonstrating increased velocities (>200 cm/s2) with deep exhalation. RESULTS: All patients underwent a laparoscopic median arcuate ligament release. Postoperatively, there were no complications, and all were discharged home on postoperative day #2. All patients have subsequently returned to athletics with resolution of their symptoms. CONCLUSION: ETAP is common in athletes and often resolves with preventative or conservative strategies. When ETAP persists despite these methods, alternative causes, including MALS, should be considered. A combination of a thorough history and physical exam, as well as radiographic data, is essential to make the appropriate diagnosis and treatment strategy.

Laparoscopic bilateral cortical-sparing adrenalectomy for pheochromocytoma.

INTRODUCTION: Since laparoscopic adrenalectomy for pheochromocytoma was reported in 1992, the laparoscopic technique has largely replaced the open approach [4]. Numerous studies have demonstrated that the laparoscopic approach is associated with decreased blood loss, shorter hospitalization, faster recovery, and lower cost [1]. Conversion rates are reported at less than 5.5 %, yet concern still exists that intraoperative hypertensive crisis may be more severe with laparoscopy due to increased intraabdominal pressure [3]. Bilateral pheochromocytomas are common in patients with multiple endocrine neoplasia type 2 (MEN 2) or von Hippel-Lindau (VHL) disease. Total adrenalectomy commits the patient to lifelong steroid hormone replacement and the risk of Addisonian crisis after bilateral adrenalectomy [5]; [8]. The risk of malignant pheochromocytomas in patients with or without MEN 2 or VHL is low. The current literature supports cortical-sparing adrenalectomy in patients with bilateral pheochromocytomas [2, 7, 10]. This video presents a patient with bilateral pheochromocytomas who underwent bilateral laparoscopic cortical-sparing adrenalectomies. METHODS: A 40-year-old female presented to her primary care physician with a history of a hypertensive crisis that required an emergent cesarean section. Her workup revealed elevated urinary metanephrines, and a CT scan showed a left adrenal lesion measuring 3.9 cm and a right adrenal lesion measuring 2.7 cm. After undergoing alpha blockade, she was consented for bilateral partial adrenalectomies. A left partial adrenalectomy was performed first using four ports. The ports were then closed and the patient was repositioned in a left lateral decubitus position for a subsequent right partial adrenalectomy. RESULTS: The patient had an uncomplicated hospital course and was discharged home on postoperative day 4. She returned for follow-up at 2 weeks and 1 month and had returned to her normal activities. Testing for MEN and von Hippel-Lindau was both negative. Her electrolyte and cortisol levels normalized, and she was weaned off her postoperative steroids by week five. At 1-year follow-up, she remains off steroids and no longer requires anti-hypertensive medications. CONCLUSION: Laparoscopic adrenalectomy is the gold standard for removal of benign lesions of the adrenal gland. Bilateral pheochromocytomas are more common in the presence of hereditary conditions such as MEN and von Hippel-Lindau and should be ruled out [8, 10]. The risk of Addisonian crisis and lifelong steroid replacement should prompt cortical preservation with bilateral disease [9]. Laparoscopic bilateral partial adrenalectomies should be considered in patients with bilateral pheochromocytomas [6]. Finally, all patients undergoing pheochromocytoma excision require lifelong follow-up to monitor for recurrence.

Laparoscopic Puestow: lateral pancreaticojejunostomy.

INTRODUCTION: Chronic pancreatitis is a painful inflammatory disease that leads to progressive and irreversible destruction of pancreatic parenchyma [1]. A lateral pancreaticojejunostomy, also known as the Puestow procedure, is performed for symptomatic chronic pancreatitis associated with a dilated pancreatic duct secondary to calcifications or strictures [4]. An open approach is used traditionally due to the complexity of the case, and there have only been a handful of laparoscopic case reports [2]. This video depicts a laparoscopic lateral pancreaticojejunostomy for chronic pancreatitis. METHODS: A 45-year-old gentleman with a 20-year history of chronic alcohol abuse presented with diffuse abdominal pain. His pain was worse postprandially and associated with loose stools. A computed tomography scan revealed multiple calcified deposits within the body and tail of the pancreas, and a dilated pancreatic duct measuring 1.4 cm with a proximal obstructing calcified stone. A 5-port foregut technique was used, and a 15-cm pancreatic ductotomy was performed with an ultrasonic scalpel. Calcified stones were cleared from the duct, and a roux-en-y pancreaticojejunostomy was performed using a hand-sewn technique. RESULTS: The patient had a relatively uncomplicated hospital course with return of bowel function on postoperative day 4. His patient-controlled analgesic device was discontinued on post operative day 3. He was ambulating, tolerating a regular diet and discharged home on postoperative day 5. At 12- and 26-month follow-up, he remains off narcotics, but still requires 1-2 tabs of pancreatic enzyme replacement per meal. Most importantly, he has not had any alcohol for over 2 years. CONCLUSION: The two primary goals in treating chronic pancreatitis include long-term pain relief and improvements in quality of life [3]. For patients with chronic pancreatitis and a dilated pancreatic duct, a laparoscopic lateral pancreaticojejunostomy may be an effective approach to decrease pain and improve quality of life.

Incisional and port-site hernias following robotic colorectal surgery.

BACKGROUND: The association between extraction site location, robotic trocar size, and the incidence of incisional hernias in robotic colorectal surgery remain unclear. Laparoscopic literature reports variable rates of incisional hernias versus open surgery, and variable rates of trocar site hernias. However, conclusions from these studies are confusing due to heterogeneity in closure techniques and may not be generalized to robotic cases. This study evaluates the effect of extraction site location on incisional hernia rates, as well as trocar hernia rates in robotic colorectal surgery. MATERIALS AND METHODS: A retrospective review of multiport and single incision robotic colorectal surgeries from a single institution was performed. Patients underwent subtotal, segmental, or proctocolectomies, and were compared based on the extraction site through either a muscle-splitting (MS) or midline (ML) incision. Hernias were identified by imaging and/or physical exam. Demographics and risk factors for hernias were assessed. Groups were compared using a multivariate logistic regression analysis. RESULTS: The study included 259 colorectal surgery patients comprising 146 with MS and 113 with ML extraction sites. Postoperative computed tomograms were performed on 155 patients (59.8 %) with a mean follow-up of 16.5 months. The overall incisional hernia rate was 5.8 %. A significantly higher hernia rate was found among the ML group compared to the MS group (12.4 vs. 0.68 %, p < 0.0001). Of the known risk factors assessed, only increased BMI was associated with incisional hernias (OR 1.18). No trocar site hernias were found. CONCLUSION: Midline extraction sites are associated with a significantly increased rate of incisional hernias compared to muscle-splitting extraction sites. There is little evidence to recommend fascia closure of 8-mm trocar sites.

Exercise-related transient abdominal pain secondary to median arcuate ligament syndrome: a case report.

Exercise-related transient abdominal pain is a common entity in young athletes. An uncommon aetiology of this type of pain is median arcuate ligament syndrome. This article details an 18-year-old field hockey player who presented with a 1-year history of exercise-related transient abdominal pain. Despite a trial of preventative strategies, the patient's pain persisted, prompting surgical intervention. Following a laparoscopic median arcuate ligament release, the patient's symptoms resolved. Therefore, when exercise-related transient abdominal pain persists despite precautionary measures, median arcuate ligament syndrome should be considered.

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA).

BACKGROUND: The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted. METHODS: The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval. RESULTS: Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy. CONCLUSIONS: Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

Changes in GIP gene expression following bariatric surgery.

BACKGROUND: After bariatric surgery, there is a significant improvement in type 2 diabetes (T2D). T2D has been linked to incretins, including glucose-dependent insulinotropic polypeptide (GIP). Analysis of bariatric surgery patients may help to understand the link between GIP and T2D. METHODS: Twenty-three morbidly obese patients underwent Roux-en-Y gastric bypass (RYGB) or gastric banding. Overall, there were 12 RYGB (5 T2D; 7 nondiabetic) patients and 11 gastric band (7 T2D; 4 nondiabetic) patients. Preoperative and postoperative blood samples were collected. Total RNA was extracted, cDNA synthesized, and real-time quantitative PCR were used to quantify gene expression. Student's t test was used for statistical analysis. RESULTS: Postoperatively, T2D resolved or improved in 83.3 % (10/12) of the diabetic patients. Six (4 RYGB, 2 bands) patients discontinued hypoglycemic medications and four (3 RYGB, 1 band) patients discontinued the majority of their hypoglycemic agents. The remaining two diabetic patients (bands) showed no improvement. Postoperative GIP gene expression increased 4.36-fold (p = 0.02) in diabetic RYGB patients, whereas diabetic band patients increased 1.4-fold (p = 0.25). All diabetic patients with either resolution or improvement of T2D, had a 3.4-fold increase (p = 0.01) but nonresponders decreased 0.69-fold (p = 0.41). Nondiabetic RYGB patients increased 2.21-fold (p = 0.07) versus a 0.81-fold (p = 0.37) decrease of nondiabetic band patients. CONCLUSIONS: This is one of the initial studies that show a significant increase in GIP gene expression following a RYGB. This increase correlates with the clinical resolution of T2D. The anatomical changes after RYGB may account for these changes. Based on this data, GIP may be a key peptide in the "foregut hypothesis" for resolution of T2D.

Resistin expression correlates with steatohepatitis in morbidly obese patients.

BACKGROUND: Morbidly obese patients are at risk for nonalcoholic steatohepatitis (NASH) even in the absence of risk factors for liver disease. Unfortunately, NASH is usually not clinically evident, and a definitive, noninvasive test for NASH does not exist. Resistin, a cytokine originating from adipose tissue, is involved in insulin resistance and also initiates proinflammatory signaling from hepatic stellate cells. This study explores the relationship between resistin expression and liver pathology in bariatric surgery patients. METHODS: Blood samples from 30 patients undergoing bariatric surgery were collected. Total RNA was extracted and cDNA was synthesized. Quantitative RT-PCR was used to quantify relative gene expression using 18s rRNA gene as an internal control. Wedge liver biopsies from these patients were sectioned and stained. Based on a previously published scoring method, biopsies were assigned an overall NASH severity score and subscores for steatosis, inflammation, and fibrosis. Results were analyzed by using Student's t test. RESULTS: Resistin mRNA levels ranged from 0.5 to 9.7. A group of five patients with very high resistin expression (>4) was identified. These patients had a significantly higher average NASH score compared with the rest of the group (7.9 vs. 4.48, p = 0.019). Steatosis and inflammation scores were significantly higher in the high-resistin group (p < 0.05 for both comparisons). There also was a trend toward higher fibrosis score in this group, which approached statistical significance (p = 0.051). CONCLUSIONS: In morbidly obese patients, high resistin expression in serum is associated with hepatic steatosis, inflammation, and fibrosis. The development of elevated resistin expression may represent a link between obesity and the onset of steatohepatitis.

Perioperative Transfusions in Veterans Following Noncardiac Procedures.

Background: Perioperative blood transfusions are associated with increased morbidity and mortality. Each surgical specialty is associated with unique operative variables. Moreover, transfusion rates vary across specialty. This article seeks to elucidate variables both common and unique to surgical specialties. Materials and Methods: This study was a retrospective review of 5344 patients from the prospectively maintained Veterans Affairs Surgical Quality Improvement Project at a single-level 1A tertiary Veterans Affairs Medical Center. Data collected included demographic information, preoperative clinical variables, postoperative outcomes, and perioperative transfusion (within 72 hours of procedure). Patients were stratified based on whether they received a transfusion. Univariate and multivariate analyses were performed. P values <.05 were significant. Results: Of the 5344 patients included in the study, 153 required perioperative transfusion of at least one unit of packed red blood cells. Patients who underwent transfusion were more likely to be men, have an underlying bleeding disorder, and have more preoperative risk factors. Although unique risk factors were found within most specialties, there was no statistically significant difference in postoperative complications between surgical specialties. Patients requiring transfusion had higher rates of morbidity and mortality. Elevated preoperative hematocrit was significantly protective against requiring transfusion across most specialties. Conclusions: Specialty-based differences in transfusion requirement may be due to the proportion of older and more frail patients, hospital transfusion thresholds, and surgical complexity. Hematocrit, however, could be an effective target for mitigating cost and morbidity associated with transfusion. Preoperative hematocrit optimization through B12, folate, iron dosing, and erythropoietin supplementation could be a useful strategy.

Factors Associated with Perioperative Transfusions in Veterans.

Background: Private sector literature demonstrates an association between perioperative transfusions and poor clinical outcomes. Hemostatic agents, surgeon training, and patient blood management programs (PBMPs) may mitigate perioperative bleeding. This study attempts to identify preoperative risk factors associated with perioperative transfusions in Veterans. Study Design and Methods: This study is a retrospective review of the prospectively maintained Veterans Affairs Surgical Quality Improvement Project database. Included patients were older than 18 years and underwent noncardiac surgery between April 1, 2016, and March 31, 2021. Data collected included demographics, surgery variables, preoperative clinical variables, postoperative outcomes, and perioperative transfusions. Cohorts were created based on transfusion status. Univariate and multivariate analyses were performed to characterize the similarities, differences, and potential predictors of perioperative transfusion. Results: Of 6108 patients included, 153 patients received perioperative transfusions. The risks for transfusion included older age, male sex, black race, smoking, and low body mass index (BMI). The highest percent of transfused patients underwent vascular (43.4%), orthopedic (22%), and general surgeries (20%). Transfusion increased risk for postoperative cerebral vascular accident (P = .041) and 30-day mortality (P < .001). Multivariate regression analysis revealed American Society of Anesthesiology class, chemotherapy within 30 days, increased age, tobacco smoking, and decreased BMI were predictive of perioperative transfusions. Discussion: Perioperative transfusions are associated with increased morbidity and mortality in the Veteran population. These retrospective data describe the complex relationships between perioperative transfusions and outcomes after noncardiac surgery. These results serve as a foundation to create predictive models and PBMP within the veteran population to decrease transfusion requirements and associated complications.

Laparoscopic Repair of a Right-Sided Diaphragmatic Hernia: A Technical Report.

Introduction: Occult diaphragmatic hernias after trauma are relatively rare and may present months to years after the traumatic event. Clinical presentations range from asymptomatic incidental findings on imaging to life-threatening incarceration of abdominal visceral organs. This study presents a case of a patient with a symptomatic diaphragmatic hernia secondary to a trauma >30 years prior. A literature review of this defect was performed examining the pathophysiology, presentation, and operative considerations. Case Presentation: A 58-year-old male with a history of multiple traumatic motor vehicle accidents 30 years prior presented with abdominal pain and obstructive symptoms. Axial imaging demonstrated a right-sided diaphragmatic hernia defect containing small intestine, colon, and omentum. He ultimately underwent a transabdominal laparoscopic repair of the defect with mesh buttressing. Postoperative the patient recovered well and was discharged without complications. Conclusion: Limited data outside of case reports exist for surgical management of occult diaphragmatic hernias secondary to trauma. Reported management options include open and minimally invasive thoracic as well as open and minimally invasive abdominal approaches; each with advantages and disadvantages. Depending on the defect size, both primary repair and repair with mesh reinforcement are appropriate options. More data comparing the approach and repair technique are needed to determine the best technique.

Laparoscopic Intragastric Cystgastrostomy: A Technical Report.

Background: Management of symptomatic pancreatic pseudocysts poses a unique challenge to minimally invasive surgeons. Despite the predominance of endoscopic management of pancreatic pseudocysts, the laparoscopic approach remains a critical skill in the armamentarium of surgeons. Methods: This report details a laparoscopic intragastric approach to create a pancreatic cystgastrostomy using intraoperative ultrasound and endoscopy. Conclusion: Laparoendoscopic techniques for pancreatic pseudocysts are still required in selective cases when endoscopic management is not available or fails. Using this technique provides patients with same clinical benefits of an endoscopic approach.

Effects of Liver Pathology on Sleeve Gastrectomy Outcomes.

Introduction: Sleeve gastrectomy engenders weight loss and improves comorbidities at 1 year postoperatively. A relationship has not been established between liver pathology and diabetic outcomes and weight loss following a sleeve gastrectomy. This study evaluates the association between liver pathology and both diabetic remission and weight loss in morbidly obese veterans. Methods: A prospective database of all patients undergoing sleeve gastrectomy with simultaneous liver biopsy at a Veterans Affairs Medical Center was analyzed from 2018 through 2020. The database included patient demographics, liver biopsy pathology, laboratory values, and antihyperglycemic medications. Patient outcomes at 12 months postoperatively were analyzed specifically for diabetic resolution and weight loss. Chi-square test and Fisher's exact test were used for categorical comparisons, and one-way analysis of variance test and two-tailed t-test were used for continuous variable comparisons. Multivariate linear regression models were created to assess the association between liver pathology and changes in body mass index (BMI) and diabetic status. A two-sided P-value of 0.05 indicated significance. Results: Of the 77 patients included in the study, 70.1% of patients achieved diabetic remission at 12 months. After condensing steatosis and fibrosis scores into low- and high-grade categories, patients with no hepatic disease had significantly lower BMI at 12 months postoperatively than patients with low- or high-grade hepatic disease (29.2 ± 3.6 kg/m2 versus 35.1 ± 4.0 kg/m2 versus 34.5 ± 3.7 kg/m2, respectively, P = .009). On multivariate linear regression model, low-grade overall hepatic disease (ß = 3.1 ± 1.5; P = .043) and preoperative oral glycemic medications (ß = 2.4 ± 1.0; P = .026) were associated with a significantly increased 12-month BMI. Also, Black or African American race compared with White race was associated with a significant decrease in postoperative BMI (ß = -1.9 ± 0.8; P = .023). Conclusions: Regardless of preexisting liver disease, most diabetic patients who undergo sleeve gastrectomy experience diabetic remission at 12 months postoperatively. Additionally, patients with no underlying liver disease lose more weight than those with low- or high-grade liver disease.

Robotic Foregut Surgery in the Veterans Health Administration: Increasing Prevalence, Decreasing Operative Time, and Improving Outcomes.

BACKGROUND: Historically, robotic surgery incurs longer operative times, higher costs, and nonsuperior outcomes compared with laparoscopic surgery. However, in areas of limited visibility and decreased accessibility such as the gastroesophageal junction, robotic platforms may improve visualization and facilitate dissection. This study compares 30-day outcomes between robotic-assisted foregut surgery (RAF) and laparoscopic-assisted foregut surgery in the Veterans Health Administration. STUDY DESIGN: This is a retrospective review of the Veterans Affairs Quality Improvement Program database. Patients undergoing laparoscopic-assisted foregut surgery and RAF were identified using CPT codes 43280, 43281, 43282, and robotic modifier S2900. Multivariable logistic regression and multivariable generalized linear models were used to analyze the independent association between surgical approach and outcomes of interest. RESULTS: A total of 9,355 veterans underwent minimally invasive fundoplication from 2008 to 2019. RAF was used in 5,392 cases (57.6%): 1.63% of cases in 2008 to 83.41% of cases in 2019. After adjusting for confounding covariates, relative to laparoscopic-assisted foregut surgery, RAF was significantly associated with decreased adjusted odds of pulmonary complications (adjusted odds ratio [aOR] 0.44, p < 0.001), acute renal failure (aOR 0.14, p = 0.046), venous thromboembolism (aOR 0.44, p = 0.009) and increased odds of infectious complications (aOR 1.60, p = 0.017). RAF was associated with an adjusted mean ± SD of 29 ± 2-minute shorter operative time (332 minutes vs 361 minutes; p < 0.001). CONCLUSIONS: Veterans undergoing RAF ascertained shorter operative times and reduced complications vs laparoscopy. As surgeons use the robotic platform, clinical outcomes and operative times continue to improve, particularly in operations where extra articulation in confined spaces is required.

Analysis of poor outcomes after laparoscopic adjustable gastric banding.

BACKGROUND: Recent studies document excess weight loss (EWL) of more than 50% with the laparoscopic adjustable gastric band (LGB). This study reviews the LGB experience at an urban academic center in terms of complications, reoperative rates, and comorbidities. METHODS: In this study, 144 consecutive patients undergoing LGB were prospectively reviewed. Data were collected including weight, body mass index (BMI), excess weight loss (EWL), comorbidities, and complications. Demographics were analyzed using a t-test. Linear regression was used to analyze the relationship of BMI, race, and age to EWL at 12 months. RESULTS: The study participants were 130 women with a mean age of 43 ± 11 years, a mean weight of 127.1 kg ± 20.5 kg, and a mean BMI of 45.6 ± 6.1. The mean follow-up period was 16 months. The mean EWL was 20% ± 14% at 6 months (n = 118), 26% ± 16% at 12 months (n = 106), 30% ± 20% at 18 months (n = 68), and 34% ± 23% at 24 months (n = 43). Patients with a BMI higher than 50 kg/m(2) had a lower EWL at 12 months than patients with a BMI lower than 50 kg/m(2) (P = 0.00005). The mean EWL at 12 months was significantly less for African Americans than for Caucasians (P = 0.0046; 95% confidence interval [CI] 3-15%). Patients older than 50 years had a lower EWL, but the difference was not statistically significant (P = 0.07). Complete and partial resolution of comorbidities occurred for 10% and 4% of the patients, respectively. Removal of the band with revision to a sleeve gastrectomy for inadequate EWL was required for 14 patients (11.5%). Complications occurred for 8% of the patients (n = 15) including port flipping, stoma obstruction, tube disconnection, port infections, dysphagia, and band slippage. Overall, 16.7% of the patients (n = 24) required reoperation. CONCLUSION: After LGB, a majority of the patients failed to achieve a 50% EWL, and 16.7% required reoperation. Laparoscopic adjustable gastric banding may not be the optimal bariatric procedure for patients older than 50 years, patients with a BMI higher than 50 kg/m(2), or African Americans.

Laparoscopic versus single-incision cholecystectomy.

BACKGROUND: Although recent reports demonstrate large series of single-incision cholecystectomies, few articles compare single-incision data with traditional laparoscopic cholecystectomy (LC) data. This article compares a large series of single-incision cholecystectomies to a series of traditional LCs performed at an urban tertiary-care center. METHODS: A consecutive series of single-incision cholecystectomies was performed from August 2008 to March 2010. All cholecystectomies were attempted through a single incision on an intent-to-treat basis. Patient demographics, including height, weight, body mass index (BMI), pathologic diagnosis, ASA classification, operative time, complications, narcotic use, and length of stay (LOS), were recorded. Data for a matched cohort of patients undergoing a traditional four-port LC were gathered over a similar time period. Data were compared using a t test with a P<0.05 for significance. RESULTS: Single-incision cholecystectomy was successful in 81 (76%) of 107 patients. The 26 (24%) converted cases showed a higher BMI (33.0±8.7 vs. 28.4±6.4 kg/m2, P<0.05) and longer operative times (98.3±33 vs. 76.1±23 min, P<0.003). Postoperatively, the converted patients had a longer LOS compared to that of the single-incision group (1.6±1.0 vs. 1.1±0.4 days, P=0.02). Overall, the single-incision group had longer operative times compared to the four-port LC group (81.5±28 vs. 69.1±21 min, P<0.004). However, after the tenth single-incision case, there was no difference in operative times. From a narcotic standpoint, the successful single-incision patients used significantly less narcotic versus the traditional LC group (20±22.7 vs. 32.3±31.2 mg, P=0.02). CONCLUSIONS: The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy. Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS. Although this data is intriguing, the overall utility of single-incision procedures requires more analysis and potentially randomized trials.

Cholecystectomy Outcomes in the Veterans Affairs Surgical Quality Improvement Program (2006-2017).

Background: Cholecystectomy trends and outcomes have been reported extensively in the private sector. Despite being one of the most common procedures performed in the United States, there is a paucity of reports on the trends and outcomes of laparoscopic and open cholecystectomy in the veteran population. Materials and Methods: Veterans who underwent laparoscopic or open cholecystectomy from 2006 to 2017 were identified using current procedural terminology codes from the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Multivariable analyses were used to compare laparoscopic and open outcomes. The primary outcome was mortality, and secondary outcomes were postoperative complications and length of stay (LOS). Results: In the VASQIP database, 53,901 patients underwent laparoscopic cholecystectomy and 8011 patients underwent open cholecystectomy during the study period. The laparoscopic approach increased from 82.0% (2006-2008) to 91.9% (2015-2017). Postoperatively, the open group had a significantly higher morbidity rate (15.4% versus 3.8%, P < .001). The 30-day mortality rate and mean LOS were also significantly higher in the open cholecystectomy group (P < .001). Earlier year of operation, diabetes diagnosis, and open approach significantly increased the likelihood of postoperative morbidity (P < .05). Conclusions: Similar to the private sector, minimally invasive cholecystectomy in the Veterans Health Administration (VHA) has increased over the last two decades. Diabetes was present in a significant percentage of the veteran population and was a predictor of all postoperative complications. Finally, the clinical outcomes in the VHA are comparable with those documented in the private sector.

Outcomes of Paraesophageal Hernia Repair: Analysis of the Veterans Affairs Surgical Quality Improvement Program Database.

BACKGROUND: While there have been many outcome studies on paraesophageal hernia repair in the civilian population, there is sparse recent data on the veteran population. This study analyzes the mortality and morbidities of veterans who underwent paraesophageal hernia repair in the Veterans Affairs Surgical Quality Improvement Program database. METHODS: Veterans who underwent paraesophageal hernia repair from 2010 to 2017 were identified using Current Procedural Terminology codes. Multivariable analysis was used to compare laparoscopic and open, including abdominal and thoracic approaches, groups. The outcomes were postoperative complications and mortality. RESULTS: There were 1607 patients in the laparoscopic group and 366 in the open group, with 84.1% men and mean age of 61 years. Gender and body mass index did not influence the type of surgical approach. The mortality rates at 30 and 180 days were 0.5% and 0.7%, respectively. Postoperative complications, including reintubation (2.2%), pneumonia (2.0%), intubation > 48 h (2.0%), and sepsis (2.0%) were higher in the open group (15.9% versus 7.2%, p < 0.001). The laparoscopic group had a significantly shorter length of stay (4.3 versus 9.6 days, p < 0.001) and a lower percentage of return to surgery within 30 days (3.9% versus 8.2%, p < 0.001) than the open group. The ratio of open versus laparoscopic paraesophageal hernia repairs varied significantly by different Veterans Integrated Services Network regions. CONCLUSIONS: Veterans undergoing laparoscopic paraesophageal hernia repair experience similar outcomes as patients in the private sector. Veterans who underwent laparoscopic paraesophageal hernia repair had significantly less complications compared to an open approach even after adjusting for patient comorbidities and demographics. The difference in open versus laparoscopic practices between various regions requires further investigation.

Elective surgery for diverticular disease in U.S. veterans: A VASQIP study of national trends and outcomes from 2004 to 2018.

BACKGROUND: Treatment for diverticular disease has evolved over time. In the United States, there has been a trend towards minimally invasive surgical approaches and fewer postoperative complications, but no study has investigated this subject in the Veterans Health Administration. METHODS: This retrospective review identified patients undergoing elective surgery for diverticular disease from 2004 to 2018. Demographics, comorbidities, operative approach, rates of ostomy creation, and 30-day outcomes were compared. The 15-year time period was divided into 3-year increments to assess changes over time. RESULTS: 4198 patients were identified. Complication rate decreased significantly over time (28.1%-15.7%, p < 0.001), as did infectious complications (21.5-6.3%, p < 0.001). Median hospital length-of-stay decreased from 7 to 5 days (p < 0.001). Rates of laparoscopic surgery increased over time (17.7%-48.1%, p < 0.001). CONCLUSIONS: Increased utilization of laparoscopy in veterans undergoing elective surgery for diverticular disease coincided with fewer complications and a shorter length-of-stay. These trends mirror outcomes reported in non-veterans.