Improving Bed Utilization in a Cohort of Bariatric Surgical Patients Using a Perioperative Obstructive Sleep Apnea Treatment and Bed Triage Protocol.

BACKGROUND: Postoperative bariatric management often includes high-intensity monitoring for respiratory complications since > 70% of patients have obstructive sleep apnea. Given the increasing number of bariatric surgeries, there is a need to determine safe and cost-effective processes for postoperative care.The objective of this study was to determine if a novel triage and perioperative management guideline reduces postoperative monitoring and costs following bariatric surgery. METHODS: Using a pre-post design, this is a retrospective analysis of 501 patients who had bariatric surgery. Half the patients were managed with usual care, and the other half received obstructive sleep apnea screening and treatment of moderate/severe obstructive sleep apnea with perioperative continuous positive airway pressure. The intervention group was triaged preoperatively to a postoperative nursing location based on risk factors. RESULTS: There were no significant differences in demographics, comorbidities, frequency, or severity of OSA between groups. In the intervention group, there were fewer admissions to the intensive care unit (2.0% vs 9.1%; p < 0.01) and high acuity unit (9.6% vs 18.3%; p < 0.01). The length of stay was shorter in the intervention group (1.3 vs 2.3 days; p < 0.01) with a 50% reduction in costs. There were no statistically significant differences in the incidence of postoperative respiratory and non-respiratory complications between the two groups. CONCLUSIONS: Most postoperative bariatric surgery patients can be safely managed on the surgical ward with monitoring of routine vitals alone if patients with moderate/severe obstructive sleep apnea receive perioperative continuous positive airway pressure.

Guidelines for Canadian bariatric surgical and medical centres: a statement from the Canadian Association of Bariatric Physicians and Surgeons.

SummaryThe goal of this statement is to offer standardization in bariatric care across Canada, to provide patients with optimal access to obesity treatment and potentially improve outcomes by reducing complications, length of hospital stay and readmission rate. The definition of Canadian standards also aims to promote a comprehensive, multidisciplinary approach to patients with obesity, to define the minimal qualifications for surgical and medical training and to offer credentialling for bariatric surgical and medical centres. In addition, we emphasize the importance of developing a national registry for the assessment of quality of care across the country and to evaluate outcomes of long-term treatment. These recommendations are based on expert opinion as well as the most recent clinical evidence.

Characterization of regulatory T cells in obese omental adipose tissue in humans.

Obesity-associated visceral adipose tissue (AT) inflammation promotes insulin resistance and type 2 diabetes (T2D). In mice, lean visceral AT is populated with anti-inflammatory cells, notably regulatory T cells (Tregs) expressing the IL-33 receptor ST2. Conversely, obese AT contains fewer Tregs and more proinflammatory cells. In humans, however, there is limited evidence for a similar pattern of obesity-associated immunomodulation. We used flow cytometry and mRNA quantification to characterize human omental AT in 29 obese subjects, 18 of whom had T2D. Patients with T2D had increased proportions of inflammatory cells, including M1 macrophages, with positive correlations to body mass index. In contrast, Treg frequencies negatively correlated to body mass index but were comparable between T2D and non-T2D individuals. Compared to human thymic Tregs, omental AT Tregs expressed similar levels of FOXP3, CD25, IKZF2, and CTLA4, but higher levels of PPARG, CCR4, PRDM1, and CXCL2. ST2, however, was not detectable on omental AT Tregs from lean or obese subjects. This is the first comprehensive investigation into how omental AT immunity changes with obesity and T2D in humans, revealing important similarities and differences to paradigms in mice. These data increase our understanding of how pathways of immune regulation could be targeted to ameliorate AT inflammation in humans.

Total intracorporeal anastomosis for right hemicolectomy: Experience from a Canadian center.

BACKGROUND: Laparoscopic right hemicolectomy (LRHC) techniques have varied in the approach to anastomosis. We compared outcomes of laparoscopic right hemicolectomy with extracorporeal anastomosis (ECA) versus intracorporeal anastomosis (ICA). METHODS: We retrospectively reviewed all LRHCs conducted at Richmond Hospital between January 2015 and October 2017. We compared the demographic, pathologic, intraoperative, and postoperative data. RESULTS: 74 LRHCs were included during the study period: 56 ECA and 18 ICA. The groups were comparable in age, gender, tumor staging, and tumor location. Incidence of clinical ileus was significantly less for ICA (0% vs. 21%, p = 0.032). Mean length of stay was significantly shorter for ICA (3.13 vs. 4.82 days, p = 0.003). There was no difference between ICA and ECA in mean operative time (158 vs. 145 min, p = 0.087), surgical site infections (6% vs. 4%, p = 1.0), emergency department visits within 30 days (5% vs. 6%, p = 1.0), and hospital readmission within 30 days (4% vs 0%, p = 1.0). There were no incidences of anastomotic leaks, perioperative deaths, or cardiopulmonary complications in either group. CONCLUSIONS: An ICA approach to LRHC results in shorter hospital stay and decreased rates of clinical ileus.

Hand-assisted laparoscopic splenectomy versus open splenectomy for massive splenomegaly: 20-year experience at a Canadian centre.

BACKGROUND: Multiple techniques for splenectomy are now employed and include open, laparoscopic and hand-assisted laparoscopic splenectomy (HALS). Concerns regarding a purely laparoscopic splenectomy for massive splenomegaly (> 20 cm) arise from potentially longer operative times, higher conversion rates and increased blood loss. The HALS technique offers the potential advantages of laparoscopy, with the added safety of having the surgeon's hand in the abdomen during the operation. In this study, we compared the HALS technique to standard open splenectomy for the management of massive splenomegaly. METHODS: We reviewed all splenectomies performed at 5 hospitals in the greater Vancouver area between 1988 and 2007 for multiple demographic and outcome measures. Open splenectomies were compared with HALS procedures for spleens larger than 20 cm. Splenectomy reports without data on spleen size were excluded from the analysis. We performed Student t tests and Pearson χ(2) statistical analyses. RESULTS: A total of 217 splenectomies were analyzed. Of these, 39 splenectomies were performed for spleens larger than 20 cm. We compared the open splenectomy group (19 patients) with the HALS group (20 patients). There was a 5% conversion rate in the HALS group. Estimated blood loss (375 mL v. 935 mL, p = 0.08) and the mean (and standard deviation [SD]) transfusion rates (0.0 [SD 0.0] units v. 0.8 [SD 1.7] units, p = 0.06) were lower in the HALS group. Length of stay in hospital was significantly shorter in the HALS group (4.2 v. 8.9 d, p = 0.001). Complication rates were similar in both groups. CONCLUSION: Hand-assisted laparoscopic splenectomy is a safe and effective technique for the management of spleens larger than 20 cm. The technique results in shorter hospital stays, and it is a good alternative to open splenectomy when treating patients with massive splenomegaly.

An 18-year review of open and laparoscopic splenectomy for idiopathic thrombocytopenic purpura.

BACKGROUND: Laparoscopic splenectomy has become the preferred surgical procedure for the management of idiopathic thrombocytopenic purpura (ITP). However, there studies have directly compared the incidence of recurrent ITP secondary to missed accessory spleens in open versus laparoscopic splenectomy. METHODS: Open and laparoscopic splenectomies performed for ITP at 4 sites over 18 years were analyzed. The incidence of recurrent disease secondary to missed accessory spleens was compared between the open and laparoscopic splenectomy groups. RESULTS: A total of 105 splenectomies (54 open/51 laparoscopic) were performed. Accessory spleens were identified in 6 laparoscopic and 6 open cases (P = .57). Recurrent disease occurred in 27.6% of open and 14.6% of laparoscopic cases (P = .222). There were no cases of recurrent ITP secondary to a missed accessory spleen in either group. CONCLUSIONS: The incidence of missed accessory spleens causing recurrent disease is similar when splenectomy is performed either open or laparoscopically.