Is Staple Line Reinforcement Necessary in Conversion From Laparoscopic Adjustable Band to Laparoscopic Sleeve Gastrectomy?

BACKGROUND: Once a common bariatric procedure, laparoscopic adjustable gastric band (LAGB) is more frequently the subject of conversion procedures, particularly to laparoscopic sleeve gastrectomy (LSG), due to failure of weight loss, weight regain, and band intolerance. Staple line reinforcement (SLR) in primary LSG has been studied extensively, but has not been evaluated in revision procedures. The aim of this study is to investigate commonly used SLR techniques and their effects on morbidity and mortality in single-stage bands converted to sleeves. METHODS: The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program (MBSAQIP) Participant Use Data Files (PUF) for 2015-2016 were utilized to assess data for single-stage bands converted to sleeves based on CPT codes, and records were stratified by technique of staple line reinforcement. The database contained all the defined variables utilized for analysis with the exception of leak rate and overall morbidity, which had to be derived. Thirty-day outcomes were analyzed using multiple bivariate analyses and Bonferroni corrections were applied. RESULTS: Of the 6,286 patients who underwent single-stage bands converted to sleeves for whom SLR data is available, 56.9% of surgeons utilized SLR only, 21.3% chose no reinforcement technique (No SLR), 13.4% chose SLR plus over-sewing of the staple line (SLR+OSL), and 8.4% chose OSL alone. There were no statistically significant differences in rates of death, reoperation, readmission, reintervention, number of bleeding events, and staple line leaks across groups. CONCLUSION: Choice of SLR does not affect number of bleeding events or staple line leak rate.

Current role of staple line reinforcement in 30-day outcomes of primary laparoscopic sleeve gastrectomy: an analysis of MBSAQIP data, 2015-2016 PUF.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a dominant bariatric procedure. In the past, significant leak rates prompted the search for staple line reinforcement (SLR) techniques. Previous analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for all LSG suggested a detrimental influence of SLR on leak rates and overall morbidity. OBJECTIVE: To investigate the relationship between various SLR techniques and bougie size with 30-day outcomes. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited bariatric surgery hospitals. METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2016 Participant Use File data, primary LSG cases were divided into study groups based on surgical techniques. All variables were reported in the Participant Use File except leak rate and overall morbidity, which had to be derived. Multiple bivariate analyses were used to analyze the 30-day outcomes. RESULTS: A total of 198,339 primary LSG operations were included and grouped into No SLR (23.0%), SLR (54.2%), oversewn staple line (9.5%), and a combination of SLR + oversewn staple line (13.3%). There were no statistical differences between study groups in mortality, overall morbidity, or leak rate. Bleeding and reoperation rates were statistically higher in the No SLR group. Bougie size was not associated with change in leak rates. CONCLUSION: Primary LSG is a safe procedure with low morbidity and mortality rates. SLR is associated with decreased rates of bleeding and reoperations but does not affect leak rates. The selection of SLR technique should be left to the surgeon's discretion with an understanding of the associated risks, benefits, and costs.

Do patients with higher baseline BMI have improved weight loss with Roux-en-Y gastric bypass versus sleeve gastrectomy?

BACKGROUND: As sleeve gastrectomy (SG) becomes the most common bariatric procedure, it remains unclear for which patients laparoscopic Roux-en-Y gastric bypass (LRYGB) may be advantageous. Some contend that patients with higher initial body mass index (BMI) achieve better weight loss with LRYGB. OBJECTIVES: This study evaluates weight loss in SG versus LRYGB patients based on preoperative BMI. SETTING: Community teaching hospital, Baltimore, Maryland. METHODS: A convenience cohort of 4935 individuals, undergoing bariatric surgery from 2001 to 2015, was studied to examine 5-year postsurgical trends in weight loss stratified by baseline BMI and procedure. Student t tests compared mean weight loss of baseline BMI groups (<45 versus ≥45; <50 versus ≥50; and <55 versus ≥55) and line graphs and plotted 95% confidence intervals of mean weight loss by year were examined to discern differences in percent excess weight loss (%EWL) by procedure type. RESULTS: All patients were more likely to be female (79%) and Caucasian (62.5%). Nearly twice as many patients underwent LRYGB (N = 3236) compared with SG (N = 1699). In patients in the BMI <45, 50, and 55 kg/m2 categories, there was no significant difference in %EWL based on procedure. However, in those patients in the BMI ≥45 and 55 kg/m2 categories, there is significantly higher %EWL in the LRYGB group over SG. CONCLUSION: In conclusion, patients with lower baseline BMI had improved %EWL regardless of procedure, but those patients with higher baseline BMI who underwent LRYGB did have higher %EWL than those undergoing SG at 2 years follow-up. BMI is one of many key factors when selecting a procedure for an individual patient.

Role of intraoperative esophagogastroenteroscopy in minimizing gastrojejunostomy-related morbidity: experience with 2,311 laparoscopic gastric bypasses with linear stapler anastomosis.

BACKGROUND: Anastomotic leaks and strictures of the gastrojejunostomy are a cause of major morbidity following laparoscopic Roux-en-Y gastric bypass (LRYGB). Reported rates of leaks vary between 0 and 5.2%. This has led bariatric surgeons to use a variety of intraoperative methods to detect incompetent suture lines. The aim of the study was to evaluate the role of intraoperative endoscopy in reducing the rate of postoperative anastomotic complications. The setting of this study is in a community teaching hospital. METHODS: Medical records of 2,311 patients who underwent a LRYGB from 2002 to 2011 were retrospectively reviewed utilizing the hospitals' bariatric surgery database. Demographics, weight, body mass index, intraoperative endoscopy results, and postoperative outcomes within 90 days after surgery were analyzed. RESULTS: Endoscopy was attempted in 2,311 patients and completed in 2,308 (99.9%). Intraoperative leak was detected in 80 (3.5%) patients; suture line was reinforced in 46 patients (2%), while in the other 34 patients the leak was transient at only high insufflation pressure. Postoperative clinical leaks were detected in four cases (0.2%) two of which had initial leaks intraoperatively. In two cases, the anastomosis was too tight and required reconstruction. Twenty-five patients (1.1%) developed early postoperative strictures requiring endoscopic dilatation within 90 days. Three patients (0.1%) had iatrogenic injury at the time of intraoperative endoscopy, all three healed without delayed morbidity. CONCLUSIONS: The routine use of intraoperative endoscopy in LRYGB with the linear stapler anastomosis technique is associated with a complication/failure rate of 0.3% and low gastrojejunostomy-related morbidity after LRYGB within 90 days (leak rate of 0.2% and stricture rate of 1.1%).

Laparoscopic Cytoreductive Surgery and HIPEC in Patients with Limited Pseudomyxoma Peritonei of Appendiceal Origin.

Introduction. Increasing numbers of patients with pseudomyxoma peritonei (PMP) of appendiceal origin are being evaluated with a low tumor burden. We explored a minimally invasive approach for this group of patients. Materials and Methods. We designed a protocol in which patients with a PMP diagnosis would have a diagnostic laparoscopy. If limited carcinomatosis (PCI ≤ 10) is identified, the procedure will continue laparoscopically. If extensive carcinomatosis (PCI > 10) is found, then the procedure will be converted to an open approach. Results. From December 2008 to December 2011, 19 patients had a complete cytoreduction and HIPEC: 18 of them (95%) were done laparoscopically and 1 of them (5%) was converted to an open procedure. Mean PCI was 4.2. Grade 3 morbidity was 0, and one patient (5%) experienced a grade 4 complication, needing a reoperation for an internal hernia. There were no mortalities. Mean length of hospital stay was 5.3 days. At a mean follow-up of 17 months (1-37) all 19 patients are alive and free of disease. Conclusion. This study demonstrates that cytoreductive surgery and HIPEC via the laparoscopic route is feasible and safe and should be offered to patients with limited pseudomyxoma peritonei of appendiceal origin.

Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with limited peritoneal surface malignancies: feasibility, morbidity and outcome in an early experience.

INTRODUCTION: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are being widely used in the treatment of patients with peritoneal surface malignancies. The open procedure has been associated with high grade III and IV morbidity and prolonged hospitalization. METHODS: Patients with peritoneal surface malignancies and no gross evidence of carcinomatosis on the computed tomographic scan were enrolled to undergo laparoscopic CRS and HIPEC. We aimed to assess the feasibility, safety, and outcome of this procedure. Postoperative complications were reported according to the National Cancer Institute Common Toxicity Criteria. RESULTS: From October 2008 to January 2010, 14 patients were enrolled into the protocol. Amongst these 14 patients, one patient was found with extensive carcinomatosis at the time of laparoscopy and had no surgical procedure. Thirteen patients had a complete cytoreduction and HIPEC, 10 (77%) laparoscopically and 3 (23%) were converted to an open procedure. There was one grade 3 morbidity (10%) and one patient (10%) in the laparoscopy group experienced a grade 4 complication, needing a reoperation for an internal hernia. Mean length of hospital stay was 6 days for those completed laparoscopically, 8 days for those converted to an open procedure and 8 days for a matched cohort of patients with an upfront open procedure. CONCLUSIONS: This initial investigative stage demonstrates the feasibility and safety of cytoreductive surgery and HIPEC via the laparoscopic route in selected patients with low-tumor volume and no small bowel involvement mainly from appendiceal malignancies. Longer follow-up and additional studies are required to evaluate its long-term efficacy.

Combined laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a patient with peritoneal mesothelioma.

The role of minimally invasive, laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) has been reported by several centers around the world, mainly to palliate intractable ascites in patients with extensive peritoneal surface malignancies who are not candidates for a complete cytoreduction. In this paper, we report on the first case of combined laparoscopic cytoreductive surgery and HIPEC with curative intent in a patient with limited peritoneal mesothelioma.

Results of curative therapy for esophageal cancer in a community training hospital.

A 12-year experience of therapy for esophageal carcinoma in a community-based cancer center was reviewed retrospectively. Of a total of 88 patients with histologically proven carcinoma of the esophagus 30 (34.1%) underwent curative esophagectomy. Twelve patients received preoperative chemoradiotherapy. Fourteen esophagectomies were performed transhiatally and 16 via the thoracolaparotomy approach. The average distance from incisors was 32.2 and 32.1 cm, respectively. Overall morbidity was 36.7%, with major complications in 30% of patients. Mortality was 3.3%. A comparison of patients treated with preoperative chemoradiotherapy (12 patients) and surgery alone (18 patients) showed no statistical difference in morbidity, mortality, or length of hospital stay. Analysis of these parameters in groups of patients operated via the transhiatal versus thoracolaparotomy approach demonstrated statistically lower morbidity (14.3% versus 56.3%, respectively), with no difference in mortality and a trend toward a shorter hospital stay in the former group. Overall survival at 3 years was 63.9%. In the combined therapy group, 90.9% of patients survived 3 years compared to 40.4% in the surgery only group (P = 0.0177). There was a trend toward better survival in the group of patients treated via the transhiatal approach. This study demonstrated that curative therapy for esophageal carcinoma can be performed with acceptable morbidity and mortality in a community teaching hospital.