Revisional surgery after restrictive surgery: midterm outcomes of a tertiary center.

INTRODUCTION: Revisional bariatric surgery (RBS) is a challenging type of procedure for the surgeons due to its specific morbidity and efficiency. The RBS has a higher prevalence nowadays and this study may help to improve scarce data upon this specific topic. METHODS: Data from 252 patients undergoing RBS after laparoscopic adjustable gastric banding (LAGB) or laparoscopic sleeve gastrectomy (LSG) between 2005 and 2019, were analyzed at 2 years of follow up. A subgroup analysis of third procedure was also performed. RESULTS: Overall morbidity occurred in 35 patients (37%) in the LSG group and 40 patients (25%) in the LAGB group (p = 0.045). At 2 years of RBS, mean weight was 92.8 ± 26.7 kg, BMI was 33.1 ± 8.56 kg/m2 for patients who had RBS after LSG. When RBS was performed after LAGB, mean weight at 2 years was 90.1 ± 20.7 kg and BMI was 32.5 ± 6.45 kg/m2. TWL for RBS performed after LSG was 12.7 ± 16.4% versus 25.5 ± 10.3% after LAGB (p < 0.001). CONCLUSION: RBS after LSG seems to lead to higher overall morbidity whereas RBS after LAGB lead to more perioperative issues.

Mid-term Results of an ERAS Program of Bariatric Surgery in a Tertiary Referral Center.

BACKGROUND: To identify preoperative risk factors for discharge failure beyond postoperative day two (POD-2) in bariatric surgery ERAS program in a tertiary referral center. METHODS: all consecutive patients who underwent laparoscopic bariatric treated in accordance with ERAS protocol between January 2017 and December 2019 were included. Two groups were identified, failure of early discharge (> POD-2) (ERAS-F) and success of early discharge (≤ POD-2) (ERAS-S). Overall postoperative morbidity, unplanned readmission rates were analyzed at POD-30 and POD-90, respectively. Multivariate logistic regression was performed to determine the independent risk factors for LOS > 2 days (ERAS-F). RESULTS: A total of 697 consecutive patients were included, 148 (21.2%) in ERAS-F group and 549 (78.8%) in ERAS-S group. All postoperative complications at POD 90, whether medical or surgical were significantly more frequent in ERAS-F group than in ERAS-S group. Neither readmission nor unplanned consultations rates at POD 90 were significantly different between both groups. History of psychiatric disorder (p = 0.01), insulin-dependent diabetes (p < 0.0001), use of anticoagulants medicine (p < 0.00001), distance to the referral center > 100 km (p = 0.006), gallbladder lithiasis (p = 0.02), and planned additional procedures (p = 0.01) were independent risk factors for delayed discharge beyond POD-2. CONCLUSIONS: One in five patients with bariatric surgery failed to discharge earlier despite the ERAS program. Knowledge of these preoperative risk factors would allow us to identify patients who need more recovery time and a tailored approach to the ERAS protocol.

Perioperative non-invasive haemodynamic optimisation using photoplethysmography: A randomised controlled trial and meta-analysis.

BACKGROUND: The present study aimed at evaluating the effect of a haemodynamic algorithm using SV maximisation by non-invasive photoplethysmography (interventional group) on the incidence of postoperative complications compared with a control group using intermittent mean arterial pressure. METHODS: The non-blinded parallel-group trial randomised low-risk patients undergoing colorectal surgery into either interventional group or control group. The primary outcome was the incidence of patients with at least one complication during the 30 days following surgery. The secondary outcomes were the total number of complications, the length of hospital stay and postoperative mortality. A meta-analysis of randomised trials comparing perioperative haemodynamic optimisation (interventional group) using photoplethysmography with control group was performed to assess the external validity. RESULTS: Among 160 randomised patients, 159 were analysed (80 and 79 in interventional and control groups, respectively). Demographic characteristics were similar in both groups. Postoperative complications occurred in 40 (50%) and 34 (43%) patients in the interventional and control groups, respectively (P=0.471). There were no significant differences between the two groups regarding the total number of complications (P=0.078), the hospital length of stay (P=0.960), or postoperative mortality (P=1.000). In the meta-analysis including 1089 patients in 7 randomised controlled studies, 203 (38%) and 221 (40%) patients suffered from at least one complication following surgery [risk ratio 0.89 (95% CI 0.68-1.17), P=0.407] in interventional and control groups, respectively. CONCLUSIONS: Based on the findings of the present study and meta-analysis, a haemodynamic perioperative algorithm using SV maximisation by non-invasive photoplethysmography cannot reduce postoperative morbidity.

Does the Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines Improve Outcomes of Bariatric Surgery? A Propensity Score Analysis in 464 Patients.

BACKGROUND: The aim of this study was to investigate whether the implementation of enhanced recovery after surgery (ERAS) guidelines according to Thorell and co. in our tertiary referral bariatric center might improve post-operative outcomes. METHODS: ERAS program was introduced in our center since January 1, 2017. Retrospective review of a prospectively collected database identified patients who underwent laparoscopic primary and revisional bariatric surgeries from October 2005 to January 2018. Patients exposed to ERAS program ("ERAS group") were matched in a 1:1 ratio with patients exposed to conventional care (control group) using a propensity score based on age, gender, preoperative body mass index (BMI), diabetes mellitus, and the type of procedures. The primary outcome was total hospital length of stay (LOS) and the secondary outcomes included the post-operative complications and readmission rates. RESULTS: During the study period, 464 patients were included, 232 in each group. Implementation of the ERAS protocol was significantly associated with a reduction of LOS (2.47 ± 1.7 vs 5.39 ± 1.9 days, p < 0.00001). One-third of patients was discharged (77/232, 33%) on the first postoperative day (POD) and more than three quarter of patients on POD 2 (182/232, 77%). At the opposite, no patients of the control group were discharged on POD 2. Overall 30-day and 90-day morbidity and readmission rates were the same in both groups. There was no death in each group. CONCLUSIONS: This large case-matched study using a propensity score analysis suggests that implementation of ERAS program significantly reduced length of hospital stay without significant increases on overall morbidity, and readmission rates.

Middle cerebral artery blood flow velocity during beach chair position for shoulder surgery under general anesthesia.

OBJECTIVES: The goal of the present study was to examine changes of middle cerebral artery (VMCA) blood flow velocity in patients scheduled for shoulder surgery in beach chair position. DESIGN: Prospective observational study. SETTING: Operating room, shoulder surgery. PATIENTS: Fifty-three consecutive patients scheduled for shoulder surgery in beach chair position. INTERVENTIONS: Transcranial Doppler performed after induction of general anesthesia (baseline), after beach chair positioning (BC1), during surgery 20minutes (BC2), and after back to supine position before stopping anesthesia (supine). MEASUREMENTS: Mean arterial pressure (MAP), end-tidal CO2, and volatile anesthetic concentration and VMCA were recorded at baseline, BC1, BC2, and supine. Postoperative neurologic complications were searched. MAIN RESULTS: Beach chair position induced decrease in MAP (baseline: 73±10mm Hg vs lower MAP recorded: 61±10mm Hg; P<.0001) requiring vasopressors and fluid challenge in 44 patients (83%). There was a significant decrease in VMCA after beach chair positioning (BC1: 33±10cm/s vs baseline: 39±14cm/s; P=.001). The VMCA at baseline (39±2cm/s), BC2 (35±14cm/s), and supine (39±14cm/s) were not different. The minimal alveolar concentration of volatile anesthetics, end-tidal CO2, SpO2, and MAP were not different at baseline, BC1, BC2, and supine. CONCLUSION: Beach chair position resulted in transient decrease in MAP requiring fluid challenge and vasopressors and a moderate decrease in VMCA.

Perioperative hemodynamic optimization using the photoplethysmography in colorectal surgery (the PANEX3 trial): study protocol for a randomized controlled trial.

BACKGROUND: Photoplethysmography with a digital sensor (ClearSight, Edwards Lifesciences, Irvine, CA, USA) connected to a dedicated monitor (EV 1000, Edwards Lifesciences) was recently proposed for use in performing hemodynamic optimization during surgery. The objective of this study is to evaluate the effect of photoplethysmography on the incidence of postoperative complications compared with the conventional hemodynamic algorithm, which uses mean arterial pressure. METHODS/DESIGN: The hemodynamic optimization using photoplethysmography (PANEX3) trial is a monocentric, randomized, single-blind, controlled, two parallel arm, superiority trial, randomizing 160 patients with an intermediate risk of postoperative complications after colorectal surgery. Informed consent will be obtained from all participants. The hemodynamic optimization is conducted using a specified hemodynamic algorithm either with photoplethysmography (the photoplethysmography group) or with conventional mean arterial pressure (the control group). The anesthesiologist performed a 1:1 randomization the day before surgery using a scratch card, which is available 24/7. The randomization sequence is generated using permutated blocks. Both the patients and surgeons are blinded to the allocation group. The primary outcome is the incidence of at least one postoperative complication during the 30 days following surgery. Two independent experts, who were blinded to the group allocations, validate the complication for each patient using an a priori classification. The secondary outcomes are to study the total number of postoperative complications, the real length of hospital stays, and the postoperative mortality between each group. DISCUSSION: The PANEX3 trial is the first randomized controlled study conducted to investigate whether perioperative hemodynamic optimization using photoplethysmography during colorectal surgery could decrease the incidence of patients having at least one postoperative complication. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02343601.