Sustained culture and surgical outcome improvement.

BACKGROUND: A focus on the culture of safety and patient outcomes continues to grow in importance. Several initiatives targeted at individual deficits have been described but few institutions have shown the effect of a global change in culture on patient outcomes. METHODS: Patient care perception was assessed using Safety Attitudes Questionnaire (SAQ) by Pascal Metrics®. A change in culture was initiated, followed by implementation of initiatives targeting communication and patient safety. ACS-NSQIP data was analyzed to assess outcomes during the period of improved culture. RESULTS: Our institution had poor outcomes as measured by ACS-NSQIP data and several deficiencies in our culture score. Both statistically improved after initiative implementation. A difference in mean culture score across time (p < 0.001 = .031) was seen from 2013 to 2015, while NSQIP odds ratios falling in the 'exemplary' category increased. CONCLUSION: Our results demonstrate an improvement in both culture and outcomes from 2013 to 2015, suggesting a correlation between culture and surgical outcomes.

Are laparoscopic bariatric procedures safe in superobese (BMI ≥50 kg/m2) patients? An NSQIP data analysis.

BACKGROUND: The safety of laparoscopic bariatric procedures in superobese patients is still debatable. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program's participant-use file, the patients who had undergone laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding for morbid obesity were identified. Several perioperative variables, including 30-day morbidity and mortality, were collected, and the data were compared within each procedure after dividing the patients according to the body mass index: <50 kg/m(2) (morbidly obese group and ≥50 kg/m(2) (superobese group). RESULTS: A total of 29,323 patients who had undergone laparoscopic bariatric procedures from 2005 to 2008 were identified. Overall, compared with the morbidly obese group, the superobese group had more men (3:2), younger patients, a greater incidence of co-morbidities (e.g., hypertension and dyspnea), a significantly increased length of stay, and a greater rate of 30-day mortality (.26% versus .07%, odds ratio [OR] 4.38, P = .0001). In the gastric bypass group, the superobese group had a significantly greater incidence of postoperative complications, including superficial wound infections (2.45%, OR 1.68, P = .0001), reintubation (.61%, OR 1.97, P = .003), pulmonary embolism (.30%, OR 2.13, P = .032), myocardial infarction (.07%, P = .017), deep vein thrombosis (.49%, OR 2.06, P = .006), septic shock (.44%, OR 1.74, P = .04), and 30-day mortality (.28%, OR 2.26, P = .026). In the laparoscopic adjustable gastric banding group, the superobese group had a significantly greater incidence of postoperative complications, including superficial (1.65%, OR 2.18, P = .0013) and deep (.23%, OR 2.56, P = .035) wound infections, sepsis, septic shock and 30-day mortality (.17%, OR 13.4, P = .0219). CONCLUSION: Laparoscopic bariatric procedures in superobese patients have been associated with significantly increased complications, including 30-day mortality, compared with morbidly obese patients. However, overall, the procedures appear to be safe, with low complication and 30-day mortality rates.

Laparoscopic Roux-en-Y gastric bypass in morbidly obese patients > or =55 years old.

BACKGROUND: Advanced age is considered a relative contraindication to bariatric surgery at some institutions because of concerns about higher morbidity and less than optimal weight loss. The aim of our study was to evaluate the operative outcomes, length of stay, weight loss, and improvement of comorbidities in patients > or =55 years old who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery in our institution. METHODS: Retrospective data on 33 patients (26 women and 7 men) > or =55 years of age who underwent LRYGB from January 2003 to December 2006 were reviewed. RESULTS: Average patient age was 59 years (range 55-68 years), and the mean preoperative body mass index was 47 kg/m2 (range 41.1-55.8 kg/m2). The median length of hospital stay was 3 days. There were no intraoperative or postoperative deaths. Early complications were one anastomotic leak, two upper gastrointestinal bleedings, and two readmissions for intractable vomiting. Late complications included four anastomotic strictures and one small bowel obstruction. Patients were followed for a mean 13 months (range 3-24 months). The mean excess body weight (EBW) loss was 13.5 kg (23%), 23.3 kg (39.8%), 33.3 kg (58.1%), 39.8 kg (66.8%), 40.1 kg (69.5%), and 40.8 kg (75.3%) at 1, 3, 6, 9, 12 and 24 months, respectively. Diabetes mellitus improved in 19 (100%) patients and completely resolved in 10 (53%). Hypertension improved in 18 (64%) patients, completely resolved in 9 (32%) and was unchanged in 10 (36%). CONCLUSIONS: LRYGB is safe and effective in morbidly obese patients > or =55 years of age.

Laparoscopic Roux-en-Y gastric bypass surgery on morbidly obese patients with hypothyroidism.

BACKGROUND: It is well known that obesity is accompanied by changes in thyroid function. Hypothyroidism is associated with increased body weight. The aim of this study was to evaluate the operative outcomes, weight loss, and the effect of weight loss on thyroid function in morbidly obese patients with hypothyroidism who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. METHODS: A retrospective review of 20 morbidly obese female patients with hypothyroidism and on thyroid replacement therapy who underwent LRYGB between January 2003 and August 2006. RESULTS: Mean preoperative body mass index (BMI) was 47.6 kg/m2 (range 38-58.5 kg/m2). Average patient age was 44.5 years (range 21-66 years). There was one early complication (pneumonia). Late complications included one death, three anastomotic strictures, and one small bowel obstruction. The patients were followed for a mean of 13.5 months (range 3-24 months). Their mean excess body weight loss was 13 kg (22%), 24.4 kg (39.4%), 33.2 kg (63.3%), 38.4 kg (65%), 41.7 kg (70%), and 43 kg (73%) at 1, 3, 6, 9, 12, and 24 months, respectively. Change in a mean BMI was the same regardless of the patient preoperative and postoperative thyroxine dose. Hypothyroidism resolved in 5(25%) patients, improved in 2(10%) patients, unchanged in 8(40%) patients, and worsened in 5 (25%) patients. Most of the five whose hypothyroidism worsened had thyroid autoimmune disease. CONCLUSIONS: Hypothyroidism appears to improve in the vast majority of morbidly obese patients who undergo LRYGB, except for those whose thyroid disease is autoimmune in nature.

Diagnosis and management of internal hernias after laparoscopic gastric bypass.

BACKGROUND: Internal hernia is a known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). However, no consensus exists regarding optimal diagnostic modality and management. We reviewed the literature and our own experience, and present an algorithm for the diagnosis and management of internal hernia after LRYGBP. METHODS: A retrospective review of 290 retrocolic LRYGBPs was performed to identify those who developed postoperative small bowel obstruction due to internal hernia. Demographics, clinical symptoms, radiologic characteristics, and operative outcomes were analyzed to determine clinical and radiological diagnostic accuracy. RESULTS: Over a 43-month period, 11 out of 290 (3.79%) post-LRYGBP patients with symptoms suggestive of a small bowel obstruction underwent operative exploration. The most common clinical symptoms included intermittent abdominal pain, and/or nausea/vomiting. All patients were initially explored laparoscopically. Etiology of obstructions included internal hernias--6 [at the transverse mesocolon (n = 1), Petersen's space (n = 2), and at the jejunojejunostomy (n = 3)], adhesions (n = 4) and a negative laparoscopy (n = 1). The mean time for development of internal hernias was 13.7 months. Mean loss of BMI units at time of re-operation was 17 kg/m2. Of the 6 patients with internal hernia, 2 (30%) had normal preoperative radiological work-up. On review of the preoperative films by the surgeon, signs of internal herniation were seen in all the patients. Management included initial laparoscopic exploration, lysis of adhesions, reduction of internal hernia and closure of mesenteric defects in all the patients. There were 2 conversions to laparotomy. CONCLUSION: Small bowel obstruction in the post-LRYGBP patient is difficult to diagnose, especially when due to an internal hernia. Most patients present with intermittent abdominal pain and/or nausea. The most frequently used radiologic study is CT scan, which is most accurate when reviewed by the bariatric surgeon preoperatively.

Telerobotic-assisted laparoscopic right and sigmoid colectomies for benign disease.

PURPOSE: Telerobotic surgical systems attempt to provide technological solutions to the inherent limitations of traditional laparoscopic surgery. In this article, we present the first two reported cases of telerobotic-assisted laparoscopic colectomies performed on March 6 and 8, 2001. METHODS: In the first patient we performed a telerobotic-assisted laparoscopic sigmoid colectomy for diverticulitis. In the second patient, we accomplished a telerobotic-assisted laparoscopic right hemicolectomy for cecal diverticulitis. The Da Vinci telerobotic surgical system was used in both cases to mobilize the bowel. The mesenteric division, bowel transection, and anastomoses were accomplished with standard laparoscopic-assisted techniques. Both operations were completed with a three-trocar technique. RESULTS: We found that the Da Vinci system adequately replaced the camera holder. The three-dimensional virtual operative field helped to maintain the surgeon's orientation during the operation. The combination of three-dimensional imaging and the hand-like motions of the telerobotic surgical instruments facilitated dissection. The Da Vinci console offered an ergonomically comfortable position for the surgeon. Operative times for the sigmoid colectomy was 340 minutes and for the right hemicolectomy 228 minutes. Telerobotic-assisted laparoscopic colectomy is feasible, but required a longer operative time than our standard laparoscopic-assisted technique. CONCLUSION: Telerobotic-assisted laparoscopic colectomy is feasible and warrants further investigations in controlled trials.

Comparison of laparoscopic colectomy with and without the aid of a robotic camera holder.

The use of a robotic camera holder (AESOP 3000; Computer Motion, Inc., Santa Barbara, CA, U.S.A.) during laparoscopic surgery is slowly becoming more popular with laparoscopic surgeons. However, few published reports document the effects of the robot on operative outcomes or operative times. In the current study, we compared the use of a voice-controlled robotic camera holder to a human camera holder in a series of laparoscopic colectomies. The outcome data measured included the number of patients with postoperative complications, the patients' length of stay at the hospital, and the operative times for the procedures. There were 2 complications among the 11 patients in group 1 (colectomies performed without a robotic camera holder), versus 2 complications among the 15 patients in group 2 (colectomies performed with a robotic camera holder) (P = NS). Patients in group 1 had an average length of stay of 4.1 days, versus 4.4 days for those in group 2 (P = NS). The operative time for group 1 was 235 minutes, compared with 213 minutes for group 2 (P = NS). The use of a voice-controlled robotic camera holder does not alter the length of the operative procedure, the patient's length of stay, or postoperative morbidity. However, surgeons often have a subjective sense that there is less smudging, fogging, and inadvertent movements of the laparoscope when it is controlled by a robotic system. In addition, using a voice-controlled robot as a camera holder does eliminate the need for a surgical assistant.