Initial experience with enhanced recovery after surgery (ERAS) and early discharge protocols after robotic extended totally extraperitoneal (eTEP) hernia surgery.

BACKGROUND: Though robotic adoption for eTEP surgery has decreased technical barriers to minimally invasive repairs of large ventral hernias, relatively few studies have examined outcomes of robotic-specific eTEP surgery. This study evaluates safety, feasibility, and early outcomes of ERAS/same-day discharge protocols for robotic eTEP ventral hernia repairs. METHODS: A retrospective chart review was performed for all robotic eTEP hernia surgeries at a single institution between 2019 and 2022. Analysis included patient demographics, hernia characteristics, intraoperative data, and post-operative outcomes at 30 days. ERAS protocol included: judicious use of urinary catheters with removal at end of case if placed, bilateral transversus abdominus plane (TAP) blocks, post-operative abdominal wall binder, and opioid-sparing perioperative analgesia. Patients were discharged same day from post-anesthesia care unit (PACU) if they lacked comorbidities requiring observation post-anesthesia and demonstrated stable vital signs, adequate pain control, ability to void, and ability to ambulate. Hospital length of stay (LOS) was considered 0 for same-day PACU discharges or hospitalizations < 24 h. RESULTS: 102 patients were included in this case series. 69% (70/102) of patients were discharged same-day (mean LOS 0.47 ± 0.80 days). Within 30 post-operative days, 3% (3/102) of patients presented to the ER, 2% (2/102) were readmitted to the hospital, and 1% (1/102) required reoperation. There was 1 serious complication (Clavien-Dindo grade 3/4) with an aggregate complication rate of 7.8%. CONCLUSIONS: Our initial experience with ERAS protocols and same-day discharges after robotic eTEP repair demonstrates this approach is safe and feasible with acceptable short-term patient outcomes. Compared to traditional open surgery for large ventral hernias, robotic eTEP may enable significant reductions in hospital LOS as adoption increases.

TAVAC: choledochoscopy disposable scopes, and the single-stage vs. two-stage approach to choledocholithiasis.

BACKGROUND: Previous studies have been published evaluating the benefits and drawbacks of clearing the common bile duct of stones using a single-stage approach (LCBDE + LC) versus a two-stage approach (ERCP followed by LC). These studies have demonstrated that a single-stage approach offers similar outcomes and morbidities as a two-stage approach, with the added benefit of a lower cost and shorter length of stays. However, it is significant we understand why LCBDE is not commonly performed currently and also the lapse in surgical trainee exposure and competence in LCBDE. This paper aims to address the lapse in surgical trainee exposure to LCBDE, evaluate the scopes currently available to perform LCBDE, and review current data evaluating the risks and benefits of single-stage versus two-stage approaches to. METHODS: We utilized PubMed to analyze all publications related to the various disposable scopes utilized to perform choledochoscopy. We also discuss the need for disposable scopes and how this new market niche is transforming the choledochoscopy space. RESULTS: We analyzed the data related to single-stage and two-stage approach to choledocholithiasis. We noted an overall shorter length of stay and also decreased costs in favor of a single-stage approach. CONCLUSION: A single-stage LCBDE is the most cost-effective treatment option for choledocholithiasis in patients with choledocholithiasis undergoing a cholecystectomy. In addition, single-stage approach is associated with shorter length of stay. Knowledge of the available choledochoscopes and tools available to surgeons to perform choledochoscopy is significant. The evidence does support the use of disposable choledochoscope from a cost and cross-contamination perspective. Additionally, efforts should be made to incorporate LCBDE into the teaching paradigm of surgical training programs.

Changes in utilization of robotic bariatric surgery and effect on patient outcomes from 2015-2020.

Robotic surgery is an increasingly popular alternative to laparoscopy for performing bariatric operations. To describe changes in utilization and complication rates of this technique over the last six years an analysis of the 2015-2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use files (MBSAQIP PUF) was performed. All patients who underwent laparoscopic or robotic bariatric surgery from 2015 to 2020 were included. 1,341,814 robotic and laparoscopic bariatric operations were included. Both the number and proportion performed robotically increased from 2015 (n = 9866, 5.87%) to 2019 (n = 54,356, 13.16%). In 2020, although the number of cases decreased, the proportion performed robotically still increased (17.37%). Yet, there has been no significant change in 30 day risk of death (p = 0.946) or infection (p = 0.721). In fact, the risk of any complication has decreased from 8.21% in 2015 to 6.43% in 2020 (p = 0.001). Robotic cases are being increasingly performed on high-risk patients with 77.06% of patients being American Society of Anesthesiologists (ASA) class 3 or higher in 2015 versus 81.03% (p = 0.001) in 2020. Robotic cases are also more likely to be revision operations than laparoscopic cases (12.16% vs 11.4%, p = 0.001). From 2015 to 2020 robotic bariatric surgery became more prevalent yet both complication rates and length of operation decreased suggesting it is an increasingly safe option. The risk of robotic complications remains higher than laparoscopy, however there are significant differences in the patient populations suggesting there may be specific patients and/or operations in which robotic bariatric surgery is being used.

Implications of declining medicare reimbursement of hernia repair for surgeons and patients.

In conclusion, billing trends reflect declining reimbursement and utilization of hernia repair, and increasing markup ratios may create a financial barrier to accessing hernia for uninsured and underinsured patients. As a new set of hernia repair CPT codes are used in practice, close attention should be paid to the downstream effects of billing practices in hernia repair on physician and patient alike.

Conversion of gastric sleeve to Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch: safe and viable options.

BACKGROUND: Sleeve gastrectomy (SG) remains the most performed bariatric surgery. As numbers of SG increase, so do the numbers of patients requiring conversion for insufficient weight loss or weight regain. However, the literature has cited complication rates as high as 30% for reoperative bariatric surgery. OBJECTIVE: With the recent inclusion of conversion surgery variables in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we compared the safety and efficacy of SG conversion to Roux-en-Y gastric bypass (RYGB) versus biliopancreatic diversion and duodenal switch (BPD/DS). SETTING: MBSAQIP database. METHODS: Analysis of the 2020 MBSAQIP Participant Use Files revealed 6020 patients who underwent SG conversion to RYGB (5348) and BPD/DS (672). We examined 30-day outcomes including death, anastomotic leak, readmission, any complication, dehydration, and weight loss. RESULTS: There was no statistically significant difference in mortality (.12% versus 0%) or; complication rate (6.5% versus 5.1%) with SG conversion to RYGB or BPD/DS. There was a statistically significant difference in anastomotic leak (.5% versus 1.2%, P = .024). Interestingly, BPD/DS was less likely to require dehydration treatments (4.2% versus 2.2%, P = .009) and had fewer readmissions within 30 days (7.3% versus 5.4%, P = .043). CONCLUSIONS: Complication rates after conversion of SG to RYGB or BPD/DS may be significantly lower than previously reported and only slightly higher than after primary weight loss surgery. SG conversion to either RYGB or BPD/DS remain safe, viable options for patients who had insufficient weight loss or regain, and BPD/DS may be the better option in the appropriate patient.

Metabolic syndrome as a predictor of perioperative outcomes in primary bariatric surgery, a MBSAQIP survey.

BACKGROUND: Among bariatric surgery patients, body mass index (BMI) does not fully capture the severity of obesity and it may be complicated to stratify patients at higher risk of peri-operative complications. In our study, we surveyed the MBSAQIP database to determine whether bariatric patients with metabolic syndrome (MetS) are at higher risk for peri-operative complications. METHODS: MBSAQIP database was used to investigate the correlation between MetS and perioperative outcomes. All patients between 2015 and 2018, ≥ 18 years old, who underwent primary bariatric surgery were included. Patients were excluded if they underwent natural orifice transluminal endoscopic surgery or had surgery performed by gastroenterologist or interventional radiologist. We modified the International Diabetes Federation definition of MetS for our study to select patients with BMI > 30 in addition to two or more of the following comorbidities: hypertension, hyperlipidemia, or diabetes. The primary outcome was perioperative mortality. Secondary outcomes included post-operative surgical site infections (SSI), perioperative MI, stroke, acute renal failure, transfusion requirement, readmission, conversion to open and reoperation. RESULTS: Between 2015 and 2018, 760,076 bariatric operations were performed. 670,935 met criteria for analysis. 190,239 patients were identified to have MetS. Patients with MetS were found to have higher odds of death (OR 2.32; 95% CI 1.97-2.72), SSI (OR 1.39; 95% CI 1.31-1.48), perioperative MI (OR 4.70; 95% CI 3.42-6.45), stroke (OR 3.30; 95% CI 2.08-5.24), acute renal failure (OR 3.04; 95% CI 2.48-3.72), and transfusion requirement (OR 1.30; 95% CI 1.33-1.39). CONCLUSION: Patients with metabolic syndrome are at increased odds of peri-operative complications after bariatric surgery.

Time to Head Computed Tomography Protocol in Traumatic Brain Injury: A Quality Improvement Metric.

BACKGROUND: Early identification of traumatic brain injury (TBI) with head CT HCT should expedite operative decision-making and improve outcome. We aimed to determine whether an early HCT protocol in TBI patients would improve outcome. METHODS: A multidisciplinary protocol to obtain an HCT within 30 minutes from arrival for patients with GCS ≤ 13 was instituted on 1/1/2015. Our trauma registry was queried for patients evaluated between 3/2012 and 12/2015. Outcomes included compliance with protocol and in-hospital mortality. RESULTS: 346 patients presented with GCS ≤ 13. Patients PRE- (n=264) and POST-protocol (n=82) were similar in demographic and physiologic characteristics. Time to HCT was lower (35 vs. 77 min; p<0.001). POST-protocol had lower odds of mortality (OR 0.65, 95% CI 0.43-0.99) adjusting for age, gender, ISS and GCS. CONCLUSION: Implementing a protocol of early HCT for TBI optimized performance of the trauma team. Time to HCT could serve as a quality metric in TBI.

Racial Disparities in Bariatric Surgery Complications and Mortality Using the MBSAQIP Data Registry.

BACKGROUND: Racial disparities in postoperative complications have been demonstrated in bariatric surgery, yet the relationship of race to complication severity is unknown. STUDY DESIGN: Adult laparoscopic primary bariatric procedures were queried from the 2015 and 2016 MBSAQIP registry. Adjusted logistic and multinomial regressions were used to examine the relationships between race and 30-day complications categorized by the Clavien-Dindo grading system. RESULTS: A total of 212,970 patients were included in the regression analyses. For Black patients, readmissions were higher (OR = 1.39, p < 0.0001) and the odds of a Grade 1, 3, 4, or 5 complication were increased compared with White patients (OR = 1.21, p < 0.0001; OR = 1.21, p < 0.0001; OR = 1.22, p = 0.01; and OR = 1.43, p = 0.04) respectively. The odds of a Grade 3 complication for Hispanic patients were higher compared with White patients (OR = 1.59, p < 0.0001). CONCLUSION: Black patients have higher odds of readmission and multiple grades of complications (including death) compared with White patients. Hispanic patients have higher odds of a Grade 3 complication compared with White patients. No significant differences were found with other races. Specific causes of these disparities are beyond the limitations of the dataset and stand as a topic for future inquiry.

Determining changes in bone metabolism after bariatric surgery in postmenopausal women.

BACKGROUND: Accelerated bone loss is a known complication after bariatric surgery. Bone mineral density has been shown to decrease significantly after Laparoscopic Roux-en-Y gastric bypass (RYGB). Laparoscopic sleeve gastrectomy (SG) effects on bone density are largely unknown. This should be considered for those with increased preoperative risk for bone loss, such as postmenopausal females. METHODS: This prospective clinical trial included postmenopausal patients, with BMI ≥ 35 k/m2, being evaluated for either RYGB or SG. Patients with history of osteoporosis, estrogen hormone replacement therapy, active smoking, glucocorticoid use, or weight > 295 lb were excluded. Patients underwent DEXA scans preoperatively and 1 year postoperatively with measurement of total body bone mineral density (BMD) and bone mineral content (BMC) as well as regional site-specific BMD and BMC. RESULTS: A total of 28 patients were enrolled. 16 (57.1%) patients underwent RYGB and 12 (42.9%) patients underwent SG. Median preoperative BMI was 44.2 k/m2 (IQR 39.9, 46.6). Median change in BMI at 12 months was - 11.3 k/m2 (IQR - 12.8, - 7.9). A significant reduction in total body BMC was seen when comparing preoperative measurements to postoperative measurements (2358.32 vs 2280.68 grams; p = 0.002). Regional site BMC and BMD significantly decreased in the ribs and spine postoperatively (p = < 0.02) representing the greatest loss in the axial skeleton. Comparing those who underwent RYGB to SG there was no significant difference between the two groups when evaluating changes in total or regional site BMD. CONCLUSION: Postmenopausal women were found to have decreased BMD and BMC after RYGB and SG, suggesting that high-risk women may benefit from postoperative DEXA screening. Further study is needed to determine the clinical significance of these findings. It is unknown if these changes in BMD are due to modifiable factors (Vitamin D level, activity level, hormone status, etc.), and whether BMD and BMC is recovered beyond 1 year.