Enhanced recovery after bariatric surgery (ERABS) in a high-volume bariatric center.

BACKGROUND: The growing demand for bariatric surgery has been accompanied by an expensive technological evolution and the need to contain healthcare costs and to increase the quality of care. The enhanced recovery after surgery (ERAS) protocols applied to the bariatric setting can be the answer to all these different issues. OBJECTIVES: Feasibility and safety of ERAS protocol in a single, high-volume bariatric center. SETTING: Humanitas Research Hospital, Rozzano MI, Italy. METHODS: Our ERAS bariatric protocol is based on the following 3 steps: (1) preoperative: optimization of all co-morbidities, counseling patients and family with information and education, and shortening fasting times (clear fluids up to 2 hr and solids up to 4 hr before induction of anesthesia); (2) intraoperative: premedication, parallel team work, awake patient positioning, standardized multimodal anesthesia and analgesia, noninvasive monitoring, video-laryngoscopy in reverse Trendelenburg position, short-acting anesthetic agents, and standardized laparoscopic surgery avoiding the nasogastric tube, catheter, and drain; and (3) postoperative: analgesia, early mobilization, early oral fluid, thromboprophylaxis, discharge planning, and follow-up telephone call. Clinical pathways were established and outcomes were retrospectively collected. RESULTS: Comparison between conventional care and ERAS protocol reveals a reduction of the length of hospital stay (from 4.7 to 2.1 d) and a low morbidity rate. From July 2015 to July 2018, a total of 2400 consecutive patients underwent primary or revisional bariatric surgery (2122 sleeve gastrectomies and 278 Roux-en-Y gastric bypasses [RYGB]). Mean body mass index was 44.9 kg/m2, mean age was 41.9 years, and the male to female ratio was 1:2.5. Total mean operative time was 85 minutes, with a surgical time of 65 minutes and an anesthesiologic/patient induction time of 4 minutes. Early complication rate was 3.5% with no perioperative mortality. Mean hospital stay was 2.1 days and the rate of readmission was .9%. CONCLUSIONS: This study demonstrates that our ERAS protocol is safe, feasible, and efficient. Patient preparation and multidisciplinary/parallel team work are crucial points.

Laparoscopic sleeve gastrectomy in a patient with situs viscerum inversus totalis: is the life easy upside-down?

INTRODUCTION: Obesity is an epidemic on the rise [1]. The number of bariatric procedures has increased worldwide. Laparoscopic sleeve gastrectomy (LSG) is a valid therapeutic option, leading to a sustained weight loss with a low complication rate [2]. Situs viscerum inversus totalis (SIT) is the complete transposition of all the abdominal organs, occurring in about 1 in 10,000 people [3]. Laparoscopic approach in SIT is challenging due to the mirror image anatomy. MATERIALS AND METHODS: We present the case of a 41-year-old man with a body mass index of 46.4 kg/m2 (131 kg; 1.68 m) previously diagnosed with SIT who has undergone LSG. RESULTS: In this video, we show a LSG performed in a patient with SIT. There were no changes in the technique compared to the "standard anatomy." The patient was placed on the operative table in anti-trendelenburg position with legs abducted. The surgeon stood between the legs while the assistant was on the right side of the patient and the scrub nurse on the opposite side. A 12-mm trocar was inserted with a direct technique in the right lateral flank. Carbon dioxide insufflation was done under vision. Other three trocars (12, 10, and 5 mm) were positioned in the left lateral flank, supraumbilical, and subxiphoid areas, respectively. Gastroepiploic dissection started at 5 cm from the pylorus up to the right crus. After the insertion of a 36-Fr boogie, an accurate stapling of the stomach was performed. The proximal side of the sleeve was reinforced with a non-absorbable suture. Titanium clips were placed leading to a complete haemostasis. The procedure lasted 45 min. The patient followed a "fast-track" protocol afterwards, with no changes in the perioperative workup compared to "standard anatomy" patients. He was discharged on day 2 postoperatively and no complication occured in the perioperative period. CONCLUSION: SIT is a rare condition leading to a mirror image that can be challenging for a laparoscopic surgeon. LSG is feasible and safe also for morbidly obese patients with SIT, not requiring any change in the surgical technique and perioperative management, as long as the surgeon is well beyond the learning curve.

Long-term outcome with the prophylactic use of polypropylene mesh in morbidly obese patients undergoing biliopancreatic diversion.

The use of prosthetic material to prevent incisional hernia in clean-contaminated procedures as bariatric surgery remains controversial. We present our experience on 45 consecutive morbidly obese patients undergoing biliopancreatic diversion that was closed using a polypropylene mesh. Moreover, we reviewed the outcome of the 50 previous consecutive obese patients who underwent biliopancreatic diversion and conventional closure of the abdomen in order to compare the outcome between the two groups after a minimum follow-up of 2 years. Between January 2006 and February 2010, 95 morbidly obese patients underwent open biliopancreatic diversion at our department. During the first 2 years of our experience, there were 50 obese patients whose open biliopancreatic diversion was closed conventionally (without mesh). Starting on February 2008 and until February 2010, 45 patients received prophylactic midline reinforcement by the positioning of retrorectal muscle polypropylene mesh. The outcome at 3, 6, 12, and 24 months was analyzed comparing the two groups of patients. No mesh infection occurred. Minor local complications occurred similarly in both groups. The incidence of postoperative hernia was significantly higher in the group conventionally closed (30%) than in the mesh group (4.4%) at 2-year follow-up (p < 0.05). The prophylactic use of mesh in open bariatric surgery is safe and effective at 2-year follow-up.

Incisional hernia prophylaxis in morbidly obese patients undergoing biliopancreatic diversion.

BACKGROUND: The development of incisional hernia after open bariatric surgery is a major cause of morbidity and hospital readmission. The use of prosthetic material in clean-contaminated procedures remains controversial and correlated to high rate of local complications. A prospective observational clinical study on two different surgical techniques used to close the abdominal wall has been performed to better assess the safety (primary end point) and the efficacy (secondary end point) of polypropylene mesh placement to prevent incisional hernia in morbidly obese patients undergoing biliopancreatic diversion (BPD). METHODS: Between January 2007 and February 2009, two consecutive series of 25 obese patients, each undergoing BPD, have been analyzed to compare prophylactic retrorectal muscle prosthetic mesh placement with conventional suture repair of the abdominal wall. The first 25 consecutive patients selected to BPD underwent abdominal closure without mesh (group A), and the next 25 consecutive ones have been treated with prophylactic retrorectal muscle prosthetic mesh placement (group B). RESULTS: No mesh infection occurred in patients in group B. The incidence of minor local complications (seroma or hematoma) was similar in both groups. The incidence of incisional hernia was significantly higher (p = 0.009) in no-mesh group (group A) than in the mesh group (group B) at 1-year follow-up (range, 12 to 24 months). The incidence of incisional hernia was 4% (one case reported) in the group treated with mesh versus an incidence of 32% (eight cases reported) in the group conventionally closed. CONCLUSIONS: The mesh placement in clean-contaminated bariatric surgery seems to be safe (primary end point) and effective (secondary end point) at 1-year follow-up.

Perforation of an adjustable gastric banding connecting tube into distal transverse colon with intra-luminal migration.

Laparoscopic adjustable gastric banding (LAGB) is one of the most common bariatric procedures performed in Europe and Australia. Major post-operative complications are limited but once they occur, prompt diagnosis and treatment are mandatory. LAGB complications are related either to the port and the connecting tube, such as infection or tubing disconnection and migration, or to the band, such as slippage, pouch dilatation, or intra-gastric migration. We report a case of intra-colonic migration of the connecting tube occurring 4 years after gastric banding placement in a patient otherwise asymptomatic.