Impact of Robotic Assistance on Complications in Bariatric Surgery at Expert Laparoscopic Surgery Centers: A Retrospective Comparative Study With Propensity Score.

OBJECTIVE: To investigate the way robotic assistance affected rate of complications in bariatric surgery at expert robotic and laparoscopic surgery facilities. BACKGROUND: While the benefits of robotic assistance were established at the beginning of surgical training, there is limited data on the robot's influence on experienced bariatric laparoscopic surgeons. METHODS: We conducted a retrospective study using the BRO clinical database (2008-2022) collecting data of patients operated on in expert centers. We compared the serious complication rate (defined as a Clavien score≥3) in patients undergoing metabolic bariatric surgery with or without robotic assistance. We used a directed acyclic graph to identify the variables adjustment set used in a multivariable linear regression, and a propensity score matching to calculate the average treatment effect (ATE) of robotic assistance. RESULTS: The study included 35,043 patients [24,428 sleeve gastrectomy (SG); 10,452 Roux-en-Y gastric bypass (RYGB); 163 single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S)], with 938 operated on with robotic assistance (801 SG; 134 RYGB; 3 SADI-S), among 142 centers. Overall, we found no benefit of robotic assistance regarding the risk of complications (average treatment effect=-0.05, P =0.794), with no difference in the RYGB+SADI group ( P =0.322) but a negative trend in the SG group (more complications, P =0.060). Length of hospital stay was decreased in the robot group (3.7±11.1 vs 4.0±9.0 days, P <0.001). CONCLUSIONS: Robotic assistance reduced the length of stay but did not statistically significantly reduce postoperative complications (Clavien score≥3) following either GBP or SG. A tendency toward an elevated risk of complications following SG requires more supporting studies.

Ambulatory colectomy for cancer: Results from a prospective bicentric study of 177 patients.

BACKGROUND: The implementation of an Enhanced Recovery After Surgery programme after colectomy reduces postoperative morbidity and shortens the length of hospital stay. OBJECTIVE: To evaluate the short and midterm outcomes of ambulatory colectomy for cancer. METHODS: This was a two-centre, observational study of a database maintained prospectively between 2013 and 2021. Short-term outcome measures were complications, admissions, unplanned consultations and readmission rates. Midterm outcome measures were the delay between surgery and initiation of adjuvant chemotherapy, length of disease-free survival and 2-year disease-free survival rate. RESULTS: A total of 177 patients were included. The overall morbidity rate was 15% and the mortality rate was 0%. The admission rate was 13% and 11% patients left hospital within 24 h of surgery. The readmission rate was 9% and all readmissions occurred before postoperative Day 4. Eight patients underwent repeat surgery because of anastomotic fistula (n = 7) or anastomotic ileocolic bleeding (n = 1). These patients had an uneventful recovery. Sixty-one patients required adjuvant chemotherapy with a median delay between surgery and chemotherapy initiation of 35 days. CONCLUSIONS: Ambulatory colectomy for cancer is feasible and safe. Adjuvant chemotherapy could be initiated before 6 weeks postsurgery. The ambulatory approach may be a step forward to further improve morbidity and oncologic prognosis.

Connected Surveillance for Detection of Complications After Early Discharge from Bariatric Surgery.

As part of a bariatric enhanced recovery after surgery (ERAS) program, at-home follow-up using a novel Internet application was used to detect early complications. The study aimed to evaluate the safety and effectiveness of this "connected surveillance" protocol over a 10-day follow-up. Patients were monitored 24/7 by a trained nursing team with daily surgeon review of patient self-reports. Morbidly obese patients (n = 281) underwent OAGB (126, 47.70%) or sleeve gastrectomy (138, 52.3%). Of 264 who completed the study (mean age 40 years [20-66]), 3 (1.1%) underwent revision for early complications; there were 6 (2.1%) readmissions and 22 (8.3%) consultations. In a bariatric surgery ERAS program, "Internet-connected surveillance" proved safe and effective in detecting 100% of early complications, and most patients were satisfied with their care.

Long-Term Outcomes After One-Anastomosis Gastric Bypass (OAGB) in Morbidly Obese Patients.

BACKGROUND: One-anastomosis gastric bypass (OAGB) has gradually gained in popularity. Evidence of the validity of the technique and the quality of life in the longer term is scarce. The aim of this study was to retrospectively evaluate the longitudinal (≥ 5 years) safety, weight-loss efficacy, comorbid disease improvement, and quality of life of patients following OAGB. METHODS: Data from patients who underwent OAGB from January 2009 to December 2011 were retrospectively reviewed. Preoperative clinical characteristics and data through 8 years were analyzed. RESULTS: A total of 163 patients completed 5 to 8 years of follow-up with a mean age of 41 ± 11.4 years (22-65). Ninety-four patients (57.6%) had undergone prior bariatric surgery (gastric band). Mean body mass index (BMI, kg/m2) at the time of OAGB was 41.2 ± 6.5 (range 30.1-50.6). Twenty-one patients (13.0%) suffered from type 2 diabetes mellitus (T2DM), 59 (36.2%) hypertension, 31 osteoarthritis (19.0%), and 24 had obstructive sleep apnea (14.7%). At 5, 6, 7, and 8 years of follow-up, respective mean BMI reduction was 12.6 (n = 163), 11.8 (n = 100), 10.7 (n = 82), and 8.8 (n = 40). Respective mean excess weight loss was 81.8 ± 23.6%, 75.9 ± 20.8%, 69.1 ± 20.4%, and 62.3 ± 23.4%. All obesity-related comorbidities decreased significantly at follow-up time points. Five patients (3%) underwent laparoscopic reoperation within 90 days after surgery. Incidence of recurrent reflux was 14.0%. At a mean follow-up of 92 months (76-111), improved or greatly improved quality of life was reported by 86.0% of patients. CONCLUSION: OAGB provided very good weight loss, comorbidity improvement, and quality of life at follow-up of ≥ 5 years.

Short-term Outcomes of Ambulatory Colectomy for 157 Consecutive Patients.

OBJECTIVE: To evaluate short-term outcomes of laparoscopic colectomy for selected consecutive patients in an ambulatory setting at two institutions. BACKGROUND: Several studies showed that an enhanced recovery protocol for colorectal surgery reduces postoperative morbidity and mortality, and shortens the length of hospital stay. The development of such a program has allowed us to gradually reduce the length of stay for colorectal surgery, until ambulatory management. METHODS: Between February, 2013 and December, 2016, all patients scheduled for elective laparoscopic colectomy and meeting rigorous criteria for ambulatory surgery were included. Outcome was prospectively studied. RESULTS: One hundred fifty-seven patients (70 women) with a median age of 61 years (range 25-82 years) were included. The ambulatory rate for colectomy was 30.5%. Median operative time and length of in-hospital stay were 95 minutes (range 45-232 minutes) and 10.0 hours (range 7-14.7 hours), respectively. The admission rate was 7.0% due to operative difficulties (4 patients), medical reasons (4 patients), and social reasons (3 patients). Outcomes for these patients were uneventful and the median length of hospital stay was 3.1 days (range 1-14 days). An unscheduled consultation was necessary for 30 patients (20.5%). Nine patients required readmission (6.1%), of whom 6 required reoperation (3.8%). The overall 30-day morbidity rate was 24.8%. The mortality rate was 0%. CONCLUSIONS: This is the first case of consecutive patients undergoing ambulatory colectomy for malignant or benign disease. We demonstrated the feasibility, safety, and reproducibility of outpatient colectomy for selected patients. In our experience, 30% of patients scheduled for elective colectomy can be managed in an ambulatory setting.

Should ambulatory appendectomy become the standard treatment for acute appendicitis?

Background: Appendectomy is increasingly performed as a 'short stay' or 'ambulatory' procedure, yet there is no consensus for selection of patients with acute appendicitis for ambulatory surgery (AS). We aimed to compare characteristics and outcomes of complicated and uncomplicated appendectomies performed in ambulatory vs. conventional settings, and to determine factors associated with unexpected re-consultations and re-hospitalizations. Methods: The authors reviewed a consecutive series of 185 laparoscopic appendectomies. Whenever possible, patients were offered AS, defined as 'discharge on the same working day.' Multivariable regressions were performed to determine associations of unexpected re-consultations and re-hospitalizations with surgery type (ambulatory or conventional) and patient characteristics (age, gender, obesity, symptoms, appendicolith, perforations, appendix diameter, serologic results, American Society of Anesthesiologists score, and Saint-Antoine score). Results: From the initial cohort, 117 patients (63.2%) were eligible for AS, of which 8 had peri- or post-operative contraindications. Therefore, 109 patients (58.9%) were operated by AS, with median length of stay 8.5 h (range, 3.3-20.5). Ambulatory cases had a lower incidence of complications (11.9%) than conventional cases (25.0%) (p = 0.029). Uni- and multi-variable regressions revealed that unexpected re-consultations were not significantly associated with any of the pre- or peri-operative variables but that unexpected re-hospitalizations were 4 times more likely for patients with appendicolith (OR, 4.32; p = 0.04). Conclusions: Ambulatory surgery could be considered as a standard procedure for both complicated and uncomplicated acute appendicitis. Appendicolith was found to be an independent risk factor for unexpected re-hospitalization and should therefore trigger closer monitoring.

Four-Year Evolution of a Thrombophylaxis Protocol in an Enhanced Recovery After Surgery (ERAS) Program: Recent Results in 485 Patients.

"Enhanced recovery after surgery" (ERAS) protocols may reduce morbidity, length of hospital stay (LOS), and costs. During the 4-year evolution of a bariatric ERAS protocol, we found that administration of thrombophylaxis selectively to high-risk morbidly obese patients (assessed postoperatively by Caprini score ≥ 3) undergoing omega loop gastric bypass ("mini" gastric bypass) or sleeve gastrectomy resulted in safe outcomes. Both procedures proved equally effective with this protocol. The vast majority of rapidly mobilized, low-risk patients did not appear to require antithrombotic heparin. Similar to other reported ERAS outcomes, our recent year's results in 485 patients included a mean LOS of 1.08 ± 0.64 days (range 1-14), with 460 (95.0%) discharged on day 1 and 99.6% by day 2. There were 13 30-day complications (2.7%), two reinterventions (0.4%), and no hemorrhages.

Medium- to Long-Term Outcomes of Gastric Banding in Adolescents: a Single-Center Study of 97 Consecutive Patients.

Morbid obesity in adolescents has been treated effectively with laparoscopic adjustable gastric banding (LAGB). We prospectively studied 97 consecutive obese adolescents undergoing LAGB over the course of 10 years. The average patient age at surgery was 17.2 ± 0.7 years; mean body mass index, 44.9 ± 6.1 kg/m2. Excluding those lost to follow-up (n = 21), respective mean total weight loss and excess weight loss were 20.0 ± 16.6 and 46.6 ± 39.5% (n = 76, 78.4%). An ascending trend line showed a significant positive correlation between excess weight loss and follow-up duration (mean 56.0 ± 22.0 months). There was no mortality or morbidity. Nineteen patients (25.0%) underwent band removal at a mean 43.0 ± 28.0 months. LAGB proved safe and effective over the mid- and longer term; it should be strongly considered as a procedure of first intention for obese adolescents.

Experience with an Enhanced Recovery After Surgery (ERAS) Program for Bariatric Surgery: Comparison of MGB and LSG in 374 Patients.

BACKGROUND: Strategic multidisciplinary protocols for "enhanced recovery after surgery" (ERAS) have demonstrated reductions in length of hospital stay (LOS), morbidity, and costs in conjunction with bariatric procedures. METHODS: We prospectively investigated the effectiveness and safety of an ERAS protocol with laparoscopic omega loop gastric bypass ("mini" gastric bypass, MGB) and LSG in morbidly obese patients. RESULTS: Average LOS was 1.24 days (range 1-14); 86.1% discharged on day 1; 96.9% by day 2, a value comparable or better than that of other ERAS studies vs standard care according to meta-analysis. Complications 2.9%; readmission 2.1%; reintervention 1.3%. CONCLUSION: The program was equally safe with both procedures. Postoperative antithrombotic heparin does not appear necessary in low-risk patients. Bariatric surgical ERAS programs are evolving and not yet standardized.

Impact of Surgical Technique on Long-term Complication Rate After Laparoscopic Adjustable Gastric Banding (LAGB): Results of a Single-blinded Randomized Controlled trial (ANOSEAN Study).

OBJECTIVE: The aim of the study was to explore the impact of the absence of band fixation on the reoperation rate and to identify other risk factors for long-term complications. BACKGROUND: Laparoscopic adjustable gastric banding has been demonstrated to permit important weight loss and comorbidity improvement, but some bands will have to be removed mainly for failure or in case of planned 2-step surgery. Then, the absence of a gastro-gastric suture (GGS) would allow easier band removal. There are insufficient data to conclude that GGS should be abandoned, as the associated risk of band slippage has not been prospectively assessed. METHODS: The ANOSEAN study was a randomized controlled single-blind trial (CPP 2009-A00346-51). Primary outcome was reintervention rate for band removal or repositioning at 3 years. It included 706 patients in 17 bariatric centers. Patients in group 1 received a gastric band with GGS. Inclusion criteria were adapted from National Institutes of Health recommendations. Surgical technique was standardized among all surgeons. RESULTS: At 3 years, the reintervention rate for band retrieval or repositioning was significantly higher in the absence of band fixation (19.4% vs11.3%; P = 0.013), partly because of the slippage rate (10.3% vs 3.6%; P = 0.005). Body mass index <40 kg/m at baseline was also an independent risk factor of slippage (odds ratio 2.769, 95% confidence interval 1.373, 5.581). CONCLUSIONS: GGS prevents band slippage and lower reintervention rate at 3 years. Fixation could be discussed for patients with high BMI who are scheduled to undergo 2-step surgery, but it needs to be specifically assessed.

Prospective, multicenter, 3-year trial of laparoscopic adjustable gastric banding with the MIDBAND™.

BACKGROUND: Although laparoscopic adjustable gastric banding (LAGB) is a popular metabolic/bariatric procedure, few prospective studies have assessed its outcomes. This study aimed to prospectively assess LAGB safety and effectiveness outcomes using the MIDBAND™ (MID, Dardilly, France). METHODS: Between May 2005 and September 2006, 262 morbidly obese patients underwent primary gastric banding with pars flaccida technique in 13 French medical centers. Excess weight loss and change in body mass index (BMI, kilogram per square meter), percentage of patients with comorbidities, and obesity-related complications were recorded. Patients were followed at 6-month intervals for 3 years. A multivariable individual growth model was used to analyze weight change over time and determine potential predictors of weight loss. RESULTS: The majority of patients were female (n = 233, 89%), with mean age of 36.4 ± 9.7 years. At 3 years, LAGB with MIDBAND resulted in significant decrease in mean BMI from 41.8 ± 4.2 to 30.7 ± 5.8 (p < 0.0001). Median excess weight loss and excess BMI loss were 61% and 68%, respectively. The prevalence of obesity-related comorbidities had significantly decreased from 71% to 15% (p < 0.0001). Complications were observed in 26 patients (10%); device-related complications occurred in 20 patients (8.2%), requiring band removal in 8 (3.3%), and port revision in 8 (3.3%). Individual growth analysis identified significant predictors of weight loss including the number of follow-up visits. CONCLUSION: Prospective outcomes demonstrate the safety and efficacy of gastric banding over time using the MIDBAND. Individual growth modeling demonstrated that postoperative weight loss is strongly related to the frequency and consistency of follow-up visits.

Depot-specific differences in perilipin and hormone-sensitive lipase expression in lean and obese.

BACKGROUND: Mainly dependent on hormone-sensitive lipase, lipolysis is differently impaired between fat depots in human obesity. Perilipin A expression is a critical element in adipocyte lipolysis. The present study aimed at comparing expression and subcellular distribution of perilipin and hormone-sensitive lipase in two abdominal adipose tissues of lean and obese women. We examined whether regional differences in perilipin expression contribute to impaired lipolytic rates. METHODS: Abdominal subcutaneous and omental adipose tissues were obtained from six lean and ten obese women. We measured total protein content and relative distribution of hormone-sensitive lipase and perilipin proteins between lipid and non-lipid fractions in tissue homogenates. Hormone-sensitive lipase and perilipin mRNA levels, adipocyte size, basal (non-stimulated) and noradrenaline-stimulated lipolysis in isolated adipocytes were determined. RESULTS: Adipocytes were significantly larger in the obese versus the lean women and in subcutaneous versus omental fat. Expressed as a function of cell number, basal lipolysis and noradrenaline responsiveness were higher in subcutaneous versus omental adipocytes from the obese women (P < 0.05). Despite higher or identical mRNA levels in the lean and the obese subjects and in subcutaneous and omental tissues, perilipin protein expression was lower in both depots in the obese versus the lean women, and in subcutaneous versus omental in both lean and obese women (P < 0.05). Perilipin was mostly (above 80%) present in the lipid fraction in both depots from the obese patients and the value decreased to 60% in the lean subjects (P < 0.05). Perilipin protein expression was inversely correlated to adipocyte size and basal lipolysis in both depots. Despite higher mRNA levels, hormone-sensitive lipase protein expression decreased in both depots of the obese women. Regional difference for hormone-sensitive lipase was reported in lipid fraction of subcutaneous fat of the obese subjects: hormone-sensitive lipase content was twice as low as in omental adipose tissue. CONCLUSION: In both fat depots, a reduced perilipin protein expression was observed in women obesity. Perilipin protein level may contribute to differences in basal lipolysis and in adipocyte size between fat depots and may regulate lipid accumulation in adipocytes. Differences in hormone-sensitive lipase subcellular distribution were reported between fat depots in the obese women.

Fixation of the access-port is not required in gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is increasingly performed in patients with morbid obesity. Suturing of the access-port in LAGB can be difficult and time consuming but is felt necessary by many surgeons to prevent migration and facilitate band adjustments. METHODS: Between 2003 and 2006, 226 patients underwent LAGB with the MIDband. All surgery was performed by the pars flaccida approach. The access-port was positioned in a subcutaneous pouch adjacent to the left hypochondrial port site and was not secured. Regular follow-up and band fills were offered. All band or port-related complications were duly recorded. A patient satisfaction survey was also conducted among 50 randomly selected post-banding patients. RESULTS: Mean age was 41.65 years (range 18-73 years) and mean BMI was 45.85 kg/m2 (range 34.0-74.93 kg/m2). The access-port was inaccessible at first attempt in 5 (2%) patients. 4 of these required radiological imaging to identify the port orientation and 1 required multiple attempts at port puncture with subsequent re-operation due to tube puncture. 91% of patients reported no significant trouble other than mild discomfort and prominence of the port. CONCLUSION: This study shows non-fixation of the access-port to be safe and effective with good patient acceptability. In addition, it avoids the need for regular X-ray localization of the port.

Comparison of the expression and activity of the lipogenic pathway in human and rat adipose tissue.

Lipogenesis is considered less active in human than in rat adipose tissue. This could be explained by different nutritional conditions, namely high-carbohydrate (HCHO) diet in rats and high-fat (HF) diet in humans. Adipose tissue was sampled (postabsorptive state) in rats and humans receiving HCHO or HF diets, ad libitum fed humans, and obese subjects. We measured 1) mRNA concentrations of fatty acid synthase (FAS), acetyl-CoA carboxylase 1 (ACC1), sterol regulatory element binding protein 1c (SREBP-1c), and carbohydrate response element binding protein (ChREBP), 2) SREBP-1c protein, and 3) FAS activity. FAS, ACC1, ChREBP, and SREBP1-c mRNA concentrations were unaffected by diet in humans or in rats. FAS and ACC1 mRNA levels were lower in humans than in rats (P < 0.05). FAS activity was unaffected by diet and was lower in humans (P < 0.05). SREBP-1c mRNA concentrations were similar in rats and humans, but the precursor and mature forms of SREBP-1c protein were less abundant in humans (P < 0.05). ChREBP mRNA concentrations were lower in humans than in rats. In conclusion, the lipogenic capacity of adipose tissue is lower in humans than in rats. This is not related to differences in diet and is probably explained by lower abundance of SREBP-1c protein. A decreased expression of ChREBP could also play a role.