Development and Implementation of an Enhanced Recovery Protocol for Bariatric Patients in a Third World Environment.

Introduction: An applicable and reproducible enhanced recovery protocol was developed and implemented to improve our outcomes in a third-world environment. Methods: We compared the results obtained prospectively. The group treated before the application of the enhanced recovery protocol was called usual care (UC) and included all bariatric surgeries operated on between 2014 and 2017. The new protocol was applied between 2017 and 2019 including all operated patients, and this group was called Fast Track (FT). The variables analyzed were the length of stay, readmissions, and complications recorded during the first 30 days. We also analyzed the milligrams of morphine used by each patient, and a cost analysis was performed. Results: During the study period, 816 patients were studied. Of these, 385 (47.2%) belonged to the UC group and 431 (52.8%) to the FT group. The mean hospital stay was 58.5 hours (UC) versus 40.3 hours (FT) (P = .0001). When comparing the global morbidity of both groups, we did not find significant differences (P = .47). There was also no statistically significant difference when comparing major complications (P = .79). No mortality was recorded. Morphine indication reported a statistically significant difference that favored FT. Costs were significantly higher in UC than in FT (P < .0001). Conclusions: We believe that the implementation of an enhanced recovery protocol in bariatric surgery is a reliable measure and can be implemented even in an underdevelopment environment enlarging the benefit for patients.

[Accelerated recovery in elective laparoscopic colorectal surgery: two years of experience. ] / Recuperación acelerada en cirugía colorrectal laparoscópica electiva: dos años de experiencia.

Background: Accelerated recovery protocols in colorectal surgery have enhanced the perioperative cares optimizing recovery in this group of patients. A reduction in surgical stress and therefore early hospital discharge and lower morbidity is pursued, however, the literature offers few outcomes regarding its application in developing countries. Objective: to analyze short- and medium-term outcomes of the application of an accelerated recovery protocol in a terciary care hospital in Argentina. Methods: In the period between January 2015 and March 2017 patients were included prospectively and consecutively with indication of elective laparoscopic colorectal surgery and under strict follow-up according to the protocol created by the institution. Patients older than 80 years, ASA IV, emergency surgeries and conventional approach were excluded. We analyzed demographic data, diagnosis of surgery, type of intervention, hospital stay, complications, readmissions and reinterventions at 30 postoperative days. Results: Sixty-four patients with a mean age of 62 years were included. The mean hospitalization was 4.9 days, with 10.9% readmissions and 4.7% of reinterventions. We recorded 69% of the patients whit not complications at all and 5 major complications (8%) . Conclusion: Based on the adaptation of the international guidelines to our health reality, it is feasible to create an accelerated recovery protocol applicable in our country, with a low complication rate and early discharge.

Introducción: El desarrollo de los protocolos de recuperación acelerada en cirugía colorrectal ha revalorizado los cuidados que conforman la recuperación perioperatoria de los pacientes sometidos a cirugía. Se persigue una reducción del stress quirúrgico y por tanto alta precoz y menor morbilidad, sin embargo, la literatura aporta pocos resultados respecto a su aplicación en países en desarrollo. Objetivo: analizar los resultados a corto y mediano plazo de un protocolo de recuperación acelerada en un hospital de alta complejidad de nuestro medio. En el periodo comprendido entre enero 2015 y marzo 2017 se incluyeron pacientes de manera prospectiva y consecutiva con indicación deAñadir colaborador/a cirugía colorrectal laparocopica electiva y bajo estricto seguimiento según protocolo creado por la institución. Fueron excluidos pacientes mayores de 80 años, ASA IV, cirugías de urgencia y abordaje convencional. Se analizaron datos demográficos indicación de cirugía, tipo de intervención, estadía hospitalaria en días, complicaciones, readmisiones y reintervenciones a los 30 días de postoperatorio. Resultados: Fueron incluidos 64 pacientes con una edad media de 62 años. El promedio de internación en días fue de 4,9, con 10,9% de reinternaciones y 4,7% de reintervenciones. El 69% de los pacientes no presento complicaciones, registrándose 5 complicaciones mayores (8%). Conclusión: A partir de la adecuación de los lineamientos internacionales a nuestra realidad sanitaria, es factible la creación de un protocolo de recuperación acelerada aplicable en nuestro medio, con baja tasa de complicaciones y alta precoz.

Obese Patients with Type 2 Diabetes: Outcomes After Laparoscopic Sleeve Gastrectomy.

Background: Bariatric surgery is superior to medical treatment for type 2 diabetes mellitus (T2DM) control in obese patients. Reports in the literature have been mainly based on Roux-en-Y gastric bypass (RYGB) or adjustable gastric band. The aim of this study was to analyze mid- and long-term metabolic results after laparoscopic sleeve gastrectomy (LSG). Methods: Obese patients with T2DM undergoing LSG were included in this study. Selection criteria for T2DM remission were: post-operatory fasting glucose (FG) level <100 mg/dL, and hemoglobin A1c (HbA1c) <6% without medication. Results: Between January 2009 and July 2016, 166 T2DM obese patients underwent LSG and completed ≥1 year follow-up. There were 101 women (60.8%; mean age 49.07 ± 12.8 years). Initial body mass index (BMI) was 46.44 ± 7.68 kg/m2. Mean time since T2DM diagnosis was 5.95 years (1-28). Preoperative HbA1c was 7.53% ± 0.97%. Before LSG, 75.3% (n = 125) were receiving oral hypoglycemic agents, and 13.25% (n = 22) insulin. Mean follow-up was 65 ± 10 months. Complete T2DM remission was achieved in 78.3%, 76.2%, and 71.4% at 1, 3, and ≥5 years respectively; in the long term, 7.2% attained partial remission, 10% improved, and 11.4% experienced recurrence of the disease. Remission rate was significantly lower in patients under insulin therapy preoperatively, and in patients with T2DM diagnosed ≥5 years before consultation (P = .0004 and .0001, respectively). Conclusions: At mid- and long-term follow-up, T2DM control was satisfactory after LSG. Preoperative insulin therapy and T2DM duration ≥5 years were predictors of less favorable outcomes.

ALPPS torniquete complicado con giro de la vena suprahepática izquierda. Nuevas complicaciones en nuevas hepatectomías / ALPPS tourniquet complicated with twisting of the left hepatic vein. New complications in new hepatectomies

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Long-Term Relationship Between Tobacco Use and Weight Loss after Sleeve Gastrectomy.

BACKGROUND: Smoking cessation had been typically associated with weight gain. We have reported that there is no relationship between tobacco use and weight loss after bariatric surgery in the short term. The objective of this study was to establish the relationship between weight loss and the smoking habit in patients undergoing bariatric surgery and to analyze weight loss on severe smokers and on those patients who stopped smoking during the long-term postoperative period. METHODS: One hundred eighty-four patients included in our previous study were contacted by phone at 7 years after sleeve gastrectomy. They were again divided into three groups: (A) smokers, (B) ex-smokers, and (C) non-smokers. Demographics and weight loss at 6, 12, 24, and 7 years were analyzed. Smokers were subdivided for further analysis into the following: group A1: heavy smokers, group A2: non-heavy smokers, group A3: active smokers after surgery, and group A4: quitters after surgery. Student test was used for statistics. RESULTS: One hundred two patients were included. The follow-up was 80.74 ± 7.25 month. Group A: 29 patients, group B: 34 patients, and group C: 39 patients. Mean BMI was 34.35 ± 8.44 kg/m2 and the %EWL was 56.95 ± 27. The subgroup analysis showed the following composition: group A1: 6 patients, group A2: 23 patients, group A3: 23 patients, and group A4: 6 patients. Weight loss difference among groups and subgroups was statistically non-significant. CONCLUSIONS: This study reaffirms the hypothesis that weight loss among bariatric patients is independent from smoking habit even at long-term follow-up and regardless from cessation.

Sleeve Gastrectomy after Renal Transplantation.

BACKGROUND: Obesity induces or accelerates diabetes (DBT), hypertension (HT), and dyslipidemia (DSL), which are the main causes of renal failure. Obesity exacerbates in patients after renal transplantation (RT), and it has been associated with increased mortality rate, postoperative complications, and graft loss. We hypothesize that bariatric surgery might have a positive effect on obese patients with history of previous RT. METHODS: This was a retrospective review from prospectively collected data. Patients with sleeve gastrectomy (SG) with history of RT were studied. Demographics, anthropometric data, effect on comorbidities, postoperative course, immunosuppressive treatment, reason for transplantation, kidney function, graft survival, and quality of life associated with SG in obese patients with previous RT were assessed using a survey. RESULTS: From January 1, 2012 to January 1, 2016, five kidney transplant patients were operated on; 80% were female, with an average preoperative BMI of 42.18 ± 8.5 kg/m2 (range 37-54). Related comorbidities: 100% of the patients had HT and DSL, whereas 40% had DBT and gout. The average time gap between RT and SG was 15 ± 8.4 years (range 3-22). Average operative time was 65 ± 12 min (range 60-85), and there were neither complications nor mortality. At 16.8 ± 14.5 months (range 5-46) of follow-up, BMI was 29.8 ± 7.3 kg/m2 (range 26-44). All patients with HT and DSL were able to decrease their medication, showing improvement in blood pressure levels and laboratory test values. Regarding DBT, insulin was discontinued in one case, limiting the treatment to the use of oral hypoglycemic agents only. In another case, insulin dosage was significantly reduced. Graft function and proteinuria level improved in 80% of patients. All patients experienced a significant improvement in their quality of life. CONCLUSION: In this specific group of high-risk patients, SG showed encouraging results in terms of weight loss and resolution/improvement of comorbidities, renal function, and quality of life.

Iatrogenic injury of the intrathoracic oesophagus with bougie during sleeve gastrectomy.

One of the most popular procedures amongst obesity surgery is the sleeve gastrectomy. There is international consensus regarding the usage of bougie for sleeve gastrectomy calibration. Nevertheless, there is a dissociation between the number of oesophageal perforations reported for any other oesophageal/gastric operation that requires bougie (e.g., anti-reflux surgery, incidence 1.2%) and bariatric surgery, where this complication seems to be almost a myth. Interestingly enough, the number of bariatric procedures is much higher than any other oesophageal/gastric surgery. This suggests that oesophageal perforations in obesity surgery are underreported. We report a case of injury of the intrathoracic oesophagus with bougie that occurred during a sleeve gastrectomy. In the infrequent case that the perforation is diagnosed during surgery, primary repair during the same intervention is highly recommended. Videothoracoscopy might be an effective option in case of necessity. We were able to complete the sleeve gastrectomy without increasing morbidity.

Laparoscopic Repair of Giant Bochdalek Hernia in Adults.

INTRODUCTION: Bochdalek hernia is a congenital diaphragmatic defect that results from improper fusion of the septum transversum and the pleuroperitoneal folds. It rarely persists asymptomatic until adulthood. The reported incidence is as low as 0.17%. Surgical repair of the defect can be performed through the abdomen or through the chest, and in both cases open or through laparoscopy/thoracoscopy. CASE REPORT: We present 2 cases of fully laparoscopic repair of giant Bochdalek hernia in adults. In both cases we used a GORE® DUALMESH® and we had neither complications nor recurrence. It is worthy of mention that hernia sac was not found in any of the cases. This has been described as a distinct characteristic that confirms diagnosis. CONCLUSION: Bochdalek hernia in the adult is a rare entity that requires surgical treatment to avoid complications. CT scan of the abdomen and chest with oral and IV contrast is the gold standard for diagnosis.