Bariatric Surgeon Ergonomics: A Comparison of Laparoscopy and Robotics.

INTRODUCTION: Bariatric surgery is routinely performed using laparoscopic and robotic approaches. Musculoskeletal injuries are prevalent among both robotic and laparoscopic bariatric surgeons. Studies evaluating ergonomic differences between laparoscopic and robotic bariatric surgery are limited. This study aims to analyze the ergonomic, physical, and mental workload differences among surgeons performing robotic and laparoscopic bariatric surgery. MATERIALS AND METHODS: All primary laparoscopic and robotic bariatric surgeries, Roux-en-Y gastric bypass, and sleeve gastrectomy between May and August 2022 were included in this study. Objective ergonomic analysis was performed by an observer evaluating each surgeon intraoperatively according to the validated Rapid Entire Body Assessment tool, with a higher score indicating more ergonomic strain. After each operation, surgeons subjectively evaluated their physical workload using the body part discomfort scale, and their mental workload using the surgery task load index. RESULTS: Five bariatric surgeons participated in this study. In total, 50 operative cases were observed, 37 laparoscopic and 13 robotic. The median total Rapid Entire Body Assessmentscore as a primary surgeon was significantly higher in laparoscopic (6.0) compared to robotic (3.0) cases (P < 0.01). The laparoscopic and robotic approaches had no significant differences in the surgeons' physical (body part discomfort scale) or mental workload (surgery task load index). CONCLUSIONS: This study identified low-risk ergonomic stress in surgeons performing bariatric surgery robotically compared to medium-risk stress laparoscopically. Since ergonomic stress can exist even without the perception of physical or mental stress, this highlights the importance of external observations to optimize ergonomics for surgeons in the operating room.

The Association of Preoperative Food Insecurity With Early Postoperative Outcomes After Bariatric Surgery.

INTRODUCTION: To assess the rate of food insecurity in patients undergoing bariatric surgery. To compare the rates of 30-d postoperative complications based on food security status. METHODS: Patients undergoing primary Roux-en-Y gastric bypass or sleeve gastrectomy between 7/2020 - 3/2022 were screened for food insecurity via telephone using questions from the Accountable Health Communities Health-Related Social Needs Screening Tool. Screens were matched to patient data and 30-d outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. RESULTS: In total, 213 (59%) of the 359 bariatric surgery patients were screened with 81 (38%) screening positive for food insecurity. Evaluation of preoperative variables based on food security status showed comparable age, body mass index, and comorbidity status. Food insecure patients were found to have an increased length of stay following surgery compared to food secure patients (P = 0.003). Food insecurity was not associated with higher rates of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program reported 30-d postoperative complications including emergency department/urgent care visits (P = 0.34) and hospital readmissions (P = 0.94). CONCLUSIONS: Food insecurity was prevalent at 38% of the bariatric surgical population. Food insecure patients had a statistically longer length of stay after primary bariatric surgery but were not associated with an increased risk of 30-d complications. Future studies are needed to determine the mid-term and long-term effects of food insecurity status on bariatric surgical outcomes and the potential impact of food insecurity on length of stay.

From Alpha to Omicron and Beyond: Associations Between SARS-CoV-2 Variants and Surgical Outcomes.

INTRODUCTION: The COVID-19 pandemic has significantly influenced surgical practices, with SARS-CoV-2 variants presenting unique pathologic profiles and potential impacts on perioperative outcomes. This study explores associations between Alpha, Delta, and Omicron variants of SARS-CoV-2 and surgical outcomes. METHODS: We conducted a retrospective analysis using the National COVID Cohort Collaborative database, which included patients who underwent selected major inpatient surgeries within eight weeks post-SARS-CoV-2 infection from January 2020 to April 2023. The viral variant was determined by the predominant strain at the time of the patient's infection. Multivariable logistic regression models explored the association between viral variants, COVID-19 severity, and 30-d major morbidity or mortality. RESULTS: The study included 10,617 surgical patients with preoperative COVID-19, infected by the Alpha (4456), Delta (1539), and Omicron (4622) variants. Patients infected with Omicron had the highest vaccination rates, most mild disease, and lowest 30-d morbidity and mortality rates. Multivariable logistic regression demonstrated that Omicron was linked to a reduced likelihood of adverse outcomes compared to Alpha, while Delta showed odds comparable to Alpha. Inclusion of COVID-19 severity in the model rendered the odds of major morbidity or mortality equal across all three variants. CONCLUSIONS: Our study examines the associations between the clinical and pathological characteristics of SARS-CoV-2 variants and surgical outcomes. As novel SARS-CoV-2 variants emerge, this research supports COVID-19-related surgical policy that assesses the severity of disease to estimate surgical outcomes.

Interval operative management in patients admitted with acute obstruction due to incarcerated paraesophageal hernia.

BACKGROUND: Acute incarcerated paraesophageal hernias (PEH) have historically been considered a surgical emergency. Emergent operations have a higher rate of morbidity and mortality compared to elective surgery. Our institution has adopted a strategy of initial conservative management in patients presenting with acute obstruction from an incarcerated PEH who are clinically stable. Patients are given at least 24 h for their symptoms to improve (selective nasogastric decompression). If symptoms resolve, contrast on an upper GI study passes to the small bowel, and liquids are tolerated, patients are discharged with planned interval repair. We sought to characterize the outcomes of this interval surgical strategy for incarcerated PEH. METHODS: A retrospective chart review was performed to identify patients admitted to a single institution between October 2019 and September 2023 with an incarcerated PEH. Patients taken directly to surgery within 24 h were excluded. RESULTS: A total of 45 patients admitted with obstruction from an incarcerated PEH were identified. Ten patients (22%) were taken urgently to surgery due to clinical instability and were excluded. Of the remaining 35 patients, 23 (66%) resolved their obstruction with conservative non-operative management and were offered planned interval PEH repair (successful conservative management). In the successful conservative management cohort, there was one unplanned readmission before interval PEH repair. Average time between discharge and repair was 25 days. Complication rates did not differ in those who failed and in those who had a successful conservative management result. The cumulative length of stay for those who succeeded in conservative management (including days for the interval surgery) was equivalent with those who underwent PEH repair during the index admission. CONCLUSION: A trial of conservative management in clinically stable patients with symptomatic incarcerated PEH appears to be safe and often avoids emergent repair without increasing perioperative complications or total days in the hospital.

Severity of Prior Coronavirus Disease 2019 is Associated With Postoperative Outcomes After Major Inpatient Surgery.

OBJECTIVE: To determine how the severity of prior history (Hx) of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection influences postoperative outcomes after major elective inpatient surgery. BACKGROUND: Surgical guidelines instituted early in the coronavirus disease 2019 (COVID-19) pandemic recommended a delay in surgery of up to 8 weeks after an acute SARS-CoV-2 infection. This was based on the observation of elevated surgical risk after recovery from COVID-19 early in the pandemic. As the pandemic shifts to an endemic phase, it is unclear whether this association remains, especially for those recovering from asymptomatic or mildly symptomatic COVID-19. METHODS: Utilizing the National COVID Cohort Collaborative, we assessed postoperative outcomes for adults with and without a Hx of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from infection to surgery were each used as independent variables in multivariable logistic regression models. RESULTS: This study included 387,030 patients, of whom 37,354 (9.7%) were diagnosed with preoperative COVID-19. Hx of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of respiratory failure. CONCLUSIONS: Impact of COVID-19 on postoperative outcomes is dependent on the severity of illness, with only moderate and severe disease leading to a higher risk of adverse outcomes. Existing perioperative policies should be updated to include consideration of COVID-19 disease severity and vaccination status.

Preoperative SARS-CoV-2 infection increases risk of early postoperative cardiovascular complications following noncardiac surgery.

As the coronavirus disease 2019 (COVID-19) pandemic progresses to an endemic phase, a greater number of patients with a history of COVID-19 will undergo surgery. Major adverse cardiovascular and cerebrovascular events (MACE) are the primary contributors to postoperative morbidity and mortality; however, studies assessing the relationship between a previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and postoperative MACE outcomes are limited. Here, we analyzed retrospective data from 457,804 patients within the N3C Data Enclave, the largest national, multi-institutional data set on COVID-19 in the United States. However, 7.4% of patients had a history of COVID-19 before surgery. When comorbidities, age, race, and risk of surgery were controlled, patients with preoperative COVID-19 had an increased risk for 30-day postoperative MACE. MACE risk was influenced by an interplay between COVID-19 disease severity and time between surgery and infection; in those with mild disease, MACE risk was not increased even among those undergoing surgery within 4 wk following infection. In those with moderate disease, risk for postoperative MACE was mitigated 8 wk after infection, whereas patients with severe disease continued to have elevated postoperative MACE risk even after waiting for 8 wk. Being fully vaccinated decreased the risk for postoperative MACE in both patients with no history of COVID-19 and in those with breakthrough COVID-19 infection. Together, our results suggest that a thorough assessment of the severity, vaccination status, and timing of SARS-CoV-2 infection must be a mandatory part of perioperative stratification.NEW & NOTEWORTHY With an increasing proportion of patients undergoing surgery with a prior history of COVID-19, it is crucial to understand the impact of SARS-CoV-2 infection on postoperative cardiovascular/cerebrovascular risk. Our work assesses a large, national, multi-institutional cohort of patients to highlight that COVID-19 infection increases risk for postoperative major adverse cardiovascular and cerebrovascular events (MACE). MACE risk is influenced by an interplay between disease severity and time between infection and surgery, and full vaccination reduces the risk for 30-day postoperative MACE. These results highlight the importance of stratifying time-to-surgery guidelines based on disease severity.

Robotic simulation: validation and qualitative assessment of a general surgery resident training curriculum.

BACKGROUND: The da Vinci skills simulation curriculum has been validated in the literature. The updated simulator, SimNow, features restructured exercises that have not been formally validated. The purpose of this study is to validate the SimNow resident robotic basic simulation curriculum. This study also consists of a qualitative assessment that gives greater insight into the learner's experience completing the robotic curriculum. METHODS: There were 18 participants in this study: 6 novices, 6 competent surgeons, and 6 expert surgeons. The curriculum comprised 5 exercises; participants completed three consecutive scored trials. Computer-derived performance metrics were recorded. The NASA Task Load Index survey was used to assess subjective mental workload. Subjects were asked a series of open-ended questions regarding their experience that were recorded and transcribed. Codes were identified using an inductive method, and themes were generated. RESULTS: Performance metrics were significantly different between novice versus competent and expert surgeons. There was no significant difference in any score metric between competent and expert surgeons. On average, overall score percentages for competent and expert surgeons were between 90.4 and 92.8% versus 70.5% for novices (p = 0.02 and p = 0.01). Expert surgeons perceived a higher level of performance completing the exercises than novice surgeons (15.8 vs. 45.8, p = 0.02). Participants noted a similar robotic experience, utilizing efficiency of motion and visual field skills. Participants agreed on exercise strengths, exercise weaknesses, and software limitations. Competent and expert surgeons were better able to assess the exercises' clinical application. CONCLUSIONS: The SimNow curriculum is a valid simulation training as part of a general surgery resident robotic curriculum. The curriculum distinguishes between novices compared to competent and expert surgeons, but not between competent and expert surgeons. Clinical training level does not affect the experience and mental workload using the robotic simulator, except for competent and expert surgeons' ability to better assess clinical application.

Implementation of a standardized multimodal pain regimen significantly reduces postoperative inpatient opioid utilization in patients undergoing bariatric surgery.

BACKGROUND: Routine opioid use in surgical patients has received attention given the opioid epidemic and a renewed focus on the dangers and drawbacks of opioids in the postoperative setting. Little is known about opioid use in bariatric surgery, especially in the inpatient setting. We hypothesize that a standardized opioid-sparing protocol reduces postoperative inpatient opioid use in bariatric surgery patients. METHODS: A retrospective cohort study was conducted of bariatric surgery patients at a single institution. From March to September 2019, a standardized intraoperative and postoperative opioid-sparing protocol was designed and implemented along with an educational program for patients regarding safe pain management. Inpatient opioid utilization in patients undergoing surgery in the preintervention phase between April and March 2019 was compared to patients from a postintervention phase of October 2019 to December 2020. Opioid utilization was measured in morphine milliequivalents (MME). RESULTS: A total of 359 patients were included; 192 preintervention and 167 postintervention. Patients were similar demographically. For all patients, mean age was 44.1 years, mean BMI 49.2 kg/m2, and 80% were female. Laparoscopic sleeve gastrectomy was performed in 48%, laparoscopic gastric bypass in 34%, robotic sleeve gastrectomy in 17%, and robotic gastric bypass in 1%. In the postintervention phase inpatient opioid utilization was significantly lower [median 134.8 [79.0-240.8] MME preintervention vs. 61.5 [35.5-150.0] MME postintervention (p < 0.001)]. MME prescribed at discharge decreased from a median of 300 MME preintervention to 75 MME postintervention (p < 0.001). In the postintervention phase, 16% of patients did not receive an opioid prescription at discharge compared to 0% preintervention (p < 0.001). When examining by procedure, statistically significant reductions in opioid utilization were seen for each operation. CONCLUSION: Implementation of a standardized intraoperative and postoperative multimodal pain regimen and educational program significantly reduces inpatient opioid utilization in patients undergoing bariatric surgery.

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD).

BACKGROUND: Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD. METHODS: Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS: The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss. CONCLUSION: Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Anatomic location and mechanism of hiatal hernia recurrence: a video-based assessment.

INTRODUCTION: Hiatal hernia recurrence following surgical repair is common. We sought to define the most common anatomic location and mechanism for hiatal failure to inform technical strategies to decrease recurrence rates. METHODS: Retrospective chart review and video analysis were performed for all recurrent hiatal hernia operations performed by a single surgeon between January 2013 and April 2020. Hiatal recurrences were defined by anatomic quadrants. Recurrences on both left and right on either the anterior or posterior portion of the hiatus were simply classified as 'anterior' or 'posterior', respectively. Three or more quadrants were defined as circumferential. Mechanism of recurrence was defined as disruption of the previous repair or dilation of the hiatus. RESULTS: There were 130 patients to meet criteria. Median time to reoperation from previous hiatal repair was 60 months (IQR19.5-132). First-time recurrent repairs accounted for 74%, second time 18%, and three or more previous repairs for 8% of analyzed procedures. Mesh had been placed at the hiatus in a previous operation in 16%. All reoperative cases were completed laparoscopically. Video analysis revealed anterior recurrences were most common (67%), followed by circumferential (29%). There were two with left-anterior recurrence (1.5%), two posterior recurrence (1.5%), and one right-sided recurrence. The mechanism of recurrence was dilation in 74% and disruption in 26%. Disruption as a mechanism was most common in circumferential hiatal failures. Neither the prior number of hiatal surgeries nor the presence of mesh at the time of reoperation correlated with anatomic recurrence location or mechanism. Reoperations in patients with hiatal disruption occurred after a shorter interval when compared to hiatal dilation. CONCLUSION: The most common location and mechanism for hiatal hernia recurrence is anterior dilation of the hiatus. Outcomes following techniques designed to reinforce the anterior hiatus and perhaps to prevent hiatal dilation should be explored.

The evolution of the general surgery resident operative case experience in the era of robotic surgery.

BACKGROUND: Robotic-assisted general surgery procedures are becoming commonplace, requiring more residency programs to establish training curricula for residents. Concerns exist regarding the impact this will have on surgical residents' operative case distribution in laparoscopic and open surgery. This study aimed to analyze the impact of a growing robotic operative case volume and established robotic surgery training curriculum on the general surgery resident operative experience. METHODS: The robotic surgery training curriculum at the Medical College of Wisconsin was established in 2017. ACGME operative case logs of residents from 2014 to 2020 were analyzed to determine resident participation in open, laparoscopic, and robotic cases. Case categories included alimentary tract, abdomen, endocrine, thoracic, pediatric, and trauma. A one-way analysis of variance (ANOVA) was used to analyze overall cases, as well as participation by case type, post-graduate year (PGY) level, resident role, and institution type. Statistical significance was defined as a p value < 0.05. RESULTS: Operative case logs from 77 residents were analyzed with a total of 34,757 cases: 59.3% open, 39.6% laparoscopic, and 1.1% robotic. There was no significant change in open or laparoscopic case volumes. However, there was a 3.4% increase in robotic cases, from 2014 to 2020 (p = 0.01), specifically in foregut (4.0%, p = 0.01), intestinal (1.6%, p = 0.03), and hernia (8.3%, p = 0.003) procedures. Academic (2.8%, p = 0.01) and veterans' hospital (2.0%, p = 0.01) institutions saw a significant increase in their residents' robotic cases. The only resident role with a significant increase in robotic cases was first assistant (8.0%, p = 0.004). There was no significant difference across PGY levels by surgical approach. CONCLUSIONS: This study highlights that the growth of robotic cases has not had a detrimental effect on the resident experience with open and laparoscopic cases. As robotic cases continually increase, the impact on laparoscopic and open case volumes must be monitored to ensure a well-balanced training experience.

Examining current patterns of opioid prescribing and use after bariatric surgery.

BACKGROUND: Evidence-based guidelines on the appropriate amount of opioid medications to prescribe following bariatric surgery are lacking. We sought to determine our current opioid-prescribing practices, patient utilization, and satisfaction with pain control following elective bariatric surgery. METHODS: A retrospective chart review and phone survey were conducted on patients who underwent laparoscopic or robotic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from April 2018 to March 2019 at a single academic medical center. Opioid medications were converted to morphine milligram equivalents provided (MMEs). RESULTS: In total, 192 patients met inclusion criteria. The median amount of opioid medication prescribed on discharge was 300 oral MMEs, although there was a significant difference between the MMEs prescribed to patients with and without chronic opioid therapy (median 300 MMEs opioid naïve vs. 375 MMEs chronic opioid therapy, p = 0.01). Significantly fewer SG patients required a refill of their opioid medication compared to RYGB (8.3% vs. 23.9%, p = 0.003). Of the 192 patients, 87 (45.3%) completed the phone survey. Fifty-six patients (64%) reported that they took half or less of the initially prescribed opioids. Of the patients with leftover medication, 36% reported that they did not dispose of the medication. Overall understanding of pain control options after surgery was significantly lower in patients who felt they were prescribed "too little" opioids (p = 0.01), patients requiring refills (p = 0.02), and patients who were not satisfied with their pain control (p = 0.02). CONCLUSION: There is a gap between the amount of opioid medication prescribed and taken by patients following bariatric surgery in our practice. Patients who were least satisfied with their pain control reported knowledge gaps about pain control options that were more significant than patients who were more satisfied. Future initiatives should focus on the reduction of opioids prescribed to bariatric surgery patients post-operatively and on opioid education for patients.

Transversus abdominis plane blocks for complex abdominal wall reconstruction decrease hospital length of stay compared to epidurals.

BACKGROUND: Complex abdominal wall reconstruction for ventral and incisional hernias can be quite painful with prolonged length of stay (LOS). There are a variety of options to manage post-operative pain after a ventral hernia repair, including epidural catheters, transversus abdominis plane (TAP) blocks, and intravenous narcotic pain medications (IVPM). We hypothesized that TAP blocks with liposomal bupivacaine decrease the LOS compared to epidurals and IVPM. METHODS: A retrospective review of all patients who underwent an open ventral hernia repair with retromuscular mesh between 2016 and 2020 was conducted. LOS was used as the primary outcome. Secondary outcomes included post-operative pain and 90-day post-operative complications. RESULTS: An epidural was used in 66 patients, a TAP block with liposomal bupivacaine in 18 patients, and IVPM in 11 patients. The epidural group was noted to have a significantly longer duration of surgery (251.11 vs. 207.94 min; P < 0.05) and larger area of mesh (461.85 vs. 338.17 cm2; P < 0.05) when compared to the TAP block group. Hospital LOS was significantly shorter for the TAP block group compared to the epidural group (4.22 vs. 5.62 days; P < 0.05). There were no differences in post-operative complications between the groups. The epidural group reported significantly lower post-operative day one (POD1) pain scores measured on a 10-point scale, compared to the IVPM and TAP block groups (5.00 vs. 6.91 vs. 7.50; P < 0.05). CONCLUSION: Patients who received a TAP block for post-operative pain management had a significantly shorter length of stay compared to those patients who received an epidural. While the TAP block group reported higher POD1 pain scores, they did not have a significant difference in post-operative complications. TAP blocks with liposomal bupivacaine should be considered for post-operative pain control in complex ventral hernia repairs.

The Impact of Hemoglobin A1c on Post-operative Outcomes in Bariatric Surgery Patients.

INTRODUCTION: Pre-operative hemoglobin (Hb) A1c levels ≥ 8% can lead to increased post-operative complications. In bariatric surgery patients, attaining a pre-operative HbA1c < 8% can be a challenge. The purpose of this study was to identify the association of pre-operative HbA1c on post-operative outcomes in bariatric surgery patients. MATERIAL AND METHODS: A retrospective chart review was conducted on diabetic patients (HbA1c ≥ 6.5%) who underwent primary bariatric surgery at a single institution between the years 2013 and 2019. Patients were divided into two groups based on their pre-operative HbA1c levels of < 8% and ≥ 8%. Univariate analyses were performed to determine an association between pre-operative HbA1c levels and post-operative outcomes. RESULTS: There were 351 primary diabetic bariatric surgery patients, 270 HbA1c <8%, and 81 HbA1c ≥ 8%. Procedure selection was significantly different between the HbA1c < 8% and HbA1c ≥ 8% group (49.3% sleeve, 50.4% bypass and 0.4% band versus 43.2% sleeve, 53.1% bypass and 3.7% band respectively, P < 0.04). There was no statistically significant difference in any 30-day post-operative outcome between the two groups. Post-operative HbA1c was significantly less in the HbA1c < 8% group at 3-6 month (6.0% ± 0.9 versus 7.4% ± 1.4, P <0.001) and 6-12 month (6.0% ± 1.1 versus 7.2% ± 1.4, P <0.001) follow-up. CONCLUSIONS: This study demonstrated no difference in post-operative outcomes of primary bariatric surgery patients based on a HbA1c cut-off of 8%. This highlights that bariatric surgery can be considered and safely performed in patients with a pre-operative HbA1c ≥ 8%.

Laparoscopic fundoplication for refractory GERD: a procedure worth repeating if needed.

BACKGROUND: Laparoscopic fundoplication is the current gold standard for medically refractory gastroesophageal reflux disease. Over a 10-year period following surgery, 5-10% of primary laparoscopic fundoplication patients undergo reoperative surgery. Our objective was to compare the symptomatic outcomes and morbidity of primary and reoperative fundoplication procedures. METHODS: This was a retrospective review of patients who underwent laparoscopic primary or reoperative fundoplication between 2011 and 2017. A single surgeon with a more than 10-year experience in reoperative foregut surgery performed all procedures. Patients in both groups completed the GERD health-related quality of life (GERD-HRQL) survey prior to surgery and postoperatively. Outcomes were reflected by the composite GERD-HRQL scores (0 to 50, with lower scores representing a better GERD-related quality of life), which were compared between groups postoperatively. Demographics, perioperative data, and complications were compared. Patient data were analyzed using Chi-Square tests and outcomes were analyzed using independent samples t tests and Mann-Whitney U tests. RESULTS: There were 136 primary and 82 reoperative fundoplications. Prior to surgery, GERD-HRQL scores were similar for primary and reoperative patients. Both groups experienced significant improvement in GERD-related quality of life at 2 years, although this improvement was greater in primary patients (8.7 ± 7.8 primary vs. 14.3 ± 13.6 reoperative, p = 0.02). Operative time and length of stay were longer following reoperative cases. The rate of moderate to severe 30-day complications requiring radiologic, endoscopic, or surgical intervention was similar (2.9% primary vs. 1.2% reoperative, p = 0.65). CONCLUSIONS: Patients who undergo reoperative fundoplication experience a significant improvement in their GERD-related symptoms, although not to the degree seen in primary antireflux surgery patients. Perioperative morbidity rates following reoperative and primary procedures can be similar in the hands of an experienced surgeon.

Ten-year trends in minimally invasive hernia repair: a NSQIP database review.

BACKGROUND: Utilization of minimally invasive techniques for ventral and inguinal hernia repairs continues to rise. The purpose of this study was to provide updates on national utilization trends and wound complications of minimally invasive versus open ventral and inguinal hernia repairs. METHODS: Data were accessed from the 2006 to 2017 National Surgical Quality Improvement Program database. All CPT codes that correlated to laparoscopic and open inguinal and ventral hernia repairs were queried. The total number of cases and wound complications, including superficial surgical site infection (SSI), deep SSI, organ space SSI, and wound dehiscence, was collected for each respective CPT code and compared for each year. IBM SPSS Statistics Software and Microsoft Excel were used to collect and analyze the data. RESULTS: Between 2009 and 2017, the percentage of minimally invasive inguinal hernia repairs increased from 23.1 to 37.8%, whereas the percentage of minimally invasive ventral hernias only increased from 31.5 to 36.6%. Open inguinal hernia repairs had a wound complication rate ranging from 0.60 to 0.74%, which was double the rate of minimally invasive repairs (0.24 to 0.49%) for nearly each respective year. Minimally invasive ventral hernia repairs had total wound complication rates ranging from 0.91 to 1.37%, whereas open ventral hernias had the highest total wound complication rates ranging from 5.07 to 6.26%. CONCLUSIONS: Over the last ten years, the utilization of minimally invasive inguinal and ventral hernia repair has increased by nearly two-fold. A larger proportion of this increase has been secondary to minimally invasive inguinal compared to ventral hernia repairs. Wound complications across all techniques remained stable or improved, and remained significantly less in the minimally invasive compared to open approaches. This study highlights the continued growth of minimally invasive techniques in hernia repair over the last decade.

Is that 'floppy' fundoplication tight enough?

BACKGROUND: Laparoscopic fundoplication is the treatment of choice for medically refractory gastroesophageal reflux disease (GERD). Surgeons seek to create a competent valve at the gastroesophageal junction (GEJ) but are careful to construct a 'floppy' fundoplication that is not too tight to minimize side effects. The endoscopic functional luminal-imaging probe (EndoFLIP®) uses impedance planimetry to assess the GEJ intraoperatively. We sought to determine if EndoFLIP variables are associated with symptomatic outcomes following fundoplication. METHODS: We conducted a retrospective review of prospectively maintained data on subjects who underwent primary laparoscopic fundoplication at a single institution between 2014 and 2018. All patients met standard indications for antireflux surgery. Minimum diameter (Dmin), cross-sectional area (CSA), intra-bag pressure, and distensibility index of the GEJ were obtained at 30 mL volumes. GERD Health Related Quality of Life (GERD-HRQL) surveys were administered pre- and postoperatively. Patients were excluded if they underwent fundoplication without EndoFLIP assessment or if they did not complete a postop GERD-HRQL survey. Receiver operating characteristic curves were used to determine if EndoFLIP measurements were correlated with symptomatic outcomes. RESULTS: Forty-three patients met inclusion criteria. The change in Dmin and CSA measures during fundoplication were associated with daily or more frequent heartburn at 6 or more months postop. A decrease in Dmin of 0.15 mm or less (AUC = 0.718, sensitivity: 71%, specificity: 69%) and a decrease in CSA of 1.5 mm2 or less (AUC = 0.728, sensitivity: 71%, specificity: 70%) were associated with severe heartburn. CONCLUSIONS: GEJ opening dynamics attained by EndoFLIP appear to be associated with symptomatic outcomes. When the Dmin and CSA do not decrease by a defined threshold, heartburn is more likely to be severe at 6 or more months postoperatively. This suggests that the fundoplication may not be tight enough to prevent persistent or recurrent GERD.

The relationship between gastroesophageal junction integrity and symptomatic fundoplication outcomes.

BACKGROUND: The majority of patients who undergo a laparoscopic fundoplication for gastroesophageal reflux disease (GERD) have a structural (hiatal hernia, shortened lower esophageal sphincter [LES]) or functional (weak LES) defect of the gastroesophageal junction (GEJ). We hypothesized that the symptomatic outcomes of fundoplication in patients with a competent GEJ prior to surgery are inferior to those with an incompetent GEJ. METHODS: This is a retrospective review of prospectively maintained data on subjects who underwent primary laparoscopic fundoplication (Nissen or Toupet) for medically refractory and confirmed GERD. Three esophageal manometry variables were used to determine GEJ competency: (1) hiatal hernia (normal = no hernia), (2) total lower esophageal sphincter length (normal ≥ 2.43 cm), and (3) lower esophageal sphincter pressure (normal = 15.0-43.7 mmHg). Patients in the competent group had normal values for all 3 variables. Symptomatic outcomes were assessed with the GERD Health-Related Quality of Life (HRQL) survey administered pre- and postoperatively, and then compared both intragroup, intergroup, and by procedure. RESULTS: A total of 78 patients met inclusion criteria-17 competent GEJ and 61 incompetent GEJ patients. GERD-HRQL scores improved in the incompetent cohort at all intervals out to 2 years postoperatively. GERD-HRQL improved in the competent cohort at 2 months, with no difference at 6 months or 2 years postoperatively compared to preoperative scores. Competent GEJ patients receiving a Nissen fundoplication had a higher rate of additional procedures (endoscopy with or without dilation, pH studies) following surgery to address recurrent or persistent GERD symptoms compared to Toupet. CONCLUSIONS: GERD patients with a competent GEJ report a lower GERD-HRQL with more frequent and severe reflux symptoms up to 2 years post-fundoplication. Competent GEJ patients receiving a Nissen fundoplication are more likely to have additional procedures to address symptoms following surgery. Surgeons should approach patients with a competent GEJ and medically refractory GERD with caution.

The impact of nausea on post-operative outcomes in bariatric surgery patients.

INTRODUCTION: The evaluation and treatment of post-operative nausea in bariatric surgery patients has not been standardized. In this patient population, nausea can have a significant impact on quality outcomes. The primary objective of this study was to determine the impact of nausea on post-operative outcomes in bariatric surgery patients. METHODS: A retrospective chart review was conducted of adult patients who underwent a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) between 2014 and 2017 at a single institution. Patients with post-operative nausea were identified. Post-operative nausea was defined as patients who had nausea that was documented by multiple providers, and which interfered with their oral intake. Demographic variables were identified for patients with and without documented nausea. Univariate analyses were performed to determine the impact of post-operative nausea on patients' length of stay, readmissions, reoperations, and overall complications. RESULTS: There were 449 primary bariatric surgery patients in the study period, 197 (43.9%) LRYGB and 252 (56.1%) LSG. Of these patients, 160 (35.6%) had documented post-operative nausea. Demographic factors that contributed to post-operative nausea included African-American race and undergoing a LSG (p = 0.004 and p = 0.01, respectively). Patients who underwent a LSG had a 2.0 times increased risk of post-operative nausea compared to LRYGB (p = 0.01). Patients with documented nausea had a statistically significant increased length of stay (2.4 ± 1.9 days vs. 1.6 ± 1.0 days; p ≤ 0.01). Documented nausea patients had an increased incidence of Emergency Department visits within 30 days post-operatively (p = 0.02). CONCLUSIONS: Post-operative nausea was more likely in patients who underwent a sleeve gastrectomy. Gastric bypass and sleeve gastrectomy patients with documented nausea had an increased length of stay and Emergency Department visits. These results highlight the need for a metric to more accurately measure post-operative nausea, as well as a standardized anti-emetic treatment pathway to improve quality outcomes.

Primary care providers' attitudes and knowledge of bariatric surgery.

BACKGROUND: Despite the increasing obesity prevalence among American adults, relatively few qualified patients proceed to bariatric surgery. Suggested explanations include referral barriers for weight loss management at primary care provider (PCP) visits. This study aims to assess the referral and practice patterns of PCPs treating patients with obesity. Our goal is to understand treatment barriers in order to implement targeted interventions that enhance quality of care. METHODS: A 39-question electronic survey was emailed to PCPs at a single academic institution with community physicians. Questions explored providers' demographics, referral patterns, and knowledge of pathophysiologic obesity mechanisms and bariatric surgery qualifications. Frequency and univariate analyses were performed and compared providers' demographics, positions, and BMIs between referring providers and non-referring providers. RESULTS: Of 121 surveys distributed, we achieved a 33.9% response rate (n = 41). 78.0% stated that > 15% of their patients in the preceding year were classified as obese. PCPs indicated initiating weight loss management conversations < 50% of the time with 48.8% of patients. Provider-identified barriers to discussing weight loss surgery included being unsure if patient's insurance would cover the procedure or if patients would qualify (24.4% vs. 19.5%). In addition, 43.9% of providers felt that the risks of bariatric surgery outweigh the benefits. CONCLUSION: Despite a large percentage of patients cared for by PCPs being classified as obese, few providers initiate discussions on weight loss options with potentially eligible surgical candidates. The barriers identified indicate an opportunity for improved education on patient qualifications, strategies for streamlining conversations and referrals, and reinforcement of the safety of surgical weight loss. Providers' desire for this education demonstrates an opportunity to work toward minimizing the referral gap by increasing patient conversations about these topics.