Does intraoperative endoscopy decrease complications after bariatric surgery? Analysis of American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Intraoperative endoscopy (IOE) has been proposed to decrease serious complications following bariatric surgeries such as leaks, bleeding, and stenosis. Such complications can lead to sepsis and eventually can be fatal. We aim to compare major postoperative complications in patients with and without IOE. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program database years 2011 till 2016 were used to identify laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) patients. We compared outcomes of IOE and non-IOE using bivariate and multivariate analysis. Thirty-day outcomes included sepsis, organ space infection, unplanned reoperations, unplanned readmissions, prolonged hospital stay, bleeding, and mortality. RESULTS: Out of 62,805 cases of LSG and 50,047 cases of LRYGB, 17.9%, and 19.7% had IOE, respectively. Endoscopy-assisted LSG was associated with a decrease in sepsis [0.37% vs. 0.21%, adjusted odds ratio (AOR) = 0.55 (0.36, 0.84)], unplanned reoperation [0.58% vs. 0.38%, AOR = 0.61 (0.44, 0.85)], prolonged hospital stay [14.9% vs. 14.0%, AOR = 0.87 (0.82, 0.92)], and composite complications [1.43% vs. 1.17%, AOR = 0.78 (0.65, 0.94)]. Outcomes after LRYGB were similar in both groups, except for decreased prolonged hospital stay with IOE [22.4% vs. 20.6%, AOR = 0.89 (0.84, 0.94)]. CONCLUSIONS: IOE is generally underutilized in baraitric procedures. IOE is associated with decreased risk of postoperative complications particularly sepsis, unplanned reoperations, prolonged hospital stay, and composite complications after LSG; and hospital stay after LRYGB. Large multicenter prospective studies are needed to explore the benefits of IOE in bariatric surgery, particularly the intermediate or long-term benefits.

Bariatric Evaluation Through AI: a Survey of Expert Opinions Versus ChatGPT-4 (BETA-SEOV).

BACKGROUND: Recent advancements in artificial intelligence, such as OpenAI's ChatGPT-4, are revolutionizing various sectors, including healthcare. This study investigates the use of ChatGPT-4 in identifying suitable candidates for bariatric surgery and providing surgical recommendations to improve decision-making in obesity treatment amid the global obesity epidemic. METHODS: We devised ten patient scenarios, thoughtfully encompassing a spectrum that spans from uncomplicated cases to more complex ones. Our objective was to delve into the decision-making process regarding the recommendation of bariatric surgery. From July 29th to August 10th, 2023, we conducted a voluntary online survey involving thirty prominent bariatric surgeons, ensuring that there was no predetermined bias in the selection of a specific type of bariatric surgery. This survey was designed to collect their insights on these scenarios and gain a deeper understanding of their professional experience and background in the field of bariatric surgery. Additionally, we consulted ChatGPT-4 in two separate conversations to evaluate its alignment with expert opinions on bariatric surgery options. RESULTS: In 40% of the scenarios, disparities were identified between the two conversations with ChatGPT-4. It matched expert opinions in 30% of cases. Differences were noted in cases like gastrointestinal metaplasia and gastric adenocarcinoma, but there was alignment with conditions like endometriosis and GERD. CONCLUSION: The evaluation of ChatGPT-4's role in determining bariatric surgery suitability uncovered both potential and shortcomings. Its alignment with experts was inconsistent, and it often overlooked key factors, emphasizing human expertise's value. Its current use requires caution, and further refinement is needed for clinical application.

The Effect of Intraoperative Dexmedetomidine Versus Morphine on Postoperative Morphine Requirements After Laparoscopic Bariatric Surgery.

BACKGROUND: Dexmedetomidine is an α2 receptor agonist with sedative and analgesic properties. During bariatric surgery, its use may reduce postoperative opioid requirements, reduce their side effects, and improve quality of recovery. The aim of this prospective randomized controlled trial was to compare the effect of dexmedetomidine bolus and infusion versus morphine bolus given prior to the end of laparoscopic bariatric surgery. METHODS: Sixty morbidly obese patients (BMI > 40 kg m-2) aged 18 to 60 years, undergoing laparoscopic sleeve gastrectomy, received morphine sulfate (bolus 0.08 mg kg-1 followed by a saline infusion) (group M, n = 30) or dexmedetomidine (loading dose of 1 µg kg-1 followed by 0.5 µg kg-1 h-1) (group D, n = 30) 30 min before the end of surgery. Data collected included morphine consumption in the post-anesthesia care unit (PACU) (primary outcome) and at 24 h, pain intensity, nausea, heart rate, blood pressure, vomiting, sedation, and quality of recovery. RESULTS: There was no significant difference in morphine consumption in the PACU (group D 12.2 ± 5.44 mg, group M 13.28 ± 6.64 mg, P = 0.54) or at 24 h (group D 40.67 ± 24.78 mg, group M 43.28 ± 27.79 mg, P = 0.75); when accounting for intraoperative morphine given group M had significantly higher morphine consumption when compared to group D (23.48 ± 6.22 mg vs. 12.22 ± 5.54 mg, respectively, P < 0.01). Group D patients had more cardiovascular stability. CONCLUSIONS: Dexmedetomidine given prior to end of laparoscopic sleeve gastrectomy provides the same level of postoperative analgesia as morphine with better hemodynamic profile.

Life-threatening liver laceration with arterial hemorrhage complicating percutaneous treatment of hepatic hydatid cyst.

We present a 76-year-old woman known to have a large right hepatic lobe hydatid cyst which recurred twice after surgical excision. CT-guided percutaneous alcohol ablation was conducted to sclerose the cyst, but the procedure was complicated by parenchymal liver laceration and active arterial hemorrhage from a branch of the right hepatic artery. Bleeding was controlled by both endovascular and surgical interventions. Liver laceration with arterial hemorrhage is a rare not previously reported serious complication of percutaneous treatment of hepatic hydatid cyst that may be potentially life-threatening.

Comparison of Outcomes Between Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in a Lebanese Bariatric Surgical Practice.

PURPOSE: Long-term studies on the outcomes of bariatric surgery are still limited in the Middle East. The aim of this study is to compare the outcomes of laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) up to 5 years of follow-up. MATERIALS AND METHODS: A retrospective analysis of patients who underwent LRYGB and LSG was performed. The primary outcome was weight loss. Postoperative complications, operative time, and hospital length of stay were secondary outcomes. RESULTS: Four hundred patients underwent primary LSG and 175 patients underwent LRYGB between 2008 and 2013. Follow-up rates at 5 years were around 60%. Percent total weight loss was similar after 3, 4, and 5 years in both groups, averaging around 28%. Mean percentage of excess weight loss (%EWL) at 5 years was 72.0 ± 31.0% in the LSG group vs. 63.0 ± 21.0% in the LRYGB group (p = 0.03). Patients undergoing LRYGB had a significantly longer operative time as well as a longer hospital stay. No significant difference was found in the rates of short- and long-term complications between the two groups. However, patients undergoing LRYGB were more likely to develop small intestinal obstruction and iron-deficiency anemia. CONCLUSIONS: Both LSG and LRYGB result in satisfactory weight loss within 5 years. Patients' comorbidities and potential risks must be included in the choice of the appropriate bariatric procedure. LSG appears to give durable weight loss with less risk of major long-term complications.

Increased adverse outcomes after laparoscopic sleeve gastrectomy in older super-obese patients: analysis of American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has become the most popular bariatric operation over the last decade. Extreme obesity and increasing age have been generally associated with higher risks of complications after bariatric surgery. The postoperative risk for complications after SG has not been previously presented according to simultaneous grouping of body mass index (BMI) and age. OBJECTIVE: We aim to explore the association of age and BMI in determining the postoperative risk of SG from a national perspective. SETTING: The American College of Surgeons National Surgical Quality Improvement Program database. METHODS: We analyzed patient characteristics and operative outcomes of the 2010 to 2013 SG cohort available in the American College of Surgeons National Surgical Quality Improvement Program (N = 21,131). Patients were grouped based on age and BMI: young-obese (N = 10,291; <50 yr, BMI <0 kg/m2; reference group), young-super-obese (N = 3594; <50 yr and BMI ≥50 kg/m2), older-obese (N = 5636; ≥50 yr, BMI <0 kg/m2), and older-super-obese (N = 1610; ≥50 yr, BMI ≥50 kg/m2). Composite morbidity and/or mortality (M&M) was used as the primary outcome and risk-adjusted odds ratios (AOR[M&M]) were derived by logistic regression. M&M was a composite of surgical site, renal, neurologic, cardiac, thromboembolic, respiratory, septic and bleeding complications, unplanned readmissions, prolonged stay, and death. RESULTS: Overall operative mortality was low (.1%) but significantly worse in older-super-obese patients (.37%; P = .005). M&M rates were lowest in young-obese (5.8%), similarly worse in young-super-obese (7.0%) and older-obese (7.0%), and highest for older-super-obese (10.1%; P < .001). After comprehensive covariate risk adjustment, the composite M&M outcome after SG was significantly increased (42%) only in older-super-obese patients (AOR = 1.42 [1.16-1.73]), while older age alone (AOR = 1.09 [.94-1.25]) and super obesity alone (AOR = 1.09 [.93-1.28]) did not. CONCLUSIONS: Analysis of the American College of Surgeons National Surgical Quality Improvement Program showed that super obesity is associated with increased complications in older patients undergoing SG. Older-super-obese patients should be appropriately counseled about increased SG perioperative risks within the context of expected long-term benefits.

Correction to: Comparison of Early Morbidity and Mortality Between Sleeve Gastrectomy and Gastric Bypass in High-Risk Patients for Liver Disease: Analysis of American College of Surgeons National Surgical Quality Improvement Program.

The authors regret that some of the article text, which was in the original manuscript and was intended for and addressed to the reviewers during the review process of this article, was mistakenly overlooked during the proofs stage and remains in the published article.

Comparison of Early Morbidity and Mortality Between Sleeve Gastrectomy and Gastric Bypass in High-Risk Patients for Liver Disease: Analysis of American College of Surgeons National Surgical Quality Improvement Program.

INTRODUCTION: Chronic liver disease is prevalent in obese patients presenting for bariatric surgery and is associated with increased postoperative morbidity and mortality (M&M). There are no comparative studies on the safety of different types of bariatric operations in this subset of patients. OBJECTIVE: The aim of this study is to compare the 30-day postoperative M&M between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-Y-gastric bypass (LRYGB) in the subset of patients with a model of end-stage liver disease (MELD) score ≥ 8. METHODS: Data for LSG and LRYGB were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from years 2012 and 2013. MELD score was calculated using serum creatinine, bilirubin, INR, and sodium. Postoperative M&M were assessed in patients with a score ≥ 8 and compared for the type of operation. This was followed by analysis for MELD subcategories. Multiple logistic regression was performed to adjust for confounders. RESULTS: Out of 34,169, 9.8% of cases had MELD ≥ 8 and were included. Primary endpoint, 30-day M&M, was significantly lower post-LSG (9.5%) compared to LRYGB (14.7%); [AOR = 0.66(0.53, 0.83)]. Superficial wound infection, prolonged hospital stay, and unplanned readmission were more common in LRYGB. M&M post-LRYGB (30.6%) was significantly higher than LSG (15.7%) among MELD15-19 subgroup analysis. CONCLUSION: LRYGB is associated with a higher postoperative risk than LSG in patients with MELD ≥ 8. The difference in postoperative complications between procedures was magnified with higher MELD. This suggests that LSG might be a safer option in morbidly obese patients with higher MELD scores, especially above 15.

Gastric bypass reduces biochemical cardiac risk factors.

BACKGROUND: Coronary artery disease (CAD) is the leading cause of death in the United States, with obesity as a leading preventable risk factor for CAD. Certain biochemical markers have demonstrated strong prediction for cardiovascular events. We hypothesized that in addition to weight reduction, gastric bypass will also induce a salutary effect on the biochemical cardiac risk factors. METHODS: At a single academic institution, from 2003 to 2004, we measured the biochemical cardiac risk factors in gastric bypass patients preoperatively and at 3, 6, and 12 months postoperatively. These risk factors included total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein cholesterol, total cholesterol/HDL cholesterol ratio, triglyceride/HDL cholesterol ratio, triglycerides, lipoprotein A, high-sensitivity C-reactive protein, and homocysteine. The data were analyzed using the Wilcoxon signed rank test. RESULTS: The mean age of the 356 patients was 43 years; 84% were women; the mean body mass index was 47 kg/m(2); 33% were diabetic; 50% were hypertensive; 23% were taking lipid-lowering medications; and 2% had known CAD. Significant improvement occurred in the biochemical cardiac factors from preoperatively to 12 months. The beneficial changes were as follows: total cholesterol, 192 mg/dL preoperatively to 166 mg/dL at 12 months; HDL cholesterol, 46 mg/dL preoperatively to 54 mg/dL at 12 months; low-density lipoprotein, 125 mg/dL preoperatively to 88 mg/dL at 12 months; total cholesterol/HDL cholesterol ratio, 4 preoperatively to 3 at 12 months; triglyceride/HDL cholesterol ratio, 3 preoperatively to 2 at 12 months; triglycerides, 133 mg/dL preoperatively to 92 mg/dL at 12 months; lipoprotein A, 14 mg/dL preoperatively to 13 mg/dL at 12 months; high-sensitivity C-reactive protein, 8 mg/L preoperatively to 1 mg/L; and homocysteine, 10 mumol/L preoperatively to 8 mumol/L at 12 months. CONCLUSIONS: The results of our study have shown that gastric bypass significantly improves all biochemical markers of CAD risk, particularly C-reactive protein, which had an 80% reduction. As a result, gastric bypass decreases the cardiac risk by both weight loss and advantageous alterations of biochemical cardiac risk factors.

Concomitant hiatal hernia repair with laparoscopic sleeve gastrectomy is safe: analysis of the ACS-NSQIP database.

BACKGROUND: Gastroesophageal acid reflux disease (GERD) is prevalent after laparoscopic sleeve gastrectomy (LSG), a common bariatric surgical procedure worldwide. Some studies have suggested that concomitant hiatal hernia repair (HHR) during LSG reduces the risk of GERD, but this has not been substantiated. Little is known about the safety of adding an HHR in this setting. The present study aims to compare 30-day morbidity and mortality and length of hospital stay between patients undergoing LSG alone and those undergoing LSG with HHR. METHODS: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify patients who underwent LSG procedures alone or with concomitant HHR between 2010 and 2014. Univariate and multivariate analyses of 30-day morbidity and mortality and length of hospital stay were performed. RESULTS: Between 2010 and 2014, 32,581 patients underwent LSG. Of those, 4687 (14.4%) underwent concomitant HHR. No significant differences in 30-day mortality; overall morbidity; reoperation; sepsis; and wound, cardiac, respiratory, and renal complications were found between the 2 study groups on univariate and multivariate analyses. Length of hospital stay, risk of thromboembolic events, and blood transfusions were lower in the LSG+HHR group, even on multivariate analysis. CONCLUSIONS: Concomitant HHR at the time of LSG is not associated with increased risk of 30-day mortality or major morbidity. However, the effectiveness of this additional procedure should be assessed using long-term data on the resolution of GERD symptoms after LSG.

Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy with Concomitant Hiatal Hernia Repair: an Unresolved Question.

PURPOSE: The effectiveness of the concomitant repair of hiatal hernia (HHR) during laparoscopic sleeve gastrectomy (LSG) in reducing gastroesophageal reflux disease (GERD) symptoms is still unclear. The aim of this study is to assess the effect of concomitant HHR on postoperative GERD symptoms in our patient population. MATERIALS AND METHODS: A retrospective review of patients who underwent LSG with or without HHR between 2011and 2014 was performed. Pre- and postoperative GERD symptoms were assessed at different time intervals until a maximum of 2 years after the surgery. RESULTS: The study included 165 patients; 76 (46%) underwent LSG with concomitant HHR (group A) while the rest underwent only LSG (group B). Baseline GERD complaints were more prevalent in group A (61.8 vs 41.6%, p = 0.04), in which 44 patients (57.9%) had evidence of hiatal hernia on preoperative EGD. In the remaining 32 patients, it was diagnosed intraoperatively. GERD symptoms did not significantly differ between the two groups after years 1 and 2. GERD remission was observed in 21.3% of the 76 patients who underwent concomitant HHR (group A) and in 29.7% of those who did not (group B) while new-onset GERD symptoms were reported in 12 patients (41.4%) in group A and in 24 patients (46.2%) in group B. CONCLUSIONS: Routine HHR at the time of LSG does not show an improvement in GERD symptoms. More prospective studies are needed to clarify the role of the routine dissection, identification, and repair of concomitant hiatal hernia during LSG.

Concomitant Removal of Gastric Band and Gastric Bypass: Analysis of Outcomes and Complications from the ACS-NSQIP Database.

BACKGROUND: Conversion of laparoscopic adjustable gastric banding (LGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) is an established procedure. However, multiple reports have indicated higher morbidity and mortality rates associated with this operation, especially when performed as a single-staged procedure. PURPOSE: We sought to compare mortality and morbidity of LRYGB vs. LRYGB with concomitant gastric band removal (LRYGB/LGBR). METHODS: Data from the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database was obtained for the time period of 2008 to 2014 using CPT codes for LRYGB and LGBR. Sepsis was the primary outcome measure with overall morbidity as a secondary outcome. Bivariate and multivariate analyses were carried out using SAS (Statistical Analysis System). RESULTS: During the study period, 64,866 patients had primary LRYGB and 1212 had LRYGB/LGBR. On bivariate analyses, mean operative time was lower for patients undergoing LRYGB rather than LRYGB/LGBR (132.88 ± 56.29 vs. 177.72 ± 70.21 min, p < 0.001). There was no statistically significant difference in the rate of postoperative mortality (0.16 vs. 0.08 %, p > 0.999), sepsis (0.78 vs. 0.74 %, p = 0.87), or other postoperative outcomes such as return to the operating room, wound infection, and venous thromboembolism. The odds ratio (OR) for sepsis remained not significant (OR = 0.74; 95 % confidence interval (CI) = (0.38-1.45)) after multivariate analysis. CONCLUSION: LRYGBP/LGBR is not associated with a higher morbidity and mortality compared to LRYGB alone. The data implies that a one-step revisional procedure is appropriate when converting a failed gastric band to LRYGB.

Long-Term Outcomes of Roux-en-Y Gastric Bypass Conversion of Failed Laparoscopic Gastric Band.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) carries a high rate of failure and reoperation. Laparoscopic conversion of failed LAGB to Roux-en-Y gastric bypass (RYGB) has been shown to be safe and feasible, but long-term follow-up data is still limited. OBJECTIVES: The aim of this study is to evaluate the safety and effectiveness of RYGB after failed LAGB in our patient population. SETTING: The setting was the University Hospital, Beirut, Lebanon. METHODS: Using a prospectively collected database, we retrospectively reviewed data of patients who underwent LAGB revision to RYGB at our institution between 2006 and 2014. RESULTS: A total of 58 patients underwent RYGB after failed LAGB in our institution between 2006 and 2014. Of those, 20 patients (34.5%) had concomitant band removal while the rest underwent a two-stage RYGB after a mean of 30 months after band removal. A follow-up was achieved in 84.5, 82, 83, 95, and 76% of patients at 1, 2, 3, 4, and 5 years after RYGB. Percentage of excess weight loss (%EWL) was 62.8, 68.1, 64.2, 63.8, and 61.3% at 1, 2, 3, 4, and 5 years, respectively, while percentage of total weight loss (%TWL) was 28.4, 30.7, 29.4, 28.9, and 28.6% at the corresponding time periods. The most common short-term complications were abscesses/leaks (5.2%) while the most common long-term complications were symptomatic gallstones necessitating laparoscopic cholecystectomy (5.2%), incisional hernias (5.2%), and small-bowel obstruction (3.4%). No surgery-related mortality was recorded. CONCLUSIONS: RYGB is a safe procedure with favorable weight loss outcomes at 5 years and can be considered a good rescue procedure after failed LAGB.

Safety of concomitant cholecystectomy at the time of laparoscopic sleeve gastrectomy: analysis of the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: The indication and safety of concomitant cholecystectomy (CC) during bariatric surgical procedures are topics of controversy. Studies on the outcomes of CC with laparoscopic sleeve gastrectomy (LSG) are scarce. OBJECTIVES: To assess the safety and 30-day surgical outcomes of CC with LSG. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database 2010 to 2013. Univariate and multivariate analyses were used. RESULTS: Between 2010 and 2013, 21,137 patients underwent LSG; of those 422 (2.0%) underwent CC (LSG+CC), and the majority (20,715 [98%]) underwent LSG alone. Patients in both groups were similar in age, sex distribution, baseline weight, and body mass index. The average surgical time was significantly higher, by 33 minutes, in the LSG+CC cohort. No differences were noted between the groups with regard to overall 30-day mortality and length of hospital stay. CC increased the odds of any adverse event (5.7% versus 4.0%), but the difference did not reach statistical significance (odds ratio 1.49, P = .07). Two complications were noted to be significantly higher with LSG+CC, namely bleeding (P = .04) and pneumonia (P = .02). CONCLUSION: CC during LSG appears to be a safe procedure with slightly increased risk of bleeding and pneumonia compared with LSG alone. When factoring the potential risk and cost of further hospitalization for deferred cholecystectomy, these data support CC for established gallbladder disease.

Concurrent gastric bypass and repair of anterior abdominal wall hernias.

BACKGROUND: Many patients seeking surgical treatment for morbid obesity present with anterior abdominal wall hernias. Although principles of hernia repair involve a tension-free repair with the use of prosthetic mesh, there is concern about the use of mesh in gastric bypass surgery due to potential contamination with the contents of the gastrointestinal tract and resultant mesh infection. We report our series of patients undergoing Roux-en-Y gastric bypass (RYGBP) and simultaneous anterior abdominal wall hernia repair. METHODS: All patients who underwent simultaneous RYGBP surgery and anterior abdominal wall hernia repair were reviewed. RESULTS: 12 patients underwent concurrent RYGBP and anterior wall hernia repair. There were 5 women and 7 men with average age 54.9 +/- 8.5 years (range 35 to 64) and average body mass index (BMI) 50.4 +/- 10.3 kg/m(2) (range 38 to 70). Two open and 10 laparoscopic RYGBP operations were performed. Nine patients (75%) underwent incisional hernia repairs and 3 patients (25%) underwent umbilical hernia repair concurrent with gastric bypass. Average size of defect was 14.7 +/- 13.4 cm(2). One patient had primary repair and 11 patients had prosthetic mesh repair: polypropylene in 3 patients (25%) and polyester in 8 patients (67%). With a 14.1 +/- 9.3 month follow-up, there have been no mesh infections and 2 recurrences, one in the patient who underwent primary repair and one in a patient repaired with polyester mesh but with two previous failed incisional hernia repairs. CONCLUSION: Concurrent RYGBP and repair of anterior abdominal wall hernias is safe and feasible. In order to optimize success, tension-free principles of hernia repair with the use of prosthetic mesh should be followed since no mesh infections occurred in our series.

Orogastric tube complications in laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Recent national efforts have focused on improving patient safety in surgical procedures including examining adverse events. An adverse event in laparoscopic Roux-en-Y gastric bypass (LRYGBP) which has not received much scrutiny involves orogastric tube complications during gastric pouch formation. METHODS: Retrospective review was conducted of all LRYGBPs (n=727) performed by 5 surgeons over 5 years at 2 institutions. Cases with intraoperative orogastric tube (OGT) related complications (n=9) were identified. RESULTS: 9 patients (1.2%) had preventable orogastric tube-related complications. Mean patient demographics were as follows: age 47 years, female 56%, pre-op BMI 52 kg/m(2), co-morbidities 3.5 and mortality 0%. 7 of 9 patients' cases were complicated by stapling of an orogastric tube during gastric pouch formation. The remaining 2 patients had complications involving suturing of the Levacuator tube during gastrojejunostomy formation. All complications required gastric pouch or anastomotic revision. 2 patients required conversion to an open procedure, 2 required re-operation for anastomotic leak, and 1 had respiratory failure and prolonged hospital stay. CONCLUSION: Orogastric tube complications can occur during laparoscopic RYGBP, but are seldom reported and can be associated with significant morbidity. Treatment options are dependent upon the situation. More importantly, prevention strategies must include constant communication with the anesthesiologist and removal or manipulation of an OGT prior to stapling or suturing, use of large bore OGTs for increased visual or tactile recognition, retraction of the OGT proximal to the anastomosis during gastrojejunal construction and employing alternatives to esophageal temperature probes (i.e. Foley temperature probes).

Management of gallbladder disease after sleeve gastrectomy in a selected Lebanese population.

BACKGROUND: Patients with morbid obesity are at a higher risk of developing gallstones after bariatric surgery. Studies on the incidence of symptomatic gallstones necessitating cholecystectomy after laparoscopic sleeve gastrectomy (LSG) are limited in the Middle East. OBJECTIVES: This study aims to assess the incidence of cholecystectomy after LSG during a 1-year follow-up and to evaluate potential risk factors and potential prophylactic measures. SETTING: Two university hospitals in Lebanon. METHODS: A prospectively maintained bariatric database of 361 patients who underwent primary LSG between January 2009 and December 2012 at the American University of Beirut Medical Center and Makassed General Hospital was reviewed. Data included demographics, preoperative weight, weight at 6 and 12 months postoperatively, and incidence of postoperative symptomatic cholelithiasis. RESULTS: A total of 319 patients (88.4%) were followed up at 1 year. Twenty-four (7.5%) had symptomatic gallstones and underwent cholecystectomy after LSG. Mean postoperative time for the development of symptomatic gallstones was 426 days (range, 91-1234 days). Patients who developed symptomatic gallstones were significantly younger (29.8 versus 34.8, P = 0.008) but comparable to patients who did not undergo cholecystectomy in terms of other baseline characteristics and weight loss results at 1 year. Out of the obesity-related co-morbidities, hypertension was the only co-morbidity associated with post-LSG cholecystectomy (OR = 3.35, P = 0.036) after multivariate adjustment. CONCLUSION: The incidence of symptomatic gallstones requiring cholecystectomy after LSG in our study cohort was higher than that of the general population (7.5%). This incidence does not warrant prophylactic cholecystectomy or routine pre- or postoperative ultrasounds.

Concomitant removal of gastric band and sleeve gastrectomy: analysis of outcomes and complications from the ACS-NSQIP database.

BACKGROUND: Conversion of adjustable gastric band to laparoscopic sleeve gastrectomy (LSG) is feasible, but multiple reports have indicated higher morbidity and staple line leak rates when this is performed as a single-stage procedure. The objective of this study is to compare the safety profile and outcomes of LSG with concomitant gastric band removal (LSG/GBR) versus LSG using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP). METHODS: Using the ACS-NSQIP database (2010-2012), LSG cases were identified using Current Procedural Terminology (CPT) code 43775 and concomitant LSG/LGBR using CPT code 43775+(43772 or 43774). Baseline patient characteristics and perioperative variables including postoperative mortality and morbidity rates were retrieved. The primary endpoint was sepsis within 30 days. Bivariate and multivariate analyses were carried out. RESULTS: During the study period, 11,189 (96.9%) patients had LSG and 357 (3.1%) had LSG/GBR for a total of 11,546 patients. On bivariate analyses, the rate of sepsis was higher after LSG/GBR (1.68% versus .58%; P = .022), and the mean operative time was longer (124.6±52.3 versus 98.6±49.0 min; P<.001). There was no statistically significant difference in the rate of postoperative mortality (.28% versus .08 %; P = .27) or that of other outcomes such as return to the operating room, wound infection, or venous thromboembolism. After multivariate analysis, the odds of developing postoperative sepsis remained significantly higher for patients undergoing LSG/GBR compared with LSG alone (odds ratio [OR] 3.32; confidence interval [CI] 1.41-7.84; P = .006). CONCLUSION: LSG/GBR can be performed with low morbidity and mortality. However, this procedure carries a higher rate of postoperative sepsis.

Incidental finding of gastrointestinal stromal tumors (GISTs) during laparoscopic gastric bypass.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for <1% of all neoplasms of the alimentary tract. GISTs have not been previously reported in association with gastric bypass surgery. METHODS: This study is a retrospective review of 517 consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP) between January 2002 and August 2005. Incidental intraoperative findings of gastric GIST were recorded. RESULTS: 4 patients (0.8%) were noted to have GISTs intra-operatively upon inspection of the stomach prior to partition. All GISTs were identified along the anterior aspect of the upper third of the stomach and were removed by laparoscopic wedge excision with at least a 1 cm margin. The 4 tumors were <1 cm in size and all had immunohistochemical analysis positive for CD117 (c-kit). None of the tumors had determinants of malignant behavior (high mitotic rate, necrosis or pleomorphism). CONCLUSION: We have found a 0.8% incidence of gastric GISTs in our morbidly obese patients undergoing LRYGBP. All of these small, benign tumors were found incidentally in asymptomatic patients. This case series underscores the need to fully assess the stomach prior to gastric pouch formation. Without the ability to grossly determine the benign or malignant behavior of GISTs, all these tumors found incidentally should be resected with adequate margins.

Laparoscopic Roux-en-Y gastric bypass: differences in outcome between attendings and assistants of different training backgrounds.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a significant learning curve. We hypothesize that differences in surgeon and assistant training backgrounds may significantly impact outcomes during the learning curve. METHODS: Retrospective analysis was performed on patients undergoing LRYGBP at an academic medical center between January 1998 and August 2003. Operations were performed by surgeons with different training backgrounds: without formal laparoscopic fellowship (S1, n=95); immediately following laparoscopic fellowship (S2, n=100); and with extensive laparoscopic experience post fellowship (S3, n=88). First assistants were attendings, fellows, or residents. The variables analyzed included demographics, operative times, estimated blood loss (EBL), rate of conversion, length of stay (LOS), ICU stay, re-operation/re-admission rate, and complications. Results were analyzed by ANOVA and Fisher's exact test. RESULTS: There were significant differences among surgeons of different training backgrounds in EBL, LOS, rate of ICU admission, and intraoperative and late complications rates. Among assistants of different training levels, there were significant differences in operative time, EBL, intraoperative complication rates and re-admission rates. CONCLUSIONS: Differences in training background of the surgeons resulted in significant differences in outcome, including EBL, LOS, ICU admission and intraoperative and late complication rates. Lower assistant training levels significantly impacted efficiency through lengthened operative times and increased EBL, as well as increased intraoperative complication rates and re-admission rates. Our results suggested that participating in a laparoscopic fellowship and operating with a more experienced assistant may improve outcomes during the learning curve.