Increased bleeding risk with enoxaparin venothromboembolism prophylaxis compared with heparin in patients undergoing bariatric surgery.

BACKGROUND: Perioperative venothromboembolism (VTE) chemoprophylaxis is an established tenant of bariatric surgery; however, there is little comparative data to guide medication choice. The objective of this study was to determine if a change in VTE prophylaxis from heparin to enoxaparin was associated with differing rates of postoperative bleeding and VTE occurrence after bariatric surgery. METHODS: This retrospective cohort study included patients 18 years or older who underwent primary bariatric surgery (sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)) at a single institution between March 2012 and December 2021. Subcutaneous unfractionated heparin was utilized for VTE prophylaxis from March 2012 through February 2018 and then enoxaparin was used from March 2018 through December 2021. Postoperative bleeding was defined as requiring a blood transfusion or reoperation for bleeding within 30 days of surgery. Chi-square test was used to test for differences between groups. RESULTS: There were 2159 patients who underwent bariatric surgery with 1324 (61.3%) patients in the heparin group and 835 (38.7%) in the enoxaparin group. Overall, 1,503 (69.6%) patients underwent SG and 656 (30.4%) RYGB. There was no difference in the ratio of SG to RYGB between the heparin and enoxaparin groups. Most patients were female (n = 1709, 79.2%) with a median age of 43.2 years (interquartile range (IQR): 35.6-52.2), and median BMI of 44.9 (IQR: 40.9-50.5). Overall postoperative bleeding occurred more frequently in the enoxaparin group (n = 26, 3.1%) compared with the heparin group (n = 12, 0.9%) (p < 0.01). Additionally, reoperation for bleeding was more frequent with enoxaparin (enoxaparin 0.8% vs. heparin 0.2%, p = 0.04). There was no difference in VTE occurrence between the two groups (heparin: n = 14, 1.1%, enoxaparin: n = 7, 0.8% (p = 0.61)). CONCLUSIONS: An institutional change from heparin to enoxaparin for bariatric surgery perioperative VTE prophylaxis was associated with a significant increase in postoperative bleeding, with no difference in VTE complications.

Percutaneous Endoscopy and Image-guided Retrieval of Dropped Gallstones - A Case Series.

BACKGROUND: Recurrent abscesses can happen due to dropped gallstones (DGs) after laparoscopic cholecystectomy (LC). Recognition and appropriate percutaneous endoscopy and image-guided treatment options can decrease morbidity associated with this condition. MATERIALS AND METHODS: We report a minimally invasive endoscopy and image-guided technique for retrieval of dropped gallstones in a series of 6 patients (M/F=3/3; median age: 75.5 years [68 to 82]) presenting with recurrent or chronic intra-abdominal abscesses secondary to dropped gallstones. Technical success was defined as the visualization and retrieval of all stones. DGs were identified on pre-procedure imaging. Number of abscesses recurrence was 12 (1/6), 1 (3/6), and 0 (2/6) with a median interval of 2 months (1 to 21) between cholecystectomy and abscess development. RESULTS: Percutaneous endoscopy and fluoroscopy guidance were utilized in all cases. Technical success was achieved in 4 patients (66%). The median procedure time was 65.8 minutes (39 to 136). The median fluoroscopy time and dose were 12.6 min (3.3 to 67) and 234 mGy (31 to 1457), respectively. There were no intraprocedure and postprocedure complications. No abscess recurrence was reported among successful procedures during a median follow-up of 193 days (51 to 308). CONCLUSION: Percutaneous image and endoscopy-guided lithotripsy/lithectomy are safe and effective. This technique is a suitable alternative to open surgery for dropped gallstones. LEVEL OF EVIDENCE: Level 4, Case Series.

Development and evaluation of a laparoscopic common bile duct exploration simulator and procedural rating scale.

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE) is an effective, single-stage treatment for choledocholithiasis. However, LCBDE requires specific cognitive and technical skills, is infrequently performed by residents, and currently lacks suitable training and assessment modalities outside of the operating room. To address this gap in training, a simulator model for transcystic and transcholedochal LCBDE was developed and evaluated. METHODS: A procedure algorithm incorporating essential cognitive and technical steps of LCBDE was developed, along with a physical model to allow performance of a simulated procedure. Modified Objective Structured Assessment of Technical Skills (OSATS) rating scales were developed to assess performance on the model. Construct validity was assessed by comparing the performance of novices (residents and surgeons without LCBDE experience) versus experienced subjects (surgeons with previous LCBDE experience). Concurrent validity was assessed by comparing scores from the LCBDE scales to those from the standard OSATS scale. Internal consistency and interrater reliability were assessed by comparing performance scores assigned by three independent raters. RESULTS: Sixteen novices and five experienced subjects performed simulated procedures, with novices scoring lower than experienced subjects on both transcystic (20 ± 3 vs. 33 ± 2 [possible score range, 0-45], p < 0.001) and transcholedochal (25 ± 8 vs. 42 ± 3 [possible score range, 0-53], p < 0.001) rating scales. Scores on the rating scales correlated significantly with scores from the standard OSATS scale. Internal consistency and interrater reliability of the LCBDE rating scales were favorable. CONCLUSIONS: The LCBDE simulator is a low-cost yet realistic physical model that allows performance and evaluation of technical skills required for LCBDE. The LCBDE rating scales show evidence of construct validity, concurrent validity, internal consistency, and interrater reliability. Use of the LCBDE model and associated rating scales allows procedure-specific feedback for trainees and could be used to improve current training.

Complications and Readmissions Associated with First Assistant Training Level Following Elective Bariatric Surgery.

BACKGROUND: Little is known regarding the variation in training level and potential clinical impact of the first assistant in bariatric surgery. We describe the postoperative 30-day complications and readmissions following elective bariatric procedures by training level of the first assistant. METHODS: The ACS-MBSAQIP database was queried to identify patients who underwent elective sleeve gastrectomy, Roux-En-Y gastric bypass, duodenal switch, band placement, and revision from 2015 to 2016. Patients were divided into cohorts based on training level of the first assistant (attending, fellow, resident, physician assistant/nurse practitioner, none). Outcomes included 30-day death or serious morbidity (DSM) and readmission. Multivariable logistic regression models, adjusting for patient and procedure characteristics, were estimated to examine differences in outcomes by first assistant training level. RESULTS: Of 410,535 procedures performed between 2015 and 2016, the training level of the first assistant included 21.3% attending, 8.7% fellow, 16.5% resident, 37.6% PA/NP, and 15.9% none. Operative time was significantly longer in the fellow and resident first assistant cohorts when compared with all other cohorts. Overall rates of 30-day DSM were low, ranging from 3.2 to 3.8%, while 30-day readmission rates ranged from 5.1 to 5.9%. Following adjustment for patient characteristics and type of procedure, first assistant training level had no significant impact on DSM or readmission. CONCLUSIONS: Variation in training level of the first assist during bariatric surgery had no influence on DSM or readmissions. This provides reassurance that the inclusion of a wide range of first assistants in bariatric procedures does not negatively impact patient outcomes.

Minimally invasive approaches to incisional hernia repairs.

Incisional hernias are a common problem following abdominal surgery, occurring when the intraabdominal contents protrude through a defect created in the abdominal wall. Several advances in the last several decades have resulted in improved outcomes for repairing these hernias. Initially, the advent of prosthetic material allowed the abdominal wall to be closed without tension. The utilization of laparoscopic techniques decreased hospital stays and wound complications. Advances in mesh technology have also aided in treatment strategies and options. However, the perfect mesh has yet to be invented. Further investigation and collaboration are required to create a material that is stable, does not alter the mechanics of the abdominal wall, is resistant to infection, and promotes adequate tissue ingrowth without adhesion or fistula formation. This review describes patient selection, preoperative preparation, mesh selection, surgical techniques, and common complications of minimally invasive approaches to incisional hernias.

Post-Operative Complications and Readmissions Associated with Smoking Following Bariatric Surgery.

BACKGROUND: The link between smoking and poor postoperative outcomes is well established. Despite this, current smokers are still offered bariatric surgery. We describe the risk of postoperative 30-day complications and readmission following laparoscopic sleeve gastrectomy and laparoscopic Roux-En-Y gastric bypass in smokers. METHODS: The National Surgical Quality Improvement Program database was queried to identify patients who underwent laparoscopic sleeve gastrectomy and Roux-En-Y gastric bypass from 2012 to 2017. Patient outcomes were compared based on smoking status. Primary outcomes included 30-day readmission and death or serious morbidity. Secondary outcomes included wound and respiratory complications. Multivariable logistic regression was used to determine the association between smoking status and measured outcomes. RESULTS: Of the 133,417 patients who underwent bariatric surgery, 12,424 (9.3%) were smokers. Smokers more frequently experienced readmission (4.9% v 4.1%, p < 0.001), death or serious morbidity (3.8% v 3.4%, p = 0.019), wound complications (2% v 1.4%, p < 0.001), and respiratory complications (0.8% v 0.5%, p < 0.001). The likelihood of death or serious morbidity (OR 1.13, 95% CI 1.01-1.26), readmission (OR 1.21, 95% CI 1.10-1.33), wound (OR 1.44, 95% CI 1.24-1.68), and respiratory complications (OR 1.69, 95% CI 1.34-2.14) were greater in smokers. The adjusted ORs remained significant on subgroup analysis of laparoscopic sleeve gastrectomy and Roux-En-Y gastric bypass patients, with the exception of death or serious morbidity in laparoscopic Roux-En-Y gastric bypass (OR 1.04, 95% CI 0.89-1.24). CONCLUSIONS: Smokers undergoing bariatric surgery experience significantly worse 30-day outcomes when compared with non-smokers. There should be a continued emphasis on perioperative smoking cessation for patients being evaluated for bariatric surgery.

Five-year follow-up after laparoscopic Roux-en-Y gastric and partial ileal bypass for treatment of morbid obesity and uncontrolled hyperlipidemia.

BACKGROUND: Morbid obesity is associated with significant co-morbid illnesses and mortality. Hyperlipidemia is strongly associated with atherosclerosis and cardiovascular disease. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a proven and effective procedure for the treatment of morbid obesity and its related co-morbid illnesses. In a randomized prospective clinical trial, partial ileal bypass showed sustained control of hyperlipidemia and reduced comorbidities. Given risks of surgery, pharmacologic agents are the current primary therapy for hyperlipidemia. However, a morbidly obese patient with medically refractory hyperlipidemia may benefit from a combined laparoscopic Roux-en-Y gastric bypass and partial ileal bypass. We are describing the first case of a totally laparoscopic approach. METHODS: A 56-year-old female patient with morbid obesity (BMI 45.2 kg/m(2)) and medically refractive hyperlipidemia underwent a combined LRYGB and partial ileal bypass in 2002. She was continuously followed for 5 years for weight profile, hyperlipidemia, post-operative complications, and morbidity. RESULTS: Five-year follow-up of the patient showed sustained excess body weight loss. Her lipid profile has approached normal ranges with less medication. She experienced no comorbidities related to surgery or hyperlipidemia. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass and partial ileal bypass may be the best option for the patient who has morbid obesity and medically refractory hyperlipidemia and should be considered for select patients.

Retrievable inferior vena cava filters in high-risk patients undergoing bariatric surgery.

BACKGROUND: Placement of retrievable inferior vena cava filters (rIVCF) may be beneficial in high-risk morbidly obese patients undergoing bariatric procedures. Patients with a previous history of venous thromboembolism (VTE) are at high risk for postoperative deep venous thrombosis (DVT) and pulmonary embolism (PE). METHODS: A prospective database of bariatric surgery patients was studied from April 2003 to May 2007. A total of 791 patients underwent bariatric procedures, of which 30 (4%) had a previous history of VTE. These patients underwent preoperative venous duplex and concurrent placement of a rIVCF. Patient demographics and clinical outcomes were examined. RESULTS: Thirty patients (12 (40%) men) had a mean age of 49 +/- 8 years and a mean body mass index of 50 +/- 8 kg/m(2). Sixteen patients (53%) underwent laparoscopic Roux-en-Y gastric bypass, ten (33%) underwent laparoscopic adjustable gastric band, and four (14%) underwent open Roux-en-Y gastric bypass. Mean operative time, including rIVCF placement, was 162 +/- 66 minutes. All patients had successful rIVCF placement with standard perioperative chemoprophylaxis. Twenty-nine patients (97%) had a follow-up ultrasound on postoperative day (POD) 19 +/- 25. Six patients (21%) had recurrent DVT. Twenty-seven patients (90%) underwent a follow-up venogram, and four patients (15%) had significant thrombus in the rIVCF. Retrieval was successful in 21 patients (70%). Nine patients (30%) did not undergo retrieval: four had significant thrombus in the filter, four had an above-knee DVT, and one due to technical reasons. We observed one complication with a DVT at the access site and no PE or mortality. CONCLUSIONS: We observed a 21% incidence of recurrent DVT and 15% incidence of thrombus in the IVCF, yet no PE occurred. IVCF retrieval was successful in 70% with one complication. Concurrent IVCF placement is safe, feasible, and an effective preventative measure in high-risk morbidly obese patients. We recommend the use of rIVCFs in conjunction with standard VTE prophylaxis in this patient population.

Laparoscopic gastrostomy and jejunostomy.

BACKGROUND: The percutaneous/endoscopic gastrostomy (PEG) has rapidly replaced the surgical gastrostomy as the preferred route for enteral access. In patients who are not candidates for a PEG, we prefer a laparoscopic gastrostomy to an open gastrostomy. Similarly, in patients who require a surgical jejunostomy, we prefer a laparoscopic approach. Minimally invasive techniques have several advantages over the standard open surgery. The purpose of this article is to review the indications, various techniques, and outcomes of laparoscopic gastrostomy and jejunostomy tubes. DATA SOURCES: Medline search from 1959-2002. CONCLUSIONS: The PEG remains the procedure of choice for placement of a gastrostomy. Laparoscopic gastrostomy is an excellent choice for patients who are not candidates for a PEG. Similarly, laparoscopic jejunostomy is an excellent choice for patients who require enteral access, but have contraindications to a gastrostomy tube. Placement of laparoscopic gastrostomy andjejunostomy tubes can be safely performed, and the success and complication rates of these procedures compare favorably with those of the corresponding open surgical procedure. Laparotomy is rarely needed to place enteral feeding tubes. Cost analysis has shown that laparoscopic procedures are similar to open procedures.

A simulator-based resident curriculum for laparoscopic common bile duct exploration.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) remains an underused treatment for choledocholithiasis, likely in part because of a lack of exposure to the procedure during surgery residency. In this study, we implemented a resident LCBDE curriculum using a previously validated procedural simulator. METHODS: Senior surgery residents underwent a curriculum consisting of deliberate practice using the LCBDE simulator. Residents performed a simulated transcystic and transcholedochal LCBDE before and after completing the curriculum, which were rated by three faculty. Passing scores were determined using an Angoff method. RESULTS: Ten residents participated. For transcystic LCBDE, all 10 residents failed the pretest. Assessment scores improved after the curriculum (20 ± 4 vs 41 ± 2; scale 0-45, P < .01), and all 10 residents passed the posttest. For transcholedochal LCBDE, all 10 residents failed the pretest. Transcholedochal scores improved after the curriculum (27 ± 6 vs 46 ± 4; scale 0-53, P < .01). Eight residents passed the initial posttest and two failed because they sutured the t-tube into the choledochotomy closure. Both underwent remedial training and passed a retest. Resident confidence in performing LCBDE clinically improved for both transcystic and transcholedochal approaches. CONCLUSION: This curriculum improved the ability of surgery residents to perform both transcystic and transcholedochal LCBDE on a procedural simulator.

Laparoscopic gastrectomy for cancer.

Gastric cancer is common worldwide. Tumor location and disease stage differ between Asian and Western countries. Western patients often have higher BMIs and comorbidities that may make laparoscopic resections challenging. Multiple trials from Asian countries demonstrate the benefits of laparoscopic gastrectomy for early gastric cancer while maintaining equivalent short-term and long-term oncologic outcomes compared with open surgery. The outcomes of laparoscopy seem to offer equivalent results to open surgery. In the United States, laparoscopic gastrectomy remains in its infancy and is somewhat controversial. This article summarizes the literature on the epidemiology, operative considerations and approaches, and outcomes for laparoscopic gastrectomy.

General surgery training without laparoscopic surgery fellows: the impact on residents and patients.

BACKGROUND: To evaluate resident case volume after discontinuation of a laparoscopic surgery fellowship, and to examine disparities in patient care over the same time period. METHODS: Resident case logs were compared for a 2-year period before and 1 year after discontinuing the fellowship, using a 2-sample t test. Databases for bariatric and esophageal surgery were reviewed to compare operative time, length of stay (LOS), and complication rate by resident or fellow over the same time period using a 2-sample t test. RESULTS: Increases were seen in senior resident advanced laparoscopic (Mean Fellow Year = 21 operations vs Non Fellow Year = 61, P < 0.01), esophageal (1 vs 11, P < .01) and bariatric volume (9 vs 36, P < .01). Junior resident laparoscopic volume increased (P < 0.05). No difference in LOS or complication rate was seen with resident vs fellow assistant. Operative time was greater for gastric bypass with resident assistant (152 ± 51 minutes vs 138 ± 53, P < .05). CONCLUSION: Discontinuing a laparoscopic fellowship significantly increases resident case volume in laparoscopic surgery. Operative time for complex operations may increase in the absence of a fellow. Other patient outcomes are not affected by this change.

A single institution's experience with single incision cholecystectomy compared to standard laparoscopic cholecystectomy.

BACKGROUND: The advent of single incision laparoscopic surgery has brought renewed attention to cholecystectomy due to the promise of improved cosmesis and less parietal trauma. Small series have demonstrated the feasibility of single incision laparoscopic cholecystectomy (LC). Our series adds to the literature by demonstrating a variety of ancillary techniques that may be employed to perform single incision LC safely, and compares our early experience with that of our standard LC. METHODS: We performed a retrospective chart review of patients who underwent single incision LC between February 2008 and April 2009. These patients were compared with an equal number of randomly selected patients undergoing LC during the same period. We identified 25 attempted single incision LC, which were included in our analysis. RESULTS: Single incision LC was successfully performed in 21 patients, with only 4 patients requiring conversion to LC. No patients in either group had acute cholecystitis. The critical view of safety was documented in 20 of 21 patients undergoing a successful single incision LC compared with all patients undergoing LC. Operative time was significantly longer in the single incision group. Complications were minor and comparable between the 2 groups. In 9 patients (43%), a suture passer helped to retract the gallbladder. In 8 patients (38%), 1 or 2 Prolene sutures placed by means of a Keith needle helped to retract the gallbladder over the liver and/or helped to retract the infundibulum. In 2 patients, ≥1 supplemental 5-mm port was utilized. In 5 patients (24%), no supplementary retraction was necessary. CONCLUSION: Single incision LC is technically more challenging than LC, but can be performed safely by experienced laparoscopic surgeons with results comparable with LC.

Revisional bariatric surgery at a single institution.

BACKGROUND: Bariatric surgery, although safe, can have long-term complications that require revision. Our series illustrates the spectrum of primary procedures, indications for surgery, and strategies for revision. METHODS: The study was a retrospective chart review. Sixty-three patients were identified. Of specific interest were complications and percentage of excess weight loss (EWL) during the follow-up period. RESULTS: Eighteen patients had a previous vertical banded gastroplasty (VBG), 26 had a Roux-en-Y gastric bypass (RYGB), 18 had a laparoscopic adjustable gastric banding (LAGB), and 1 had a jejunal-ileal bypass. All VBG patients were revised to RYGB. Seventeen RYGB patients were revised with RYGB. Eight LAGB patients were revised with RYGB. Eight RYGB patients had placement of LAGB. Two LAGB patients were revised with LAGB because of a slipped band. Eight LAGB patients had the band removed. The morbidity rate was 30% with a major morbidity rate of 11%. There were 2 leaks, neither required reoperation. Other major complications included 3 pneumonias, 2 reoperations, and 2 intra-abdominal abscesses. There were no mortalities. In the 15 patients who had conversion of VBG to RYGB, the mean EWL was 50%, with 60% of patients achieving more than 50% EWL. In the 10 patients who had revision of their RYGB, the mean EWL was 51%, with 60% of patients achieving more than 50%. In the 6 patients who had revision of LAGB to RYGB, the mean EWL was 39%, with 33% of patients achieving more than 50% EWL. In the 8 patients who had LAGB after RYGB the mean EWL was -2%, with 0% of patients achieving more than 50%. CONCLUSIONS: Revisional surgery is effective, although complication rates are higher than primary bariatric surgery. The type of initial and revisional procedure affects EWL.