Impact of fellowship training on the learning curve for laparoscopic gastric bypass.

BACKGROUND: We have previously shown that the learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGBP) is approximately 75 cases. Patients have worse outcomes during the learning curve. Our aim was to evaluate the impact of fellowship training on outcomes during a surgeon's early experience with LRYGBP. METHODS: The study population consisted of the first 75 consecutive LRYGBP operations attempted by two laparoscopic surgeons, one with laparoscopic gastric bypass fellowship training (Group A) and one without laparoscopic bypass fellowship training (Group B). OUtcome parameters included mortality, major perioperative complications, operative time, and conversion to an open operation. RESULTS: Age, BMI, and gender distribution were similar in both groups. Operative time was significantly longer in Group B (189 min. vs 122 min., P<0.05). Conversion to an open procedure occurred uncommonly in both groups (3%). Major complications occurred more frequently in Group B (13% vs 8%, P=NS). In addition, the complications in Group B were more severe, resulting in 2 deaths. No deaths occurred in Group A. CONCLUSION: Laparoscopic bypass fellowship training improves perioperative outcomes during a surgeon's early experience with LRYGBP.

Short-term results of laparoscopic gastric bypass in patients with BMI > or = 60.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been shown to be safe and effective. Little information is available about the subgroup of patients with BMI > or = 60. The goal of this study was to evaluate the feasibility and safety of LRYGBP for patients with BMI > or = 60. METHODS: The study consisted of the first 300 attempted LRYGBPs performed by one surgeon (HJS). This population was analyzed as 2 groups of patients: those with BMI < 60 and those with BMI > or = 60. Outcome variables included mortality, complications, conversion, and operative time. RESULTS: Of the first 300 LRYGBP patients, 261 had BMI < 60 and 39 had BMI > or = 60. Age, comorbidity rate, and gender distribution were similar in both BMI groups. Conversion rates were < 3% in both groups. Mean operative time for the BMI > or = 60 group was 156 minutes vs 139 minutes in the lighter group (P = 0.04). Major complications occurred more commonly in the BMI > or = 60 group (10% vs 6%) but this difference was not significant. The types of complications differed between the 2 groups, with infectious complications and gastrointestinal leak occurring more frequently in the heavier group. The mortality rate was higher in the heavier group (5% vs 0.4%, P = 0.055). CONCLUSION: LRYGBP is feasible for patients with BMI > or = 60. Our data suggest that these patients are at a higher risk for GI leak, postoperative infection, and death.

An assessment of the severity of recurrent appendicitis.

BACKGROUND: This study examines the clinical characteristics of patients who developed recurrent appendicitis after previous nonoperative management of perforated appendicitis. METHODS: Retrospective chart review was performed, and data from the recurrent and initial episode of appendicitis were collected. RESULTS: In all, 237 patients from 1989 to 2001 were managed nonoperatively for perforated appendicitis and 32 (14%) were readmitted for recurrent appendicitis. Median white blood cell count at recurrence was 9.5 (interquartile range [IQR]: 6.6 to 13.2] versus 13.1 [IQR: 10.8 to 16.1] at initial presentation (P = 0.002). Maximum temperature was 98.6 degrees F [IQR: 98.2 to 100.5] at recurrence versus 100.3 degrees F [IQR: 99.5 to 101.5] (P = 0.008). Median time for intravenous antibiotics use was 3 [IQR: 3 to 7] days at recurrence versus 6 [IQR: 4 to 8] days initially (P = 0.01). Inpatient stay was also shorter; median length was 6 [IQR: 3 to 8] days compared with 7 [IQR: 5 to 9] days at initial presentation (P = 0.02). CONCLUSIONS: Patients managed nonoperatively for perforated appendicitis who later developed recurrent appendicitis exhibited a milder clinical course at recurrence. Elective interval appendectomy may be reserved until a recurrent episode.

Body lift: an account of 200 consecutive cases in the massive weight loss patient.

BACKGROUND: The epidemic of obesity in the United States has led to a rapid increase in the number of bariatric procedures performed over the past several years. The dramatic changes to the torso following massive weight loss are only partially addressed by routine procedures such as abdominoplasty and liposuction. Circumferential body lifts or simultaneous abdominoplasty, thigh, and buttock lifts are becoming the method of choice for treating the postbariatric condition. In this article, the authors review the senior author's experience of 200 body lifts with massive weight loss individuals. METHODS: The charts of 200 consecutive body lift patients were reviewed for complications and other variables. The preoperative markings, current surgical technique, and postoperative care are described. The patients were classified into three types according to their body mass index at the time of surgery. Type I individuals had a body mass index less than 28, type II individuals had a body mass index between 28 and 32, and type III individuals had a body mass index greater than 32. RESULTS: Type I and II patients in many instances achieved a nearly ideal body contour. Type II and III individuals also had a significant functional and aesthetic improvement but were more likely to have complications. The overall complication rate was 50.0 percent. The most frequent complications were skin dehiscence and seroma formation at 32.5 percent and 16.5 percent, respectively. CONCLUSIONS: The body lift very effectively addresses the functional and aesthetic concerns of the massive weight loss patient. Careful patient selection and education are essential to a good outcome.