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A novel 15mm trocar port closure technique to prevent incision complications after bariatric surgery
Poster Presentations / Surgery for Obesity and Related Diseases 12 (2016) S76–S232
laparoscopic Roux-en-Y gastric bypass (RNYGB), 20 patients underwent open RNYGB, 290 patients underwent laparoscopic sleeve gastrectomy. 80.3% of patients were females, 19.7% males. Mean BMI was 47.5 (SEM 8.1). Seven patients had a history of PE (0.9%); 10 patients had a history of DVT requiring therapy (1.3%). 744 patients reported being functionally independent prior to surgery (99.7%), 2 were partially dependent (0.3%). Of the 746 patients undergoing bariatric surgery at our institution, anticoagulation for 5 patients (0.67%) was initiated for presumed/ confirmed DVT/PE. Of these 5 patients, 0 had PE; 3 had confirmed DVTs. As compared with the other MBSAQIP sites, our site has a lower incidence of VTE (0.67% vs 1.0%). Eight patients (1.1%) developed postoperative bleeding complications within 30 days postoperatively. No mortality occurred. Conclusions: The use of moderately higher dose of lower molecular weight heparin (LMWH) with longer duration for DVT/VTE prophylaxis used in our institution seems to be safe, effective and with a low complication rate.
A5090
EFFECT OF A MOBILE HEALTH PATIENT ENGAGEMENT TOOL FOR POSTOPERATIVE CARE OF BARIATRIC SURGERY PATIENTS Caterina Masino1; Timothy Samuel1,2; M. Carolina Jimenez1,2; Sanjeev Sockalingam1; Timothy Jackson2; Fayez Quereshy2; Mugs Zweerman2; Danae McKenzie2; Allan Okrainec2; 1UHN Toronto Western Hospital, Toronto Ontario; 2UHN- Toronto Western Hospital, Toronto Ontario Background: Engaging patients in self-care processes can increase self-awareness in their recovery process. This may lead to earlier recognition of postoperative concerns, prompting patients to seek appropriate medical help earlier. The objective of this pilot study was to develop a mobile app to help patients manage their recovery at home after bariatric surgery. Methods: A total of 116 bariatric surgery patients installed the mobile app on their device at hospital discharge. Participants were asked to complete a daily health check for 30 days using the app. The app generated alerts and instructions based on the patient's symptoms. A patient education library provided selfcare information. Outcome measures included app usage and alert compliance. Readmission to hospital was compared to a historical control group. Results: There were no significant differences between the intervention and control groups on age, sex, BMI, and bariatric surgical procedure. Patients had high app engagement during week one (75.9%) and maintained an average rate of 49.5% over the 30 days. The most frequently captured postoperative patient concerns were no bowel movement and gas pain. Patients highly recommended the app (98%) and 77% favorably rated the app in helping to manage their recovery. There was no significant difference in readmission rates between groups. Conclusion: Patient engagement with a mobile app following bariatric surgery was highest during the first week, with most recommending use of the app in the future. Mobile app use did not decrease readmission rates as part of this pilot study.
S113
A5091
OUTCOMES FOLLOWING LAPAROSCOPIC CONVERSION OF ROUX-EN-Y GASTRIC BYPASS TO BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH Dustin Bermudez; Peter Ng; Lindsey Sharp; University of North Carolina / Rex Hospital, Raleigh NC Background: The Roux en Y gastric bypass has been performed for decades. Many patients experience weight regain or never achieve their ideal body weight following surgery. The biliopancreatic diversion with duodenal switch (BPD-DS) is a more malabsorptive procedure than the gastric bypass as greater than 60% of the small bowel is bypassed whereas only 10-15% is bypassed with a gastric bypass. The BPD-DS has been shown to have more robust weight loss and better long-term weight loss when compared to the gastric bypass. Concern exists regarding vitamin deficiencies. Conversion of a gastric bypass to a duodenal switch is one revisional operation that is offered to bypass patients with weight recidivism and persons with persistent obesity postoperatively. Methods: 18 patients underwent elective laparoscopic revisions of Roux en Y gastric bypass procedures to a biliopancreatic diversion with duodenal switch (BPD-DS). Electronic health records were reviewed retrospectively. Postoperative nutrition labs were performed that included vitamin A, D, E, K, thiamin, folate, B12, ferritin, PTH, copper, zinc and selenium levels. Results: No mortalities were seen postoperatively. One patient experienced a leak at the gastrogastrostomy that was treated with endoscopic stent placement. Two patients had early postoperative small bowel obstructions. Mean initial BMI was 46.56 kg/m2. Mean BMI change was 10.08 kg/m2. Mean excess weight loss was 44.44%. One patient underwent surgery for recalcitrant ulcer while all others had it performed for weight recidivism. Three patients had resolution of hypertension while one had remission of diabetes mellitus. Postop follow-up time varied between 1 and 21 months. Three patients were lost to follow-up after a month. Vitamin deficiencies were found in 6 patients. Two patients had vitamin D deficiencies, two had zinc deficiencies, two had vitamin K deficiencies and one patient had vitamin A deficiency. Conclusions: For those patients who have had Roux en Y gastric bypass and postoperatively develop weight recidivism or do not achieve adequate weight loss a conversion to a duodenal switch may be a viable option. Complications overall were minimal. Vitamin deficiencies were fairly mild and treated with oral supplements. This patient group is marked by a propensity for non-compliance. Thorough preoperative preparation with nutritional and psychological counseling will be crucial to ensure success. Further study is needed to look at long-term outcomes.
A5092
A NOVEL 15MM TROCAR PORT CLOSURE TECHNIQUE TO PREVENT INCISION COMPLICATIONS AFTER BARIATRIC SURGERY Wah Yang Guangzhou; Jingge Yang; Cunchuan Wang; First Affiliated Hospital of Jinan Unive, Guangzhou Guangdong Province
S114
Poster Presentations / Surgery for Obesity and Related Diseases 12 (2016) S76–S232
Background: Trocar site pain and hernias after laparoscopic bariatric surgeries is common because of the thick, fatty preperitoneal space and elevated intra-abdominal pressure. The incidence ranged from 0.14 to 8 % in literature. Hand suturing is timeconsuming and may be unsuccessful at times, and trocar site closure devices are expensive and are not well-suited for use in morbidly obese patients. Moreover, most of these devices are not available in market in the developing countries like China. Objectives: We describe a novel convenient peritoneal closure technique which could prevent these complications without using expensive wound closure devices. Methods: We retrospectively analyzed the clinical data in all laparoscopic bariatric surgeries (sleeve gastrectomy and gastric bypass) performed by a single surgeon. The technique: An elongated stainless steel hook was completely penetrating the thick abdominal wall to the fascial layer at an optimal distance from the wound and suture with the help of a grasper. Pain score, analgesic usage, cosmetic satisfaction and other clinical outcomes were evaluated. Results: This technique was performed in 179 cases (83 males, 96 females; 113 LRYGB, 66 LSG ) with mean body mass index (BMI) 40.3⫾10.4 kg/m2. 17 cases (9.5%) required additional analgesic in the post-operative period, no significant difference between the two procedures (P¼0.603). Cosmetics results were satisfactory with average score 9.3 out of 10. There were no port site related complications on clinical examination during two-year follow up. Conclusion: This peritoneal closure technique offers an economic, safe and quick alternative to suture the trocar wound defects after bariatric surgeries. In addition it reduces the incidence of port site pain and hernias and enhances recovery.
A5093
SAFETY AND EFFECTIVENESS OF ANTERIOR FUNDOPLICATION SLEEVE GASTRECTOMY IN PATIENTS WITH SEVERE REFLUX Rena Moon; Andre Teixeira; Muhammad Jawad; Orlando Regional Medical Center, Orlando Florida Introduction: Laparoscopic sleeve gastrectomy (LSG) has become a popular bariatric surgery in recent years. However, it has been linked to worsening of, or newly developed gastroesophageal reflux disease (GERD) in the postoperative period. Our practice has published a case report, and presented in many meetings about the techniques of performing anterior fundoplication at the time of sleeve gastrectomy to prevent worsening of GERD symptoms. The purpose of this study is to determine the safety and effectiveness of anterior fundoplication sleeve gastrectomy (AF-SG) in patients with reflux. Material and Methods: We prospectively collected data on 30 sleeve gastrectomy patients who concurrently underwent anterior fundoplication between July 2014 and March 2016. Patients were selected when they complained of severe reflux prior to the procedure. Each patient was interviewed for the GERD score questionnaire (scaled severity and frequency of heartburn, regurgitation, epigastric pain, epigastric fullness, dysphagia, and cough) before and 4 months after the procedure. Results: Our patients consisted of 26 females and 4 males with a mean age of 49.9⫾1.8 years (range, 28-63). They had a preoperative body mass index of 42.5⫾5.5 kg/m2 (range, 33.3-58.4),
and 66.7% (n¼20) of these patients underwent hiatal hernia repair as well. Preoperatively, patients had a mean heartburn score of 6.7⫾3.6 (range, 0-12), regurgitation 5.9⫾4.2 (range, 0-12), epigastric pain 1.6⫾2.6 (range, 0-9), epigastric fullness 2.5⫾3.1 (range, 0-12), dysphagia 0.9⫾2.3 (range, 0-9), and cough score of 0.8⫾1.7 (range, 0-6). Mean preoperative GERD score was 17.6⫾8.6 (range, 6-36) in these patients.Postoperatively, patients were interviewed with the same questionnaire approximately 4 months after the procedure. Patients had a mean heartburn score of 1.6⫾3.4 (range, 0-12), regurgitation 0.8⫾1.7 (range, 0-8), epigastric pain 0.6⫾1.7 (range, 0-8), epigastric fullness 0.9⫾2.4 (range, 0-8), epigastric fullness, 0.2⫾1.2 (range, 0-6), and cough score of 0. Mean postoperative GERD score dropped down to 4.1⫾6.0 (range, 0-28), and the difference was statistically significant (po0.01). No patients required readmission or reoperation due to the procedure within 30 days. Conclusion: Anterior fundoplication sleeve gastrectomy (AF-SG) may be a safe and effective alternative in obese patients with severe reflux who wants to undergo sleeve gastrectomy.
A5094
LAPAROSCOPIC VERSUS ROBOTIC CHOLECYSTECTOMY IN THE OBESE POPULATION: IS THERE A PREFERRED APPROACH? John Mitko1; William Main2; Lala Hussain3; Katherine Meister2; George Kerlakian2; Kevin Tymitz2; 1Good Samaritan Hospital, Cincinnati OH; 2Division of General Surgery, TriHealth, Cincinnati OH; 3TriHealth Hatton Research Institute, Cincinnati OH Introduction: Since the early 1990's, laparoscopic cholecystectomy (LC) has been considered the gold standard treatment for gallbladder disease. Laparoscopic surgery can be challenging in
laparoscopic Roux-en-Y gastric bypass (RNYGB), 20 patients underwent open RNYGB, 290 patients underwent laparoscopic sleeve gastrectomy. 80.3% of patients were females, 19.7% males. Mean BMI was 47.5 (SEM 8.1). Seven patients had a history of PE (0.9%); 10 patients had a history of DVT requiring therapy (1.3%). 744 patients reported being functionally independent prior to surgery (99.7%), 2 were partially dependent (0.3%). Of the 746 patients undergoing bariatric surgery at our institution, anticoagulation for 5 patients (0.67%) was initiated for presumed/ confirmed DVT/PE. Of these 5 patients, 0 had PE; 3 had confirmed DVTs. As compared with the other MBSAQIP sites, our site has a lower incidence of VTE (0.67% vs 1.0%). Eight patients (1.1%) developed postoperative bleeding complications within 30 days postoperatively. No mortality occurred. Conclusions: The use of moderately higher dose of lower molecular weight heparin (LMWH) with longer duration for DVT/VTE prophylaxis used in our institution seems to be safe, effective and with a low complication rate.
A5090
EFFECT OF A MOBILE HEALTH PATIENT ENGAGEMENT TOOL FOR POSTOPERATIVE CARE OF BARIATRIC SURGERY PATIENTS Caterina Masino1; Timothy Samuel1,2; M. Carolina Jimenez1,2; Sanjeev Sockalingam1; Timothy Jackson2; Fayez Quereshy2; Mugs Zweerman2; Danae McKenzie2; Allan Okrainec2; 1UHN Toronto Western Hospital, Toronto Ontario; 2UHN- Toronto Western Hospital, Toronto Ontario Background: Engaging patients in self-care processes can increase self-awareness in their recovery process. This may lead to earlier recognition of postoperative concerns, prompting patients to seek appropriate medical help earlier. The objective of this pilot study was to develop a mobile app to help patients manage their recovery at home after bariatric surgery. Methods: A total of 116 bariatric surgery patients installed the mobile app on their device at hospital discharge. Participants were asked to complete a daily health check for 30 days using the app. The app generated alerts and instructions based on the patient's symptoms. A patient education library provided selfcare information. Outcome measures included app usage and alert compliance. Readmission to hospital was compared to a historical control group. Results: There were no significant differences between the intervention and control groups on age, sex, BMI, and bariatric surgical procedure. Patients had high app engagement during week one (75.9%) and maintained an average rate of 49.5% over the 30 days. The most frequently captured postoperative patient concerns were no bowel movement and gas pain. Patients highly recommended the app (98%) and 77% favorably rated the app in helping to manage their recovery. There was no significant difference in readmission rates between groups. Conclusion: Patient engagement with a mobile app following bariatric surgery was highest during the first week, with most recommending use of the app in the future. Mobile app use did not decrease readmission rates as part of this pilot study.
S113
A5091
OUTCOMES FOLLOWING LAPAROSCOPIC CONVERSION OF ROUX-EN-Y GASTRIC BYPASS TO BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH Dustin Bermudez; Peter Ng; Lindsey Sharp; University of North Carolina / Rex Hospital, Raleigh NC Background: The Roux en Y gastric bypass has been performed for decades. Many patients experience weight regain or never achieve their ideal body weight following surgery. The biliopancreatic diversion with duodenal switch (BPD-DS) is a more malabsorptive procedure than the gastric bypass as greater than 60% of the small bowel is bypassed whereas only 10-15% is bypassed with a gastric bypass. The BPD-DS has been shown to have more robust weight loss and better long-term weight loss when compared to the gastric bypass. Concern exists regarding vitamin deficiencies. Conversion of a gastric bypass to a duodenal switch is one revisional operation that is offered to bypass patients with weight recidivism and persons with persistent obesity postoperatively. Methods: 18 patients underwent elective laparoscopic revisions of Roux en Y gastric bypass procedures to a biliopancreatic diversion with duodenal switch (BPD-DS). Electronic health records were reviewed retrospectively. Postoperative nutrition labs were performed that included vitamin A, D, E, K, thiamin, folate, B12, ferritin, PTH, copper, zinc and selenium levels. Results: No mortalities were seen postoperatively. One patient experienced a leak at the gastrogastrostomy that was treated with endoscopic stent placement. Two patients had early postoperative small bowel obstructions. Mean initial BMI was 46.56 kg/m2. Mean BMI change was 10.08 kg/m2. Mean excess weight loss was 44.44%. One patient underwent surgery for recalcitrant ulcer while all others had it performed for weight recidivism. Three patients had resolution of hypertension while one had remission of diabetes mellitus. Postop follow-up time varied between 1 and 21 months. Three patients were lost to follow-up after a month. Vitamin deficiencies were found in 6 patients. Two patients had vitamin D deficiencies, two had zinc deficiencies, two had vitamin K deficiencies and one patient had vitamin A deficiency. Conclusions: For those patients who have had Roux en Y gastric bypass and postoperatively develop weight recidivism or do not achieve adequate weight loss a conversion to a duodenal switch may be a viable option. Complications overall were minimal. Vitamin deficiencies were fairly mild and treated with oral supplements. This patient group is marked by a propensity for non-compliance. Thorough preoperative preparation with nutritional and psychological counseling will be crucial to ensure success. Further study is needed to look at long-term outcomes.
A5092
A NOVEL 15MM TROCAR PORT CLOSURE TECHNIQUE TO PREVENT INCISION COMPLICATIONS AFTER BARIATRIC SURGERY Wah Yang Guangzhou; Jingge Yang; Cunchuan Wang; First Affiliated Hospital of Jinan Unive, Guangzhou Guangdong Province
S114
Poster Presentations / Surgery for Obesity and Related Diseases 12 (2016) S76–S232
Background: Trocar site pain and hernias after laparoscopic bariatric surgeries is common because of the thick, fatty preperitoneal space and elevated intra-abdominal pressure. The incidence ranged from 0.14 to 8 % in literature. Hand suturing is timeconsuming and may be unsuccessful at times, and trocar site closure devices are expensive and are not well-suited for use in morbidly obese patients. Moreover, most of these devices are not available in market in the developing countries like China. Objectives: We describe a novel convenient peritoneal closure technique which could prevent these complications without using expensive wound closure devices. Methods: We retrospectively analyzed the clinical data in all laparoscopic bariatric surgeries (sleeve gastrectomy and gastric bypass) performed by a single surgeon. The technique: An elongated stainless steel hook was completely penetrating the thick abdominal wall to the fascial layer at an optimal distance from the wound and suture with the help of a grasper. Pain score, analgesic usage, cosmetic satisfaction and other clinical outcomes were evaluated. Results: This technique was performed in 179 cases (83 males, 96 females; 113 LRYGB, 66 LSG ) with mean body mass index (BMI) 40.3⫾10.4 kg/m2. 17 cases (9.5%) required additional analgesic in the post-operative period, no significant difference between the two procedures (P¼0.603). Cosmetics results were satisfactory with average score 9.3 out of 10. There were no port site related complications on clinical examination during two-year follow up. Conclusion: This peritoneal closure technique offers an economic, safe and quick alternative to suture the trocar wound defects after bariatric surgeries. In addition it reduces the incidence of port site pain and hernias and enhances recovery.
A5093
SAFETY AND EFFECTIVENESS OF ANTERIOR FUNDOPLICATION SLEEVE GASTRECTOMY IN PATIENTS WITH SEVERE REFLUX Rena Moon; Andre Teixeira; Muhammad Jawad; Orlando Regional Medical Center, Orlando Florida Introduction: Laparoscopic sleeve gastrectomy (LSG) has become a popular bariatric surgery in recent years. However, it has been linked to worsening of, or newly developed gastroesophageal reflux disease (GERD) in the postoperative period. Our practice has published a case report, and presented in many meetings about the techniques of performing anterior fundoplication at the time of sleeve gastrectomy to prevent worsening of GERD symptoms. The purpose of this study is to determine the safety and effectiveness of anterior fundoplication sleeve gastrectomy (AF-SG) in patients with reflux. Material and Methods: We prospectively collected data on 30 sleeve gastrectomy patients who concurrently underwent anterior fundoplication between July 2014 and March 2016. Patients were selected when they complained of severe reflux prior to the procedure. Each patient was interviewed for the GERD score questionnaire (scaled severity and frequency of heartburn, regurgitation, epigastric pain, epigastric fullness, dysphagia, and cough) before and 4 months after the procedure. Results: Our patients consisted of 26 females and 4 males with a mean age of 49.9⫾1.8 years (range, 28-63). They had a preoperative body mass index of 42.5⫾5.5 kg/m2 (range, 33.3-58.4),
and 66.7% (n¼20) of these patients underwent hiatal hernia repair as well. Preoperatively, patients had a mean heartburn score of 6.7⫾3.6 (range, 0-12), regurgitation 5.9⫾4.2 (range, 0-12), epigastric pain 1.6⫾2.6 (range, 0-9), epigastric fullness 2.5⫾3.1 (range, 0-12), dysphagia 0.9⫾2.3 (range, 0-9), and cough score of 0.8⫾1.7 (range, 0-6). Mean preoperative GERD score was 17.6⫾8.6 (range, 6-36) in these patients.Postoperatively, patients were interviewed with the same questionnaire approximately 4 months after the procedure. Patients had a mean heartburn score of 1.6⫾3.4 (range, 0-12), regurgitation 0.8⫾1.7 (range, 0-8), epigastric pain 0.6⫾1.7 (range, 0-8), epigastric fullness 0.9⫾2.4 (range, 0-8), epigastric fullness, 0.2⫾1.2 (range, 0-6), and cough score of 0. Mean postoperative GERD score dropped down to 4.1⫾6.0 (range, 0-28), and the difference was statistically significant (po0.01). No patients required readmission or reoperation due to the procedure within 30 days. Conclusion: Anterior fundoplication sleeve gastrectomy (AF-SG) may be a safe and effective alternative in obese patients with severe reflux who wants to undergo sleeve gastrectomy.
A5094
LAPAROSCOPIC VERSUS ROBOTIC CHOLECYSTECTOMY IN THE OBESE POPULATION: IS THERE A PREFERRED APPROACH? John Mitko1; William Main2; Lala Hussain3; Katherine Meister2; George Kerlakian2; Kevin Tymitz2; 1Good Samaritan Hospital, Cincinnati OH; 2Division of General Surgery, TriHealth, Cincinnati OH; 3TriHealth Hatton Research Institute, Cincinnati OH Introduction: Since the early 1990's, laparoscopic cholecystectomy (LC) has been considered the gold standard treatment for gallbladder disease. Laparoscopic surgery can be challenging in