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Buttressing of the EEA Stapler During Gastrojejunal Anastomosis Decreases Complications for Laparoscopic Gastric Bypass
Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S1–S32
Predictive factors of mortality in bariatric surgery: Data from the Nationwide Inpatient Sample. Surgery. 2011; 150:347-51[3] Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240:416-23[4] Garcia et al. 2010. Emergency Department Visitors and Visits: Who Used the Emergency Room in 2007? CDC, NCHS Data Brief No 38.[5] Karas LA, Schultz S, Siddeswarappa M, Slane S, Ramachandra P, Goldenberg EA. Preliminary Report on Home Nurse Visits for Prevention of Readmission for Dehydration following Bariatric Surgery. Mercy Catholic Medical Center, Philadelphia, PA. Poster presented at SAGES 2015, Nashville, TN.[6] Hall MH, Esposito RA, Pekmezaris R, Lesser M, Moravick D, Jahn L, Blenderman R, Akerman M, Nouryan CN, Hartman AR. Cardiac surgery nurse practitioner home visits prevent coronary artery bypass graft readmissions. Ann Thoracic Surg. 2014 May;97 (5): 1488-93.
A122
READMISSION RATES AFTER BARIATRIC SURGERY IN SWEDEN – A POPULATION BASED STUDY Richard Marsk1; Erik Naslund1; Eva Szabo2,3; Ingmar Naslund2,4; Johan Ottosson2,5; 1Karolinska Institutet, Stockholm Stockholm; 2 Orebro University Hospital, Stockholm N/A; 3Orebro University Hospital, Örebro Närke; 4Orebro University Hospital, Orebro Sweden; 5Orebro University Hospital, Orebro Orebro Background: Several studies have addressed short-term readmission rates after bariatric surgery. However, studies on longterm readmission rates are few and population based studies are even scarcer. The aim of this study was to assess short-term (1-30 days), medium-term (31-365 days) and long-term (366-720 days) readmission rates after bariatric surgery in Sweden. Methods: Data from the Scandinavian Obesity Surgery Registry (SOReg) (450 000 procedures, 96% Roux-en-Y gastric bypass, 95% laparoscopic, 99% coverage) between 1998 and 2013 was cross-referenced with the national patient registry (NPR) (100% coverage) to assess all readmissions, at all Swedish hospitals, after bariatric surgery. The different ICD10 and NOMESKO surgical procedures codes were used to classify the readmission as all cause or gastrointestinal. Furthermore, we assessed to which degree a severe complication according to the Clavien-Dindo classification impacted readmissions. Results: The all cause readmission rates were 7, 18 and 25%, during the 1-3, 30-365 and 366-720 days, respectively after surgery. The readmission rates with a gastrointestinal diagnosis/ surgical procedure were 3, 8 and 9%, respectively. There was a large degree of variability in the all cause readmission rates between the different primary surgical departments in Sweden (range 2.8-15%) during the first 30 days and (range 13-33%) during the second year after surgery. Patients with a severe complication after surgery were at a higher risk of all cause readmission compared to those without a surgical complication (50, 35, 30% and 4, 16, 23%, respectively, at 1-30, 31-365, 366720 days post-operatively). There was a trend of decreased readmission rates during the study period. Conclusion: This population based study demonstrates a significant risk of readmission after bariatric surgery in Sweden with readmission rates slightly higher than those previously reported in
S15
the literature. One reason for this may be the nationwide coverage of this study. An early severe complication was associated with a significantly higher all cause readmission rate during the first postoperative year which also carried through to the second postoperative year.
A123
BUTTRESSING OF THE EEA STAPLER DURING GASTROJEJUNAL ANASTOMOSIS DECREASES COMPLICATIONS FOR LAPAROSCOPIC GASTRIC BYPASS Zach Ichter; Lindsey Voller; Ovet Esparza; Dan Azagury; Homero Rivas; John Morton; Stanford School of Medicine, Stanford California Background: Bariatric surgery is a safe and effective treatment for morbid obesity, a chronic condition affecting one-third of the U.S. adult population. Newer surgical techniques and equipment have improved safety standards surrounding bariatric surgery. These include enhanced optics, insufflation equipment, and advanced stapling technology. In particular buttressing of the staple line in sleeve gastrectomy has been shown to decrease rates of clinically significant postoperative bleeding. The current study investigates the effectiveness of buttressing the circular stapled anastomosis during Laparoscopic Roux-en-Y gastric bypass (LRYGB). Methods: 243 patients undergoing LRYGB at a single academic institution were included in this retrospective study between 2014 and 2015. Buttressing material was used in 128 of these cases while 125 cases did not use buttressing material. The buttressing material (Gore) was placed on the anvil of the EEA stapler as well as the end of the EEA stapler. Demographic information was collected from both groups preoperatively. Body mass index (BMI) and percentage of excess weight loss (%EWL) were calculated pre- and postoperatively. Surgical characteristics were also obtained including operating time, length of stay, and rates of complications, readmissions, and reoperations. Continuous and dichotomous variables were analyzed using unpaired-t or Chi-square tests, respectively, using GraphPad Prism v6.01. Results: There were no significant demographic differences between the two groups prior to surgery; both buttressing and non-buttressing groups were on average 46 years old and predominantly female (79.2% vs. 74.2% female, respectively), with a BMI of approximately 48 kg/m2. Postoperative weight loss did not significantly differ between groups at any time point (buttressing vs. non-buttressing %EWL: 39.5% vs. 41.5% at 3 months, p¼0.3860; 56.4% vs. 56.7% at 6 months, p¼0.9341). Similarly, there were no significant differences for operating time, length of stay, readmissions, or reoperations. Specific rates of bleeding-related complications were significantly lower for the group in which buttressing was utilized (0.0% buttressing vs. 3.1% non-buttressing, p¼0.0463). Complications due to strictures trended to be lower for the buttressing group (0.0% buttressing vs. 2.3% non-buttressing, p¼0.0851). Conclusion: The incidence of complications following LRYGB has decreased over the past several decades, yet bleeding from the gastrojejunal anastomosis remains a primary concern for both surgeon and patient. Buttressing of the GJ anastomosis during
S16
Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S1–S32
LRYGB significantly reduces bleeding-related complications and increases safety of the procedure.
A124
SURGICAL MANAGEMENT OF GASTROPARESIS: A SINGLE INSTITUTION EXPERIENCE Kotaro Wakamatsu1; Federico Perez Quirante1; Lisandro Montorfano1; David Nguyen1; Morris Sasson1; Emanuele Lo Menzo1; Samuel Szomstein1; Raul Rosenthal2; 1Cleveland Clinic, Florida, Tokyo Tokyo; 2Cleveland Clinic of FL, Weston Florida Background: Gastroparesis (GP) is a chronic disorder of gastric motility with delayed gastric emptying. The gastric electrical stimulator (GES) implantation and Roux-en Y bypass surgery (RYGB) are surgical options for medically refractory GP. The aim of this study was to evaluate the surgical outcomes of GP patients who underwent surgical treatment at our institution. Methods: A retrospective chart review was performed of all patients who underwent surgical treatment of GP from February 2003 to December 2014. Subgroup analysis was performed based on the etiology of the GP, diabetes mellitus (DM) vs. idiopathic (IP), and the type of procedure (GES vs RYGB). Postoperative outcomes and postoperative symptom improvements were assessed and compared between these groups. Results: A total of 93 patients were identified. Based on etiology 47 (50.5%) had DM and 46 (49.5%) had IP. Based on surgical treatment the majority of patients (83.8% n¼ 78) underwent GES implantation, whereas 15 patients (16%) had RYGB.When analyzing the population based on etiology, there are significant differences in hospital-stay (2.0 (1.0-4.0) vs 3 (2.0-7.8) days; p¼0.03) and reoperation rate (30% vs 7%, po0.01) between the idiopathic and diabetic patients when they were matched within the same procedure. Operation time, complication rate, and 30days readmission rate were similar in the both groups. Reoperation rate was higher in IP than in DM (29% vs7%; po0.01). DM
patients significantly improved their GP related complains (nausea, vomiting and abdominal pain) compared to preoperatively (76% vs 21%, 63% vs 14% and 42% vs 13%, po0.01). In addition, IP patients also improved significantly nausea and vomiting but not abdominal pain (95% vs 32% and 87% vs 45%, po0.01, 37% vs 24% p¼0.16). On other hand the analysis based of surgical treatment we found that there are significant differences in hospital-stay 4 (3.0-5.0) vs 2 (1.0-4.8) days; p¼0.01) and operation time 180 (155-211) vs 150 (120-150) min, po0.01 between RYGB and GES. However, complication, 30-days readmission and reoperation rates were comparable in the both groups (6% vs 0%, p¼0.19, 6% vs 17% ,p¼0.32, 6% vs 21%, p¼0.20 respectively) .GES showed significant improvement of the symptoms nausea, vomiting and abdominal pain ( 83% vs 27%, 80% vs 36% and 37% vs 20%, po0.01). However, RYGB only showed improvement of nausea, but not of the vomiting and abdominal pain (100% vs 20%, 40% vs 20%, 50% vs 10%, po0.01, p¼0.14, and p¼0.29). The average follow up for all our population was 410 days (182-857) Conclusions: Surgery is feasible and effective for GP treatment for both DM and IP patients. However there is special care needed for the postoperative period for IP patients due to the high incidence of reoperation. Although both procedures have some degree of efficacy, GES seems to provide improvement of more of the GP symptoms.
A125
READMISSIONS AFFECT REIMBURSEMENT IN BARIATRIC SURGERY, BUT WHAT IS UNDER PROVIDER CONTROL? Shannon Brindle1; Anthony Petrick2; 1Geisinger Medical Institution, Danville PA; 2Geisinger Medical Center, Danville PA Background: Hospital readmissions have become a key surrogate for quality with higher rates of readmission resulting in financial penalties. Therefore, understanding the factors that predict
Predictive factors of mortality in bariatric surgery: Data from the Nationwide Inpatient Sample. Surgery. 2011; 150:347-51[3] Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240:416-23[4] Garcia et al. 2010. Emergency Department Visitors and Visits: Who Used the Emergency Room in 2007? CDC, NCHS Data Brief No 38.[5] Karas LA, Schultz S, Siddeswarappa M, Slane S, Ramachandra P, Goldenberg EA. Preliminary Report on Home Nurse Visits for Prevention of Readmission for Dehydration following Bariatric Surgery. Mercy Catholic Medical Center, Philadelphia, PA. Poster presented at SAGES 2015, Nashville, TN.[6] Hall MH, Esposito RA, Pekmezaris R, Lesser M, Moravick D, Jahn L, Blenderman R, Akerman M, Nouryan CN, Hartman AR. Cardiac surgery nurse practitioner home visits prevent coronary artery bypass graft readmissions. Ann Thoracic Surg. 2014 May;97 (5): 1488-93.
A122
READMISSION RATES AFTER BARIATRIC SURGERY IN SWEDEN – A POPULATION BASED STUDY Richard Marsk1; Erik Naslund1; Eva Szabo2,3; Ingmar Naslund2,4; Johan Ottosson2,5; 1Karolinska Institutet, Stockholm Stockholm; 2 Orebro University Hospital, Stockholm N/A; 3Orebro University Hospital, Örebro Närke; 4Orebro University Hospital, Orebro Sweden; 5Orebro University Hospital, Orebro Orebro Background: Several studies have addressed short-term readmission rates after bariatric surgery. However, studies on longterm readmission rates are few and population based studies are even scarcer. The aim of this study was to assess short-term (1-30 days), medium-term (31-365 days) and long-term (366-720 days) readmission rates after bariatric surgery in Sweden. Methods: Data from the Scandinavian Obesity Surgery Registry (SOReg) (450 000 procedures, 96% Roux-en-Y gastric bypass, 95% laparoscopic, 99% coverage) between 1998 and 2013 was cross-referenced with the national patient registry (NPR) (100% coverage) to assess all readmissions, at all Swedish hospitals, after bariatric surgery. The different ICD10 and NOMESKO surgical procedures codes were used to classify the readmission as all cause or gastrointestinal. Furthermore, we assessed to which degree a severe complication according to the Clavien-Dindo classification impacted readmissions. Results: The all cause readmission rates were 7, 18 and 25%, during the 1-3, 30-365 and 366-720 days, respectively after surgery. The readmission rates with a gastrointestinal diagnosis/ surgical procedure were 3, 8 and 9%, respectively. There was a large degree of variability in the all cause readmission rates between the different primary surgical departments in Sweden (range 2.8-15%) during the first 30 days and (range 13-33%) during the second year after surgery. Patients with a severe complication after surgery were at a higher risk of all cause readmission compared to those without a surgical complication (50, 35, 30% and 4, 16, 23%, respectively, at 1-30, 31-365, 366720 days post-operatively). There was a trend of decreased readmission rates during the study period. Conclusion: This population based study demonstrates a significant risk of readmission after bariatric surgery in Sweden with readmission rates slightly higher than those previously reported in
S15
the literature. One reason for this may be the nationwide coverage of this study. An early severe complication was associated with a significantly higher all cause readmission rate during the first postoperative year which also carried through to the second postoperative year.
A123
BUTTRESSING OF THE EEA STAPLER DURING GASTROJEJUNAL ANASTOMOSIS DECREASES COMPLICATIONS FOR LAPAROSCOPIC GASTRIC BYPASS Zach Ichter; Lindsey Voller; Ovet Esparza; Dan Azagury; Homero Rivas; John Morton; Stanford School of Medicine, Stanford California Background: Bariatric surgery is a safe and effective treatment for morbid obesity, a chronic condition affecting one-third of the U.S. adult population. Newer surgical techniques and equipment have improved safety standards surrounding bariatric surgery. These include enhanced optics, insufflation equipment, and advanced stapling technology. In particular buttressing of the staple line in sleeve gastrectomy has been shown to decrease rates of clinically significant postoperative bleeding. The current study investigates the effectiveness of buttressing the circular stapled anastomosis during Laparoscopic Roux-en-Y gastric bypass (LRYGB). Methods: 243 patients undergoing LRYGB at a single academic institution were included in this retrospective study between 2014 and 2015. Buttressing material was used in 128 of these cases while 125 cases did not use buttressing material. The buttressing material (Gore) was placed on the anvil of the EEA stapler as well as the end of the EEA stapler. Demographic information was collected from both groups preoperatively. Body mass index (BMI) and percentage of excess weight loss (%EWL) were calculated pre- and postoperatively. Surgical characteristics were also obtained including operating time, length of stay, and rates of complications, readmissions, and reoperations. Continuous and dichotomous variables were analyzed using unpaired-t or Chi-square tests, respectively, using GraphPad Prism v6.01. Results: There were no significant demographic differences between the two groups prior to surgery; both buttressing and non-buttressing groups were on average 46 years old and predominantly female (79.2% vs. 74.2% female, respectively), with a BMI of approximately 48 kg/m2. Postoperative weight loss did not significantly differ between groups at any time point (buttressing vs. non-buttressing %EWL: 39.5% vs. 41.5% at 3 months, p¼0.3860; 56.4% vs. 56.7% at 6 months, p¼0.9341). Similarly, there were no significant differences for operating time, length of stay, readmissions, or reoperations. Specific rates of bleeding-related complications were significantly lower for the group in which buttressing was utilized (0.0% buttressing vs. 3.1% non-buttressing, p¼0.0463). Complications due to strictures trended to be lower for the buttressing group (0.0% buttressing vs. 2.3% non-buttressing, p¼0.0851). Conclusion: The incidence of complications following LRYGB has decreased over the past several decades, yet bleeding from the gastrojejunal anastomosis remains a primary concern for both surgeon and patient. Buttressing of the GJ anastomosis during
S16
Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S1–S32
LRYGB significantly reduces bleeding-related complications and increases safety of the procedure.
A124
SURGICAL MANAGEMENT OF GASTROPARESIS: A SINGLE INSTITUTION EXPERIENCE Kotaro Wakamatsu1; Federico Perez Quirante1; Lisandro Montorfano1; David Nguyen1; Morris Sasson1; Emanuele Lo Menzo1; Samuel Szomstein1; Raul Rosenthal2; 1Cleveland Clinic, Florida, Tokyo Tokyo; 2Cleveland Clinic of FL, Weston Florida Background: Gastroparesis (GP) is a chronic disorder of gastric motility with delayed gastric emptying. The gastric electrical stimulator (GES) implantation and Roux-en Y bypass surgery (RYGB) are surgical options for medically refractory GP. The aim of this study was to evaluate the surgical outcomes of GP patients who underwent surgical treatment at our institution. Methods: A retrospective chart review was performed of all patients who underwent surgical treatment of GP from February 2003 to December 2014. Subgroup analysis was performed based on the etiology of the GP, diabetes mellitus (DM) vs. idiopathic (IP), and the type of procedure (GES vs RYGB). Postoperative outcomes and postoperative symptom improvements were assessed and compared between these groups. Results: A total of 93 patients were identified. Based on etiology 47 (50.5%) had DM and 46 (49.5%) had IP. Based on surgical treatment the majority of patients (83.8% n¼ 78) underwent GES implantation, whereas 15 patients (16%) had RYGB.When analyzing the population based on etiology, there are significant differences in hospital-stay (2.0 (1.0-4.0) vs 3 (2.0-7.8) days; p¼0.03) and reoperation rate (30% vs 7%, po0.01) between the idiopathic and diabetic patients when they were matched within the same procedure. Operation time, complication rate, and 30days readmission rate were similar in the both groups. Reoperation rate was higher in IP than in DM (29% vs7%; po0.01). DM
patients significantly improved their GP related complains (nausea, vomiting and abdominal pain) compared to preoperatively (76% vs 21%, 63% vs 14% and 42% vs 13%, po0.01). In addition, IP patients also improved significantly nausea and vomiting but not abdominal pain (95% vs 32% and 87% vs 45%, po0.01, 37% vs 24% p¼0.16). On other hand the analysis based of surgical treatment we found that there are significant differences in hospital-stay 4 (3.0-5.0) vs 2 (1.0-4.8) days; p¼0.01) and operation time 180 (155-211) vs 150 (120-150) min, po0.01 between RYGB and GES. However, complication, 30-days readmission and reoperation rates were comparable in the both groups (6% vs 0%, p¼0.19, 6% vs 17% ,p¼0.32, 6% vs 21%, p¼0.20 respectively) .GES showed significant improvement of the symptoms nausea, vomiting and abdominal pain ( 83% vs 27%, 80% vs 36% and 37% vs 20%, po0.01). However, RYGB only showed improvement of nausea, but not of the vomiting and abdominal pain (100% vs 20%, 40% vs 20%, 50% vs 10%, po0.01, p¼0.14, and p¼0.29). The average follow up for all our population was 410 days (182-857) Conclusions: Surgery is feasible and effective for GP treatment for both DM and IP patients. However there is special care needed for the postoperative period for IP patients due to the high incidence of reoperation. Although both procedures have some degree of efficacy, GES seems to provide improvement of more of the GP symptoms.
A125
READMISSIONS AFFECT REIMBURSEMENT IN BARIATRIC SURGERY, BUT WHAT IS UNDER PROVIDER CONTROL? Shannon Brindle1; Anthony Petrick2; 1Geisinger Medical Institution, Danville PA; 2Geisinger Medical Center, Danville PA Background: Hospital readmissions have become a key surrogate for quality with higher rates of readmission resulting in financial penalties. Therefore, understanding the factors that predict