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Concurrent cholecystectomy at the time of laparoscopic gastric bypass does not increase short-term morbidity, mortality, or length of stay
BARIATRIC SURGERY RESULTS: The groups were similar in terms of age and sex. The SADI-S group had significantly higher Body Mass Index (BMI) (42.37 vs 45.34, p ¼ 0.001) and more comorbidities (hypertension, type 2 diabetes and obstructive sleep apnea). Early complications occurred more often in LGB than in SADI-S (20% vs 8.9%; P ¼ <0.05).The difference in severe complications did not reach statistical significance (5% for LGB vs 2% for SADI-S; P ¼ 0.66).The mean % of Excess weight loss (EWL) for both groups during the first year after the surgery was similar. The SADI-S group presented a higher and maintained EWL at 18 months (80 21.43 vs 95.47 20.4; P ¼ 0.001), 24 months (77.68 19.39 vs 93.67 23.14; P ¼ 0.001) and 36 months (75.84 27.88 vs 91.33 29.07; P ¼ 0.03).The SADI-S group presented more remission of hypertension (27% 39 % p 0.002) and type 2 diabetes (67% vs 85%, p<0.005).
National prevalence, causes and risk factors for bariatric surgery readmissions John M Morton, MD, MPH, Trit Garg, BA, Ulysses S Rosas, BA, Dan Azagury, MD, Homero Rivas, MD, MBA, FACS Stanford University, Stanford, CA INTRODUCTION: National bariatric surgery readmissions are understudied. Here we investigate the causes and characteristics of readmissions after bariatric surgery. METHODS: The 2012 American College of Surgeons National Surgical Quality Improvement Program PUF was utilized to analyze primary bariatric surgeries, band, bypass, and sleeve. Causes of readmissions were categorized using ICD-9 codes. Variables were analyzed using regression, t-test, and chi-square analysis as appropriate with SAS v9.3.
CONCLUSIONS: Both techniques carry out a low rate of postoperative complications. Both procedures were efficient regarding weight loss and improvement of comorbidities. In the mid-term, SADI-S, a modified duodenal switch, offers a better weight loss and a better metabolic response than LGB.
RESULTS: 18,296 patients were included, with 10,080 (55.1%) LRYGB, 1,829 (10.0%) LAGB, and 6,387 (34.9%) LSG. 955 (5.22%) were readmitted at 30 days. There was no significant difference in age or gender between patients with and without readmissions. Readmitted patients had higher BMI (46.8 vs. 45.9, p¼0.001), and greater percent BMI>50 (30.2% vs. 24.6%, p<0.001). Readmitted patients had higher operative time (132 minutes vs. 115, p<0.001), and greater percent LOS>4 days (9.57% vs. 3.36%, p<0.001). Readmitted patients were more likely to have preoperative diabetes (31.1% vs. 27.7%, p¼0.02), COPD (2.63% vs. 1.72%, p¼0.04), and HTN (54.5% vs. 50.8%, p¼0.03). Common readmissions were GI-related (45.0%), dietary (33.5%), and bleed (6.57%). Readmissions were more likely to have SSI (15.5% vs. 1.15%, p<0.001), UTI (3.15% vs. 0.65%, p<0.001), bleed (3.05% vs. 1.27%, p<0.001), DVT (3.58% vs. 0.13%, p<0.001), and return to OR (22.6% vs. 0.92%, p<0.001). Logistic regression found readmission was associated with white race (OR¼1.53, 95% CI: 1.07 e 2.19, p¼0.02), complication (OR¼11.3, 95% CI: 7.91 e 16.0, p<0.001), and resident involvement (OR¼0.53, 95% CI: 0.29 e 0.96, p¼0.04).
Concurrent cholecystectomy at the time of laparoscopic gastric bypass does not increase short-term morbidity, mortality, or length of stay Byron F Santos, MD, Dino Spaniolas, MD, FACS, Thadeus Trus, MD Dartmouth-Hitchcock Medical Center, Lebanon, NH and East Carolina University, Greenville, NC INTRODUCTION: Up to 15% of laparoscopic roux-en-y gastric bypass (RYGB) patients require cholecystectomy long-term. However, prophylactic cholecystectomy concurrent with RYGB (RYGB+LC) is not widely performed due to concerns about safety and prolonging length of stay (LOS). We hypothesized that RYGB+LC would be associated with higher morbidity, mortality, and LOS compared to RYGB alone.
CONCLUSIONS: Understanding the causes and risk factors for bariatric surgery readmissions may aid in preventing their future occurrence.
METHODS: American College of Surgeons National Surgical Quality Improvement Program data (2005-2011) for RYGB and RYGB+LC were analyzed. Baseline characteristics, co-morbidities, postoperative morbidity/mortality, and LOS were compared, with multivariate analysis performed to determine which factors were independently associated with worse outcomes or prolonged LOS (PLOS¼greater than median). Odds ratios (OR) and 95% confidence intervals (CI) were calculated (p-values < 0.05 considered statistically significant).
Single anastomosis duodeno-ileal bypass with sleeve gastrectomy: mid-term results of a novel technique compared with laparoscopic gastric bypass Emmy Arrue Del Cid, MD, Andres Sanchez Pernaute, MD, PhD, Esther Sanchez Lopez, MD, Patricia Saez Carlin, Elia Perez Aguirre, PhD, MD, Miguel Angel Rubio, Antonio J Torres, PhD, FACS San Carlos Clinical Hospital, Madrid, Spain
RESULTS: 33,075 patients were analyzed, with 3.1% (n¼1,034) undergoing RYGB+LC. Mean age (44 11 years-old) and BMI (47 8 kg/m2) were similar between groups. Overall morbidity (5.04 vs 5.80%, p ¼ 0.27), mortality (0.16 vs 0.29%, p¼ 0.23), mean LOS (2.46 vs 2.55 days, p ¼ 0.53), and PLOS (27.9 vs 25.2%, p ¼ 0.06) were similar for RYGB versus RYGB + LC. After controlling for confounding variables, RYGB+LC was not associated with higher overall morbidity (OR ¼ 0.82, 95% CI 0.62 e 1.09, p ¼ 0.17), mortality (OR ¼ 0.43, 95%
INTRODUCTION: To compare mid-term results of LGB and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), a modified one-loop duodenal switch. METHODS: We performed a prospective comparison of 215 morbidly obese patients submitted to LGB (n¼ 115) or SADI-S (n¼ 89) between July 2009 and December 2012.
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
e1
http://dx.doi.org/10.1016/j.jamcollsurg.2014.07.390 ISSN 1072-7515/14
e2
Scientific Papers: 2014 Clinical Congress
CI 0.13-1.41, p ¼ 0.16), or PLOS (OR ¼ 1.12, 95% CI 0.961.31, p ¼ 0.14) compared to RYGB. CONCLUSIONS: Concurrent cholecystectomy is not associated with worse outcomes or longer LOS compared to RYGB alone. Given its safety profile, concurrent cholecystectomy may currently be under-utilized in RYGB patients. Benefits of bariatric surgery do not reach obese men Hans F Fuchs, MD, Ryan C Broderick, MD, Cristina R Harnsberger, MD, David C Chang, PhD, MPH, MBA, Bryan J Sandler, MD, FACS, Garth R Jacobsen, MD, FACS, Santiago Horgan, MD, FACS University of California-San Diego, San Diego, CA INTRODUCTION: Epidemiological studies have shown an equal gender distribution of obese patients in the United States (U.S.), but literature suggests around 80% of patients undergoing bariatric surgery are female. The aim of this study is to identify factors that contribute to this skewed gender distribution. METHODS: A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Obese patients who underwent open or laparoscopic gastric bypass or sleeve gastrectomy were identified by ICD-9 codes. Patients <18 years were excluded. Female gender was used as an outcome variable to determine factors that influence gender distribution. Multivariate analyses adjusted for age, race, state, Charlson comorbidity index, income level and insurance status.
J Am Coll Surg
controversial whether simultaneous routine cholecystectomy should be performed in these patients or if a selective approach is appropriate. The purpose of this study is to evaluate the incidence of biliary complications in the patients who underwent BPD/DS with or without cholecystectomy. METHODS: Retrospective review of all patients who underwent BPD/DS between 2006 and 2012 at Abington hospital. Demographic data, operative details, weight loss trends were collected and incidence of biliary complications was calculated in simultaneous cholecystectomy and no cholecystectomy group. RESULTS: 361 patients were included in the study. 97 males (26.8%), mean age 44.8 (range 20-72), mean weight 317.2 pounds (range 205-547), average BMI 50.5 (range 34-71.4), average follow-up was 31 months (12-72 months). In simultaneous chole group (n¼61), no biliary complications were observed during the operation. 239 patients still had their gallbladder after the BPD/ DS. Follow-up rate was 95.6% at 12 months and 92.8% at 18 months. 10 patients were lost to follow-up. Out of the 239 patients, total of 52 patients (22.7%) developed gallbladder related symptomse13 (5.4%) in the first year, 25 (11%) in the second year and 14 (6.1%) after the second year. 40 elective laparoscopic cholecystectomies, 9 urgent laparoscopic cholecystectomies and 2 open urgent cholecystectomies were performed. One patient underwent open common bile duct exploration for cholangitis. CONCLUSIONS: Routine simultaneous cholecystectomy with BPD/DS doesn’t appear to be necessary since majority of the patients don’t develop gallbladder related complications.
RESULTS: From 1998-2010, 190,668 patients underwent inpatient bariatric surgery (93% gastric bypass, 7% sleeve gastrectomy). Females comprised 81.36% of the population. An 80 to 20 percent female to male distribution was maintained for each year in the study period, and additionally was unchanged within individual states. Patients were more likely to be female if they earned a lower income, were African American or Hispanic (p<0.05). Patients were less likely to be female with increasing age, more comorbidities, or private insurance (p<0.05, Fig.1).
Reduction of surgical site infections after laparoscopic gastric bypass with circular stapled gastrojejunostomy Patrick J Shabino, MD, Ryan Schmocker, MD, Michael J Nabozny, MD, Anuoluwapo F Elegbede, MD, Mohammad J Khoraki, MBBS, Luke M Funk, MD, Jacob A Greenberg, MD, FACS, Guilherme M Campos, MD, FACS University of Wisconsin, Madison, WI
CONCLUSIONS: The unequal gender distribution in bariatric surgery is influenced by demographic and socioeconomic factors. This disparity is narrowed in patients who are older and have more comorbidities, while the disparity is widened for certain races and lower incomes. Given the equal distribution of obesity in the U.S., the widespread gender gap in bariatric surgery may suggest an underuse in obese men.
INTRODUCTION: A circular stapled gastrojejunostomy (GJ) is favored by many surgeons during laparoscopic gastric bypass (LGB) given its ease of use, reproducibility and shorter operative times. However, this technique has been associated with higher rates of surgical site infections (SSI), with reported rates between 5 and 30%. Our aim was to study the impact of introducing a standardized technique for circular stapler use (utilizing a modified stapler cover, antibiotic wound irrigation and primary wound closure), on the incidence of SSI after LGB.
Biliary complications following biliopancreatic diversion with duodenal switch Moaz Abulfaraj, MD, Gintaras Antanavicius, MD, Mary C Naglak, PhD, RD Abington Memorial Hospital, Abington, PA INTRODUCTION: Biliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric operation in terms of weight loss and resolution of metabolic diseases. It remains
METHODS: Consecutive patients who underwent primary LGB between 5/2010 and 1/2014 were studied into pre-intervention and post-intervention cohorts. Patient demographics, operative details and SSI rates were obtained from the electronic health records. SSI was defined according to American College of Surgeons National Surgical Quality Improvement Program guidelines. Student’s T-tests and Chi-square tests were used to compare continuous and categorical data respectively. Logistic regression
National prevalence, causes and risk factors for bariatric surgery readmissions John M Morton, MD, MPH, Trit Garg, BA, Ulysses S Rosas, BA, Dan Azagury, MD, Homero Rivas, MD, MBA, FACS Stanford University, Stanford, CA INTRODUCTION: National bariatric surgery readmissions are understudied. Here we investigate the causes and characteristics of readmissions after bariatric surgery. METHODS: The 2012 American College of Surgeons National Surgical Quality Improvement Program PUF was utilized to analyze primary bariatric surgeries, band, bypass, and sleeve. Causes of readmissions were categorized using ICD-9 codes. Variables were analyzed using regression, t-test, and chi-square analysis as appropriate with SAS v9.3.
CONCLUSIONS: Both techniques carry out a low rate of postoperative complications. Both procedures were efficient regarding weight loss and improvement of comorbidities. In the mid-term, SADI-S, a modified duodenal switch, offers a better weight loss and a better metabolic response than LGB.
RESULTS: 18,296 patients were included, with 10,080 (55.1%) LRYGB, 1,829 (10.0%) LAGB, and 6,387 (34.9%) LSG. 955 (5.22%) were readmitted at 30 days. There was no significant difference in age or gender between patients with and without readmissions. Readmitted patients had higher BMI (46.8 vs. 45.9, p¼0.001), and greater percent BMI>50 (30.2% vs. 24.6%, p<0.001). Readmitted patients had higher operative time (132 minutes vs. 115, p<0.001), and greater percent LOS>4 days (9.57% vs. 3.36%, p<0.001). Readmitted patients were more likely to have preoperative diabetes (31.1% vs. 27.7%, p¼0.02), COPD (2.63% vs. 1.72%, p¼0.04), and HTN (54.5% vs. 50.8%, p¼0.03). Common readmissions were GI-related (45.0%), dietary (33.5%), and bleed (6.57%). Readmissions were more likely to have SSI (15.5% vs. 1.15%, p<0.001), UTI (3.15% vs. 0.65%, p<0.001), bleed (3.05% vs. 1.27%, p<0.001), DVT (3.58% vs. 0.13%, p<0.001), and return to OR (22.6% vs. 0.92%, p<0.001). Logistic regression found readmission was associated with white race (OR¼1.53, 95% CI: 1.07 e 2.19, p¼0.02), complication (OR¼11.3, 95% CI: 7.91 e 16.0, p<0.001), and resident involvement (OR¼0.53, 95% CI: 0.29 e 0.96, p¼0.04).
Concurrent cholecystectomy at the time of laparoscopic gastric bypass does not increase short-term morbidity, mortality, or length of stay Byron F Santos, MD, Dino Spaniolas, MD, FACS, Thadeus Trus, MD Dartmouth-Hitchcock Medical Center, Lebanon, NH and East Carolina University, Greenville, NC INTRODUCTION: Up to 15% of laparoscopic roux-en-y gastric bypass (RYGB) patients require cholecystectomy long-term. However, prophylactic cholecystectomy concurrent with RYGB (RYGB+LC) is not widely performed due to concerns about safety and prolonging length of stay (LOS). We hypothesized that RYGB+LC would be associated with higher morbidity, mortality, and LOS compared to RYGB alone.
CONCLUSIONS: Understanding the causes and risk factors for bariatric surgery readmissions may aid in preventing their future occurrence.
METHODS: American College of Surgeons National Surgical Quality Improvement Program data (2005-2011) for RYGB and RYGB+LC were analyzed. Baseline characteristics, co-morbidities, postoperative morbidity/mortality, and LOS were compared, with multivariate analysis performed to determine which factors were independently associated with worse outcomes or prolonged LOS (PLOS¼greater than median). Odds ratios (OR) and 95% confidence intervals (CI) were calculated (p-values < 0.05 considered statistically significant).
Single anastomosis duodeno-ileal bypass with sleeve gastrectomy: mid-term results of a novel technique compared with laparoscopic gastric bypass Emmy Arrue Del Cid, MD, Andres Sanchez Pernaute, MD, PhD, Esther Sanchez Lopez, MD, Patricia Saez Carlin, Elia Perez Aguirre, PhD, MD, Miguel Angel Rubio, Antonio J Torres, PhD, FACS San Carlos Clinical Hospital, Madrid, Spain
RESULTS: 33,075 patients were analyzed, with 3.1% (n¼1,034) undergoing RYGB+LC. Mean age (44 11 years-old) and BMI (47 8 kg/m2) were similar between groups. Overall morbidity (5.04 vs 5.80%, p ¼ 0.27), mortality (0.16 vs 0.29%, p¼ 0.23), mean LOS (2.46 vs 2.55 days, p ¼ 0.53), and PLOS (27.9 vs 25.2%, p ¼ 0.06) were similar for RYGB versus RYGB + LC. After controlling for confounding variables, RYGB+LC was not associated with higher overall morbidity (OR ¼ 0.82, 95% CI 0.62 e 1.09, p ¼ 0.17), mortality (OR ¼ 0.43, 95%
INTRODUCTION: To compare mid-term results of LGB and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), a modified one-loop duodenal switch. METHODS: We performed a prospective comparison of 215 morbidly obese patients submitted to LGB (n¼ 115) or SADI-S (n¼ 89) between July 2009 and December 2012.
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
e1
http://dx.doi.org/10.1016/j.jamcollsurg.2014.07.390 ISSN 1072-7515/14
e2
Scientific Papers: 2014 Clinical Congress
CI 0.13-1.41, p ¼ 0.16), or PLOS (OR ¼ 1.12, 95% CI 0.961.31, p ¼ 0.14) compared to RYGB. CONCLUSIONS: Concurrent cholecystectomy is not associated with worse outcomes or longer LOS compared to RYGB alone. Given its safety profile, concurrent cholecystectomy may currently be under-utilized in RYGB patients. Benefits of bariatric surgery do not reach obese men Hans F Fuchs, MD, Ryan C Broderick, MD, Cristina R Harnsberger, MD, David C Chang, PhD, MPH, MBA, Bryan J Sandler, MD, FACS, Garth R Jacobsen, MD, FACS, Santiago Horgan, MD, FACS University of California-San Diego, San Diego, CA INTRODUCTION: Epidemiological studies have shown an equal gender distribution of obese patients in the United States (U.S.), but literature suggests around 80% of patients undergoing bariatric surgery are female. The aim of this study is to identify factors that contribute to this skewed gender distribution. METHODS: A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Obese patients who underwent open or laparoscopic gastric bypass or sleeve gastrectomy were identified by ICD-9 codes. Patients <18 years were excluded. Female gender was used as an outcome variable to determine factors that influence gender distribution. Multivariate analyses adjusted for age, race, state, Charlson comorbidity index, income level and insurance status.
J Am Coll Surg
controversial whether simultaneous routine cholecystectomy should be performed in these patients or if a selective approach is appropriate. The purpose of this study is to evaluate the incidence of biliary complications in the patients who underwent BPD/DS with or without cholecystectomy. METHODS: Retrospective review of all patients who underwent BPD/DS between 2006 and 2012 at Abington hospital. Demographic data, operative details, weight loss trends were collected and incidence of biliary complications was calculated in simultaneous cholecystectomy and no cholecystectomy group. RESULTS: 361 patients were included in the study. 97 males (26.8%), mean age 44.8 (range 20-72), mean weight 317.2 pounds (range 205-547), average BMI 50.5 (range 34-71.4), average follow-up was 31 months (12-72 months). In simultaneous chole group (n¼61), no biliary complications were observed during the operation. 239 patients still had their gallbladder after the BPD/ DS. Follow-up rate was 95.6% at 12 months and 92.8% at 18 months. 10 patients were lost to follow-up. Out of the 239 patients, total of 52 patients (22.7%) developed gallbladder related symptomse13 (5.4%) in the first year, 25 (11%) in the second year and 14 (6.1%) after the second year. 40 elective laparoscopic cholecystectomies, 9 urgent laparoscopic cholecystectomies and 2 open urgent cholecystectomies were performed. One patient underwent open common bile duct exploration for cholangitis. CONCLUSIONS: Routine simultaneous cholecystectomy with BPD/DS doesn’t appear to be necessary since majority of the patients don’t develop gallbladder related complications.
RESULTS: From 1998-2010, 190,668 patients underwent inpatient bariatric surgery (93% gastric bypass, 7% sleeve gastrectomy). Females comprised 81.36% of the population. An 80 to 20 percent female to male distribution was maintained for each year in the study period, and additionally was unchanged within individual states. Patients were more likely to be female if they earned a lower income, were African American or Hispanic (p<0.05). Patients were less likely to be female with increasing age, more comorbidities, or private insurance (p<0.05, Fig.1).
Reduction of surgical site infections after laparoscopic gastric bypass with circular stapled gastrojejunostomy Patrick J Shabino, MD, Ryan Schmocker, MD, Michael J Nabozny, MD, Anuoluwapo F Elegbede, MD, Mohammad J Khoraki, MBBS, Luke M Funk, MD, Jacob A Greenberg, MD, FACS, Guilherme M Campos, MD, FACS University of Wisconsin, Madison, WI
CONCLUSIONS: The unequal gender distribution in bariatric surgery is influenced by demographic and socioeconomic factors. This disparity is narrowed in patients who are older and have more comorbidities, while the disparity is widened for certain races and lower incomes. Given the equal distribution of obesity in the U.S., the widespread gender gap in bariatric surgery may suggest an underuse in obese men.
INTRODUCTION: A circular stapled gastrojejunostomy (GJ) is favored by many surgeons during laparoscopic gastric bypass (LGB) given its ease of use, reproducibility and shorter operative times. However, this technique has been associated with higher rates of surgical site infections (SSI), with reported rates between 5 and 30%. Our aim was to study the impact of introducing a standardized technique for circular stapler use (utilizing a modified stapler cover, antibiotic wound irrigation and primary wound closure), on the incidence of SSI after LGB.
Biliary complications following biliopancreatic diversion with duodenal switch Moaz Abulfaraj, MD, Gintaras Antanavicius, MD, Mary C Naglak, PhD, RD Abington Memorial Hospital, Abington, PA INTRODUCTION: Biliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric operation in terms of weight loss and resolution of metabolic diseases. It remains
METHODS: Consecutive patients who underwent primary LGB between 5/2010 and 1/2014 were studied into pre-intervention and post-intervention cohorts. Patient demographics, operative details and SSI rates were obtained from the electronic health records. SSI was defined according to American College of Surgeons National Surgical Quality Improvement Program guidelines. Student’s T-tests and Chi-square tests were used to compare continuous and categorical data respectively. Logistic regression