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Fast-Track Protocol for Laparoscopic Roux-en-Y Gastric Bypass
LETTERS
discharge of the vast majority of patients undergoing LRYGB on day 1. In addition, our ongoing experience with the FTP management of patients undergoing LRYGB has shown that 12-hour C-reactive protein is highly prognostic of major complications (unpublished data), potentially supporting the faster (<23 hours) discharge of patients. We believe FTPs should be the norm for all patients undergoing LRYGB.
Fast-Track Management after Laparoscopic Roux-en-Y Gastric Bypass Thomas W Pike, MSc, MRCS, J Peter A Lodge, MD, FRCS Leeds, United Kingdom We read with great interest the recent article by Raftopoulos and colleagues.1 The authors are to be commended on the number of patients they were able to recruit to their study and the inclusion of revisional procedures. We agree that there is a lack of high-quality evidence supporting the use of fast-track protocols (FTPs) after laparoscopic Roux-en-Y gastric bypass (LRYGB). Despite this, we wholly support the use of FTPs for the management of all patients undergoing LRYGB, and are encouraged by the increasing number of studies reporting successfully implemented FTPs.2-4 We believe an FTP can be instigated from the conception of an LRYGB service for all patients, not just those deemed to be low risk. Although FTPs are likely to be associated with a significant cost saving (due to a shorter inpatient hospital stay), one of the primary drivers for the implementation of our own FTP5 was a belief that it would offer an improved patient experience (when compared with a prolonged hospital stay). We were consequently very interested in the authors’ evaluation of patient satisfaction and were heartened by their findings of high patient satisfaction with an FTP after LRYGB. Again, we are in agreement with the authors that the success of an FTP, and ensuring patient satisfaction, are contingent on excellent patient education, both before and after operation. One issue that warrants additional discussion is the use of postoperative investigations to try to delineate those patients that have developed early complications. We question the efficacy of gastrograffin swallow studies so soon after the competence of anastomoses have been confirmed intraoperatively. The majority of complications occur after postoperative day 1,6 and the reliability of a number of routinely performed postoperative investigations to detect serious complications is questionable. For our own patients, we are convinced of the utility of C-reactive protein as a prognosticator of major complications and, when used in conjunction with routine physiologic parameters and a thorough clinical examination, can be used to support the
ª 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
REFERENCES 1. Raftopoulos I, Giannakou A, Davidson E. Prospective 30-day outcome evaluation of a fast-track protocol for 23-hour ambulatory primary and revisional laparoscopic Roux-en-Y gastric bypass in 820 consecutive unselected patients. J Am Coll Surg 2016;222:1189e1200. 2. Bamgbade OA, Adeogun BO, Abbas K. Fast-track laparoscopic gastric bypass surgery: outcomes and lessons from a bariatric surgery service in the United Kingdom. Obes Surg 2012;22: 398e402. 3. McCarty TM, Arnold DT, Lamont JP, Fisher TL. Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass. Ann Surg 2005;123:188e195. 4. Elliott JA, Patel VM, Kirresh A, et al. Fast-track laparoscopic bariatric surgery: a systematic review. Updates Surg 2013;65: 85e94. 5. Pike TW, White AD, Snook NJ, et al. Simplified fast-track laparoscopic Roux-en-y gastric bypass. Obes Surg 2014;25: 413e417. 6. Ballesta C, Berindoague R, Cabrera M, et al. Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2008;18:623e630.
Disclosure Information: Nothing to disclose.
Fast-Track Protocol for Laparoscopic Roux-en-Y Gastric Bypass In reply to Pike and Lodge Ioannis Raftopoulos, MD, FACS Holyoke, MA and Athens, Greece My coauthors and I would like to thank Drs Pike and Lodge for their kind remarks, and we are equally heartened by their group’s strong support for implementation of fast-track protocols (FTP) for all patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). This is
203
http://dx.doi.org/10.1016/j.jamcollsurg.2016.04.015 ISSN 1072-7515/16
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J Am Coll Surg
Letters
our observation as well. In addition, it is our opinion that Drs Pike and Lodge hit the nail on the head questioning the value of gastrograffin swallow study (GSS) soon after LRYGB to delineate those patients in which early complications have developed. I have yet to recall one case in which a routine GSS, without the presence of any other suspicious signs, revealed any abnormal pathology that would have been missed otherwise or would have changed the clinical management. I would also add that GSS does not only add some cost and potential delay to the smooth execution of an FTP, but also often contributes to the onset of a variety of mild gastrointestinal symptoms that could disturb the patient’s recovery. The value of an early GSS is also diminished by the fact that, according to our FTP protocol, all bariatric patients undergo a thorough intraoperative gastroscopic examination and are discharged with a closed suction drain.1 Despite my doubts of its prognostic value, I have continued to request an early GSS as an additional protection from a potential malpractice allegation and as a baseline test that can confirm initial normal postoperative anatomy and serve as a comparison with a future GSS, if needed. In addition, Drs Pike and Lodge’s personal experience and suggestion not to perform an early GSS and to instead use C-reactive protein (CRP) in conjunction with routine physiologic parameters and a thorough clinical examination as a potential prognostic marker for early major complications find us in agreement as well. In my experience, CRP has been used mostly by US surgeons to assess the longterm metabolic benefits of bariatric surgery,2 and it has been underused as a prognostic marker of early major complications after general and bariatric surgery compared with our colleagues throughout the world.3-5 During my recent experience performing bariatric procedures in Greece as well, I have come to appreciate the diagnostic value and cost-effectiveness of CRP, not only in the detection of post-bariatric surgery complications, but also of many common general surgery emergencies. We do intend to include CRP in our routine postoperative diagnostic workup, with the eventual goal to transition away from early GSS. We recommend that all US bariatric practices take this into consideration as well. REFERENCES 1. Raftopoulos I, Giannakou A, Davidson E. Prospective 30-day outcome evaluation of a fast-track protocol for 23-hour ambulatory primary and revisional laparoscopic roux-en-y gastric bypass in 820 consecutive unselected patients. J Am Coll Surg 2016;222:1189e1200. 2. Torriani M, Oliveira AL, Azevedo DC, et al. Effects of Roux-en-Y gastric bypass surgery on visceral and subcutaneous fat density by computed tomography. Obes Surg 2015;25:381e385.
3. Mun˜oz JL, Ruiz-Tovar J, Miranda E, et al. C-reactive protein and procalcitonin as early markers of septic complications after laparoscopic sleeve gastrectomy in morbidly obese patients within an enhanced recovery after surgery program. J Am Coll Surg 2016;222:831e837. 4. Romain B, Chemaly R, Meyer N, et al. Diagnostic markers of postoperative morbidity after laparoscopic Roux-en-Y gastric bypass for obesity. Langenbecks Arch Surg 2014;399:503e508. 5. Warschkow R, Tarantino I, Folie P, et al. C-reactive protein 2 days after laparoscopic gastric bypass surgery reliably indicates leaks and moderately predicts morbidity. J Gastrointest Surg 2012;16:1128e1135.
Disclosure Information: Nothing to disclose.
Cholecystectomy for Gallbladder Dyskinesia Peter Cotton, MD, FRCS, FRCP, Katherine Morgan, MD, Juliane Bingener, MD, FACS, Mark D Topazian, MD Charleston, SC Gallbladder dyskinesia is a common and increasing indication for cholecystectomy in the US. It is now reported to be present in 10% to 20% of cases in adults, and up to 50% in children.1 It is much less common in other developed countries. Although some studies and reviews claim good results, others are skeptical, calling for more stringent research.2 We therefore congratulate Richmond and colleagues3 on their attempt to provide additional meaningful data to help patients and practitioners in this clinical minefield, as reported recently in JACS. They randomized 30 patients with no stones and a reduced ejection fraction on dynamic biliary scanning to cholecystectomy or medical treatment (low dose tricyclic). Almost all crossed over to surgery (as permitted in the protocol), and most claimed clinical benefit from it. The authors concluded that patients would not enroll in a larger randomized controlled trial, that a sham-controlled study may have ethical concerns, and that cholecystectomy is an effective treatment. We believe that these claims are not justified by the data they presented. Patients were allowed to cross over from nonoperative treatment at any time. The mean time was only 3.5 days, scarcely long enough to draw any conclusions, not least because the beneficial effect of amitriptyline may not be seen until 2 weeks after initiating an
discharge of the vast majority of patients undergoing LRYGB on day 1. In addition, our ongoing experience with the FTP management of patients undergoing LRYGB has shown that 12-hour C-reactive protein is highly prognostic of major complications (unpublished data), potentially supporting the faster (<23 hours) discharge of patients. We believe FTPs should be the norm for all patients undergoing LRYGB.
Fast-Track Management after Laparoscopic Roux-en-Y Gastric Bypass Thomas W Pike, MSc, MRCS, J Peter A Lodge, MD, FRCS Leeds, United Kingdom We read with great interest the recent article by Raftopoulos and colleagues.1 The authors are to be commended on the number of patients they were able to recruit to their study and the inclusion of revisional procedures. We agree that there is a lack of high-quality evidence supporting the use of fast-track protocols (FTPs) after laparoscopic Roux-en-Y gastric bypass (LRYGB). Despite this, we wholly support the use of FTPs for the management of all patients undergoing LRYGB, and are encouraged by the increasing number of studies reporting successfully implemented FTPs.2-4 We believe an FTP can be instigated from the conception of an LRYGB service for all patients, not just those deemed to be low risk. Although FTPs are likely to be associated with a significant cost saving (due to a shorter inpatient hospital stay), one of the primary drivers for the implementation of our own FTP5 was a belief that it would offer an improved patient experience (when compared with a prolonged hospital stay). We were consequently very interested in the authors’ evaluation of patient satisfaction and were heartened by their findings of high patient satisfaction with an FTP after LRYGB. Again, we are in agreement with the authors that the success of an FTP, and ensuring patient satisfaction, are contingent on excellent patient education, both before and after operation. One issue that warrants additional discussion is the use of postoperative investigations to try to delineate those patients that have developed early complications. We question the efficacy of gastrograffin swallow studies so soon after the competence of anastomoses have been confirmed intraoperatively. The majority of complications occur after postoperative day 1,6 and the reliability of a number of routinely performed postoperative investigations to detect serious complications is questionable. For our own patients, we are convinced of the utility of C-reactive protein as a prognosticator of major complications and, when used in conjunction with routine physiologic parameters and a thorough clinical examination, can be used to support the
ª 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
REFERENCES 1. Raftopoulos I, Giannakou A, Davidson E. Prospective 30-day outcome evaluation of a fast-track protocol for 23-hour ambulatory primary and revisional laparoscopic Roux-en-Y gastric bypass in 820 consecutive unselected patients. J Am Coll Surg 2016;222:1189e1200. 2. Bamgbade OA, Adeogun BO, Abbas K. Fast-track laparoscopic gastric bypass surgery: outcomes and lessons from a bariatric surgery service in the United Kingdom. Obes Surg 2012;22: 398e402. 3. McCarty TM, Arnold DT, Lamont JP, Fisher TL. Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass. Ann Surg 2005;123:188e195. 4. Elliott JA, Patel VM, Kirresh A, et al. Fast-track laparoscopic bariatric surgery: a systematic review. Updates Surg 2013;65: 85e94. 5. Pike TW, White AD, Snook NJ, et al. Simplified fast-track laparoscopic Roux-en-y gastric bypass. Obes Surg 2014;25: 413e417. 6. Ballesta C, Berindoague R, Cabrera M, et al. Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2008;18:623e630.
Disclosure Information: Nothing to disclose.
Fast-Track Protocol for Laparoscopic Roux-en-Y Gastric Bypass In reply to Pike and Lodge Ioannis Raftopoulos, MD, FACS Holyoke, MA and Athens, Greece My coauthors and I would like to thank Drs Pike and Lodge for their kind remarks, and we are equally heartened by their group’s strong support for implementation of fast-track protocols (FTP) for all patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). This is
203
http://dx.doi.org/10.1016/j.jamcollsurg.2016.04.015 ISSN 1072-7515/16
204
J Am Coll Surg
Letters
our observation as well. In addition, it is our opinion that Drs Pike and Lodge hit the nail on the head questioning the value of gastrograffin swallow study (GSS) soon after LRYGB to delineate those patients in which early complications have developed. I have yet to recall one case in which a routine GSS, without the presence of any other suspicious signs, revealed any abnormal pathology that would have been missed otherwise or would have changed the clinical management. I would also add that GSS does not only add some cost and potential delay to the smooth execution of an FTP, but also often contributes to the onset of a variety of mild gastrointestinal symptoms that could disturb the patient’s recovery. The value of an early GSS is also diminished by the fact that, according to our FTP protocol, all bariatric patients undergo a thorough intraoperative gastroscopic examination and are discharged with a closed suction drain.1 Despite my doubts of its prognostic value, I have continued to request an early GSS as an additional protection from a potential malpractice allegation and as a baseline test that can confirm initial normal postoperative anatomy and serve as a comparison with a future GSS, if needed. In addition, Drs Pike and Lodge’s personal experience and suggestion not to perform an early GSS and to instead use C-reactive protein (CRP) in conjunction with routine physiologic parameters and a thorough clinical examination as a potential prognostic marker for early major complications find us in agreement as well. In my experience, CRP has been used mostly by US surgeons to assess the longterm metabolic benefits of bariatric surgery,2 and it has been underused as a prognostic marker of early major complications after general and bariatric surgery compared with our colleagues throughout the world.3-5 During my recent experience performing bariatric procedures in Greece as well, I have come to appreciate the diagnostic value and cost-effectiveness of CRP, not only in the detection of post-bariatric surgery complications, but also of many common general surgery emergencies. We do intend to include CRP in our routine postoperative diagnostic workup, with the eventual goal to transition away from early GSS. We recommend that all US bariatric practices take this into consideration as well. REFERENCES 1. Raftopoulos I, Giannakou A, Davidson E. Prospective 30-day outcome evaluation of a fast-track protocol for 23-hour ambulatory primary and revisional laparoscopic roux-en-y gastric bypass in 820 consecutive unselected patients. J Am Coll Surg 2016;222:1189e1200. 2. Torriani M, Oliveira AL, Azevedo DC, et al. Effects of Roux-en-Y gastric bypass surgery on visceral and subcutaneous fat density by computed tomography. Obes Surg 2015;25:381e385.
3. Mun˜oz JL, Ruiz-Tovar J, Miranda E, et al. C-reactive protein and procalcitonin as early markers of septic complications after laparoscopic sleeve gastrectomy in morbidly obese patients within an enhanced recovery after surgery program. J Am Coll Surg 2016;222:831e837. 4. Romain B, Chemaly R, Meyer N, et al. Diagnostic markers of postoperative morbidity after laparoscopic Roux-en-Y gastric bypass for obesity. Langenbecks Arch Surg 2014;399:503e508. 5. Warschkow R, Tarantino I, Folie P, et al. C-reactive protein 2 days after laparoscopic gastric bypass surgery reliably indicates leaks and moderately predicts morbidity. J Gastrointest Surg 2012;16:1128e1135.
Disclosure Information: Nothing to disclose.
Cholecystectomy for Gallbladder Dyskinesia Peter Cotton, MD, FRCS, FRCP, Katherine Morgan, MD, Juliane Bingener, MD, FACS, Mark D Topazian, MD Charleston, SC Gallbladder dyskinesia is a common and increasing indication for cholecystectomy in the US. It is now reported to be present in 10% to 20% of cases in adults, and up to 50% in children.1 It is much less common in other developed countries. Although some studies and reviews claim good results, others are skeptical, calling for more stringent research.2 We therefore congratulate Richmond and colleagues3 on their attempt to provide additional meaningful data to help patients and practitioners in this clinical minefield, as reported recently in JACS. They randomized 30 patients with no stones and a reduced ejection fraction on dynamic biliary scanning to cholecystectomy or medical treatment (low dose tricyclic). Almost all crossed over to surgery (as permitted in the protocol), and most claimed clinical benefit from it. The authors concluded that patients would not enroll in a larger randomized controlled trial, that a sham-controlled study may have ethical concerns, and that cholecystectomy is an effective treatment. We believe that these claims are not justified by the data they presented. Patients were allowed to cross over from nonoperative treatment at any time. The mean time was only 3.5 days, scarcely long enough to draw any conclusions, not least because the beneficial effect of amitriptyline may not be seen until 2 weeks after initiating an