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Superior Mesenteric Arterial Catheter Directed TPA for Treatment of Portal Vein Thrombosis and Superior Mesenteric Vein Thrombosis after Weight loss surgery
Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S1–S32 A118
LAPAROSCOPIC CONVERSION TO SLEEVE GASTERECTOMY FOR FAILED GASTRIC BYPASS: REPORT OF 50 CASES Nawaf Alkhalifah; Wei-Jei Lee; Taoyuan Taiwan Background: Laparoscopic gastric bypass is a commonly performed bariatric surgery for the treatment of morbid obesity. Revision surgery for patients who have gastric bypass complications is a challenge for bariatric surgeon. Our aim is to present the early results of the conversions of gastric bypass complications to sleeve gastrectomies. Material and Methods: From January 2001 to December 2015, 50 of 2382 gastric bypasses underwent revisional surgery to convert gastric bypasses to sleeve gastrectomies. The demographic data, surgical parameters and outcomes were studied. Results: The mean age of the study group was 35.0 years (range 20 to 55), and the average body mass index (BMI) prior to the reoperation was 25.3 kg/m2. Seven patients had previous laparoscopic Roux-en-Y gastric bypasses (LRYGBs), and 42 had laparoscopic single anastomosis (mini-) gastric bypasses (LSAGBs). The main reasons for the revisions were malnutrition (58%), weight regain (10%), intolerance (18%) and others (14%). The revisional surgeries had longer operative times, greater blood loss and longer flatus passage times than the primary gastric bypass surgeries. Four patients (8.1%) developed major complications during revisional surgery, including three (6.1%) cases of leakage and one (2.0%) case of internal bleeding. No mortality was noted. After conversion to sleeve gastrectomy, the body weights of the patients remained stable, and all patients improved in terms of malnutrition, including anemia, hypoalbuminemia, and secondary hyperparathyroidism. Conclusion: Conversion to sleeve gastrectomy is an effective and safe option for patients with gastric bypass complications. The conversions to sleeve gastrectomy resulted in significant improvements in malnutrition and maintained weight loss at the early follow-ups.
S13
guide dosing and duration of chemoprophylaxis. There is greater than 90% self-reported compliance with these guidelines amongst MBSC surgeons. We sought to determine the accuracy of selfreported dosing practices and whether the level of discordance is associated with increased risk of VTE. Methods: We utilized prospectively collected, rigorously audited data from the MBSC-a statewide quality improvement program comprised of 38 hospitals with over 6,000 bariatric operations performed per year. Sixty-five participating bariatric surgeons were surveyed about their routine VTE chemoprophylaxis practices, including medication type, dosage, timing, and duration. All those that developed VTE and twenty other randomly selected patient charts were audited in each surgical practice to assess actual perioperative ordered and administered VTE chemoprophylaxis. We assessed the degree to which survey responses and chart abstracted medication administration were associated. Finally, we evaluated VTE and postoperative bleeding events based on degree of concordance between self-reported and actual chemoprophylaxis regimens. A contingency table analysis was performed to evaluate the interrelation between surgeon survey responses and chart data in both the pre-operative and post-operative setting. Results: Pre-operative VTE dosing regimens demonstrated 26% overall discordance between self-reported and actual chart data. Among patients who had a VTE, 43% of chart responses did not match the surgeon survey responses. Conversely, among patients who did not have a VTE, only 23% were discordant. This difference was statistically significant (p¼0.005). With post-operative VTE dosing, overall 32% of chart data did not match with the self-reported surgeon responses. There was again a difference in the proportion of discordance in patients with and without a VTE (53% discordance vs 27%, po0.001). Conclusions: Greater discordance between surgeon self-reported and actual peri-operative VTE chemoprophylaxis is associated with significantly increased risk of VTE. Further understanding of the macro and micro system characteristics of these practices may yield insights into how best to improve appropriate VTE chemoprophylaxis and translate evidence based guidelines into practice.
THURSDAY NOVEMBER 3, 2016 A120
PAPER SESSION IV: COMPLICATIONS: PREVENTIONS AND TREATMENTS 8:00am – 9:30am A119
DISCORDANCE BETWEEN SURGEON SELF-REPORTED AND ACTUAL VENOUS THROMBOEMBOLISM CHEMOPROPHYLAXIS IS ASSOCIATED WITH INCREASED VENOUS THROMBOEMBOLIC EVENTS Arthur Carlin1; Alirio deMeireles2; Haley Stevens2; Amanda Stricklen2; Rachel Ross2; Ruth Cassidy2; Anne CainNielsen2; Jonathan Finks2; Oliver Varban2; Amir Ghaferi2; 1Henry Ford Health System, Detroit MI; 2University of Michigan, Ann Arbor MI Background: Venous thromboembolism (VTE) remains the most common cause of mortality following bariatric surgery. In order to mitigate VTE risk, the Michigan Bariatric Surgery Collaborative (MBSC) developed an evidence-based VTE risk calculator to
SUPERIOR MESENTERIC ARTERIAL CATHETER DIRECTED TPA FOR TREATMENT OF PORTAL VEIN THROMBOSIS AND SUPERIOR MESENTERIC VEIN THROMBOSIS AFTER WEIGHT LOSS SURGERY Hinali Zaveri; Amit Surve; Daniel Cottam; Legrand Belnap; Austin Cottam; Bariatric Medicine Institute, Salt Lake City Utah Background: Acute Portal Vein Thrombosis (PVT) and Superior Mesenteric Vein Thrombosis (SMVT) are relatively rare but insidious and potentially lethal abdominal diseases. Recently, there has been a significant increase in the number of these cases after bariatric surgery. Systemic anticoagulation as well as systemic tissue plasminogen activator (TPA) both have high failure rates in cases of high grade partial or complete occlusion of portal flow. In such cases, activated plasmin is shunted away from the thrombus. The failure rate also increases with delayed diagnosis, more organized thrombosis and a greater extent of mesenteric venous involvement. This study describes the effectiveness, safety and clinical outcomes of catheter directed tissue plasminogen activator
S14
Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S1–S32
(TPA) by route of superior mesenteric artery (SMA) for acute PVT and SMVT after weight loss surgery. Method: Nine patients were identified with PVT and SMVT after weight loss surgery from a single practice. In all the patients, the diagnosis was established with a contrast enhanced abdominal CT scan, occasionally preceded by duplex ultrasound of the portal venous system. Depending on the extent of the thrombosis, thrombolytic therapy via SMA catheter was utilized. All patients received long term anticoagulation. Result: Two out of nine patients received mesenteric portovenous TPA via a catheter placed in the SMA accessed by interventional radiologists using a femoral approach. Both the patients were admitted with abdominal pain, nausea and vomiting, approximately two weeks after their primary weight loss surgery. The CT scan for the first patient revealed occlusive thrombosis of SMV and branches of PV. Patient was initially started on heparin. Since there was no resolution for the clot, we electively decided to place SMA catheter and continuously infuse TPA at 1 mg/hour with a systemic heparin drip at 300 units per hour. We then titrated TPA to 1.5 mg/hour and continued heparin drip for next 3 days. The patient had complete resolution of the clot on subsequent CT scan and was later discharged on oral anticoagulation.The CT scan for the second patient revealed nonocclusive thrombus of main PV and occlusive thrombus of the left intrahepatic PV. This patient was treated with TPA continuously infused by SMA catheter at 1mg per hour along with a systemic heparin drip at 400 units per hour for less than 36 hours. However, we could not titrate TPA to 2 mg/hour as the radiologist pulled the catheter prematurely. This patient did not improve and was later put on systemic anticoagulant. Over next few days, her symptoms improved but her clot did not dissolved. She was discharged on oral anticoagulant. Conclusion: Catheter directed mesenteric portovenous clot perfusion with TPA can be beneficial in patients with SMVT and PVT occurring after weight loss surgery. The greater risk of systemic TPA is avoided by the lower total dose required and by significant reduction of plasmin exposure to the gastric staple lines. It also helps preventing systemic bleeding risk and achieving an excellent mesenteric anticoagulation with much lower systemic aPTT. However, TPA needs to be titrated till 2mg per hour for at least 36 hours for complete dissolution of the clot.
A121
POST-OPERATIVE HOME NURSING PROGRAM DECREASES BARIATRIC HOSPITAL REVISITS Linden Karas1; Priya Chhikara1; Steve Slane2; Prashanth Ramachandra1,3; E. Adam Goldenberg1,4; 1Mercy Catholic Medical Center, Aldan PA; 2Cleveland State University, Lansdowne PA; 3Cleveland State University, darby PA; 4 Cleveland State University, Philadelphia Pennsylvania Background: Bariatric surgery has been proven to effectively treat obesity and its related comorbidities[1][2][3]. High readmission rates following bariatric surgery have led public and private insurance companies to question the financial efficacy of these procedures. In our community hospital, a Bariatric Surgery Center of Excellence, the bariatric population is uniquely composed of almost 60% publically insured (Medicare/Medicaid) patients, a population more likely to seek care in the emergency department
(ED)[4]. Our previous retrospective chart review determined that the ED visit and hospital readmission rate due to any cause in our post-operative bariatric patients was 23.6% and that most occurred during the six weeks immediately post-surgery. Approximately 30% of these were due to the common post-surgical triad of dehydration, nausea/vomiting, and the resulting non-specific abdominal pain. [5] Inspired by cardiothoracic surgeons who have decreased hospital readmissions by having nurse practitioners perform home care visits on coronary artery bypass graft (CABG) patients[6], we designed a similar program to target our bariatric patients. Methods: To decrease readmission rates and costs, we developed a protocol for home healthcare visits (HHV) twice in the first month following surgery, with a specific focus on early diagnosis of dehydration. We recruited 193 patients into the study from January 2014 to August 2014. An HHV was scheduled for all participants approximately 72 hours after discharge from the hospital and at 3 weeks post-operatively. In addition, all patients had their first post-operative office visit 10-14 days after surgery, ensuring that all patients were assessed once per week for the first month after surgery. A checklist concerning patients' diet, lifestyle choices, and physical exam findings consistent with dehydration was provided to each home health nurse as well as to the patients on discharge. If the patient showed early signs of dehydration they received home hydration therapy or were referred to the ED for evaluation. Treatment at home and in the ED included infusion of one banana bag (1mg Folic Acid, 100mg Thiamine, Multivitamin in 1L NSS) and at least 2-liter boluses of normal saline. A Chisquare analysis compared 30-day revisit rates due to any complaint and 30-day revisit rates due to dehydration before and after establishment of the HHV program. Results: Of the 193 patients who received HHV, 23 patients (11.9%) returned to the hospital with a diverse number of complaints, only some of which were related to their surgery; 12 patients (6.2%) had revisits specifically for dehydration. Revisits for dehydration decreased by 28% (p¼0.4) and all-cause hospital revisits were reduced by 50% (Po0.01) from rates prior to the HHV program. Patient demographics as well as the overall number and type of medical comorbidities were comparable in those patients who returned to the hospital when compared to those who did not. No single comorbidity predicted hospital revisits. Conclusions: The financial burden of post-operative complications and readmissions following bariatric surgery has garnered concern about cost-effectiveness. ED visits and hospital readmissions are especially common in publically insured patients, a population primarily served by our practice. We found that two HHV's specifically assessing adherence to post-operative diet and lifestyle changes and signs/symptoms of dehydration significantly decreased all-cause revisit rates. The addition of an assessment focused on bariatric post-operative concerns by a home nurse to standard follow-up practices ensures that patients are evaluated weekly during the first month following surgery. The cost of an ED visit for rehydration is approximately $3,000 and a 2-day inpatient admission can cost upwards of $18,000, while two HHV's cost $300. This simple and inexpensive intervention drastically decreases the need for publically insured patients to seek care in the ED and return to the hospital.[1] McCarty TM, Arnold DT, Lamont P et al: Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass. Ann Surg. 2005; 242: 494-98.[2] Nguyen NT, Hossein M, Laugenour K, et al.
LAPAROSCOPIC CONVERSION TO SLEEVE GASTERECTOMY FOR FAILED GASTRIC BYPASS: REPORT OF 50 CASES Nawaf Alkhalifah; Wei-Jei Lee; Taoyuan Taiwan Background: Laparoscopic gastric bypass is a commonly performed bariatric surgery for the treatment of morbid obesity. Revision surgery for patients who have gastric bypass complications is a challenge for bariatric surgeon. Our aim is to present the early results of the conversions of gastric bypass complications to sleeve gastrectomies. Material and Methods: From January 2001 to December 2015, 50 of 2382 gastric bypasses underwent revisional surgery to convert gastric bypasses to sleeve gastrectomies. The demographic data, surgical parameters and outcomes were studied. Results: The mean age of the study group was 35.0 years (range 20 to 55), and the average body mass index (BMI) prior to the reoperation was 25.3 kg/m2. Seven patients had previous laparoscopic Roux-en-Y gastric bypasses (LRYGBs), and 42 had laparoscopic single anastomosis (mini-) gastric bypasses (LSAGBs). The main reasons for the revisions were malnutrition (58%), weight regain (10%), intolerance (18%) and others (14%). The revisional surgeries had longer operative times, greater blood loss and longer flatus passage times than the primary gastric bypass surgeries. Four patients (8.1%) developed major complications during revisional surgery, including three (6.1%) cases of leakage and one (2.0%) case of internal bleeding. No mortality was noted. After conversion to sleeve gastrectomy, the body weights of the patients remained stable, and all patients improved in terms of malnutrition, including anemia, hypoalbuminemia, and secondary hyperparathyroidism. Conclusion: Conversion to sleeve gastrectomy is an effective and safe option for patients with gastric bypass complications. The conversions to sleeve gastrectomy resulted in significant improvements in malnutrition and maintained weight loss at the early follow-ups.
S13
guide dosing and duration of chemoprophylaxis. There is greater than 90% self-reported compliance with these guidelines amongst MBSC surgeons. We sought to determine the accuracy of selfreported dosing practices and whether the level of discordance is associated with increased risk of VTE. Methods: We utilized prospectively collected, rigorously audited data from the MBSC-a statewide quality improvement program comprised of 38 hospitals with over 6,000 bariatric operations performed per year. Sixty-five participating bariatric surgeons were surveyed about their routine VTE chemoprophylaxis practices, including medication type, dosage, timing, and duration. All those that developed VTE and twenty other randomly selected patient charts were audited in each surgical practice to assess actual perioperative ordered and administered VTE chemoprophylaxis. We assessed the degree to which survey responses and chart abstracted medication administration were associated. Finally, we evaluated VTE and postoperative bleeding events based on degree of concordance between self-reported and actual chemoprophylaxis regimens. A contingency table analysis was performed to evaluate the interrelation between surgeon survey responses and chart data in both the pre-operative and post-operative setting. Results: Pre-operative VTE dosing regimens demonstrated 26% overall discordance between self-reported and actual chart data. Among patients who had a VTE, 43% of chart responses did not match the surgeon survey responses. Conversely, among patients who did not have a VTE, only 23% were discordant. This difference was statistically significant (p¼0.005). With post-operative VTE dosing, overall 32% of chart data did not match with the self-reported surgeon responses. There was again a difference in the proportion of discordance in patients with and without a VTE (53% discordance vs 27%, po0.001). Conclusions: Greater discordance between surgeon self-reported and actual peri-operative VTE chemoprophylaxis is associated with significantly increased risk of VTE. Further understanding of the macro and micro system characteristics of these practices may yield insights into how best to improve appropriate VTE chemoprophylaxis and translate evidence based guidelines into practice.
THURSDAY NOVEMBER 3, 2016 A120
PAPER SESSION IV: COMPLICATIONS: PREVENTIONS AND TREATMENTS 8:00am – 9:30am A119
DISCORDANCE BETWEEN SURGEON SELF-REPORTED AND ACTUAL VENOUS THROMBOEMBOLISM CHEMOPROPHYLAXIS IS ASSOCIATED WITH INCREASED VENOUS THROMBOEMBOLIC EVENTS Arthur Carlin1; Alirio deMeireles2; Haley Stevens2; Amanda Stricklen2; Rachel Ross2; Ruth Cassidy2; Anne CainNielsen2; Jonathan Finks2; Oliver Varban2; Amir Ghaferi2; 1Henry Ford Health System, Detroit MI; 2University of Michigan, Ann Arbor MI Background: Venous thromboembolism (VTE) remains the most common cause of mortality following bariatric surgery. In order to mitigate VTE risk, the Michigan Bariatric Surgery Collaborative (MBSC) developed an evidence-based VTE risk calculator to
SUPERIOR MESENTERIC ARTERIAL CATHETER DIRECTED TPA FOR TREATMENT OF PORTAL VEIN THROMBOSIS AND SUPERIOR MESENTERIC VEIN THROMBOSIS AFTER WEIGHT LOSS SURGERY Hinali Zaveri; Amit Surve; Daniel Cottam; Legrand Belnap; Austin Cottam; Bariatric Medicine Institute, Salt Lake City Utah Background: Acute Portal Vein Thrombosis (PVT) and Superior Mesenteric Vein Thrombosis (SMVT) are relatively rare but insidious and potentially lethal abdominal diseases. Recently, there has been a significant increase in the number of these cases after bariatric surgery. Systemic anticoagulation as well as systemic tissue plasminogen activator (TPA) both have high failure rates in cases of high grade partial or complete occlusion of portal flow. In such cases, activated plasmin is shunted away from the thrombus. The failure rate also increases with delayed diagnosis, more organized thrombosis and a greater extent of mesenteric venous involvement. This study describes the effectiveness, safety and clinical outcomes of catheter directed tissue plasminogen activator
S14
Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S1–S32
(TPA) by route of superior mesenteric artery (SMA) for acute PVT and SMVT after weight loss surgery. Method: Nine patients were identified with PVT and SMVT after weight loss surgery from a single practice. In all the patients, the diagnosis was established with a contrast enhanced abdominal CT scan, occasionally preceded by duplex ultrasound of the portal venous system. Depending on the extent of the thrombosis, thrombolytic therapy via SMA catheter was utilized. All patients received long term anticoagulation. Result: Two out of nine patients received mesenteric portovenous TPA via a catheter placed in the SMA accessed by interventional radiologists using a femoral approach. Both the patients were admitted with abdominal pain, nausea and vomiting, approximately two weeks after their primary weight loss surgery. The CT scan for the first patient revealed occlusive thrombosis of SMV and branches of PV. Patient was initially started on heparin. Since there was no resolution for the clot, we electively decided to place SMA catheter and continuously infuse TPA at 1 mg/hour with a systemic heparin drip at 300 units per hour. We then titrated TPA to 1.5 mg/hour and continued heparin drip for next 3 days. The patient had complete resolution of the clot on subsequent CT scan and was later discharged on oral anticoagulation.The CT scan for the second patient revealed nonocclusive thrombus of main PV and occlusive thrombus of the left intrahepatic PV. This patient was treated with TPA continuously infused by SMA catheter at 1mg per hour along with a systemic heparin drip at 400 units per hour for less than 36 hours. However, we could not titrate TPA to 2 mg/hour as the radiologist pulled the catheter prematurely. This patient did not improve and was later put on systemic anticoagulant. Over next few days, her symptoms improved but her clot did not dissolved. She was discharged on oral anticoagulant. Conclusion: Catheter directed mesenteric portovenous clot perfusion with TPA can be beneficial in patients with SMVT and PVT occurring after weight loss surgery. The greater risk of systemic TPA is avoided by the lower total dose required and by significant reduction of plasmin exposure to the gastric staple lines. It also helps preventing systemic bleeding risk and achieving an excellent mesenteric anticoagulation with much lower systemic aPTT. However, TPA needs to be titrated till 2mg per hour for at least 36 hours for complete dissolution of the clot.
A121
POST-OPERATIVE HOME NURSING PROGRAM DECREASES BARIATRIC HOSPITAL REVISITS Linden Karas1; Priya Chhikara1; Steve Slane2; Prashanth Ramachandra1,3; E. Adam Goldenberg1,4; 1Mercy Catholic Medical Center, Aldan PA; 2Cleveland State University, Lansdowne PA; 3Cleveland State University, darby PA; 4 Cleveland State University, Philadelphia Pennsylvania Background: Bariatric surgery has been proven to effectively treat obesity and its related comorbidities[1][2][3]. High readmission rates following bariatric surgery have led public and private insurance companies to question the financial efficacy of these procedures. In our community hospital, a Bariatric Surgery Center of Excellence, the bariatric population is uniquely composed of almost 60% publically insured (Medicare/Medicaid) patients, a population more likely to seek care in the emergency department
(ED)[4]. Our previous retrospective chart review determined that the ED visit and hospital readmission rate due to any cause in our post-operative bariatric patients was 23.6% and that most occurred during the six weeks immediately post-surgery. Approximately 30% of these were due to the common post-surgical triad of dehydration, nausea/vomiting, and the resulting non-specific abdominal pain. [5] Inspired by cardiothoracic surgeons who have decreased hospital readmissions by having nurse practitioners perform home care visits on coronary artery bypass graft (CABG) patients[6], we designed a similar program to target our bariatric patients. Methods: To decrease readmission rates and costs, we developed a protocol for home healthcare visits (HHV) twice in the first month following surgery, with a specific focus on early diagnosis of dehydration. We recruited 193 patients into the study from January 2014 to August 2014. An HHV was scheduled for all participants approximately 72 hours after discharge from the hospital and at 3 weeks post-operatively. In addition, all patients had their first post-operative office visit 10-14 days after surgery, ensuring that all patients were assessed once per week for the first month after surgery. A checklist concerning patients' diet, lifestyle choices, and physical exam findings consistent with dehydration was provided to each home health nurse as well as to the patients on discharge. If the patient showed early signs of dehydration they received home hydration therapy or were referred to the ED for evaluation. Treatment at home and in the ED included infusion of one banana bag (1mg Folic Acid, 100mg Thiamine, Multivitamin in 1L NSS) and at least 2-liter boluses of normal saline. A Chisquare analysis compared 30-day revisit rates due to any complaint and 30-day revisit rates due to dehydration before and after establishment of the HHV program. Results: Of the 193 patients who received HHV, 23 patients (11.9%) returned to the hospital with a diverse number of complaints, only some of which were related to their surgery; 12 patients (6.2%) had revisits specifically for dehydration. Revisits for dehydration decreased by 28% (p¼0.4) and all-cause hospital revisits were reduced by 50% (Po0.01) from rates prior to the HHV program. Patient demographics as well as the overall number and type of medical comorbidities were comparable in those patients who returned to the hospital when compared to those who did not. No single comorbidity predicted hospital revisits. Conclusions: The financial burden of post-operative complications and readmissions following bariatric surgery has garnered concern about cost-effectiveness. ED visits and hospital readmissions are especially common in publically insured patients, a population primarily served by our practice. We found that two HHV's specifically assessing adherence to post-operative diet and lifestyle changes and signs/symptoms of dehydration significantly decreased all-cause revisit rates. The addition of an assessment focused on bariatric post-operative concerns by a home nurse to standard follow-up practices ensures that patients are evaluated weekly during the first month following surgery. The cost of an ED visit for rehydration is approximately $3,000 and a 2-day inpatient admission can cost upwards of $18,000, while two HHV's cost $300. This simple and inexpensive intervention drastically decreases the need for publically insured patients to seek care in the ED and return to the hospital.[1] McCarty TM, Arnold DT, Lamont P et al: Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass. Ann Surg. 2005; 242: 494-98.[2] Nguyen NT, Hossein M, Laugenour K, et al.