Feasibility and safety of robot-assisted bariatric conversions and revisions

BackgroundConversions and revisions after bariatric procedures are inevitable and associated with longer operative time and higher complication rates. Because robot-assisted procedures allow better dissection, robotic conversions and revisions may be more beneficial to the patients than laparoscopic ones.ObjectivesThis study aimed to compare the feasibility and safety of robot-assisted conversions and revisions to laparoscopic procedures.SettingAcademic Hospital, United States.MethodsA retrospective chart review was performed on 94 consecutive patients who underwent a bariatric conversion or revision (revision of gastrojejunostomy, conversions of vertical sleeve gastrectomy to Roux-en-Y gastric bypass, adjustable gastric banding to sleeve gastrectomy, Roux-en-Y gastric bypass to sleeve gastrectomy, adjustable gastric banding to Roux-en-Y gastric bypass, Roux-en-Y gastric bypass to duodenal switch, and adjustable gastric banding to duodenal switch) between January 1, 2017, and February 28, 2019. Of these, 30 underwent a robot-assisted conversion or revision.ResultsPatients who underwent a robot-assisted approach were more likely to be older (45.4-versus 38.8-yr old) and lighter (44.6 versus 50.3 kg/m²) than patients who underwent a laparoscopic approach. The mean operative time was longer in the robot-assisted group (155.5 min) than in the laparoscopic group (113.3 min). No difference was observed between the 2 groups in the mean length of hospital stay, 30-day readmission rate, or 30-day reoperation rate. Results were similar when the baseline difference in age and body mass index were accounted for.ConclusionsRobot-assisted conversions and revisions were as feasible and safe as laparoscopic procedures. However, operative time was longer in robot-assisted conversions.     

Use and outcomes of laparoscopic versus open gastric bypass at academic medical centers

BACKGROUND: A large outcome study of laparoscopic gastric bypass has not been done because of difficulty in differentiating between open and laparoscopic procedures in the absence of a specific ICD-9 procedural code for the laparoscopic operation. The University HealthSystem Consortium (UHC) clinical database recently added a specific procedural code for laparoscopic gastric bypass. The goal of this study was to compare the use and outcomes of laparoscopic versus open gastric bypass at academic centers. STUDY DESIGN: Using ICD-9 diagnosis and procedure codes, we obtained data from the UHC clinical database for all patients who underwent laparoscopic or open Roux-en-Y gastric bypass for treatment of morbid obesity between 2004 and 2006 (n = 22,422). The main outcomes measures were demographics, comorbidities, length of hospital stay, 30-day readmission, morbidity, observed and expected (risk-adjusted) mortality, and costs. RESULTS: There were 16,357 patients who underwent laparoscopic gastric bypass and 6,065 patients who underwent open gastric bypass. Laparoscopic gastric bypass patients had a shorter length of hospital stay (2.7 days versus 4.0 days, p < 0.01); lower overall complications (7.4% versus 13.0%, p < 0.01); lower rates of pneumonia, venous thrombosis, leak, wound infection, and pulmonary complications; costs were also lower. The observed-to-expected in-hospital mortality ratio was similar between groups (1.0 versus 1.0). CONCLUSIONS: This nationwide analysis of academic medical centers between 2004 and 2006 showed that bariatric surgery has shifted to a predominately laparoscopic approach. In addition, laparoscopic gastric bypass is as safe as open gastric bypass and is considerably associated with a lower 30-day morbidity.     

Outcomes of laparoscopic and open surgery in children with and without congenital heart disease

Background

Children with congenital heart disease (CHD) often require noncardiac surgery. We compared outcomes following open and laparoscopic intraabdominal surgery among children with and without CHD.

Utilization and outcomes of laparoscopic versus open paraesophageal hernia repair

The optimal operative approach for repair of diaphragmatic hernia remains debated. The aim of this study was to examine the utilization of laparoscopy and compare the outcomes of laparoscopic versus open paraesophageal hernia repair performed at academic centers. Data was obtained from the University HealthSystem Consortium database on 2726 patients who underwent a laparoscopic (n = 2069) or open (n = 657) paraesophageal hernia repair between 2007 and 2010. The data were reviewed for demographics, length of stay, 30-day readmission, morbidity, in-hospital mortality, and costs. For elective procedures, utilization of laparoscopic repair was 81 per cent and was associated with a shorter hospital stay (3.7 vs 8.3 days, P < 0.01), less requirement for intensive care unit care (13% vs 35%, P < 0.01), and lower overall complications (2.7% vs 8.4%, P < 0.01), 30-day readmissions (1.4% vs 3.4%, P < 0.01) and costs ($15,227 vs $24,263, P < 0.01). The in-hospital mortality was 0.4 per cent for laparoscopic repair versus 0.0 per cent for open repair. In patients presenting with obstruction or gangrene, utilization of laparoscopic repair was 57 per cent and was similarly associated with improved outcomes compared with open repair. Within the context of academic centers, the current practice of paraesophageal hernia repair is mostly laparoscopy. Compared with open repair, laparoscopic repair was associated with superior perioperative outcomes even in cases presenting with obstruction or gangrene.     

Laparoscopic gastrostomy in children with congenital heart disease

AIM: The aim of this study was to study the type and frequency of complications and change in weight after a laparoscopic gastrostomy procedure in 31 children with congenital heart disease, comparing patient groups of children with univentricular and biventricular circulation, and with completed and uncompleted cardiac surgery. METHODS: The method used was that of a retrospective study of all 31 children with congenital heart disease who underwent a laparoscopic gastrostomy at our center from 1995 to 2004. MAIN OUTCOME MEASURES: Postoperative complications and body weight changes during follow-up were the main outcome measures used in this study. RESULTS: Minor stoma-related problems were common in both groups. Two severe complications requiring an operative intervention occurred in the univentricular circulation group. Weight was normal at birth, low at the time of the gastrostomy procedure, and did not catch up completely during the follow-up period of a mean of 20 months. There were no significant differences regarding mean weight gain between the groups. CONCLUSIONS: The complication rate after the laparoscopic gastrostomy procedure was higher in our patient group, compared to previously studied children with various diseases. Comparisons regarding mean weight gain between the groups showed no significant differences. The mean weight gain was low, suggesting that the energy expenditure in this patient group of children with severe congenital heart disease may be even higher than previously assumed.     

Parastomal Hernia Repair: a Single Center Experience

Background/Objectives:

Despite multiple options for operative repair of parastomal hernia, results are frequently disappointing. We review our experience with parastomal hernia repair.

Methods:

A retrospective chart review was performed on all patients with parastomal hernia who underwent LAP or open repair at our institution between 1999 and 2006. Information collected included demographics, indication for stoma creation, operative time, length of stay, postoperative complications, and recurrence.

Results:

Twenty-five patients who underwent laparoscopic or open parastomal hernia repair were identified. Laparoscopic repair was attempted on 12 patients and successfully completed on 11. Thirteen patients underwent open repair. Operative time was 172±10.0 minutes for laparoscopic and 137±19.1 minutes for open cases (P=0.14). Lengths of stay were 3.1±0.4 days (laparoscopic) and 5.1±0.8 days (open), P=0.05. Immediate postoperative complications occurred in 4 laparoscopic patients (33.3%) and 2 open patients (15.4%), P=0.38. Parastomal hernia recurred in 4 laparoscopic patients (33.3%) and 7 open patients (53.8%) after 13.9±4.5 months and 21.4±4.3 months, respectively, P=0.43.

Conclusion:

Laparoscopic modified Sugarbaker technique in the repair of parastomal hernia affords an alternative to open repair for treating parastomal hernia.     

Laparoscopic insertion of ventriculoperitoneal shunts in pediatric patients — A retrospective cohort study

IntroductionVentriculoperitoneal shunts (VPSs) are the mainstay of treatment of hydrocephalus but have frequent complications including shunt failure and infection. There has been no comparison of laparoscopic versus open primary VPS insertion in children. We hypothesized that laparoscopic VP shunt insertion may improve patient outcomes.MethodsA prospectively-maintained, externally-validated database of pediatric patients who underwent VPS insertion at a single center between 2012 and 2016 was reviewed. Outcomes including subsequent revisions, shunt infections, operative time, and hospital stay between open and laparoscopic groups were compared.Results210 patients underwent VPS insertion — 41 laparoscopically and 169 open. Operative time was longer for laparoscopic insertions. There was no difference in shunt infections, complications or length of stay. There was no difference between overall revisions or in confirmed peritoneal obstructions in the laparoscopic (12%) versus open VPS insertions (5%), p = 0.13.ConclusionsThis first cohort analysis of laparoscopic versus open VPS insertion in pediatric patients indicates no difference in confirmed peritoneal obstructions. With increasing use of laparoscopic placement in some centers, it remains important to elucidate if there is a subset of pediatric patients who might benefit from this technique; possible candidates may be those who are overweight/obese or have had previous intra-abdominal surgery.Level of evidenceIII — Retrospective cohort study.     

LigaSure in laparoscopic transperitoneal heminephroureterectomy in children: a comparative study

Background: This study was conducted to evaluate the feasibility of using the LigaSure vessel sealing system (Valleylab, Boulder, CO) in laparoscopic transperitoneal vs. open retroperitoneal heminephroureterectomy in children. Materials and Methods: Seven consecutive patients with impaired renal duplex systems underwent laparoscopic heminephroureterectomies using LigaSure between April 2003 and April 2005. The operative time, complications, and hospital stay were analyzed prospectively. The data of 7 consecutive patients who had undergone open retroperitoneal heminephroureterectomy from 2001 to 2003 were analyzed for comparison purposes. The mean ages, underlying disease, and location of the affected kidney pole were not significantly different between these groups. Results: There were no intraoperative complications during laparoscopic heminephroureterectomy and all procedures were completed laparoscopically. The mean operative time of 144 minutes (range, 90-210 minutes) for laparoscopic heminephroureterectomy was somewhat longer than in open heminephroureterectomy-mean time 110 minutes (range, 60-165 minutes) (P = 0.5). Complications of open retroperitoneal heminephroureterectomy included bleeding of the surface of the remaining kidney pole in one patient, requiring extensive hemostatic suturing. Postoperative recovery was uneventful in all laparoscopic procedures, whereas intermittent retention of urine was noticed in one patient undergoing the open procedure. Conclusion: Laparoscopic heminephroureterectomy using LigaSure is feasible in children and has a similar operative time compared to conventional heminephroureterectomy.     

Risk factors for readmission within thirty days following revision total hip arthroplasty

BackgroundThe number of total hip arthroplasties (THA) being performed has been steadily increasing for decades. With increased primary THA surgical volume, revision THA numbers are also increasing at a steady pace. With the aging, increasingly comorbid patient populations and newly imposed financial penalties for hospitals with high readmission rates, refining understanding of factors influencing readmission following THA is a research priority. We hypothesize that numerous preoperative medical comorbidities and postoperative medical complications will emerge as significant positive risk factors for 30-day readmission.MethodsACS-NSQIP database identified patients who underwent revision THA from 2005 to 2015. The primary outcome assessed was hospital readmission within 30 days. Patient demographics, preoperative comorbidities, laboratory studies, operative characteristics, and postsurgical complications were compared between readmitted and non-readmitted patients. Logistic regression identified significant independent risk factors for 30-day readmission among these variables.Results10,032 patients underwent revision THA in the ACS-NSQIP from 2005 to 2015; 855 (8.5%) were readmitted within 30-days. Increasing age, the presence of preoperative comorbidities, high ASA class, and increased operative time were significant positively associated independent risk factors for 30-day readmission. Several postoperative medical and surgical complications such as myocardial infarction, stroke, pneumonia, and sepsis demonstrated significant positive associations with readmission.ConclusionIdentifying and understanding risk factors associated with readmission allows for the implementation of evidence-based interventions aimed at minimizing risk and reducing 30-day readmission rates following revision THA.     

Is same-day discharge associated with increased 30-day postoperative complications and readmissions in patients undergoing laparoscopic adrenalectomy?

BackgroundAdvances in minimally invasive surgery and perioperative care have decreased substantially the duration of time that patients spend recovering in hospital, with many laparoscopic procedures now being performed on an ambulatory basis. There are limited studies, however, on same-day discharge after laparoscopic adrenalectomy. The objectives of this study were to investigate the outcomes and trends of ambulatory laparoscopic adrenalectomy in a multicenter cohort of patients.MethodsAdult patients who underwent elective laparoscopic adrenalectomy between 2005 and 2016 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Baseline demographics and 30-day outcomes were compared between patients who underwent ambulatory laparoscopic adrenalectomy and those who were discharged after an inpatient stay. Multivariable logistic regression and Cox proportional hazards modelling were used to investigate the association between same-day discharge and 30-day complications and unplanned readmissions.ResultsOf the 4,807 patients included in the study, 88 (1.8%) underwent ambulatory laparoscopic adrenalectomy and 4,719 (98.2%) were admitted after the adrenalectomy. The same-day discharge group contained fewer obese patients (37.2% vs 50%; P = .04), a lesser proportion of American Society of Anesthesiologists class III patients (45.5% vs 61%; P = .003), and more patients with primary aldosteronism (14.8% vs 6%; P = .002) compared with the inpatient group. After adjustment for confounders, same-day discharge was not associated with 30-day overall complications (OR 1.17, 95% CI 0.35–3.85; P = .80) or unplanned readmissions (HR 2.77, 95% CI 0.86–8.96; P = .09). The percentage of laparoscopic adrenalectomies performed on an ambulatory basis at hospitals participating in the ACS NSQIP remained low throughout the study period (0–3.1% per year) with no evidence of an increasing trend over time (P = .21).ConclusionAmbulatory laparoscopic adrenalectomy is a safe and feasible alternative to inpatient hospitalization in selected patients. Further study is needed to determine the cost savings, barriers to uptake, and optimal selection criteria for this approach.     

腹腔镜切除5～10 cm肾上腺嗜铬细胞瘤的安全性分析

目的 探讨5～10 cm肾上腺嗜铬细胞瘤腹腔镜切除术的安全性. 方法 2001年1月至2007年6月在北京大学第一医院泌尿外科行肾上腺嗜铬细胞瘤切除的连续79例患者中肿瘤最大径5～10 cm者共41例,回顾分析其临床资料.腹腔镜组11例(其中2例中转开放,数据分析时排除在外),开放手术组30例.应用t检验、Mann-Whitney U检验对两组患者的临床资料及围手术期数据进行分析. 结果 两组患者年龄、肿瘤最大径、术前最高收缩压及舒张压、术前心率、血儿茶酚胺水平的差异均无统计学意义(P>0.05).腹腔镜组均经腹膜后途径.开放手术组经腹腔途径11例,经腹膜后途径19例.两组患者手术时间分别为(132±54)min和(178±64)min;术中出血量分别为100 ml(0～800 m1)和450 ml(0～9500 ml);术后住院时间分别为(7±2)d和(9±4)d,差异均有统计学意义(P<0.05).腹腔镜组术中均未输血,开放手术组术中输血量的中位值为225 ml(0～3800 ml).2组患者术中最高血压、最低血压、最快心率、最慢心率、收缩压增加基础血压30%的次数、收缩压≥200 mm Hg(1 mm Hg=0.133 kPa)次数、收缩压≤90 mm Hg次数、心率≥110次/min次数、心率≤50次/min次数的差异均无统计学意义(P>0.05).两组患者引流量、拔管时间、住ICU时间、术后开始进食时间、住院费用差异均无统计学意义(P>0.05). 结论 腹腔镜切除5～10 cm肾上腺嗜铬细胞瘤的手术时间、术中出血量、术中输血量、术后住院日较开放手术有优势,且术中血压、心率波动等指标不高于开放手术.因此,5～10 cm的肾上腺嗜铬细胞瘤不是腹腔镜的绝对禁忌,经验丰富的术者可以考虑开展腹腔镜手术切除较大肾上腺嗜铬细胞瘤.     

Congenital paraesophageal hernia: Contemporary results and outcomes of laparoscopic approach to repair in symptomatic infants and children

BackgroundCongenital paraesophageal hernia (CPEH) is a rare diaphragmatic anomaly for which repair has primarily been described by laparotomy, although, more recent case series describe laparoscopic repair. In reports with over five patients, the predominant approach has been with laparotomy. The purpose of our study was to review our recent institutional experience and results with exclusively laparoscopic repair of CPEH in infants and children.MethodsAn IRB approved retrospective review of all patients with CPEH who underwent laparoscopic treatment at a tertiary children's hospital from 2010 to 2017 was performed. We included only those patients from our own institution with primary CPEH, or CPEH with prior repair (s) at other centers, with recurrence presenting for operation. Data including demographics, diagnostic studies, operative details, complications, outcomes, and follow up were analyzed. Age at diagnosis was 1 day to 25 years of age (mean 2.5 years).ResultsA total 28 patients underwent 30 operations to treat CPEH. All operations were completed laparoscopically with no conversions to open. There were 6 Type II, 16 Type III, and 6 Type IV CPEH patients. Seventeen patients were less than one year of age (61%). Weight at time of repair was 10.3 kg (1.2–44 kg). Twelve patients were less than 5 kg (43%), eight patients (28.5%) were less than 10 kg, and 8 were more than 10 kg (28.5%). Operative time averaged 125 min (range 61–247 min). Three patients underwent initial CPEH repair (s) (open: 2 and laparoscopic: 1) at other institutions before laparoscopic revision was performed at our hospital (11%). Crural repair was performed in all patients, fundoplication in 26 (93%) and concomitant gastrostomy was performed in 14 patients (50%). Complications included two patients with recurrent hiatal hernias, which were redone laparoscopically (2/28 or 7% recurrence) and 1 capnothorax requiring pigtail drainage postoperatively. There were no deaths, no requirement for esophageal dilations, or esophageal lengthening. One patient required laparoscopic gastrostomy six weeks post initial repair for failure to thrive. Follow-up ranged from 4 months to 8 years (average 36 months).ConclusionCongenital paraesophageal hernia in infants and children is uncommon. Based on our experience, the laparoscopic approach to repair is feasible, even for neonates, with excellent results, acceptably low recurrence rate, and may even be considered for revisional operations.Study typeClinical research paper.Level of evidenceType IV.     

Trends in mortality,readmissions, and complications after endovascular and open infrainguinal revascularization

BackgroundAlthough short-term outcomes of endovascular and open infrainguinal revascularization in patients with peripheral arterial disease have been previously reported, 30-day readmission and resource utilization after these procedures remain unknown.MethodsWe used the 2010–2014 Nationwide Readmissions Database and the International Classification of Diseases, Ninth Edition, to identify patients with peripheral arterial disease undergoing either in-hospital endovascular or open infrainguinal revascularization.ResultsOf an estimated 574,201 hospitalized patients treated for peripheral arterial disease, 308,056 and 266,145 underwent lower limb endovascular and open infrainguinal revascularization, respectively. Compared with patients who underwent open revascularization, endovascular patients were more commonly female (44.8% vs 36.7%, P < .001) and older (69.5 vs 67.2 years, P < .001). Moreover, they had higher rates of 30-day readmission (15.6% vs 13.5%, P < .001), in-hospital complications (22.3% vs 20.9%, P < .001), and in-hospital index mortality (2.1% vs 1.8%, P < .001). In contrast, risk-adjusted multivariable analysis found open revascularization to be independently associated with increased odds of 30-day readmission (odds ratio, 1.13; 95% confidence interval 1.10–1.16), index complications (odds ratio, 1.23; 95% confidence interval 1.20–1.27), and mortality (odds ratio, 1.26; 95% confidence interval 1.16–1.36) compared with those who underwent endovascular revascularization. Trend analysis revealed an overall decrease in the utilization of both endovascular and open revascularization procedures in the inpatient setting.ConclusionDespite lower rates of adverse events compared to endovascular, open infrainguinal revascularization is independently associated with increased risk of short-term readmission, complications, and mortality. These findings should be considered in the selection of appropriate surgical therapy for lower extremity arterial occlusive disease.     

Preoperative frailty predicts postoperative outcomes in intestinal-cutaneous fistula repair

BackgroundThe outcomes of operative repair of intestinal-cutaneous fistulas vary widely throughout the literature. We aimed to investigate whether the modified frailty index-5 is a reliable tool to account for physiologic reserve and whether it serves as a predictor of Clavien-Dindo grade IV complications in those with intestinal-cutaneous fistulas undergoing operative repair.MethodsWe queried the American College of Surgeons National Surgical Quality Improvement Program 2006 to 2017 database to include patients who underwent intestinal-cutaneous fistulas repair. The outcome of interest was 30-day Clavien-Dindo grade IV complications. The incidence of 30-day post-operative Clavien-Dindo grade IV complications were evaluated based on calculated modified frailty index-5 score. Multivariable logistic regression analyses were performed to assess the association of Clavien-Dindo grade IV complications and modified frailty index-5.ResultsA total of 3,995 patients were identified who underwent an intestinal-cutaneous fistulas repair. The median age (interquartile range) was 57 years (46, 67), and most patients were female (2,143 [53.7%]), White (3,206 [80.3%]), and 1,512 (38.2%) were obese. After adjusting for relevant covariates such as demographics, comorbidities, and operative details, modified frailty index-5 was independently associated with Clavien-Dindo grade IV complications (odds ratio = 2.81, 95% confidence interval 1.64–4.82; P < .001).ConclusionModified frailty index-5 is an independent predictor of Clavien-Dindo grade IV complications following intestinal-cutaneous fistulas repair. It can be used to account for physiologic reserve, thus reducing the variability of outcomes reported for intestinal-cutaneous fistulas repair.     

Minimally invasive esophagectomy is safe in patients with previous gastric bypass

BackgroundThe prevalence of morbid obesity in the United States has been steadily increasing, and there is an established relationship between obesity and the risk of developing certain cancers. Patients who have undergone prior gastric bypass (GB) and present with newly diagnosed esophageal cancer represent a new and challenging cohort for surgical resection of their disease. We present our case series of consecutive patients with previous GB who underwent minimally invasive esophagectomy (MIE).MethodsRetrospective review of consecutive patients with a history of GB who underwent a MIE for esophageal cancer between July 2010 and August 2012.ResultsFive patients were identified with a mean age of 57 years. Mean follow-up was 9.1 months. Four patients had undergone laparoscopic GB, and 1 patient had an open GB. Two patients received neoadjuvant chemoradiation therapy for locally advanced disease. Minimally invasive procedures were thoracoscopic/laparoscopic esophagectomy with cervical anastomosis in 4 patients and colonic interposition in 1 patient. Mean operative time was 6 hours and 52 minutes. Median length of stay was 7 days. There was no mortality. Postoperative complications occurred in 3 patients and included pneumonia/respiratory failure, recurrent laryngeal nerve injury, and pyloric stenosis. All patients are alive and disease free at last follow-up.ConclusionsMinimally invasive esophagectomy after prior GB is well tolerated, is technically feasible, and has acceptable oncologic and perioperative outcomes. We conclude that precise endoscopic evaluation before bariatric surgery in patients with gastroesophageal reflux disease is essential, as is the necessity for continuing postsurgical surveillance in patients with known Barrett’s esophagitis and for early evaluation in patients who develop new symptoms of gastroesophageal reflux disease after bariatric surgery.     

Impact of Bariatric Fellowship Training on Perioperative Outcomes for Laparoscopic Roux-en-Y Gastric Bypass in the First Year as Consultant Surgeon

There have been few reports of improved perioperative outcomes for laparoscopic gastric bypass in the surgeon’s independent practice following completion of fellowship training but none from outside of USA. The aim was to evaluate the impact of fellowship training on perioperative outcomes for gastric bypass in the first year as consultant surgeon. Data of all patients undergoing primary bariatric procedures by the author were extracted from prospectively maintained database. Patients who underwent laparoscopic sleeve gastrectomy and gastric banding were excluded. Data on patient demographics, operative time, conversion to open, length of stay, 30-day complications and mortality were analysed. The Obesity Surgery Mortality Risk Score (OS-MRS) was used for risk stratification. The risk score and perioperative outcomes were compared to mentors’ post-learning curve results from host training institution. Out of 83 primary bariatric procedures performed, 74 (63 females, 11 males) were gastric bypasses in first year. The mean age was 45.1 (25–66) years and body mass index was 47.7 (36–57) kg/m². There were no immediate postoperative complications, no conversions to open surgery and no mortality. One patient was re-admitted within 30 days (1.4%) with small bowel obstruction following internal hernia and needed re-laparoscopy. As compared with host training institution, the OS-MRS distribution and perioperative outcomes of the author did not differ significantly from that of mentors’ post-learning curve results. Bariatric fellowship ensured skills acquisition for the author to safely and effectively perform gastric bypass without any learning curve and with surgical outcomes similar to that of experienced mentor at host training institution. Fellowships should be an essential part of bariatric training worldwide.     

A ten-year experience with ninety-two cases of Hirschsprung''s disease. Including sixty-seven consecutive endorectal pull-through procedures.

From July 1974 through November 1984, 92 patients with Hirschsprung's disease (congenital aganglionosis) have been treated at the University of Michigan-Mott Children's Hospital. This series includes 67 consecutive modified endorectal pull-through (ERPT) procedures in children. Fifty-one of these 67 patients had standard rectosigmoid disease and underwent a successful ERPT with only two major complications. One of these 51 children underwent a successful ERPT but died in the late postoperative period from severe congenital heart disease. Eighteen of the 92 patients suffered from total aganglionosis or long-segment disease. Sixteen of these have undergone an ERPT with no mortality or operative morbidity. The follow-up ranges from 6 months to 10 years. All of the children who have reached 3 years of age are continent. Of the remaining 23 patients, 12 were referred following an unsuccessful pull-through at another hospital. The 12 operations included five Swenson pull-throughs, five Duhamel procedures, one ERPT, and one subtotal colectomy. It was possible to redo or revise the pull-through procedures successfully in all but one patient, who required a permanent colostomy. Finally, 11 children were referred for management of a variety of complications following pull-through procedures performed at other institutions. None of these 11 patients required a reperformance of their pull-through, and all were successfully treated with lesser surgical procedures or with medical management. The excellent functional results and the low morbidity and zero operative mortality are attributed to the technical ease of performing the modified ERPT.     

Is Robotic Revisional Bariatric Surgery Justified? An MBSAQIP Analysis

Background

The laparoscopic approach is utilized in greater than 90% of bariatric surgeries. With the growing prevalence of robotic-assisted surgery in bariatrics, there has been limited consensus on the superiority of either laparoscopic or robotic approaches, especially in revisional procedures (conversion from sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB)).

Methods

A retrospective analysis was performed of the MBSAQIP PUF database of patients who underwent conversion from SG to RYGB procedures in either laparoscopic or robotic-assisted approaches. The groups underwent 2:1 propensity matching and primary outcomes included post-conversion days until discharge (POD), conversion operation length, total and major morbidity, 30-day readmission, 30-day reoperation, 30-day reintervention, and 30-day mortality after conversion.

Results

After 2:1 propensity score matching, 3411 patients (2274 laparoscopic vs 1137 robotic) were included in the study. Intraoperatively, no significant difference was found in total morbidity (6.5% lap vs 5.9% robotic) or major morbidity (1.9% lap vs 1.7% robotic); however, the operative times were significantly longer robotically (126 min vs 164 min). Post-operatively, no significant differences were found in discharge day (1.8 lap vs 1.8 robotic), 30-day readmission (7.6% lap vs 8.6% robotic), reoperation rate (2.9% lap vs 3.7% robotic), additional intervention rate (2.5% lap vs 3.3% robotic), or 30-day mortality (0.1% vs 0.1%).

Conclusion

There is no significant difference in perioperative or intraoperative outcomes between laparoscopic and robotic-assisted SG to RYGB conversion procedures other than a longer operative time in the robotic approach, suggesting increased efficiency with the laparoscopic approach.

Graphical abstract