A Pre-Hospital Patient Education Program Improves Outcomes of Bariatric Surgery

Background

We designed an assessment and education program which was delivered to patients prior to first outpatient appointment for bariatric surgery. We hypothesised that this program would streamline care and would lead to improved weight loss following bariatric surgery.

Methods

The program incorporates a structured general practitioners (GP) review, a patient information evening and an on-line learning package. It was introduced in September 2012. Patient flow through the program was recorded. Outcomes of the new program were compared with contemporaneously treated patients who did not undertake the pre-hospital program.

Results

All 636 patients on the waiting list for first appointment at the Alfred Health bariatric surgery clinic were invited to participate. There were 400 patients ultimately removed from the waiting list for first appointment. Of the remaining 236 patients, 229 consented to participate in the new program. The mean BMI was 47.8?±?9.2. The fail to attend first appointment rate dropped from 12 to 2.1 %. At 12 months post-bariatric surgery, patients who undertook the new program (n?=?82) had a mean excess weight loss (EWL) of 41.1?±?20.3 % where as those treated on the standard pathway (n?=?61) had a mean EWL 32?±?18.0 % (p?=?0.012).

Conclusions

The introduction of a pre-hospital education program has led to an improvement in attendance rates and early weight loss post-bariatric surgery.

     

Outcomes of Bariatric Surgery in Patients with Inflammatory Bowel Disease

Background

Obesity has become prevalent in patients with inflammatory bowel disease (IBD). Bariatric surgery can be considered to be contraindicated in IBD patients. We aimed to evaluate feasibility, safety, and efficacy of bariatric surgery in IBD patients.

Methods

We retrospectively identified all morbidly obese patients with a known diagnosis of IBD, who underwent bariatric surgery between January 2005 and December 2012. Postoperative outcomes and status of IBD in patients on maintenance therapy for their disease were assessed.

Results

We identified 20 IBD patients including 13 ulcerative colitis (UC) and 7 Crohn’s disease (CD) patients with a mean age of 54.0?±?10.5 years, BMI of 50.1?±?9.0 kg/m², and duration of IBD of 11.3?±?5.2 years. Eleven patients were on medication for IBD at baseline. Bariatric procedures included sleeve gastrectomy (N?=?9), gastric bypass (N?=?7), gastric banding (N?=?3), and one conversion of band to gastric bypass. There were no intraoperative complications, but two conversions to laparotomy due to adhesions. Mean BMI change and excess weight loss at 1 year was 14.3?±?5.7 kg/m² and 58.9?±?21.1 %, respectively. Seven early postoperative complications occurred including dehydration (N?=?5), pulmonary embolism (N?=?1), and wound infection (N?=?1). During a mean follow-up of 34.6?±?21.7 months, five patients developed complications including pancreatitis (N?=?2), ventral hernia (N?=?2), and marginal ulcer (N?=?1). Nine out of ten eligible patients experienced improvement in their IBD status.

Conclusions

Bariatric surgery is feasible and safe in morbidly obese patients suffering from IBD. In addition to being an effective weight loss procedure, bariatric surgery may help mitigate symptoms in this patient population.

     

Bariatric Surgery in Patients with Cirrhosis and Portal Hypertension

Introduction

Studies on bariatric patients with cirrhosis and portal hypertension are limited. The aim of this study was to review our experience in cirrhotic patients with portal hypertension who had bariatric surgery.

Method

All cirrhotic patients with portal hypertension who underwent laparoscopic bariatric surgery, from 2007 to 2017, were retrospectively reviewed.

Results

Thirteen patients were included; eight (62%) were female. The median age was 54 years (interquartile range, IQR 49–60) and median BMI was 48 kg/m² (IQR 43–55). Portal hypertension was diagnosed based on endoscopy (n?=?5), imaging studies (n?=?3), intraoperative increased collateral circulation (n?=?2), and endoscopy and imaging studies (n?=?3). The bariatric procedures included sleeve gastrectomy (n?=?10, 77%) and Roux-en-Y gastric bypass (n?=?3, 23%). The median length of hospital stay was 3 days (IQR 2–4). Three 30-day complications occurred including wound infection (n?=?1), intra-abdominal hematoma (n?=?1), and subcutaneous hematoma (n?=?1). No intraoperative or 30-day mortalities. There were 11 patients (85%) at 1-year follow-up and 9 patients (69%) at 2-year follow-up. At 2 years, the median percentage of excess weight loss (EWL) and total weight loss (TWL) were 49 and 25%, respectively. There was significant improvement in diabetes (100%), dyslipidemia (100%), and hypertension (50%) at 2 years after surgery.

Conclusion

Bariatric surgery in selected cirrhotic patients with portal hypertension is relatively safe and effective.

     

Knowledge and Perception of Bariatric Surgery Among Primary Care Physicians: a Survey of Family Doctors in Ontario

Purpose

The primary objective of this study was to identify Ontario family physicians’ knowledge and perceptions of bariatric surgery.

Methods

The study population included all physicians practicing family medicine in Ontario who were listed in the Canadian Medical Directory. A self-administered questionnaire consisting of 28 questions was developed and validated using a focus group of seven primary care physicians. The questionnaire was distributed to 1328 physicians.

Results

One hundred sixty-five surveys were completed. 8.8 % of physicians did not have any bariatric surgical patients, and 71.3 % had no more than five in their practice. 70.2 % referred no more than 5 % of their morbidly obese patients for surgery. Only 32.1 % had the appropriate equipment and resources to manage obese patients. 92.5 % of physicians would like to receive more education about bariatric surgery. Physicians with no history of referral (n?=?21) were earlier into their practices and had less morbidly obese patients than physicians with previous referrals (n?=?141). They were also less likely to discuss bariatric surgery with their patients (30 vs. 79.3 %; p?<?0.001) and less likely to feel comfortable explaining procedure options (5.6 vs. 33.9 %; p?=?0.013) and providing postoperative care (26.7 vs. 64.2 %; p?=?0.005). 55.6 % would refer a family member for surgery, compared to 85.4 % of physicians with previous referrals; p?=?0.002.

Conclusion

There appears to be a knowledge gap in understanding the role of bariatric surgery in the treatment of obesity. There is an opportunity to improve education and available resources for primary care physicians surrounding patient selection and follow-up care. This may improve access to treatment.

     

Indications and Operative Outcomes of Gastric Bypass Reversal

Background

Roux-en-Y gastric bypass (RYGB) is one of the best-known and most commonly performed bariatric procedures. However, this procedure carries infrequent but serious long-term complications, which may require revisional procedures. This study reports the indications and outcomes of gastric bypass reversal that have not been described well in the literature.

Methods

A multicenter retrospective study of 50 patients who underwent reversal of RYGB conducted between 2006 and 2015 was reviewed to describe the usual indications and outcomes of gastric bypass reversal surgeries.

Results

Of 50 patients, 7 (14 %) were males and 43 (86 %) were females. The mean age of the patient population was 40.4?±?11.6 years (range 19–66). Reasons for reversal included anastomotic ulcers (n?=?27), anastomotic complications (n?=?9), malnutrition (n?=?2), and functional disorder (n?=?12). The mean BMI before the reversal was 29?±?9.4 kg/m² (range 16–60). The mean time between the primary procedure and reversal was 60?±?65.5 months (range 2–300). Fourteen of the reversals were done via laparotomy. Mean hospital stay was 8.4?±?7.3 days (range 3–34 days). There was no peri-operative death 30 days after reversal. Following gastric bypass reversal, 92.6 % (n?=?25) of the patient population had resolution from ulcers, 77.8 % (n?=?7) of the patient population had resolution from anatomic complications, 100 % (n?=?2) of the patient population had resolution from malnutrition, and 66.7 % (n?=?8) of the patient population had resolution from functional disorders.

Conclusions

Gastric bypass reversal is a reasonable and safe treatment for complications arising from the GBP surgery. A laparoscopic approach is feasible in select patients.

     

Perioperative Outcomes of Laparoscopic and Robotic Revisional Bariatric Surgery in a Complex Patient Population

Background

Utilization of the robotic platform has become more common in bariatric applications. We aim to show that robotic revisional bariatric surgery (RRBS) can be safely performed in a complex patient population with perioperative outcomes equivalent to laparoscopic revisional bariatric surgery (LRBS).

Methods

Retrospective review was conducted of adult patients undergoing laparoscopic revisional bariatric surgery (LRBS) or robotic revisional bariatric surgery (RRBS) at our institution from September 2007 to December 2016. Patients undergoing planned two-stage bariatric procedures were excluded.

Results

A total of 84 patients who underwent LRBS (n?=?66) or RRBS (n?=?18) were included. The index operation was adjustable gastric banding (AGB) in 39/84 (46%), sleeve gastrectomy (VSG) in 23/84 (27%), Roux-en-Y gastric bypass (RYGB) in 13/84 (16%), and vertical banded gastroplasty (VBG) in 9/84 (11%). For patients undergoing conversion from AGB (n?=?39), there was no difference in operative time, length of stay, or complications by surgical approach. For patients undergoing conversion from a stapled procedure (n?=?45), the robotic approach was associated with a shorter length of stay (5.8?±?3.3 vs 3.7?±?1.7 days, p?=?0.04) with equivalent operative time and post-operative complications. There were three leaks in the LRBS group and none in the RRBS group (p?=?0.36). Major complications occurred in 3/39 (8%) of patients undergoing conversion from AGB and 2/45 (4%) of patients undergoing conversion from a stapled procedure (p?=?0.53) with no difference by surgical approach.

Conclusions

RRBS is associated with a shorter length of stay than LRBS in complex procedures and has at least an equivalent safety profile. Long-term follow-up data is needed.

     

Impacts of Supervised Exercise Training in Addition to Interdisciplinary Lifestyle Management in Subjects Awaiting Bariatric Surgery: a Randomized Controlled Study

Background

Experts recommend physical activity (PA) to optimize bariatric surgery (BS) results. However, evidence on the effect of PA before BS is missing. The aim of this study was to assess the impact of adding a Pre-Surgical Exercise Training (PreSET) to an interdisciplinary lifestyle intervention on physical fitness, quality of life, PA barriers, and anthropometric parameters of subjects awaiting BS.

Methods

Thirty candidates for BS (43.2?±?9.2 years, 47.5?±?8.1 kg/m²) have been randomized in two groups: one group following the PreSET (endurance and strength training) and another receiving usual care. Before and after 12 weeks, we assessed physical fitness with a battery of tests (symptom-limited exercise test, 6-min walk test (6MWT), sit-to-stand test, half-squat test, and arm curl test), quality of life with the laval questionnaire, and PA barriers with the physical exercise belief questionnaire.

Results

One control group subject abandoned the study. Subjects in the PreSET group participated in 60.0 % of the supervised exercise sessions proposed. Results showed significant improvements in the 6MWT (17.4?±?27.2 vs. ?16.4?±?42.4 m; p?=?0.03), half-squat test (17.1?±?17.9 vs. ?0.9?±?14.5 s; p?=?0.05), arm curl repetitions (4.8?±?2.3 vs. 1.0?±?4.1; p?=?0.01), social interaction score (10.7?±?12.5 vs. ?2.1?±?11.0 %; p?=?0.02), and embarrassment (?15.6?±?10.2 vs. ?3.1?±?17.8 %; p?=?0.02) in completers (n?=?8) compared to the non-completers (n?=?21). No significant difference between groups in BMI and other outcomes studied was observed after the intervention.

Conclusions

Adding a PreSET to an individual lifestyle counselling intervention improved physical fitness, social interactions, and embarrassment. Post-surgery data would be interesting to confirm these benefits on the long term.

     

Bariatric Surgery in Patients on Chronic Anticoagulation Therapy

Background

Perioperative management of chronically anti-coagulated patients undergoing bariatric surgery requires a balance of managing hemorrhagic and thromboembolic risks. The aim of this study is to evaluate the incidence of hemorrhagic complications and their management in chronically anticoagulated (CAT) patients undergoing bariatric surgery.

Methods

A retrospective review of CAT patients undergoing bariatric surgery at an academic center from 2008 to 2015 was studied.

Results

A total of 153 patients on CAT underwent surgery [Roux-en-Y gastric bypass (n?=?79), sleeve gastrectomy (n?=?63), and adjustable gastric banding (n?=?11)] during the study period: 85 patients (55%) were females; median age was 56 years (interquartile range [IQR] 49–64), and median BMI was 49 kg/m² (IQR 43–56). The most common indications for CAT were venous thromboembolism (n?=?87) and atrial fibrillation (n?=?83). Median duration of procedure and estimated intraoperative blood loss was 150 min (IQR 118–177) and 50 ml (IQR 25–75), respectively. Thirty-day postoperative complications were reported in 33 patients (21.6%) including postoperative bleeding (n?=?19), anastomotic leak (n?=?3), and pulmonary embolism (n?=?1). Nineteen patients (12%) with early postoperative bleeding were further categorized to intra-abdominal (n?=?10), intraluminal (n?=?6), and at the port site or abdominal wall (n?=?3). All-cause readmissions within 30 days of surgery occurred in 19 patients (12%). There was no 30-day mortality.

Conclusion

In our experience, patients who require chronic anticoagulation medication are higher than average risk for postoperative complications and all-cause readmission rates. Careful surgical technique and close attention to postoperative anticoagulation protocols are essential to decrease perioperative risk in this high-risk cohort.

     

<Emphasis Type="Italic">FABP2</Emphasis>, <Emphasis Type="Italic">LEPR223</Emphasis>, <Emphasis Type="Italic">LEP656</Emphasis>, and <Emphasis Type="Italic">FTO</Emphasis> Polymorphisms: Effect on Weight Loss 2 Years After Bariatric Surgery

Purpose

Differences in weight loss outcomes after bariatric surgery may be related to individual preoperative characteristics. The aim of this study was to evaluate the potential effect of fatty acid binding protein-2 (rs1799883), leptin receptor (LEP223, rs1137101 and LEP656, rs1805094), and fat mass and obesity-related (rs9939609) genotypes on weight loss 2 years after bariatric surgery in Brazilian patients.

Materials and Methods

Prospective observational study involving 105 patients (lost to follow-up, 25.7%). In the preoperative period, patients were clinically evaluated and a fasting blood sample for genetic analysis (by real-time DNA amplification technique) was collected. From the patient’s medical records, follow-up weight loss (3, 6, 12, 24 months) was obtained. Percentage of excess weight loss (%EWL) was examined by pairwise comparison across the polymorphisms.

Results

At baseline, the mean weight was 127.5 (23.3) kg and age 43.1 (10.9) years old. The %EWL was significant over time (p?<?0.01). Only the LEP223 genotype showed association (p?<?0.01). Up to 6 months after surgery, no differences were observed. At 12 months, a significant difference (p?=?0.03) between AA (n?=?19) and GG (n?=?34) groups was observed, with 76.5% EWL versus 52.0%, respectively. This difference remained at 24 months. Other genotypes did not present any significant association.

Conclusions

There is a different evolution of weight loss in carriers of the LEP223 after bariatric surgery. The AA genotype seems to be associated with a higher weight loss. However, this pattern was evident only at 12 months after surgery.

     

The unresolved problem of beta-2 microglobulin amyloid deposits in the intervertebral discs of long-term dialysis patients

Background

Dialysis-related destructive spondyloarthropathy caused by beta-2 microglobulin (β2M) amyloid deposits in intervertebral discs is a major burden for patients undergoing long-term dialysis. This study aimed to quantify the presence of β2M amyloid deposits in the intervertebral disc tissue of such patients and analyze whether there was a significant correlation between β2M accumulation and the duration of dialysis.

Methods

Two groups of patients who had undergone surgery for degenerative spinal pathologies were selected: the dialysis group (n?=?29) with long-term dialysis and the control group (n?=?10) with no renal impairment. Tissue sections were prepared from specimens of intervertebral disc tissue obtained during spinal surgery and analyzed via histological staining, including immunohistochemistry (IHC) and Congo red.

Results

There was a statistically significant multifold increase of β2M expression in the disc tissue of long-term dialysis patients when compared to non-dialysis patients, as shown by both IHC (0.019?±?0.023 μm² vs. 0.00020?±?0.00033 μm², respectively; p?=?0.012) and Congo red staining (0.027?±?0.041 μm² vs. 9.240?×?10^?5?±?5.261?×?10^?5 μm², respectively; p?=?0.047). We also note a moderate strength positive correlation between the duration of dialysis and positive IHC (r?=?0.39; p?=?0.015) and Congo-red staining (r?=?0.42; p?=?0.007).

Conclusions

The problem of β2M amyloidosis in long-term dialysis patients remains unresolved even with predominant use of high-flux dialysis membranes. This highlights the insufficiency of current dialysis modalities to effectively filter β2M.

     

Development of De Novo Diabetes in Long-Term Follow-up After Bariatric Surgery

Introduction

While bariatric surgery leads to significant prevention and improvement of type 2 diabetes, patients may rarely develop diabetes after bariatric surgery. The aim of this study was to determine the incidence and the characteristic of new-onset diabetes after bariatric surgery over a 17-year period at our institution.

Methods

Non-diabetic patients who underwent bariatric surgery at a single academic center (1997–2013) and had a postoperative glycated hemoglobin (HbA1c) ≥?6.5%, fasting blood glucose (FBG) ≥?126 mg/dl, or positive glucose tolerance test were identified and studied.

Results

Out of 2263 non-diabetic patients at the time of bariatric surgery, 11 patients had new-onset diabetes in the median follow-up time of 9 years (interquartile range [IQR], 4–12). Bariatric procedures performed were Roux-en-Y gastric bypass (n?=?7), adjustable gastric banding (n?=?3), and sleeve gastrectomy (n?=?1). The median interval between surgery and diagnosis of diabetes was 6 years (IQR, 2–9). At the last follow-up, the median HbA1c and FBG values were 6.3% (IQR, 6.1–6.5) and 95 mg/dl (IQR, 85–122), respectively. Possible etiologic factors leading to diabetes were weight regain to baseline (n?=?6, 55%), steroid-induced after renal transplantation (n?=?1), pancreatic insufficiency after pancreatitis (n?=?1), and unknown (n?=?3).

Conclusion

De novo diabetes after bariatric surgery is rare with an incidence of 0.4% based on our cohort. Weight regain was common (>?50%) in patients who developed new-onset diabetes suggesting recurrent severe obesity as a potential etiologic factor. All patients had good glycemic control (HbA1c ≤?7%) in the long-term postoperative follow-up.

     

Intraperitoneal Ropivacaine Irrigation in Patients Undergoing Bariatric Surgery: a Prospective Randomized Clinical Trial

Background

Despite most bariatric procedures are actually performed by laparoscopic approach, management of postoperative pain remains a major challenge. The aim of this study was to analyze the analgesic effect of intraperitoneal ropivacaine infusion in patients undergoing bariatric surgery.

Methods

A prospective randomized clinical trial of all the patients undergoing laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) between January and November 2015 was performed. Patients were randomized to experimental (EG: those patients undergoing intraperitoneal ropivacain irrigation) and control groups (CG: those undergoing intraperitoneal irrigation with normal saline).

Results

One hundred ten patients were included, 83 LRYGB (75.5 %) and 27 LSG (24.5 %). Mean pain, as measured by VAS score, was 21.7?±?14.5 mm in CG and 13.3?±?10.9 mm in EG (p?=?0.002). Morphine needs during the first 24 h postoperatively were 21.8 % in CG and 3.6 % in EG (p?=?0.01). Early taking of fluids by mouth was possible 6 h after surgery in 76.4 % in EG vs 34.5 % in CG (p?=?0.001). Early mobilization ability (6 h after surgery) was feasible in 72.7 % in EG and 32.7 % in CG (p?=?0.001). Median hospital stay was 3 days (range 2–10 days) in CG and 2 days (2–7 days) in EG (p?=?0.009).

Conclusions

The intraoperative peritoneal infusion with ropivacaine in patients undergoing bariatric surgery is associated with a reduction in postoperative pain, lower morphine needs, earlier mobilization and earlier oral intake of fluids after surgery, and a shorter hospital stay.ClinicalTrials.gov Identifier: NCT02641288

     

IV Acetaminophen Results in Lower Hospital Costs and Emergency Room Visits Following Bariatric Surgery: a Double-Blind,Prospective, Randomized Trial in a Single Accredited Bariatric Center

Background

Postoperative pain control in bariatric surgery is challenging, despite use of intravenous (IV) narcotics. IV acetaminophen is one pain control alternative.

Objective

The aim of this study was to investigate the economic impact of IV acetaminophen in bariatric surgery and its effect on patients’ pain, satisfaction, and hospital length of stay.

Methods

In a randomized controlled trial, Group 1 (treatment) received IV acetaminophen plus IV narcotics 30 min before surgery, then medication plus IV narcotics/PO narcotics for the remaining 18 h. Group 2 (control) received IV normal saline plus IV/PO narcotics. Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (SG). Primary outcomes included direct hospital costs, length of stay, postoperative pain, and patient satisfaction. Secondary outcomes included indirect costs, rescue narcotics dosage, and 30-day outcomes.

Results

Mean direct hospital cost in the treatment group (n?=?50) was $3089.18 versus $2991.62 for the control group (n?=?50) (p?>?0.05). Pain scores did not differ significantly (p?=?0.61). After adjusting for surgery type, there was no significant difference in length of stay (p?=?0.95). Significantly more control group patients incurred surgery-related indirect costs (10 versus 2 %, p?<?0.05), with greater presentation to the emergency department (ED) for abdominal pain (5/50 versus 1/50), yielding higher total indirect costs ($39,293 versus $13,185).

Conclusions

Using IV acetaminophen for postoperative pain management produced notable indirect cost savings and reduced ED visits in the first 30 days postoperatively, with good safety and tolerance. Decreased statistical power may have accounted for certain non-significant findings.

     

The Correlation Between Obesity-Related Diseases and Non-alcoholic Fatty Liver Disease in Women in the Pre-operative Evaluation for Bariatric Surgery Assessed by Transient Hepatic Elastography

Background

Non-alcoholic fatty liver disease (NAFLD) is a common, severe disease in obese patients. However, NAFLD is usually underestimated by ultrasonography. Liver biopsy is not routinely done in bariatric surgery or during the follow-up. This study therefore examined the correlation between metabolic syndrome and NAFLD in morbidly obese patients based on an assessment using transient hepatic elastography (THE).

Material and Methods

This study involved 50 female patients in the pre-operative phase for bariatric surgery. Before surgery, we collected clinical, laboratory, and anthropometric variables. THE measurements were obtained using a FibroScan® device (Echosens, Paris, France), and steatosis was quantified using Controlled Attenuation Parameter software (CAP). Statistical analyses were done using linear correlation and the Kruskal-Wallis test.

Results

The mean of THE and CAP values were 7.56?±?4.78 kPa and 279.94?±?45.69 dB/m, respectively, and there was a significant linear correlation between the two measurements (r?=?0.651; p?<?0.001). The numbers of metabolic syndrome parameters did not influence the THE (p?=?0.436) or CAP (p?=?0.422) values. HbA1c and HOMA-IR showed a strong linear correlation with CAP (r?=?0.643, p?=?0.013 and r?=?0.668, p?=?0.009, respectively) and a tendency to some linear correlation with THE (r?=?0.500, p?=?0.05 and r?=?0.500, p?=?0.002, respectively).

Conclusion

Morbidly obese women submitted to FibroScan® presented a high prevalence of severe steatosis and advanced fibrosis in our sample. Insulin resistance parameters were correlated with steatosis, but less with fibrosis.

     

Comparison of Vela and holmium laser enucleation of the prostate: a retrospective clinical trial with a 12-month follow-up

Purpose

This study aimed to estimate the validity and applicability of Vela laser enucleation of the prostate (VoLEP) in the management of benign prostatic hyperplasia (BPH).

Methods

A retrospective chart review of 112 patients with BPH who underwent VoLEP (n?=?60) or holmium laser enucleation of the prostate (HoLEP) (n?=?56) was conducted at our institution from January 2015 to June 2015. The general and perioperative characteristics of the patients were collected. The 12-month follow-up data, including the lower urinary tract symptom (LUTS) indexes (International Prostate Symptom Score [I-PSS], quality-of-life [QoL] score and maximum flow rate [Qmax]), as well as rates of perioperative and late complications, were analyzed.

Results

No significant differences were observed in pre- and perioperative parameters, including operation time (58.05?±?10.14 vs. 60.14?±?12.30 min, P?=?0.44), serum sodium decrease (3.49?±?0.83 vs. 3.48?±?0.84 mmol/L, P?=?0.97), hemoglobin decrease (1.28?±?0.38 vs. 1.24?±?0.77 g/dL, P?=?0.71), catheterization time (3.63?±?1.10 vs. 3.89?±?1.11 days, P?=?0.21) and hospital stay (4.57?±?1.25 vs. 4.68?±?1.18 days, P?=?0.63) between the two groups of patients. Compared with the HoLEP group, the noise during operation was lower in VoLEP group (47.22?±?10.31 vs. 59.45?±?9.65 db, P?<?0.05). During 1, 6 and 12 months of follow-up visits, the LUTS indexes (I-PSS, QoL score and Qmax) were remarkably improved in both groups when comparing with the baseline values. Furthermore, LUTS indexes were comparable in both groups (P?>?0.05).

Conclusion

Similarly as the holmium laser, the Vela laser is a potent, safe, efficient durable and surgical treatment option for minimally invasive surgery in patients with BPH-induced LUTS.

     

Minimally invasive repair of pectus carinatum: a retrospective analysis based on a single surgeon’s 10 years of experience

Objectives

Over the past decade, minimal invasive surgery for correction of pectus carinatum has gained worldwide acceptance. This study reviews our clinical experience with minimally invasive repair of pectus carinatum (MIRPC) since 2008.

Methods

Between 2008 and 2018, 101 patients (77 male, 24 female) underwent correction of pectus carinatum with the MIRPC technique. The mean age of the patients was 14.7?±?4.8 (3–38) years. Over an 8 years’ experience we slightly modified the original Abramson technique. All patients presented with cosmetic complaints and all had a flexible chest wall on “compression test”. Early follow-up was on postoperative day 15 and 30.

Results

The mean operative time was 42.1?±?16.9 min. The mean hospital stay was 4.2?±?0.9 days. Postoperative complications included pneumothorax (n?=?2, 1.9%), wound infection (n?=?2, 1.9%), skin perforation (n?=?2, 1.9%), intolerable pain (n?=?1, 0.9%), skin hyperpigmentation (n?=?1, 0.9%), and overcorrection (n?=?1, 0.9%). Initial postoperative results were excellent in all patients. The bars were removed at a median of 24.8?±?4.5 months in 44 of 101 patients. 43 of 44 (97.7%) patients whose bar were removed reported excellent results.

Conclusions

MIRPC is a feasible procedure with low morbidity and excellent cosmetic results in the treatment of pectus carinatum deformities in selected patients.

     

Postoperative Changes in Body Composition After Pancreaticoduodenectomy Using Multifrequency Bioelectrical Impedance Analysis

Background

Nutritional status is one of the most important clinical determinants of outcome after surgery. The aim of this study was to compare changes in the body composition of patients undergoing pancreaticoduodenectomy (PD), distal gastrectomy (DG), or total gastrectomy (TG).

Methods

The parameters of body composition were measured using multifrequency bioelectrical impedance analysis with an inBody 720 (Biospace Inc. Tokyo. Japan) in 60 patients who had undergone PD (n?=?18), DG (n?=?30), or TG (n?=?12). None of the patients had recurrence or were treated with chemotherapy. Changes between the preoperative data and results and those obtained 12 months after surgery were evaluated.

Results

Twelve months after surgery, the body weight change in the PD group was significantly lower than in the TG and DG groups (?1.2?±?3.8 vs ?7.4?±?4.4 and ?4.0?±?3.2 kg, respectively; p?<?0.01 vs TG, p?<?0.05 vs DG). The body weight change correlated with the fat mass change in all groups.

Conclusions

The type and extent of surgery has a different effect on long-term body weight and body composition. Bioelectric impedance analysis can be used to assess body composition and may be useful for nutritional assessment in patients who have undergone these surgeries.

     

Effect of anesthesia type on perioperative outcomes with a midurethral sling

Introduction and hypothesis

There is no consensus on the most appropriate type of anesthesia for placement of a midurethral sling. Our objective was to compare intra- and perioperative outcomes for this procedure performed under general anesthesia versus monitored anesthesia care.

Methods

Retrospective cohort analysis of women undergoing outpatient placement of synthetic retropubic midurethral sling under general anesthesia (n?=?141) or monitored anesthesia care (n?=?84). Patients undergoing concomitant procedures were excluded. Primary outcome was operating room time. Secondary outcomes included surgical and recovery times, cost, discharge home with a catheter, and postoperative pain and/or nausea.

Results

In the general anesthesia group, both operating room time (mean?±?SD, 67.6?±?13.3 min vs 56.9?±?11.8 min, p?<?0.001) and recovery room time (240.0?±?69.8 min vs 190.1?±?78.3 min, p?<?0.001) were longer, whereas there was no difference in surgical time (30.0?±?8.9 min vs 29.0?±?9.7 min, p?=?0.43). Cost was significantly higher in the general anesthesia group ($4,095?±?715 vs $3,877?±?777, p?=?0.03). There was no difference in rates of bladder perforation (6.4 % vs 11.9 %, p?=?0.33). Patients who underwent general anesthesia had higher rates of discharge with a catheter (27.0 % vs 15.8 %, p?=?0.04).

Conclusion

Monitored anesthesia care may offer significant benefits over general anesthesia in women undergoing retropubic midurethral sling, including shorter operating room and recovery times, lower costs, and less voiding dysfunction in the immediate postoperative period.

     

The Role of Attachment in Body Weight and Weight Loss in Bariatric Patients

Purpose

The aim of this study is to explore the role of attachment styles in obesity.

Material and Methods

The present study explored differences in insecure attachment styles between an obese sample waiting for bariatric surgery (n = 195) and an age, sex and height matched normal weight control group (n = 195). It then explored the role of attachment styles in predicting change in BMI 1 year post bariatric surgery (n = 143).

Results

The bariatric group reported significantly higher levels of anxious attachment and lower levels of avoidant attachment than the control non-obese group. Baseline attachment styles did not, however, predict change in BMI post surgery.

Conclusion

Attachment style is different in those that are already obese from those who are not. Attachment was not related to weight loss post surgery.

     

Trocar Port Hernias After Bariatric Surgery

Background

Laparoscopic bariatric surgery is increasingly being performed worldwide. It is estimated that trocar port hernias occur more often in obese patients due to their obesity and because the ports are not closed routinely. The aim of the present study was to analyze the incidence, risk factors, and management of patients with trocar port hernias after laparoscopic bariatric surgery.

Methods

All patients who were operated between 2006 and 2013 were included. During the study period, the trocar ports were not closed routinely. All patients who had any symptomatic abdominal wall hernia during follow-up were included.

Results

Overall, 1524 laparoscopic bariatric procedures were performed. There were 1249 female (82 %) and 275 male (18 %) patients. The mean age was 44 years, and median body mass index was 43 kg/m². Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) (n?=?859), laparoscopic adjustable gastric banding (LAGB) (n?=?364), laparoscopic sleeve gastrectomy (LSG) (n?=?68), revisional surgery (n?=?226), and other procedures (n?=?7). Three hundred and one patients (20 %) had one or more postoperative complications and the overall mortality was 0.3 % (four patients). There were 14 patients (0.9 %) with an abdominal wall hernia, of which eight (0.5 %) had a trocar port hernia, three (0.2 %) an incisional hernia from other previous surgery, and three (0.2 %) an umbilical hernia. Gender, age, BMI, smoking, type II diabetes, procedure type, complications, and weight loss were not associated with the occurrence of abdominal wall hernias.

Conclusions

Trocar port hernias after bariatric surgery occur seldom if the trocar port is not routinely closed.