Perioperative outcomes of bariatric surgery in adolescents compared with adults at academic medical centers.

BACKGROUND: To compare the perioperative outcomes of bariatric surgery between adolescent (12-18 years) and adult (>18 years) patients for the treatment of morbid obesity using an administrative database. METHODS: Using the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedural codes, we obtained data from the University HealthSystem Consortium for 55,501 morbidly obese patients (309 adolescents and 55,192 adults) who had undergone laparoscopic or open gastric bypass, laparoscopic gastric banding, or laparoscopic gastroplasty from 2002 to 2006. The outcome measures included demographics, length of hospital stay, intensive care unit stay, 30-day readmission, morbidity, and observed and expected (risk-adjusted) mortality. RESULTS: The overall 30-day complication rate was significantly lower in the adolescent group (5.5% adolescents and 9.8% adults). The in-hospital and observed/expected mortality ratios were similar between groups. The greatest morbidity was associated with open gastric bypass procedures (7.6% for adolescents and 11.1% for adults) followed by laparoscopic gastric bypass (4.3% and 7.5%, respectively). Open gastric bypass in adults had the greatest observed/expected mortality ratio (1.0). In adolescents, the 30-day morbidity and mortality rate was 0% for restrictive procedures (laparoscopic adjustable gastric banding and gastroplasty). CONCLUSION: Bariatric surgery in adolescents represents a small subset of all bariatric operations performed at academic centers, although the number has increased threefold since 2002. Gastric bypass is the most commonly performed bariatric procedure in adolescents. The outcomes of bariatric surgery in adolescents appear to be as safe as those in adults, with lower 30-day morbidity.     

Trends in utilization and outcomes of laparoscopic versus open appendectomy

BACKGROUND: Although a number of trials have analyzed the outcomes of laparoscopic versus open appendectomy, the clinical advantages, and cost-effectiveness of laparoscopic appendectomy in the management of acute and perforated appendicitis are still not clearly defined. The aim of this study was to examine utilization and outcomes of laparoscopic versus open appendectomy using a national administrative database of academic medical centers and teaching hospitals. METHODS: Using ICD-9 diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent appendectomy for acute and perforated appendicitis between 1999 and 2003 (n = 60,236). Trends in utilization of laparoscopic appendectomy were examined over the 5-year period. The outcomes of laparoscopic and open appendectomy were compared including length of hospital stay, 30-day readmission, complications, observed and expected (risk-adjusted) in-hospital mortality, and costs. RESULTS: Overall, 41,085 patients underwent open appendectomy and 19,151 patients underwent laparoscopic appendectomy. The percentage of appendectomy performed by laparoscopy increased from 20% in 1999 to 43% in 2003 (P <0.01). Compared with patients who underwent open appendectomy, patients who underwent laparoscopic appendectomy were more likely female, more likely white, had a lower severity of illness, and were less likely to have perforated appendicitis. Laparoscopic appendectomy was associated with a shorter length of hospital stay (2.5 days vs 3.4 days), lower rate of 30-day readmission (1.0% vs 1.3%), and lower rate of overall complications (6.1% vs 9.6%). There was no significant difference in the observed to expected mortality ratio between laparoscopic and open appendectomy (0.5 vs 0.6, respectively). The mean cost per case was similar between the two groups (US$ 6,242 vs US$ 6,260). CONCLUSIONS: Utilization of laparoscopic appendectomy at academic centers has increased more than two-fold between 1999 and 2003. Patients selected for laparoscopic appendectomy have less advanced appendicitis and have a shorter length of stay and fewer complications without increasing the inpatient care cost.     

National trends in use and outcome of laparoscopic adjustable gastric banding

BACKGROUND: Laparoscopic adjustable gastric banding is gaining popularity in the United States. Our objective was to examine the use and outcomes of laparoscopic adjustable gastric banding at academic medical centers. METHODS: Using the "International Classification of Diseases, Ninth Revision" diagnosis and procedure codes, data were obtained from the University Health System Consortium Clinical Database for all laparoscopic adjustable gastric banding and gastric bypass procedures performed from 2004 to 2007. Quartile trends in the use of all procedures were determined, and a comparison of in-hospital morbidity and mortality between laparoscopic adjustable gastric banding and laparoscopic gastric bypass was performed. RESULTS: A total of 31,333 bariatric surgery procedures were performed from 2004 to 2007. During this period, the use of laparoscopic adjustable gastric banding and gastric bypass procedures increased from 7% to 23% and 53% to 66%, respectively. A concurrent decrease occurred in the use of open gastric bypass procedures from 40% to 11%. Compared with laparoscopic gastric bypass, laparoscopic adjustable gastric banding was associated with a significantly shorter length of stay (1.3 versus 2.7 d, P <.01), lower morbidity (2.8% versus 7.5%, P <.01), lower 30-day readmission rate (.7% versus 2.5%, P <.01), lower in-hospital mortality (.02% versus .08%, P <.01), and lower hospital cost ($8689 versus 14,386, P <.01). CONCLUSION: From 2004 to 2007, significant growth occurred in the number of laparoscopic adjustable gastric banding (+329%) and laparoscopic gastric bypass (+125%) procedures, with a precipitous decrease in the number of open gastric bypass (-73%) procedures. The increasing popularity of the laparoscopic adjustable gastric band procedure could in part be related to the lower cost and lower morbidity compared with laparoscopic gastric bypass.     

Laparoscopic fundoplication compared with laparoscopic gastric bypass in morbidly obese patients with gastroesophageal reflux disease

BackgroundGastroesophageal reflux disease (GERD) is commonly associated with morbid obesity. Laparoscopic fundoplication is a standard surgical treatment for GERD, and laparoscopic gastric bypass has been shown to effectively resolve GERD symptoms in the morbidly obese. We sought to compare the in-hospital outcomes of morbidly obese patients who underwent laparoscopic fundoplication for the treatment of GERD versus laparoscopic gastric bypass for the treatment of morbid obesity and related conditions, including GERD, at U.S. academic medical centers.MethodsUsing the “International Classification of Diseases, 9th Revision” procedural and diagnoses codes for morbidly obese patients with GERD, we obtained data from the University HealthSystem Consortium database for all patients who underwent laparoscopic fundoplication or laparoscopic gastric bypass from October 2004 to December 2007 (n = 27,264). The outcome measures included the patient demographics, length of stay, in-hospital overall complications, mortality, risk-adjusted mortality ratio (observed to expected mortality), and hospital costs.ResultsCompared with the patients who underwent laparoscopic gastric bypass, those who underwent laparoscopic fundoplication had a lower severity of illness score (P <.05). The overall in-hospital complications were significantly lower in the laparoscopic gastric bypass group (P <.05). The mean length of stay, observed mortality, risk-adjusted mortality, and hospital costs were comparable between the 2 treatment groups.ConclusionLaparoscopic gastric bypass is as safe as laparoscopic fundoplication for the treatment of GERD in the morbidly obese. Hence, morbidly obese patients with GERD should be referred for bariatric surgery evaluation and offered laparoscopic gastric bypass as a surgical option.     

Comparison of Laparoscopic vs Open Sigmoid Colectomy for Benign and Malignant Disease at Academic Medical Centers

Few studies have examined outcomes of laparoscopic and open sigmoid colectomy performed at US academic centers. Using ICD-9 diagnosis and procedural codes, data was obtained from the University HealthSystem Consortium (UHC) Clinical Database of 10,603 patients who underwent laparoscopic or open sigmoid colectomy for benign and malignant disease between 2003–2006. A total of 1,092 patients (10.3%) underwent laparoscopic sigmoid colectomy. Laparoscopic sigmoid colectomy was associated with a significantly shorter length of stay (5.4 vs 7.4 days), lower overall complication rate (19.7 vs 26.0%), lower 30-day readmission rate (3.4 vs 4.6), and a lower hospital cost ($13,814 vs $15,626). When a subset analysis of malignant and benign groups was performed, a significantly shorter length of stay in both the malignant laparoscopic group (6.4 ± 6.4 vs 7.8 ± 6.6 days) and in the benign laparoscopic groups (5.1 ± 3.5 vs 7.2 ± 7.6) exists. A lower wound complication rate (2.1 vs 5.5%, malignant and 4.0 vs 6.1, benign) is also evident. Laparoscopic sigmoid colectomy was associated with a shorter length of stay, less complications, and a lower 30-day readmission rate. The shorter length of stay and wound infection rate maintain significance when comparing laparoscopic vs open sigmoid resections for malignant and benign disease. Presented at the 48th annual meeting of the Society for Surgery of the Alimentary Tract at Digestive Disease Weak, Washington, DC, May 21st 2007. The information contained in this article was based on the Clinical Data Base provided by the University HealthSystem Consortium.     

Increasing utilization of laparoscopic gastric banding in the adolescent: data from academic medical centers, 2002-2009

Bariatric surgery in the adolescent continues to be a controversial topic. This study compared the utilization and perioperative outcomes of adolescent bariatric surgery performed at academic centers from 2002 to 2006 versus 2007 to 2009. We obtained data from the University HealthSystem Consortium for all adolescent patients (ages 12-18 years) who underwent bariatric surgery for the treatment of morbid obesity between 2002 and 2009. Outcomes including type of procedure, characteristics, length of stay, 30-day readmission, morbidity, and in-hospital mortality were compared between the two time periods. From 2007 to 2009, 340 adolescents underwent bariatric surgery at 63 academic hospitals. The mean number of adolescent bariatric procedures performed/year increased from 61.8 in 2002 to 2006 to 113.3 procedures/year in 2007 to 2009. There was an increase in utilization of laparoscopic gastric banding from 29 per cent to 50 per cent with a decrease in utilization of gastric bypass from 62 per cent to 48 per cent, respectively. For 2007 to 2009, the overall morbidity was 2.9 per cent with a 30-day readmission of 1.5 per cent and an in-hospital mortality of 0 per cent. Within the context of academic medical centers, adolescent bariatric surgery is associated with low morbidity and no mortality. Compared with 2002 to 2006, there has been an increase in the number of adolescent bariatric operations with increase in utilization of the laparoscopic gastric banding.     

Outcomes of laparoscopic and open colectomy at academic centers

BACKGROUND: Laparoscopic techniques have emerged as a suitable approach for colon resection. This study determined and compared the outcomes of patients undergoing laparoscopic or open colectomy at United States academic centers. METHODS: Using ICD-9-CM codes, we obtained data from the University HealthSystem Consortium database for 50,443 patients who underwent open (n = 47,090; 94%) or laparoscopic (n = 3,353; 6%) colectomy during a 5-year period (2002 to 2006). Outcomes studied included length of stay (LOS), costs, in-hospital morbidity and risk-adjusted mortality rates. RESULTS: Mean LOS (open = 11 days and laparoscopic = 7 days) was significantly shorter and mean costs (open = $23,000 and laparoscopic = $17,000) significantly fewer with the laparoscopic approach. The overall in-hospital morbidity rate was significantly lower with laparoscopic colectomy (open = 33% and laparoscopic = 24%). The risk-adjusted mortality ratio was comparable between groups (open = .9 and laparoscopic = .7). Comments: Despite the major biases inherent in this retrospective review of the University Health System Consortium, which favors the use of laparoscopic colectomy by United States academic surgeons, laparoscopic colectomy offers the potential of significantly shorter LOS, fewer costs, lower in-hospital morbidity rates, and comparable risk-adjusted mortality rates compared with open colectomy. Laparoscopic colectomy is as safe as the open approach.     

Laparoscopy should be the approach of choice for acute appendicitis in the morbidly obese

BACKGROUND: The current study compared the outcome of morbidly obese patients undergoing laparoscopic versus open appendectomy. METHODS: We obtained data from the University HealthSystem Consortium (UHC) database on 1,943 morbidly obese patients who underwent appendectomy for acute or perforated appendicitis between 2002 and 2007. RESULTS: Compared to open appendectomy, laparoscopic appendectomy was associated with a shorter length of stay (3 vs 4 days) and a lower overall complication rate (9% vs 17%). Most notably, a lower rate of wound infection was noted (1% vs 3%). Within a subset analysis of morbidly obese patients who underwent appendectomy for perforated appendicitis, there was a higher overall complication rate (27% vs 18%) and cost ($16,600 vs $12,300) in the open appendectomy group. CONCLUSION: In the morbidly obese, laparoscopic appendectomy performed for acute and perforated appendicitis is associated with a shorter length of stay and lower morbidity and costs. Laparoscopic appendectomy should be the procedure of choice for the treatment of acute appendicitis in the morbidly obese population.     

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.     

Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass

OBJECTIVE: To analyze long-term weight loss, changes in comorbidities and quality of life, and late complications after laparoscopic and open gastric bypass. SUMMARY BACKGROUND DATA: Early results from our prospective randomized trial comparing the outcome of laparoscopic versus open gastric bypass demonstrated less postoperative pain, shorter length of hospital stay, fewer wound-related complications, and faster convalescence for patients who underwent laparoscopic gastric bypass. METHODS: Between May 1999 and March 2001, 155 morbidly obese patients were enrolled in this prospective trial, in which 79 patients were randomized to laparoscopic gastric bypass and 76 to open gastric bypass. Two patients in the laparoscopic group required conversion to open surgery; their data were analyzed within the laparoscopic group on an intention-to-treat basis. The 2 groups were well matched for body mass index, age, and gender. Outcome evaluation included weight loss, changes in comorbidities and quality of life, and late complications. RESULTS: The mean follow-up was 39+/-8 months. There were no significant differences in the percent of excess body weight loss between the 2 groups at the 3-year follow-up (77% for laparoscopic versus 67% for open). The rate of improvement or resolution of comorbidities was similar between groups. Improvement in quality of life, measured by the Moorehead-Ardelt Quality of Life Questionnaire, was observed in both groups without significant differences between groups. Late complications were similar between groups except for the rate of incisional hernia, which was significantly greater after open gastric bypass (39% versus 5%, P<0.01), and the rate of cholecystectomy, which was greater after laparoscopic gastric bypass (28% versus 5%, P=0.03). CONCLUSIONS: In this randomized trial with a 3-year follow-up, we found that laparoscopic gastric bypass was equally effective as open gastric bypass with respect to weight loss and improvement in comorbidities and quality of life. A major advantage at long-term follow-up for patients who underwent laparoscopic gastric bypass was the reduction in the rate of incisional hernia.     

Impact on Perioperative Outcomes of Concomitant Hiatal Hernia Repair with Laparoscopic Gastric Bypass

Background

The role of laparoscopic hiatal hernia repair (LHHR) at the time of laparoscopic Roux-en-y gastric bypass (LRYGB) is still debatable. This study aims to assess the safety of concomitant LHHR with LRYGB.

Methods

This study is a multi-center, retrospective analysis of a large administrative database. The University Health System Consortium (UHC) is a group of 112 academic medical centers and 256 of their affiliated hospitals. The UHC database was queried using International Classification of Diseases??9 codes and main outcome measures were analyzed.

Results

From October 2006 to January 2010, we found 33,717 patients who underwent LRYGB and did not have a hiatal hernia. In this same time period, 644 patients underwent concomitant LRYGB and LHHR, while 1,589 patients underwent LRYGB without repair of their hiatal hernias. On comparison of patients undergoing LRYGB with simultaneous LHHR with those who underwent LRYGB without a diagnosis of HH, there was no significant difference in mortality, morbidity, length of stay (LOS), 30-day readmission, or cost shown. On comparison of patients with HH who underwent LRYGB and simultaneous LHHR with those who had LRYGB without LHHR, no significant difference with regards to all the outcome measures was also shown.

Conclusions

In conclusion, concomitant hiatal hernia repair with LRYGB appears to be safe and feasible. These patients did not have any significant differences in morbidity, mortality, LOS, readmission rate, or cost. Randomized controlled studies should further look into the benefit of hiatal hernia repair in regards to reflux symptoms and weight loss for LRYGB patients.     

Laparoscopic versus open gastric bypass for morbid obesity: a multicenter, prospective, risk-adjusted analysis from the National Surgical Quality Improvement Program

OBJECTIVE: To compare laparoscopic versus open gastric bypass procedures with respect to 30-day morbidity and mortality rates, using multi-institutional, prospective, risk-adjusted data. SUMMARY BACKGROUND DATA: Laparoscopic Roux-en-Y gastric bypass for weight loss is being performed with increasing frequency, partly driven by consumer demand. However, there are no multi-institutional, risk-adjusted, prospective studies comparing laparoscopic and open gastric bypass outcomes. METHODS: A multi-institutional, prospective, risk-adjusted cohort study of patients undergoing laparoscopic and open gastric bypass procedures was performed from hospitals (n = 15) involved in the Private Sector Study of the National Surgical Quality Improvement Program (NSQIP). Data points have been extensively validated, are based on standardized definitions, and were collected by nurse reviewers who are audited for accuracy. RESULTS: From 2000 to 2003, data from 1356 gastric bypass procedures was collected. The 30-day mortality rate was zero in the laparoscopic group (n = 401), and 0.6% in the open group (n = 955) (P = not significant). The 30-day complication rate was significantly lower in the laparoscopic group as compared with the open group: 7% versus 14.5% (P < 0.0001). Multivariate logistic regression analysis was performed to control for potential confounding variables and showed that patients undergoing an open procedure were more likely to develop a complication, as compared with patients undergoing an laparoscopic procedure (odds ratio = 2.08; 95% confidence interval, 1.33-3.25). Propensity score modeling revealed similar results. A prediction model was derived, and variables that significantly predict higher complication rates after gastric bypass included an open procedure, a high ASA class (III, IV, V), functionally dependent patient, and hypertension as a comorbid illness. CONCLUSIONS: Multicenter, prospective, risk-adjusted data show that laparoscopic gastric bypass is safer than open gastric bypass, with respect to 30-day complication rate.     

The relationship between hospital volume and outcome in bariatric surgery at academic medical centers

OBJECTIVE: To examine the effect of hospital volume of bariatric surgery on morbidity, mortality, and costs at academic centers. SUMMARY BACKGROUND DATA: The American Society for Bariatric Surgery recently proposed categorization of certain bariatric surgery centers as "Centers of Excellence." Some of the proposed inclusion criteria were hospital volume and operative outcomes. The volume-outcome relationship has been well established in several complex abdominal operations; however, few studies have examined this relationship in patients undergoing bariatric surgery. METHODS: Using the International Classification of Diseases, 9th edition, diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent Roux-en-Y gastric bypass for the treatment of morbid obesity between 1999 and 2002 (n = 24,166). Outcomes of bariatric surgery, including length of hospital stay, 30-day readmission, morbidity, observed and expected (risk-adjusted) mortality, and costs were compared between high-volume (>100 cases/year), medium-volume (50-100 cases/year), and low-volume hospitals (<50 cases/year). RESULTS: There were 22 high-volume (n = 13,810), 27 medium-volume (n = 7634), and 44 low-volume (n = 2722) hospitals included in our study. Compared with low-volume hospitals, patients who underwent gastric bypass at high-volume hospitals had a shorter length of hospital stay (3.8 versus 5.1 days, P < 0.01), lower overall complications (10.2% versus 14.5%, P < 0.01), lower complications of medical care (7.8% versus 10.8%, P < 0.01), and lower costs ($10,292 versus $13,908, P < 0.01). The expected mortality rate was similar between high- and low-volume hospitals (0.6% versus 0.6%), demonstrating similarities in characteristics and severity of illness between groups. The observed mortality, however, was significantly lower at high-volume hospitals (0.3% versus 1.2%, P < 0.01). In a subset of patients older than 55 years, the observed mortality was 0.9% at high-volume centers compared with 3.1% at low-volume centers (P < 0.01). CONCLUSIONS: Bariatric surgery performed at hospitals with more than 100 cases annually is associated with a shorter length of stay, lower morbidity and mortality, and decreased costs. This volume-outcome relationship is even more pronounced for a subset of patients older than 55 years, for whom in-hospital mortality was 3-fold higher at low-volume compared with high-volume hospitals. High-volume hospitals also have a lower rate of overall postoperative and medical care complications, which may be related in part to formalization of the structures and processes of care.     

Comparison of laparoscopic and open gastrectomy for gastric cancer

BACKGROUND: The role of minimally invasive gastrectomy in the treatment of gastric cancer is not well defined. The aim of the current study was to compare the operative outcomes and adequacy of resection of laparoscopic gastrectomy compared to open gastrectomy for gastric cancer. METHODS: The clinical course of 15 consecutive patients who underwent minimally invasive gastrectomy or esophagogastrectomy for gastric cancer were compared with that of 21 patients who underwent open gastrectomy. Main outcome measures included operative time, blood loss, length of stay, morbidity, 30-day mortality, and adequacy of lymphadenectomy and resection margins. RESULTS: There was no conversion to laparotomy in the laparoscopic group. Intraoperative blood loss was significantly lower in the laparoscopic group (138 mL vs. 357 mL). There was no significant differences in the mean operative time (244 vs. 241 min.), transfusion rate (6% vs. 29%), median length of stay (6 vs. 7 days), morbidity (7% vs. 24%), or number of lymph nodes harvested (15 vs. 14 nodes) between the 2 groups. Resection margins were negative in all patients. There were no leaks and the 30-day mortality was 0 in both groups. Anastomotic strictures were higher in the laparoscopic patients. CONCLUSION: Laparoscopic gastrectomy is feasible and can be performed safely with adequate lymphadenectomy compared with open gastrectomy.     

Endoscopic injection of fibrin sealant in repair of gastrojejunostomy leak after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: A leak at the gastrojejunostomy (GL) is a potentially life-threatening complication of laparoscopic Roux-en-Y gastric bypass. Because operative repair of acute leaks is usually unsuccessful, these patients often require prolonged hospitalization with drainage and parenteral hyperalimentation. METHODS: A total of 354 consecutive patients underwent primary laparoscopic Roux-en-Y gastric bypass at a New Jersey hospital. We reviewed the records of all patients who had GLs and were treated using either endoscopic injection of fibrin sealant (EIFS) at the site of the GL or open surgical drainage. RESULTS: A GL occurred in 8 patients (2.25%). Of these 8 patients, 3 with unstable vital signs underwent exploratory laparotomy and drainage, and 5 clinically stable patients with GL were treated nonoperatively and subsequently underwent EIFS into the GL. In the operative group, the mean duration of treatment between the identification of the GL and closure was 24 days, with a mean length of stay of 66 days. Of the 5 patients in the EIFS group, 1 required 2 injections within 11 days to achieve successful closure and 4 underwent closure of the GL within 2 days after injection, with a mean length of stay of 13.5 days. No complications or recurrences developed in the EIFS group. CONCLUSION: EIFS was successful in the 5 consecutive patients who developed a GL after laparoscopic Roux-en-Y gastric bypass. This technique reduces the morbidity and length of stay associated with open drainage. EIFS should be used as the primary treatment in stable patients with controlled GLs after major gastrointestinal operations.     

Outcomes and Use of Laparoscopic Versus Open Gastric Resection

Background and Objectives:

The advantages of laparoscopy over open surgery are well established. Laparoscopic resection for gastric cancer is safe and results in equivalent oncologic outcomes when compared with open resection. The purpose of this study was to assess the use of laparoscopy to treat gastric cancer and the associated outcomes.

Methods:

The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) dataset was queried for patients with gastric cancer (ICD-9 Code 151.0–151.9) from January 2005 through December 2012. Logistic regression was used to evaluate the 30-day morbidity and mortality of open gastrectomy (CPT code 43620-2, 43631-4) versus that of the laparoscopic procedure on the stomach (CPT code 43650), while adjusting for preoperative risk factors.

Results:

A total of 4116 patients with gastric cancer were identified and divided by surgical approach into 2 groups: open gastrectomy (n = 3725; 90.5%) and laparoscopic procedure on the stomach (n = 391; 9.5%). After adjustment for preoperative risk factors, complications were significantly fewer in laparoscopic versus open gastric resection (odds ratio [OR] 0.61, 95% confidence interval [CI] = 0.45–0.82; P = .001). After adjusting for preoperative risk factors, there was no statistically significant difference in mortality with laparoscopic compared to open gastric resection (OR 0.74; 95% CI = 0.32–1.72; P = .481).

Conclusions:

Laparoscopy is underused in the treatment of gastric cancer. Given that laparoscopic gastric resection has a lower morbidity in comparison to open resection, steps should be made toward advancing the use of laparoscopy for gastric cancer.     

A comparison study of laparoscopic versus open gastric bypass for morbid obesity

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (GBP) has been previously described, but a comparative study between laparoscopic and open GBP has not been reported. The purpose of this study was to compare surgical outcomes oflaparoscopic GBP with those of open GBP for treatment of morbid obesity. STUDY DESIGN: From August 1998 to September 1999, we prospectively collected outcome data on 35 patients with body-mass indices between 40 kg/m2 and 60 kg/m2 who underwent laparoscopic GBP. Demographics, operative data, perioperative complications, and weight losses were collected and compared with those obtained from a retrospective chart review of 35 patients with body-mass indices between 40 kg/m2 and 60 kg/m2 who underwent open GBP before August 1998. RESULTS: Age, gender, preoperative body-mass index, preoperative comorbidity, and earlier abdominal surgery were similar in both groups. All laparoscopic operations were completed without conversion to laparotomy. Mean operative time, operative blood loss, length of intensive care stay, and length of hospital stay were significantly less after laparoscopic GBP than after open GBP (p<0.05). There was no 30-day mortality in either group. At 1-year followup, analysis of the percentage of excess body weight loss showed no significant difference between the two groups (p<0.05). CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is technically feasible and safe. Laparoscopic GBP confers the clinical benefits of laparoscopy and an initial weight loss similar to that of open GBP.     

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.     

Outcomes after open versus laparoscopic gastric bypass

In expert hands, laparoscopic gastric bypass (LGB) is associated with reduced morbidity and mortality compared with open bariatric surgery. The purpose of our study was to determine whether or not the results of LGB have been realized in the general US population. We used data from the nationwide inpatient sample to define differences in outcomes after LGB versus open techniques (OGB). We calculated hospital stay, in-hospital mortality, and major complications for both OGB and LGB. We noted a total of 26,940 gastric bypass procedures: LGB was coded in 16.3% and OGB in 83.7%. The mean hospital stay, mortality, wound, gastrointestinal, pulmonary, and cardiovascular complications were significantly lower after LGB (P<0.001). After we adjusted for covariates, hospital stay, pulmonary morbidity, and mortality remained significantly lower after LGB (P<0.001). In conclusion, LGB is associated with significantly lower mean hospital stay and with reduced morbidity and mortality as compared with OGB.     

Laparoscopic gastric and biliary bypass: a single-center cohort prospective study

PURPOSE: Relief of gastric outlet and distal biliary obstruction may be accomplished by open surgery or by minimally invasive techniques including endoscopic and laparoscopic approaches. We examined the feasibility and safety of laparoscopic gastric and biliary bypass in all patients with malignant and benign disease requiring surgical relief of obstructive symptoms. MATERIALS AND METHODS: Patients with benign duodenal stricture or inoperable malignancy underwent therapeutic laparoscopic bypass surgery. Prophylactic gastric or biliary bypass was added in selected patients with nonmetastatic malignancy. RESULTS: Twenty-eight patients (17 of them female) with a median age of 67 years (range, 26-81 years) underwent 29 laparoscopic bypass procedures for malignant (n = 23) or benign (n = 6) disease. One patient who underwent a Roux-en-Y gastrojejunostomy for non-steroidal anti-inflammatory drug induced ulcer disease developed stenosis of the stoma that required laparoscopic refashioning 2 months later, accounting for the 29th procedure reported herein in 28 patients. Surgery included the construction of a single gastric (n = 16) or biliary (n = 5) bypass or a double bypass (n = 8), and an additional prophylactic bypass in 5 of 23 cancer patients (21.8%). All procedures were completed laparoscopically. The median operative time was 90 minutes (range, 60-153 minutes) and mean postoperative hospital stay was 4 days (range, 3-6 days). Complications developed following 4 procedures (13.8%) and 1 patient died (3.4%). No complications occurred in patients with prophylactic bypass. One patient required laparoscopic revision of the gastroenterostomy 2 months postoperatively, for benign disease. No recurrence of obstructive symptoms was observed in cancer patients during follow-up. CONCLUSION: Laparoscopic bypass surgery for distal biliary and gastric obstruction in patients with benign or malignant disease results in low morbidity and mortality and short postoperative hospital stay. The addition of prophylactic bypass in patients with nonmetastatic unresectable malignancy appears safe and effective.