Analgesic Efficacy of Bilateral Superficial Cervical Plexus Block in Robot-Assisted Endoscopic Thyroidectomy Using a Transaxillary Approach

Background

Nerve blocks and infiltration with local anesthetics are commonly employed methods for postoperative pain control. This prospective, randomized trial was conducted to determine whether bilateral superficial cervical plexus block (BSCPB) is effective for reducing acute postoperative pain after robot-assisted endoscopic thyroidectomy (RAET) and to compare its effects with that of local wound infiltration (LWI).

Methods

Ninety-seven patients who were to undergo RAET were randomly assigned to one of three groups to receive BSCPB with either 20?mL of 0.525?% ropivacaine (BSCPB group, n?=?32) or 20?mL of isotonic sodium chloride solution (Control group, n?=?32) or LWI with 20?mL of 0.525?% ropivacaine (LWI group, n?=?33). Postoperative pain scores were assessed at the postoperative anesthesia care unit (PACU) and at 6, 24, and 48?h postoperatively using a visual analog scale (VAS). Patients with VAS scores of ≥40 were administered rescue analgesics according to a standardized protocol. The main outcome variables were pain scores during the first postoperative 24?h and the number of patients requiring postoperative analgesic rescue.

Results

The BSCBP and LWI groups showed lower pain scores compared with the Control group at the PACU. The BSCPB group continued to show significantly lower pain scores compared with the LWI and Control groups at postoperative 6 and 24?h. The number of patients requiring analgesic rescue at the PACU was lower in the BSCPB and LWI groups than in the Control group. The number of patients requiring additional rescue analgesics after discharge from the PACU until the first 24 postoperative h was lower in the BSCPB group than in the LWI group.

Conclusions

BSCPB and LWI are effective for reducing pain scores and analgesic requirements during the immediate postoperative period in patients who undergo RAET, with BSCPB being superior to LWI at postoperative 6–24?h.     

Single-site Laparoscopic Colorectal Surgery Provides Similar Lengths of Hospital Stay and Similar Costs Compared with Standard Laparoscopy: Results of a Retrospective Cohort Study

Background

The present study sought to compare the length of stay (LOS) and hospital costs for elective single-site (SSL) and standard laparoscopic (SDL) colorectal resections performed at a tertiary referral center.

Methods

An IRB-approved, retrospective cohort study of all elective SDL and SSL colorectal resections performed from 2008 to 2012 was undertaken. Patient charges and inflation adjusted hospital costs (US dollars) were compared with costs subcategorized by operating room expense, room and board, and pharmacy and radiology utilization.

Results

A total of 149 SDL and 111 SSL cases were identified. Compared with SSL, SDL surgeries were associated with longer median operative times (SSL: 153 min vs. SDL: 189 min, p?=?0.001); however, median operating room costs were similar (p?>?0.05). Median postoperative LOS was similar for both groups (SSL: 3 days; SDL: 4 days; p?>?0.05). There was no difference between SSL and SDL with respect to either total patient charges (SSL: $34,847 vs. SDL: $38,306; p?>?0.05) or hospital costs (SSL: $13,051vs. SDL: $12,703; p?>?0.05). Median costs during readmission were lower for SSL patients (SSL: $3,625 vs. SDL: $6,203, p?=?0.04).

Conclusions

SSL provides similar LOS as well as similar costs to both patients and hospitals compared with SDL, making it a cost-feasible alternative.     

Routine Gastrostomy Tube Placement in Gastric Bypass Patients: Impact on Length of Stay and 30-Day Readmission Rate

Background

Laparoscopic Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity. Current average length of hospital stay (LOS) after RYGB is 2–3 days and 30-day readmission rate is 8–13 %. The aim of our study is to evaluate the effect of routine gastrostomy tube placement in perioperative outcomes of RYGB patients.

Methods

Between January 2008 and December 2010, a total of 840 patients underwent RYGB at our institution. All RYGB patients had gastrostomy tube placed, which was kept for 6 weeks. A retrospective review of a prospectively collected database was performed for all RYGB patients, noting the outcomes and complications of the procedure.

Results

Average LOS in our patient population was 1.1 days (range, 1–14 days), and 824 (98.3 %) patients were discharged on postoperative day 1. Readmissions within 30 days after the index RYGB was observed in 31 (3.7 %) patients. Reasons included abdominal pain (n?=?14), nausea/vomiting (n?=?6), gastrostomy tube-related complications (n?=?5), chest pain (n?=?3), allergic reaction (n?=?1), urinary tract infection (n?=?1), and dehydration (n?=?1). Of these readmitted patients, nine (1.1 %) patients required reoperations due to small bowel obstruction (n?=?5), perforated anastomotic ulcer (n?=?1), anastomotic leak (n?=?1), subphrenic abscess (n?=?1), and appendicitis (n?=?1).

Conclusions

Routine gastrostomy tube placement in the gastric remnant at the time of RYGB seems to have contributed to our short LOS and low 30-day readmission rate.     

Early Post-operative Complications: Incidence, Management, and Impact on Length of Hospital Stay. A Retrospective Comparison Between Laparoscopic Gastric Bypass and Sleeve Gastrectomy

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most common obesity surgeries. Their early complications may prolong hospital stay (HS).

Methods

Data for patients who underwent LRYGB and LSG in our clinic from 2009 through August 2012 were collected. Early post-operative complications prolonging HS (>5 days) were retrospectively analyzed, highlighting their relative incidence, management, and impact on length of HS.

Results

Sixty-six patients (4.9 %) after 1,345 LRYGB operations vs. 49 patients (7.14 %) after 686 LSG operations developed early complications. This difference is statistically significant (p?=?0.039). Male gender percentage was significantly higher in complicated LSG group vs. complicated LRYGB group [23 patients (46.9 %) vs. 16 patients (24.2 %)] (p?=?0.042). Mean BMI was significantly higher in the complicated LSG group (54.2?±?8.3) vs. complicated LRYGB group (46.8?±?5.7; p?=?0.004). Median length of HS was not longer after complicated LSG compared with complicated LRYGB (11 vs. 10 days; p?=?0.287). Leakage and bleeding were the most common complications after either procedure. Leakage rate was not higher after LSG (12 patients, 1.7 %) compared with LRYGB (22 patients, 1.6 %; p?=?0.304). Bleeding rate was significantly higher after LSG (19 patients, 2.7 %) than after LRYGB (10 patients, 0.7 %; p?=?0.004). Prolonged elevation of inflammatory markers was the most common presentation for complications after LSG (18 patients, 36.7 %) and LRYGB (31 patients, 46.9 %).

Conclusions

LSG was associated with more early complications. This may be attributed to higher BMI and predominance of males in LSG group.     

The Burden of Gastrointestinal Anastomotic Leaks: an Evaluation of Clinical and Economic Outcomes

Objective

To evaluate the clinical and economic burden associated with anastomotic leaks following colorectal surgery.

Methods

Retrospective data (January 2008 to December 2010) were analyzed from patients who had colorectal surgery with and without postoperative leaks, using the Premier Perspective? database. Data on in-hospital mortality, length of stay (LOS), re-admissions, postoperative infection, and costs were analyzed using univariate and multivariate analyses, and the propensity score matching (PSM) and generalized linear models (GLM).

Results

Of the patients, 6,174 (6.18 %) had anastomotic leaks within 30 days after colorectal surgery. Patients with leaks had 1.3 times higher 30-day re-admission rates and 0.8–1.9 times higher postoperative infection rates as compared with patients without leaks (P?<?0.001 for both). Anastomotic leaks incurred additional LOS and hospital costs of 7.3 days and $24,129, respectively, only within the first hospitalization. Per 1,000 patients undergoing colorectal surgery, the economic burden associated with anastomotic leaks—including hospitalization and re-admission—was established as 9,500 days in prolonged LOS and $28.6 million in additional costs. Similar results were obtained from both the PSM and GLM for assessing total costs for hospitalization and re-admission.

Conclusions

Anastomotic leaks in colorectal surgery increase the total clinical and economic burden by a factor of 0.6–1.9 for a 30-day re-admission, postoperative infection, LOS, and hospital costs.     

Postoperative Nausea and Vomiting with Application of Postoperative Continuous Positive Airway Pressure after Laparoscopic Gastric Bypass

Background

This study was performed to assess postoperative nausea and vomiting (PONV) with application of postoperative continuous positive airway pressure (CPAP) for patients undergoing Roux-en-Y gastric bypass (RYGB).

Methods

The anesthesia database was searched for patients who underwent RYGB for 5 years. Three hundred fifty-six patients met the inclusive criteria. Wilcoxon two-sample rank test, Fisher’s exact test, and multivariate logistic regression were used to analyze the data and identify the potential factors. A p value less than 0.05 was considered significant.

Results

The overall incidence of the PONV (nausea or emesis or both) was 42%during the first 24 h postoperatively. Thirty-six percent and 35% in CPAP and no-CPAP groups respectively had reported nausea in postanesthesia care unit (PACU). There was no difference between groups (p?>?0.05). There was a less frequent occurrence of emesis in both groups. The incidence of emesis in PACU was 19% in CPAP group and 17% in no-CPAP group (p?>?0.05). No statistically significant differences of PONV in postoperative 24 h could be shown between the groups (p?>?0.05). The postoperative hypertension occurred more often and intravenous antihypertensive medications were required more in no-CPAP patients (p?=?0.013). More patients in no-CPAP group developed oxygenation disturbances (p?=?0.012).The mean length of PACU stay was significantly longer in this group (p?=?0.029). Reintubation and intensive care unit admission occurred more frequently in no-CPAP patients; however, the difference did not reach statistical significance.

Conclusions

There was no significantly increased risk of PONV with the use of postoperative CPAP. We recommend the routine use of postoperative CPAP for patients with obstructive sleep apnea undergoing RYGB to optimize their respiratory function.     

Combined spinal and general anesthesia vs general anesthesia for robotic sacrocervicopexy: a randomized controlled trial

Introduction and hypothesis

Gynecologic laparoscopic surgery is frequently accompanied by early postoperative pain. This study assessed the effect of combined general and spinal anesthesia on postoperative pain score, analgesic use, and patient satisfaction following robotic surgeries.

Methods

This was a randomized controlled trial. Thirty-eight consecutive women who underwent robotic surgeries for pelvic organ prolapse (sacrocolpopexy with or without subtotal hysterectomy) were randomly assigned to receive general anesthesia (control group, n?=?20) or combined general with spinal anesthesia (study group, n?=?18). Pain scores were assessed at rest and while coughing using a visual analog scale (VAS) 0–10. Dosage of analgesic medication consumption was retrieved from patients’ charts.

Results

There were no statistically significant differences between the two groups with respect to demographic data and intraoperative hemodynamic parameters. In the postanesthesia care unit (PACU) mean total IV morphine and meperidine dosages were significantly lower for the study than the control group (0.33 vs 7.59 mg, 1.39 vs 27.89 mg, respectively, P?<?0.003, <0.001, respectively). In addition, a significantly lower percentage of patients belonging to the study group demanded analgesic medications while in the PACU (33 vs 53 %, P?=?0.042). Pain scores in the PACU and during postoperative day 1 were significantly lower in the study group than in the control group (delta VAS 1.9 vs 3.0, P?=?0.04). Satisfaction with pain treatment among both patients and nurses was significantly higher in the study group.

Conclusions

Reported levels of pain and analgesic use during the first 24 h following robotic gynecologic surgery were significantly lower following general and spinal anesthesia compared to general anesthesia alone.     

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.

     

Incidence of Gastrojejunostomy Stricture in Laparoscopic Roux-en-Y Gastric Bypass Using an Autologous Fibrin Sealant

Background

Anastomotic leak at the gastrojejunostomy is a life-threatening complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Fibrin sealants have been used as topical adjuncts to reduce leaks at the gastrojejunostomy. Our clinical observations suggest that an unintended consequence may be the promotion of anastomotic stricture. We hypothesized that the use of fibrin sealant at the gastrojejunostomy in patients undergoing LRYGB decreases the incidence of anastomotic leak but increases the incidence of clinically significant stricture.

Methods

Following institutional review board approval, medical records of patients undergoing LRYGB by two surgeons at a single institution over a 5-year period were retrospectively reviewed. Preoperative demographics and postoperative complication rates including incidence of gastrojejunostomy leak and endoscopically diagnosed stricture requiring dilation within 1 year of surgery were recorded.

Results

Four hundred twenty-five patients had fibrin sealant routinely applied to their gastrojejunostomy site and 104 did not. Four leaks occurred in the sealant group and two leaks occurred in the control group (p?=?0.2). Of patients who received sealant, 1.6 % needed postoperative blood transfusion compared to those 1.6 % of patient who did not receive sealant (p?=?0.05). There was a significantly increased rate of strictures requiring dilation in the sealant group (11.3 % compared to 4.8 % stricture rate in patients who did not receive sealant, p?=?0.04).

Conclusions

In our experience, the use of fibrin sealant at linear stapled gastrojejunostomy site during LRYGB increases the incidence of clinically significant postoperative stricture and does not reduce the incidence of anastomotic leak.     

Laparoscopic Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy as a Definitive Surgical Procedure for Morbid Obesity. Mid-Term Results

Background

Laparoscopic sleeve gastrectomy (LSG) has been gaining acceptance because it has shown good short- and mid-term results as a single procedure for morbid obesity. The aim of this study was to compare short- and mid-term results between laparoscopic Roux-en-Y gastric bypass (LRYGB) and LSG.

Methods

Observational retrospective study from a prospective database of patients undergoing LRYGB and LSG between 2004 and 2011, where 249 patients (mean age 44.7 years) were included. Patients were followed at 1, 3, 6, 12, and 18 months, and annually thereafter. Short- and mid-term weight loss, comorbidity improvement or resolution, postoperative complications, re-interventions, and mortality were evaluated.

Results

One hundred thirty-five LRYGB and 114 LSG were included. Significant statistical differences between LRYGB and LSG were found in operative time (153 vs. 93 min. p?<?0.001), minor postoperative complications (21.5 % vs. 4.4 %, p?=?0.005), blood transfusions (8.8 % vs. 1.7 %, p?=?0.015), and length of hospital stay (4 vs. 3 days, p?<?0.001). There were no differences regarding major complications and re-interventions. There was no surgery-related mortality. The percentage of excess weight loss up to 4 years was similar in both groups (66?±?13.7 vs. 65?±?14.9 %). Both techniques showed similar results in comorbidities improvement or resolution at 1 year.

Conclusions

There is a similar short- and mid-term weight loss and 1-year comorbidity improvement or resolution between LRYGB and LSG, although minor complication rate is higher for LRYGB. Results of LSG as a single procedure need to be confirmed after a long-term follow-up.     

High Performing Whipple Patients: Factors Associated with Short Length of Stay after Open Pancreaticoduodenectomy

Introduction

Despite the decreasing mortality of pancreaticoduodenectomy (PD), it continues to be associated with prolonged length of postoperative hospital stay (LOS). This study aimed to determine factors that could predict short LOS after PD. Additionally, as preliminary data of minimally invasive PD emerges, we sought to determine the average LOS after open PD at a high-volume center to set a standard to which minimally invasive PD can be compared.

Methods

A total of 634 consecutive patients who underwent open PD between January 2007 and December 2012 at the Massachusetts General Hospital comprised the study cohort. “High performers” were defined as patients with postoperative LOS ≤5 days.

Results

Median LOS was 7 days. A total of 61 patients (9.6 %) had LOS ≤5 days and were deemed “high performing.” In multivariate logistic regression analysis, male gender (p?=?0.032), neoadjuvant chemoradiation (p?=?0.001), epidural success (p?=?0.019), epidural duration ≤3 days (p?=?0.001), lack of complications (p?p?=?0.001), and discharge on Monday through Wednesday (p?5 days, but high performance was predictive of beginning therapy <8 weeks after surgery (p?=?0.010).

Conclusion

In our experience, median LOS was 7 days, and early discharge (≤5 days) after open PD is safe and feasible in about 10 % of patients. These high performers are more likely to be male, have received neoadjuvant therapy, and had successful epidural analgesia. High performers with cancer are more likely to start chemotherapy <8 weeks after surgery. Minimally invasive PD should be compared to this high standard for median LOS, among other quality metrics, to justify its increased cost, operative duration, and learning curve.     

Usefulness of an enhanced recovery after surgery protocol for perioperative management following open repair of an abdominal aortic aneurysm

Purpose

To achieve early recovery and early discharge from the hospital by applying an enhanced recovery after surgery (ERAS) protocol, which is mainly used with colonic surgery, for the perioperative management of open AAA surgery.

Method

One hundred twenty-seven open AAA surgery cases successfully carried out between 2003 and 2011 were included in this study. The ERAS protocol was used for the cases from April 2008 onward, and we performed a comparison of the conventionally treated cases with ERAS cases regarding the start of postoperative oral consumption, the postoperative hospital stay, and hospitalization medical costs.

Results

The time to restarting oral consumption and the postoperative hospital stay were significantly shorter for the ERAS group (n?=?52) compared to the conventionally managed group (n?=?75); with values of 59?±?15 and 93?±?25?h (p?=?0.021), 9?±?3 and 16?±?5?days (p?=?0.001), respectively. The medical costs for the ERAS group were 92?% of the costs of the conventionally managed group.

Conclusion

Use of the ERAS protocol for the perioperative management of open AAA surgery shortened the time before recommencing oral consumption, the postoperative hospital stay, and reduced the medical costs compared to the conventional approach.     

The feasibility of short-stay laparoscopic appendectomy for acute appendicitis: a prospective cohort study

Background

Short-stay laparoscopic appendectomy for acute appendicitis (AA) has not yet been validated. This study was designed to prospectively evaluate the hospital length of stay (LOS) after laparoscopic appendectomy for AA and to determine predictive factors for successful short-stay surgery (LOS <24?h).

Methods

Between January and December 2010, all consecutive adults admitted for AA were prospectively treated with LOS <24?h as a patient management goal. The proportion of patients with LOS <24?h was analyzed for the intention-to-treat (ITT) population and for the population eligible for short-stay surgery. Predictive factors for LOS <24?h were analyzed.

Results

Of the 123 patients included in this study, 71.5?% (88/123) were eligible for short-stay surgery. The proportion of LOS <24?h cases was 52?% (64/123) in the ITT population and 72.7?% (64/88) in the eligible population. LOS <12?h was achieved in 17.8?% (22/123) in the ITT patients and 25?% (22/88) of the eligible patients. The main cause of unexpected readmission was postoperative pain (n?=?10, 8.1?%). Age <23?years and a serum C-reactive protein level <18?mg/l had a positive predictive value of 100?% for LOS <24?h. Of the eligible patients, 27.2?% (24/88) were subject to unplanned overnight admissions and postsurgery readmissions.

Conclusions

LOS <24?h was feasible for 52?% of patients admitted for AA and for 72.7?% of the patients eligible for short-term surgery. Low age and a low preoperative serum CRP level are predictive factors for the feasibility of short-stay laparoscopic appendectomy for AA.     

Trends in adolescent bariatric surgery evaluated by UHC database collection

Background

With increasing childhood obesity, adolescent bariatric surgery has been increasingly performed. We used a national database to analyze current trends in laparoscopic bariatric surgery in the adolescent population and related short-term outcomes.

Methods

Discharge data from the University Health System Consortium (UHC) database was accessed using International Classification of Disease codes during a 36?month period. UHC is an alliance of more than 110 academic medical centers and nearly 250 affiliate hospitals. All adolescent patients between 13 and 18?years of age, with the assorted diagnoses of obesity, who underwent laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (SG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) were evaluated. The main outcome measures analyzed were morbidity, mortality, length of hospital stay (LOS), overall cost, intensive care unit (ICU) admission rate, and readmission rate. These outcomes were compared to those of adult bariatric surgery.

Results

Adolescent laparoscopic bariatric surgery was performed on 329 patients. At the same time, 49,519 adult bariatric surgeries were performed. One hundred thirty-six adolescent patients underwent LAGB, 47 had SG, and 146 patients underwent LRYGB. LAGB has shown a decreasing trend (n?=?68, 34, and 34), while SG has shown an increasing trend (n?=?8, 15, and 24) over the study years. LRYGB remained stable (n?=?44, 60, and 42) throughout the study period. The individual and summative morbidity and mortality rates for these procedures were zero. Compared to adult bariatric surgery, 30?day in-hospital morbidity (0 vs. 2.2?%, p?<?0.02), the LOS (1.99?±?1.37 vs. 2.38?±?3.19, p?<?0.03), and 30?day readmission rate (0.30 vs. 2.02?%, p?<?0.05) are significantly better for adolescent bariatric surgery, while the ICU admission rate (9.78 vs. 6.30?%, p?<?0.02) is higher and overall cost ($9,375?±?6,452 vs. $9,600?±?8,016, p?=?0.61) is comparable.

Conclusion

Trends in adolescent laparoscopic bariatric surgery reveal the increased use of sleeve gastrectomy and adjustable gastric banding falling out of favor.     

Impact of remifentanil use on early postoperative outcomes following brain tumor resection or rectal cancer surgery

Purpose

Remifentanil, a mu-opioid receptor agonist, has important characteristics for neuroanesthesia, but data about its effects on postoperative recovery and mortality are currently lacking.

Methods

Using the Japanese Diagnosis Procedure Combination database in 2007, we selected patients who underwent elective brain tumor resection with open craniotomy under general anesthesia using either remifentanil or fentanyl and divided them into two categories: remifentanil patients and non-remifentanil patients. After propensity score matching for potential confounders, we compared the in-hospital mortality and postoperative length of stay (LOS) between the two groups. For comparison, the same endpoints were evaluated for patients underwent rectal cancer surgery under general anesthesia with intraoperative epidural anesthesia.

Results

In patients who underwent brain tumor resection (936 pairs), remifentanil patients had significantly lower in-hospital mortality (1.5?% vs. 3.0?%; P?=?0.029). Logistic regression analysis revealed that the odds ratio for use of remifentanil for in-hospital mortality was 0.47 (95?% confidence interval, 0.25–0.91; P?=?0.025). Remifentanil patients also showed earlier discharge from hospital (median LOS, 17 vs. 19?days; hazard ratio, 1.19, 95?% confidence interval, 1.08–1.30; P?<?0.001). In contrast, in 2,756 pairs of patients undergoing rectal cancer surgery, no significant difference was seen in either in-hospital morality (1.2?% vs. 1.3?%; P?=?0.518) or median LOS (19 vs. 19?days; P?=?0.148) between the two groups.

Conclusions

Our data suggest a possible association between use of remifentanil and better early postoperative recovery for patients undergoing neurosurgery with craniotomy. Further studies, including a randomized controlled trial, are required to confirm the present results.     

A Randomized Clinical Trial of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for the Treatment of Morbid Obesity in China: a 5-Year Outcome

Background

No randomized comparative trials have presented long-term outcomes for laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). The present study was designed to compare the efficacy and safety of these two procedures.

Methods

From January 2007 to July 2008, 64 eligible patients were randomly assigned to LSG or LRYGB. During the 5-year follow-up, we compared morbidity rate, body mass index (BMI), percent of excess weight loss (%EWL), Moorehead-Ardelt (M-A) II quality of life, and resolution or improvement rate of obesity-related comorbidities between the groups.

Results

Both groups were matched with respect to age, gender, and BMI. Slightly more major complications were observed in patients undergoing LRYGB (P?>?0.05). Weight loss was significantly better with LRYGB except during the first postoperative year. At 5 years, %EWL for LSG and LRYGB was 63.2?±?24.5 % and 76.2?±?21.7 % (P?=?0.02), respectively. No statistical difference was observed in quality of life between the groups at all intervals (P?>?0.05). At the last follow-up, most comorbidities in both groups were resolved or improved, with no difference between the groups (P?>?0.05).

Conclusion

LRYGB and LSG are equally safe and effective in quality of life and improvement or resolution of comorbidities, and LRYGB possesses the superiority in terms of weight loss. Further studies are needed to evaluate micronutrient deficiencies of these procedures.     

Perioperative experience of pelvic organ prolapse repair with the Prolift® and Elevate® vaginal mesh procedures

Introduction and hypothesis

We compared the operative and immediate postoperative experience of the trocar-based Prolift® and non-trocar-based Elevate® techniques used to repair vaginal prolapse.

Methods

A retrospective review of Prolift and Elevate repairs was performed. Baseline characteristics and operative and postoperative variables evaluated included compartment(s) repaired, adjacent organ injury, operative time (OT), change in hemoglobin (ΔH), pain score, narcotic use, length of stay (LOS), and short-term complications. Categorical variables were assessed as counts and percent frequency. Data were compared using chi-squared analysis and paired t test.

Results

Prolift (n?=?143) and Elevate (n?=?77) patients were similar in age (p?=?0.19). Concurrent hysterectomy was done in 22 (15.4 %) and 24 (31.2 %), respectively, and concurrent midurethral sling placed in 100 (70 %) and 50 (65 %), respectively. LOS (median, 25th,75th) after anterior/apical compartment repairs was shorter with Elevate, whether with (1.0; 1.0,1.5 vs. 2.0 days;1.0, 2.0; p?=?0.003) or without (2.0; 1.0, 2.0 vs. 2.0 days; 2.0, 3.0; p?=?0.024) hysterectomy, but no differences in OT, ΔH, pain score, or narcotic use occurred. Posterior compartment mean pain scores were lower with Prolift (3.6 ± 2.2 vs. 1.7 ± 1.5, p?=?0.035), and three-compartment-repair pain scores were lower with Elevate (0.6 ± 1.3 vs 2.5 ± 1.9; p?=?0.013). Three bladder injuries occurred with Prolift but none with Elevate.

Conclusions

Operative and postoperative experiences were similar between groups; however, Elevate anterior/apical repairs had shorter LOS, which might reflect more aggressive discharge planning. There were no bowel or major vascular injuries, and the Prolift trocar bladder injuries did not alter the surgical procedure.     

Use of preoperative antidepressants is not associated with postoperative hospital length of stay

Purpose

Antidepressant medications are commonly prescribed for the treatment of depression, anxiety, and chronic pain. Their use may lead to a number of side effects with important implications in the perioperative period. Our aim was to examine the effect of preoperative antidepressant administration on post-surgical hospital length of stay (LOS) in elective non-cardiac surgery patients.

Design

Historical cohort study.

Methods

Demographic and preoperative data were collected by chart review for all non-cardiac surgery patients who were assessed in the preoperative consult clinic from April 2008 through February 2009. Patients were grouped according to whether or not they were taking antidepressant medications. Median length of stay was compared between patients who took antidepressants preoperatively and those who did not.

Results

Data were collected for 3,692 patients. Two hundred eighty-nine (7.8%) patients were taking antidepressants preoperatively. Use of antidepressants was not associated with an increased hospital LOS. The median LOS was four days both for patients who took antidepressants preoperatively (95% confidence interval [CI] 4 to 4) and for those who did not (95% CI 3 to 5) (P = 0.13).

Conclusions

The preoperative use of antidepressant medications was not associated with increased postoperative hospital LOS following elective non-cardiac surgery.     

The Impact of Preoperative Weight Loss Before Laparoscopic Gastric Bypass

Background

The impact of preoperative weight loss on outcomes following laparoscopic Roux-en-Y gastric bypass (LRYGB) is a controversial issue. We evaluated our outcomes of LRYGB in patients who lost different amount of weight prior to surgery.

Methods

Patients who underwent primary LRYGB were divided in three groups on the basis of preoperative weight loss percentage. Group A comprised 166 patients, who lost <5 % of their weight preoperatively; group B comprised 239 patients who lost >5 to 10 % and group C included 143 patients who lost >10 %. Intra- and postoperative complications at 30 days, hospital stay, and outcomes were evaluated.

Results

Significant difference was found in operative (mean ± SD) time [104.43?±?36.40 min in group A, 80.08?±?23.07 min in group B, and 76.99?±?23.23 min in group C; p?<?0.001 in group A versus group B or group C; p?=?0.210 in group B versus group C]. Difference in hospital stay was significant (3.33?±?3.22 days in group A, 2.10?±?2.77 in group B, and 1.87?±?1.44 in group C; p?<?0.001 in group A versus groups B or C). Overall postoperative morbidity rate was 33.13 % in group A, 19.25 % in group B, and 11.89 % in group C, with significant difference in group A versus groups B or C (p?=?0.002 and p?<?0.001). Mean excess weight loss was significantly higher (72.7 %) in group C versus group A (63.1 %) (p?=?0.015) at 12 months.

Conclusions

Weight loss >5 % prior to LRYGB may reduce morbidity, and preoperative weight loss >10 % may improve weight loss outcomes at 1-year follow-up.