Impact of the Surgical Experience on Leak Rate After Laparoscopic Sleeve Gastrectomy

Introduction

Laparoscopic sleeve gastrectomy (LSG) has become one of the most commonly performed bariatric procedures, largely due to several advantages it carries over more complex bariatric procedures. LSG is generally considered a straightforward procedure, but one of the major concerns is a staple line leak.

Objective

The objectives of this study are to evaluate the correlation between surgeon’s experience and leak rate and to assess the different risk factors for developing a gastric leak after LSG.Setting: Private hospital, France.

Methods

The analysis of a single surgeon’s yearly leak rate since the introduction of LSG for possible risk factors was done.

Results

A total of 2012 LSGs were performed in between September, 2005 and December, 2014. Twenty cases (1 %) of gastric leak were recorded. Of these, 17 patients were women (94.4 %) with a mean age of 39.4 years (range 22–61) and mean body mass index (BMI) 41.2 kg/m² (range 34.8–57.1). On a yearly basis, the leak rate was 4.8 % (2006), 5.7 % (2007), 0 (2008), 2.6 % (2009), 2 % (2010), 0.8 % (2011), 0.6 % (2012), 0.2 % (2013), and 0 (2014). In the first 1000 cases (group A), there were 18 cases of gastric leak and in the last 1000 cases, there were 800 with GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement (group B) 2 cases of gastric leak (p?=?0.009). A revisional LSG, 395 patients after gastric banding and 61 patients re-sleeve gastrectomy, was performed in 456 cases (22.7 %). There were 3 cases of leak (0.65 %). There were two deaths.

Conclusion

LSG can be performed with a low complication rate. This large series of a single surgeon’s experience demonstrated that the leak rate after LSG could be significantly decreased over time with changes in techniques.

     

经腹膜外腹腔镜前列腺癌根治术的关键点及操作技巧（附33例报告）

目的：总结经腹膜外腹腔镜前列腺癌根治术治疗前列腺癌的手术经验和操作技巧.方法：2006年1月～2010年3月对33例前列腺癌患者行经腹膜外腹腔镜前列腺癌根治术,手术经腹膜外顺行路径切除前列腺,切开膀胱颈部前先以1-0可吸收线缝扎背血管复合体,采用单针连续吻合法进行膀胱与尿道的吻合.结果：33例手术均获得成功,无中转开放手术.手术时间120～575 min,平均234 min,术中出血量100～1500 ml,平均320 ml,术后48小时内胃肠功能恢复,术后1～2天下地活动,没有直肠损伤和吻合口尿漏出现.标本切缘阳性1例.2例术后出现轻度尿失禁.2例出现尿道狭窄.对其中31例患者随访3～51个月,未发现肿瘤局部和生化复发和远处转移;术后3个月前列腺特异性抗原0～0.1 μg/L.结论：经腹膜外腹腔镜前列腺癌根治术是一种安全有效的手术方法.熟悉前列腺局部解剖及熟练掌握各种腹腔镜下操作技术是手术成功的关键.     

The Implementation of a Standardized Approach to Laparoscopic Rectal Surgery

Background and Objectives:

The purpose of this study was to audit our results after implementation of a standardized operative approach to laparoscopic surgery for rectal cancer within a fast-track recovery program.

Methods:

From January 2009 to February 2011, 100 consecutive patients underwent laparoscopic surgery on an intention-to-treat basis for rectal cancer. The results were retrospectively reviewed from a prospectively collected database. Operative steps and instrumentation for the procedure were standardized. A standard perioperative care plan was used.

Results:

The following procedures were performed: low anterior resection (n=26), low anterior resection with loop-ileostomy (n=39), Hartmann''s operation (n=14), and abdominoperineal resection (n=21). The median length of hospital stay was 7 days; 9 patients were readmitted. There were 9 cases of conversion to open surgery. The overall complication rate was 35%, including 6 cases (9%) of anastomotic leakages requiring reoperation. The 30-day mortality was 5%. The median number of harvested lymph nodes was 15 (range, 2 to 48). There were 6 cases of positive circumferential resection margins. The median follow-up was 9 (range, 1 to 27) months. One patient with disseminated cancer developed port-site metastasis.

Conclusions:

The results confirm the safety of a standardized approach, and the oncological outcomes are comparable to those of similar studies.     

A Standardized Technique for Laparoscopic Rectal Resection

Introduction

Laparoscopic rectal resection (LRR) has not gained the same acceptance as laparoscopic segmental colonic resection because of technical challenges, increased operating time and costs, and concerns about the oncological outcome.

Discussion

One way to overcome these challenges is by standardizing the laparoscopic technique in the same way as has been done with the open rectal cancer surgery. We have established a standardized, stepwise laparoscopic procedure for rectal resections that enhances the transformation of laparoscopic skills, identifies indications for conversion early in the operation, and makes the operation predictable and reproducible for the whole surgical team.

Conclusion

We believe this saves time in the operating room and builds up laparoscopic team expertise.     

Students' Interest in Surgery Affects Laparoscopic Practicing Performance

Methods:A laparoscopic simulation curriculum was introduced at Taipei Medical University, Wan-Fang Medical Center. Study participants included 36 sixth-year and 14 seventh-year students who were divided according to whether they had indicated an interest (group A) or not (group B) in surgery. The students had twice-a-week practice sessions for 2 weeks. They underwent baseline measurement (BM) before training and posttraining measurement (PTM). Self-guided practice on the simulator was allowed. The learning outcomes were assessed comparing the BM and PTM scores by using the interquartile range (IQR) test. We also tested the correlation between total score and number of self-guided practice sessions.Results:All study participants showed improvement. No differences were observed between BM and PTM scores and between 6th- and 7th-year medical students. Significant differences were found in PTM scores between groups A and B (P < .001). Analysis of variance with a post hoc test for different groups revealed that the PTMs were significantly higher for both the 6th- and 7th-year medical students in group A than for those in group B (P < .001). Total performance scores were improved with a higher number of self-guided practice sessions. Linear regression analysis demonstrated a significant correlation between the number of self-guided practice sessions and total performance score (P < .001).Conclusion:Those clerks and interns interested in surgery who had more sessions for self-guided practice, displayed more improvement than those not interested in surgery did. Improvement in performance correlated highly with trainees'' number of self-guided practice sessions.     

ABO Blood Incompatibility Positively Affects Early Graft Function: Single-Center Retrospective Cohort Study

BackgroundWe investigated the association between ABO-incompatible (ABO-I) kidney transplantation and early graft function.MethodsWe retrospectively analyzed 95 patients who underwent living donor kidney transplantation between May 2009 and July 2019. It included 61 ABO-compatible (ABO-C) and 34 ABO-I transplantations. We extracted data on immunologic profile, sex, age, cold ischemic time, type of immunosuppression, and graft function. Two definitions were used for slow graft function (SGF) as follows: postoperative day (POD) 3 serum creatinine level >3 mg/dL and estimated glomerular filtration rate (eGFR) <20 mL/min/1.73 m². Logistic regression analysis was performed to analyze the effect of ABO-I on the incidence of SGF.ResultsThe characteristics between the ABO-C and ABO-I were not different. ABO-I received rituximab and plasma exchange. Patients also received tacrolimus and mycophenolate mofetil for 2 weeks and prednisolone for 1 week before transplantation as preconditioning. Of the 95 study patients, 19 (20%) and 21 (22%) were identified with SGF according to POD 3 serum creatinine level or eGFR, respectively. Multivariable analysis revealed that ABO-I significantly reduced the incidence of SGF (odds ratio, 0.15; 95% confidence interval, 0.03-0.7; P = .02), and cold ischemic time >150 min increased the incidence of SGF (odds ratio, 6.5; 95% confidence interval, 1.7-25; P = .006). Similar results were identified in POD 3 eGFR. Inferior graft function in patients with SGF was identified up to 6 months after transplantation.ConclusionABO-I reduces the incidence of SGF, which is associated with an inferior graft function up to 6 months.     

Total Laparoscopic Hysterectomy Utilizing a Robotic Surgical System

Objectives:

To describe the use of a robotic surgical system for total laparoscopic hysterectomy.

Methods:

We report a series of laparoscopic hysterectomies performed using the da Vinci Robotic Surgical System. Participants were women eligible for hysterectomy by standard laparoscopy. Operative times and complications are reported.

Results:

We completed 10 total laparoscopic hysterectomies between November 2001 and December 2002 with the use of the da Vinci Robotic Surgical System. Operative results were similar to those of standard laparoscopic hysterectomy. Operative time varied from 2 hours 28 minutes to 4 hours 37 minutes. Blood loss varied from 25 mL to 350 mL. Uterine weights varied from 49 g to 227 g. A cystotomy occurred in a patient with a history of a prior cystotomy unrelated to the robotic system.

Conclusion:

Total laparoscopic hysterectomy is a complex surgical procedure requiring advanced laparoscopic skills. Tasks like lysis of adhesions, suturing, and knot tying were enhanced with the robotic surgical system, thus providing unique advantages over existing standard laparoscopy. Total laparoscopic hysterectomy can be performed using robotic surgical systems.     

Seasoned Surgeons Assessed in a Laparoscopic Surgical Crisis

Objective

Maintenance of certification is a relatively new concept in the United States, and there is no mandatory retirement for surgeons. Our aim was to compare technical and team performance of surgeons of different ages in a simulated laparoscopic surgical crisis and validate a potential recredentialing tool for surgeons.

Methods

Using a single-blinded protocol, the performance of six “Seasoned” surgeons >55 years (mean 64, range 55–83) was compared to six “control” surgeons <55 years (mean 46, range 34–53) in a simulation. Surgical teams established pneumoperitoneum, trocar access, and managed intraabdominal hemorrhage in a simulated laparoscopic cholecystectomy while videotaped as part of an IRB protocol. Surgeons’ performance was scored using validated technical and team performance scales.

Results

All of the “seasoned” surgeons relegated the use of unfamiliar technology to their assistants. All control surgeons achieved intraabdominal pneumoperitoneum themselves. Mean blood loss for seasoned surgeons and control surgeons was 2,555 versus 2,725 ml (NS), respectively. After recognition of bleeding in the unstable patient, senior surgeons converted to an urgent laparotomy case after 2.4 vs. 3.3 min for control group (NS). No difference was observed in overall technical and team abilities (p?=?NS). On debriefing, 85% of surgeons recommended simulation for training and recertification.

Conclusions

Seasoned surgeons can use their assistant surgeon well to assure a safe and effective operation. Mandatory operating room retirement based on age may be arbitrary and should be replaced by performance measures. Simulation may prove a valuable tool for self -assessment and recredentialing.     

腹腔镜胆囊切除术的经验与教训

为了腹腔镜胆囊切除术的旋行和安全推广,将4000例且无手术死亡病例的经验与大家交流。虽然腹腔镜胆囊切除手术适应证现在有所放宽,但对于初学者应严格选择病例。气腹的制备应注意安全和有助于以后的手术操作。以后的手术操作应该在密切监视下进行,尽量保持术野的干净和清楚。便于辨清解剖,在解剖不清或怀疑解剖变异时。可顺逆结合,仍有疑问则果断中转开腹,以减少手术的并发症。     

Laparoscopic cholecystectomy: Experience of a single surgeon

Gallbladder removal using laparoscopic techniques has rapidly been adopted by surgeons around the world. Questions have been raised concerning laparoscopic cholecystectomy, including the safety of the operation, its implications for management of common bile duct stones, and the means by which surgeons should be trained. In the present series, 424 patients were referred to a single surgeon for cholecystectomy during a 22-month period. A traditional open cholecystectomy was performed in 9 patients (2.1%) because of presumed contraindications to laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted in the remaining 415 patients (97.9%). On the basis of preoperative investigations, 19 patients (4.6%) underwent endoscopic retrograde cholangiopancreatography. Endoscopic sphincterotomy and stone extraction were performed in the 13 patients (3.1%) demonstrating choledocholithiasis. Laparoscopic cholecystectomy was converted to an open operation in 8 patients (1.9%) owing to dense adhesions, obscure anatomy, or cholangiographic abnormalities. Laparoscopic cholecystectomy was successfully performed in 407 patients (96%) in 95 ± 2 minutes (mean ± SEM). Surgical trainees were involved in all operations and performed 68% of the procedures under supervision. Cystic duct cholangiograms were obtained selectively in 129 patients (30.4%). Intraoperative complications occurred in 3 patients, including 1 patient with a minor injury to the common bile duct (0.2%). There was no perioperative mortality, and major complications occurred in 6 patients (1.4%). Minor complications were seen in 12 others (2.8%), and one patient required reoperation for a trocar injury to the jejunum. Prolonged follow-up has revealed one case of asymptomatic retained common bile duct stones (0.2%). Laparoscopic cholecystectomy can therefore be performed in more than 95% of patients with no mortality and minimal morbidity. The operation is safely taught to surgical trainees. Choledocholithiasis may be treated by a combination of endoscopic and laparoscopic techniques. Because of these considerations, laparoscopic cholecystectomy has become the preferred therapy for symptomatic cholelithiasis at our institution.

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Resumen La remoción de la vesícula biliar mediante técnicas laparoscópicas ha sido rápidamente adoptada por los cirujanos del mundo entero. Se han planteado interrogantes sobre la colecistectomía laparoscópica, incluyendo la seguridad de la operación, sus implicaciones en cuanto al manejo de cálculos capacitados. En la serie que aquí se presenta, 424 patientes fueron referidos para colecistectomía a un mismo cirujano en un periodo de 22 meses. Se practicó colecistectomía abierta tradicional en 9 pacientes (2.1%) debido a presumibles contraindicaciones de la colecistectomía laparoscópica. Se intento realizar colecistectomía laparoscópica en los 415 pacientes restantes (97.9%). Con base en la valoración preoperatoria, 19 pacientes (4.6%) fueron sometidos a colangiopancreatografía retrógada, y se practicó esfinterotomía endoscópica con extracción de cálculos en los 13 (3.1%) en que se demostró colelitiasis. La colecistectomía laparoscópica fue convertida a operación abierta en 8 (1.9%) debido a adherencias densas, anatomía no esclarecida o anomalías colangiográficas. La colecistectomía laparoscópica fue completada exitosamente en 407 pacientes (98.9%) en un tiempo de 95±2 min (promedio ± DEM). Los cirujanos en adiestramiento estuvieron involucrados en la totalidad de las operaciones y realizar el 68% de los procedimientos bajo supervisión. Se realizaron colangiogramas por vía del canal cístico en forma selectiva en 129 pacientes (31%). Complicaciones intraoperatorias fueron registradas en 3 pacientes, incluyendo uno que sufrió minima lesión del colédoco (0.2%). No hubo mortalidad perioperatoria y se presentaron complicaciones mayores en 6 pacientes (1.4%). Complicaciones menores fueron observadas en 12 casos (2.9%) y un paciente tuvo que ser reoperado por una lesión del yeyuno causada por trócar. El segumiento postoperatorio ha revelado un caso de cálculos retenidos en el colédoco (0.2%). Nuestra conclusión es que la colecistectomia laparoscópica puede ser realizada en más del 95% de los pacientes sin mortalidad y con mínima morbilidad; la operación puede ser enseñada en forma segura a cirujanos en adiestramiento. La coledolitiasis puede ser tratada mediante la combinación de técnicas endoscópicas y laparoscópicas. Por razón de tales consideraciones, la colecistectomia laparoscópica se ha convertido en la modalidad terapéutica de preferencia para colelitiasis sintomática en nuestra institución.

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Résumé L'ablation de la vésicule biliare par des techniques coelioscopiques a été rapidement adoptée par les chirurgiens dans le monde entier. On s'interroge cependant sur: a) la sûreté de l'intervention, b) l'attitude à envisager en cas de lithiase de la voie biliaire principale et c) la meilleure faÇon d'enseigner cette technique aux autres chirurgiens. La série présentée ici comporte 424 patients consécutifs opérés par un seul chirurgien pendant une période de 22 mois. Une cholécystectomie traditionnelle a été réalisée d'emblée dans 9 cas (2.1%) car la cholécystectomie sous coelioscopie avait été jugée contreindiquée. Une cholécystectomie a été envisagée sous coelioscopie chez les 415 patients restants (97.9%). Selon les données préopératoires, une cholangiopancréaticographie rétrograde par voie endoscopique a été réalisée chez 19 patients (4.6%). Une sphinctérotomie endoscopique avec extraction des calculs a été réalisée chez les 13 patients (3.1%) chez lesquels une lithiase de la voie biliaire principale avait été mise en évidence. Une conversion en cholécystectomie traditionnelle a été nécessaire chez 8 patients (1.9%) en raison d'adhérences serrées, de difficultés pour reconnaÎtre l'anatomie locale ou devant des anomalies cholangiographiques. La cholécystectomie coelioscopique a été réalisée avec succès chez 407 patients (98.9%) en 95 minutes (moyenne +/- erreur standardisée). Des chirurgiens en formation ont participé à toutes les interventions et, sous surveillance, en ont réalisée 68%. Une cholangiographie a été réalisée de faÇon sélective chez 129 patients (32%). Une complication peropératoire a été notée chez 3 patients, y compris une lésion de la voie biliaire principale (0.2%). Il n'y avait aucune mortalité alors qu'on a enrégistré 6 complications (1.4%) dans la période périopératoire. Des complications mineures ont été observées chez 12 autres patients (2.9%) et un patient a eu besoin d'Être réopéré en raison d'une lésion jéjunale provoquée par un trocard. Le suivi a permis de mettre en évidence un seul cas de lithiase résiduelle de la voie biliaire principale, asymptomatique (0.2%). La cholécystectomie coelioscopique peut donc Être réalisée chez plus de 95% des patients sans mortalité et avec une morbidité minime. L'intervention peut Être enseignée avec sécurité. La lithiase de la voie biliaire principale peut Être traitée par une combinaison de techniques endoscopiques et coelioscopiques. Au vu de ces conclusions, la cholécystectomie sous coelioscopie est devenue la thérapeutique de choix pour la lithiase biliare symptomatique dans notre service.

     

Laparoscopic Adjustable Esophagogastric Banding: a Preliminary Experience

Background: Laparoscopic adjustable gastric banding is an efficient surgical method in the treatment of morbid obesity. In order to reduce the number of complications, we have modified the technique to what we term ‘laparoscopic adjustable esophagogastric banding’. Methods: Between December 1994 and July 1997, 126 laparoscopic adjustable banding procedures were carried out. Of these, 40 underwent a gastric banding operation (group 1), and 86 underwent an esophagogastric banding procedure (group 2). Results: The percentage loss of excess body weight curve was less rapid in group 2 compared to group 1 due to a different strategy in band filling. Follow-up to date shows that no problems with the pouch or the stoma have arisen in the esophagogastric banding group. Conclusions: Laparoscopic adjustable esophagogastric banding is a simpler and safer procedure than laparoscopic adjustable gastric banding. It also works as a very efficient anti-reflux procedure, at least in the short term. It appears to be equally efficient as a weight-reducing operation as gastric banding. Further follow-up of the patients involved is necessary in order to evaluate the results in the longer term.     

同时经腹腔镜手术治疗肥胖症和胆囊结石的体会

目的 探讨同时经腹腔镜手术治疗肥胖症和胆囊结石的技巧、体会.方法 我科从2006年10月至2009年11月期间行腹腔镜可调节胃束带减容术(laparoscopic adjustable gastric banding, LAGB)治疗178例单纯肥胖患者,其中18例合并胆囊结石,同时行腹腔镜胆囊切除术(laparoscopic cholecystectomy, LC),对其临床资料进行回顾性分析.结果 18例肥胖症伴胆囊结石患者同时行腹腔镜手术治疗,全部成功,手术时间为(126±24) min,术中出血量为(50±16) ml;3例术后出现轻度恶心、呕吐,2例腹部穿刺切口轻度脂肪液化,1例腹腔少量积液,均经对症处理痊愈,无腹腔感染等严重并发症发生;术后1、3、6个月来院调整胃绑带松紧度,随访减重效果明显,胆囊结石引起的腹部症状消失.结论 LAGB手术创伤小且减重效果好;对合并胆囊结石者,通过调整LAGB腹壁戳孔位置可同时完成LC手术,无需增加新的腹部戳孔,创伤减少,且不影响LAGB手术效果,可达到同时治疗两种疾病的目的.     

Comparison of Preoperative Surgical Risk Estimated by Thoracic Surgeons vs a Standardized Surgical Risk Prediction Tool

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