Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: First 250 cases

BackgroundA growing body of evidence supports the laparoscopic sleeve gastrectomy (LSG) as a safe and effective procedure for sustained weight loss and amelioration of weight-related co-morbidities. Procedures performed in ambulatory surgery centers (ASC) can provide several advantages over hospital-based surgery. We present our results of 250 consecutive patients undergoing LSG in an ASC. The objective of this study was to assess the safety and efficacy of outpatient LSG in a freestanding ASC.MethodsData was collected prospectively from 250 consecutive patients who underwent LSG at a freestanding ASC. Patients were excluded from the ASC if they weighed>450 pounds, if anticipated operative time was>2 hours, if the patient had impaired mobility limiting early ambulation, or if there were medical problems requiring postoperative monitoring beyond 23 hours. Revisions were not included in this study.ResultsMean age was 47 years (range, 23–74 yr). Mean preoperative body mass index (BMI) was 43 kg/m² (29–71 kg/m²). Mean operative time was 60 minutes (31–161 min). Mean recovery room time was 131 minutes (30–385 min). Mean percent excess weight loss (%EWL) was 60% at 1 year and 63% at 2 years. Nine patients (3.6%) were readmitted within 30 days. Two patients (.8%) were transferred from the ASC to a hospital. There was 1 staple line leak (.4%). There were no open conversions and no deaths.ConclusionsLSG can be performed safely in a freestanding ASC in select patients with outcomes comparable to the inpatient standard. Additional studies are needed to formulate selection criteria and guidelines to maximize patient safety and outcomes.     

Laparoscopic sleeve gastrectomy as day-case surgery: a review of the literature

Day-case surgery (DCS) in digestive surgery is a hot topic, and new indications for DCS in the field of gastrointestinal surgery have recently been described. Laparoscopic sleeve gastrectomy (LSG) has become a popular bariatric procedure in recent years. LSG is a reproducible, standardized procedure with a short operating time and possibly simple perioperative management. It therefore meets the criteria to be performed as a DCS procedure. Recently published series of LSG as DCS have demonstrated its feasibility. In this review on LSG performed as DCS, we focused on the management of risks associated with DCS and the results of such type of management. A literature search was conducted in the PubMed and Embase databases. Six studies were selected, comprising a total of 6227 patients. Most published series were retrospective single-center studies. Inclusion criteria were similar between most studies (primary sleeve gastrectomy for most series, patients with a body mass index ≥40 kg/m² or a body mass index ≥35 kg/m² in the presence of co-morbidities), while exclusion criteria were based on literature data for some studies (using series on risk factors for morbidity and mortality after Roux-en-Y gastric bypass) and personal experience for other series. The mortality rate of LSG as DCS ranges 0%–.08%, while the overall complication rate ranges 0%–10%. The unplanned overnight admission rate after LSG ranges .8%–8%. The unscheduled hospitalization rates range 2.1%–8.5%. LSG performed as DCS is feasible with good results, but cannot be proposed for all patients. Good selection is necessary in others to avoid increased risk of morbidity and mortality.     

Outcomes of same-day discharge sleeve gastrectomy and Roux-en-Y gastric bypass: a systematic review and meta-analysis

Length of stay after bariatric surgery has progressively shortened. Same-day discharge (SDD) has been reported for the 2 most common bariatric procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). The aim of this study is to evaluate the safety and success of SDD following SG and RYGB. Systematic literature search on SDD after bariatric surgery was conducted in Medline, Cochrane library, Google Scholar, and Embase. SDD was defined as discharging the patient during the day of the bariatric operation, without an overnight stay. The primary outcomes of interest were successful SDD, readmission, and morbidity rates. The secondary endpoints included reoperation and mortality rates. A proportion meta-analysis was performed to assess the outcomes of interest. A total of 14 studies with 33,403 patients who underwent SDD SG (32,165) or RYGB (1238) were included in the qualitative synthesis. Seven studies with 5000 patients who underwent SDD SG were included in the quantitative analysis, and pooled proportions (PPs) were calculated for the outcomes of interest. The SDD success rate was 63%–100% (PP: 99%) after SG and 88%–98.1% after RYGB. The readmission rate ranged from .6% to 20.8% (PP: 4%) after SDD SG and 2.4%–4% after SDD RYGB. Overall morbidity, reoperation, and mortality were 1.1%–10% (PP:4%), .3%–2.1% (PP: 1%), and 0%–.1% (PP: 0%), respectively, for SDD SG, and 2.5%–4%,1.9%–2.5%, and 0%–.9%, respectively, for SDD RYGB. SDD after SG seems feasible and safe. The outcomes of SDDRYGB seem promising, but the evidenceis stilllimitedto draw definitive conclusions. Selection criteria and perioperative protocolsmust be standardized to adequately introduce this practice.     

Effect of the COVID-19 pandemic on bariatric surgery in North America: a retrospective analysis of 834,647 patients

BackgroundCOVID-19 has transformed surgical care, yet little is known regarding implications for bariatric surgery.ObjectiveWe sought to characterize the effect of COVID-19 on bariatric surgery delivery and outcomes.SettingThe Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 885 centers in North America.MethodsThe MBSAQIP database was evaluated with 2 cohorts described: the COVID-19 and the pre–COVID-19, with patients receiving surgery in 2020 and 2015–2019, respectively. Yearly operative trends were characterized, and bivariate analysis compared demographics and postoperative outcomes. Multivariable modeling evaluated 30-day readmission, reintervention, and reoperation rates and factors associated with undergoing Roux-en-Y gastric bypass.ResultsWe evaluated 834,647 patients, with 155,830 undergoing bariatric surgery during the 2020 pandemic year. A 12.1% reduction in total cases (177,208 in 2019 versus 155,830 in 2020; P < .001) and 13.8% reduction in cases per center occurred (204.2 cases per center in 2019 versus 176.1 cases per center in 2020; P < .001). Patients receiving bariatric surgery during the pandemic were younger and had fewer co-morbidities. Use of sleeve gastrectomy increased (74.5% versus 72.5%; P < .001), and surgery during COVID-19 was associated with reduced Roux-en-Y gastric bypass procedure selection (odds ratio = .83; 95% CI: .82–.84; P < .001). Length of stay decreased significantly (1.4 ± 1.4 days versus 1.6 ± 1.4 days; P < .001), yet postoperative outcomes were similar. After adjusting for co-morbidities, patients during COVID-19 had decreased 30-day odds of readmission and reintervention and a small increase in odds of reoperation.ConclusionThe COVID-19 pandemic dramatically changed bariatric surgery delivery. Further studies evaluating the long-term effects of these changes are warranted.     

Postoperative pneumonia after bariatric surgery during the COVID-19 pandemic: a National Surgical Quality Improvement Program study

BackgroundDuring the COVID-19 pandemic, surgical centers had to weigh the benefits and risks of conducting bariatric surgery. Obesity increases the risk of developing severe COVID-19 infections, and therefore, bariatric surgery is beneficial. In contrast, surgical patients who test positive for COVID-19 have higher mortality rates.ObjectiveThis study investigates the national prevalence of postoperative pneumonia during the COVID-19 pandemic in the bariatric surgery population.SettingThe American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database.MethodsThis is a cross-sectional study using the ACS-NSQIP database. The population of concern included patients who underwent sleeve gastrectomy and Roux-en-Y gastric bypass procedures. Information was extracted on rate of postoperative pneumonia and other 30-day complications between 2018 and 2020.ResultsAll baseline characteristics were similar among patients who underwent bariatric surgery between 2018 and 2020. However, there was a 156% increase in postoperative pneumonia in 2020 compared with the previous year. Furthermore, despite the similar postoperative complication rates across the years, there was a statistically significant increase in all-cause mortality in 2020. The multivariate analysis showed that having surgery in 2020 was a statistically significant risk factor for pneumonia development postoperatively.ConclusionsThis study showed a statistically significant increase in the prevalence of postoperative pneumonia during the COVID-19 pandemic among bariatric surgery patients. Surgical centers must continuously evaluate the risks associated with healthcare-associated exposure to COVID-19 and weigh the benefits of bariatric surgery.     

Laparoscopic sleeve gastrectomy as day-case surgery versus conventional hospitalization: results of the DAYSLEEVE randomized clinical trial

BackgroundLaparoscopic sleeve gastrectomy (LSG) is an effective bariatric intervention with short operative time and low morbidity and mortality. However, ambulatory sleeve gastrectomy is underutilized.ObjectiveThis clinical trial compares feasibility, perioperative outcomes, and weight loss of patients undergoing ambulatory LSG with same-day discharge versus conventional hospitalization with next-day discharge.SettingHospital and ambulatory surgery center.MethodsPatients who satisfied low-acuity criteria were randomized to undergo day-case LSG in the ambulatory surgery center with same-day discharge (DC LSG) or LSG with conventional hospitalization and next-day discharge (CH LSG) between December 2018 and December 2020. The primary outcomes were 30-day adverse events, hospitalizations, reoperations, and readmissions, and the secondary outcome was weight loss during the first year.ResultsOf 2541 screened patients, 1544 patients were randomized in the study. Mean age and body mass index were 31.7 ± 9.1 years versus 31.8 ± 9.2 years and 39.6 ± 5.8 kg/m² versus 40.0 ± 5.7 kg/m² in the DC LSG group (n = 777) and in the CH LSG group (n = 777), respectively. Eighteen patients (2.3%) in the DC LSG were transferred to the hospital for overnight stay. Additionally, 13 patients (1.7%) requested additional stay without a medical indication for a total overnight stay rate of 4%. One DC LSG patient (.1%) was readmitted, and 2 CH LSG patients (.3%) stayed for an extra day. Seventeen percent of DC LSG patients had unscheduled consultations during the first postoperative week compared with 6% of CH LSG patients (P < .001). Those 2 groups were similar in baseline characteristics. There were no reoperations or mortality in either group, and weight loss results were similar; At 1-year follow-up, DC LSG percent excess weight loss was 87% ± 17% compared with 85% ± 17% in the CH LSG group. The follow-up rate was 100%.ConclusionLSG is feasible as a day-case procedure with comparable outcomes to conventional hospitalization.     

COVID-19 and education: restructuring after the pandemic

COVID-19 challenges to keep a valuable educational offer with lockdown measures and social distancing are reviewed. Scientific Societies had to think of new alternatives to maintain meetings with conversion to a virtual format and development of online resources, rapidly available and broadly accessible. Other in person activities as face-to-face clinics have been substituted by telemedicine; the same happened with surgical training in theatre, given the suspension of most of the operations. Finally, the need to share and communicate in a continuous evolving scenario, has impacted negatively the integrity of peer review process, not following the normal procedures to ensure scientific integrity and reproducibility in the earliest phases of the pandemic.     

The Pan London Emergency Cardiac Surgery service: Coordinating a response to the COVID-19 pandemic

Over the last 4 months, the novel coronavirus, SARS-CoV-2, has caused a significant economic, political, and public health impact on a global scale. The natural history of the disease and surge in the need for invasive ventilation has required the provision of intensive care beds in London to be reallocated. NHS England have proposed the formation of a Pan-London Emergency Cardiac surgery (PLECS) service to provide urgent and emergency cardiac surgery for the whole of London. In this initial report, we outline our experience of setting up and delivering a pan-regional service for the delivery of urgent and emergency cardiac surgery with a focus on maintaining a COVID-free in-hospital environment. In doing so, we hope that other regions can use this as a starting point in developing their own region-specific pathways if the spread of coronavirus necessitates similar measures be put in place across the United Kingdom.     

Resilience strategies to manage psychological distress among healthcare workers during the COVID-19 pandemic: a narrative review

The COVID-19 pandemic marks an extraordinary global public health crisis unseen in the last century, with its rapid spread worldwide and associated mortality burden. The longevity of the crisis and disruption to normality is unknown. With COVID-19 set to be a chronic health crisis, clinicians will be required to maintain a state of high alert for an extended period. The support received before and during an incident is likely to influence whether clinicians experience psychological growth or injury. An abundance of information is emerging on disease epidemiology, pathogenesis and infection control prevention. However, literature on interventions for supporting the psychological well-being of healthcare workers during disease outbreaks is limited. This article summarises the available management strategies to increase resilience in healthcare workers during the COVID-19 pandemic and beyond. It focuses on self-care and organisational justice. It highlights various individual as well as organisational strategies. With the success of slowing disease spread in many countries to date, and reduced work-load due to limitations on elective surgery in many institutions, there is more time and opportunity to be pro-active in implementing measures to mitigate or minimise potential adverse psychological effects and improve, restore and preserve the well-being of the workforce now and for years to come. The purpose of this review is to review available literature on strategies for minimising the psychological impact of the COVID-19 pandemic on clinicians and to identify pro-active holistic approaches which may be beneficial for healthcare workers both for the current crisis and into the future.     

Victoria's surgical response to the COVID-19 pandemic: the first two years

Victoria suffered three major waves during the first two years of the COVID-19 pandemic. Melbourne became the longest locked down city in the world at 267 days. This narrative review documents the chronological waves of COVID-19 in Victoria and key themes influencing the State-wide surgical response. In 2020, Victoria needed to secure supplies of personal protective equipment (PPE) and later, recognizing the importance of aerosol transmission, introduced a respiratory protection program to protect health care workers (HCWs) with fit-tested N-95 masks. It established routine preoperative PCR testing for periods when community prevalence was high and developed strategies to restrict elective surgery when hospital capacity was limited. In 2021, three short-term outbreaks were contained and eliminated whilst vaccination of HCWs and the vulnerable was taking place. A third major wave (Delta) occurred July to November 2021, succeeded by another involving the Omicron variant from December 2021. Planned surgery waiting list numbers, and waiting times for surgery, doubled between March 2020 and March 2022. In early 2022, almost 300 patients underwent surgery when infected with Omicron, with a low mortality (2.6%), though mortality was significantly higher in the unvaccinated (7.3% versus 1.4%). In conclusion, the Victorian response to COVID-19 involved tight state-wide social restrictions, contact tracing, furlough, escalating PPE guidance and respiratory protection. HCW infections were greatly reduced in 2021 compared with 2020. Pre-operative PCR testing gave confidence for emergency and urgent elective surgery to proceed during pandemic waves. Other elective cases were performed as health system capacity allowed, without compromising outcomes.     

Cardiac surgery considerations and lessons learned during the COVID-19 pandemic

The COVID-19 pandemic has transformed cardiac surgical practices. Limitations in intensive care resources and personal protective equipment have required many practices throughout the globe to pause elective operations and now slowly resume operations. However, much of cardiac surgery is not elective and patients continue to require surgery on an urgent or emergent basis during the pandemic. This continued need for providing surgical services has introduced several unique considerations ranging from how to prioritize surgery, how to ensure safety for cardiac surgical teams, and how best to resume elective operations to ensure the safety of patients. Additionally, the COVID-19 pandemic has required a careful analysis of how best to carry out heart transplantation, extra-corporeal membrane oxygenation, and congenital heart surgery. In this review, we present the many areas of multidisciplinary consideration, and the lessons learned that have allowed us to carry out cardiac surgery with excellence during the COVID-19 pandemic. As various states experience plateaus, declines, and rises in COVID-19 cases, these considerations are particularly important for cardiac surgical programs throughout the globe.     

Laparoscopic sleeve gastrectomy versus intragastric balloon: a case-control study

Aim

To compare the efficacy of laparoscopic sleeve gastrectomy (LSG) and BioEnterics intragastric balloon (BIB^®) to lose weight and comorbidities after 12 months of follow-up before a more invasive bariatric procedure.

Methods

From January 2004 to December 2006, 40 patients underwent laparoscopic sleeve gastrectomy (LSG) as a first step in biliopancreatic diversion with duodenal switch. Controls (n = 80) were selected based on charts of patients who, during the same period, underwent BioEnterics intragastric balloon therapy. In both groups we considered: length of procedure, hospital stay, intraoperative or endoscopic complications, postoperative or postendoscopic complications, comorbidities at baseline, after 6 months (time of BIB removal), and after 12 months from baseline, and weight loss parameters [weight in kg, percentage excess weight less (%EWL), body mass index (BMI), and percentage excess BMI loss (%EBL)]. Results are expressed as mean ± standard deviation.

Results

Mortality, intra- and postoperative complications (in LSG group), and intra- and postendoscopic complications (in BIB group) were absent. Mean operative time in the LSG group was 120 ± 40 (range 60–200) min. Mean positioning time for BIB was 15 ± 5 (range 10–25) min. BMI at baseline was 54.1 ± 2.9 (range 45.1–55.9) kg/m² and 54.8 ± 2.5 (range 45.1–56.2) kg/m² in BIB and LSG groups, respectively. At 6-month follow-up, mean BMI was 46.2 ± 3.5 and 45.3 ± 5.5 kg/m² in the BIB and LSG patients, respectively [p = not significant (ns)]. After 12 months BIB patients regained BMI, even if strictly followed with a diet regimen, while LSG patients continued to lose weight. Significant differences between groups were absent for the comorbidities considered.

Conclusions

Laparoscopic sleeve gastrectomy and BioEnterics intragastric balloon are two valid options for producing weight loss as a first-step procedure. LSG has all the related risks of general anesthesia, laparoscopic surgery, and digestive anastomosis, whereas BIB presents a very low rate of minor complications, such as psychological intolerance. For all these reasons, at this time, BIB is considered a better option than LSG as a first-step procedure in the short term (12 months).     

How the COVID-19 pandemic is affecting paediatric orthopaedic practice in Turkey

PurposeChanges to routine clinical approaches during the corona virus disease 2019 (COVID-19) pandemic are necessary to decrease the risk of infection in patients and healthcare providers. Because the treatment of many conditions is time sensitive, it is crucial to modify the management of paediatric orthopaedic cases by minimizing any subsequent morbidity. Our purpose was to describe the different measures and management strategies that have been applied by paediatric orthopaedic surgeons and to show how paediatric orthopaedic practice is affected in Turkey.MethodsAll active practicing members of the Turkish Society of Children’s Orthopedic Surgery (TSCOS) were contacted via telephone and asked to fill out a survey (24 questions). For participants, either an email or web link was sent to their mobile phones. An online survey generator was used.ResultsA total of 54 survey responses were collected, for a response rate of 55%. In all, 62% reported a 75% decrease in their outpatient frequency, whilst 75% reported a 75% decrease in their surgery frequency. A total of 86% of the performed surgeries were emergency cases. None of the participants performed elective surgeries, and 61% did not have the consent form specific to COVID. Choice of protective measures have changed considerably; 96% stated that they needed an algorithm to follow for situations such as pandemic.ConclusionThis national survey revealed that the COVID-19 pandemic has had a detrimental effect on paediatric orthopaedic practice and practitioner response varies in terms of reactions and precautions. The necessity of creating a protocol based on what we have learned must be taken into consideration.Level of evidenceV