Faculty Bibliography

BACKGROUND: Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG. METHODS: A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls. RESULTS: Of 1762 LSG operations, 20 (1.1 %) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean = 1.3 days, range (1, 2)], while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89 %). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95 % CI (4.04, 68.10), p < 0.0001], SIRS criteria [OR 7.0, 95 % CI (1.47, 33.26), p = 0.014], and pain score >/=9 [OR 19.1, 95 % CI (1.38, 263.87), p = 0.028]. CONCLUSIONS: Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2-3 weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.

INTRODUCTION: Weight loss after laparoscopic adjustable gastric banding (LAGB) can be influenced by a variety of factors. The objective of this study is to investigate whether the maximum amount of previous weight loss with diet and exercise, prior to evaluation for bariatric surgery, is predictive of postoperative weight loss success among primary LAGB patients. METHODS: A retrospective cohort study was designed from a prospectively collected database at a single institution. Inclusion criteria consisted of age >/=18 years, initial body mass index (BMI) >/=35 kg/m2, intake information on the maximum weight loss at any time prior to referral to our bariatric practice, and at least 2 years of postoperative follow-up. Patients with prior bariatric surgery were excluded. Outcomes included mean % excess weight loss (EWL), percent that achieved weight loss success (%EWL >/= 40), and percent with suboptimal weight loss (%EWL < 20) at 2 years post-LAGB. RESULTS: In the study, 462 primary LAGB patients were included. Mean previous weight loss was 29.7 lb (SD 27.6, range 0-175). These patients were divided into four previous weight loss groups (0, 1-20, 21-50, >50 lb) for analysis. In adjusted multivariate analyses, patients with >50 lb of maximum previous weight loss had a significantly higher mean %EWL, (p < 0.0001) and %BMIL (p < 0.0001), were more likely to reach weight loss success (>/=40 % EWL, p = 0.047), and were less likely to experience suboptimal weight loss (<20 % EWL, p = 0.027) at 2 years postoperatively. CONCLUSION: Previous weight loss appears to be a significant predictor of weight loss after LAGB. With multiple options for weight loss surgery, this study helps elucidate which patients may be more likely to achieve greater weight loss with the LAGB, allowing clinicians to appropriately counsel patients preoperatively.

Aims: Leaks after laparoscopic sleeve gastrectomy (LSG) often present after discharge from the hospital, making it difficult to diagnose leak in the early postoperative period. This study evaluates preoperative, intraoperative, and postoperative factors in their association with leaks after LSG. Methods: A retrospective case-controlled study of 1762 LSG from 2006-2014 was performed. All radiographically confirmed leaks were included. Controls were patients who underwent LSG without leak, selected using a 10:1 (control:study) case-match. Data included patient characteristics, intraoperative factors, and esophagram results. Clinical indicators including SIRS criteria (presence of = 2: temperature<36 degreeC or >38 degreeC, heart rate>90 bpm, respiratory rate>20 breaths/min,WBC>12,000 or <4,000) and self-reported pain score were collected on postoperative day (POD) 2 and at the time of leak, if applicable. Statistics included univariate analyses and multivariate logistic regression. Results: Of the 1762 LSG, 20 (1.1 %) leaks were compared with 200 case-matched controls. Three patients developed leak during their index admission (mean = 1.3 days, range = [1,2]), while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days (median = 15, range = [4,63]) postoperatively. Leaks were similar to controls in baseline characteristics; however, the leak group had fewer black patients (5 % vs. 17 %, p = 0.022). There were no differences in intraoperative characteristics including staple reinforcement, bougie size, leak test, or operativetime between groups. Contrast extravasation on routine postoperative esophagram was seen in only two (10 %) of the twenty patients with enteric leaks; other esophagram findings (e.g. delay, dilatation) did not differ between leaks and controls. Patients with both early and late leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent factors associated with leak included fever (p<0.0001), SIRS criteria (p = 0.0034), and pain score = 9 (p = 0.010). Conclusions: Contrast extravasation on routine postoperative esophagram may detect early leaks after LSG, but the vast majority of leaks have normal results and present days to weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study, and may be used as criteria to selectively obtain postoperative esophagrams after LSG

Introduction: The impact of resident involvement on outcomes after bariatric procedures is not well understood. Prior studies have demonstrated increased complication rates with resident involvement in Roux-en-y gastric bypass (RYGB). These studies did not include data for laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric band (LAGB). At our institution, attending surgeons operate with both residents and physician assistants (PA) interchangeably, thus controlling for surgeon variability. Our objective was to demonstrate that resident involvement in complex bariatric surgeries does not increase complication rates when residents and PA's work with the same attending surgeons. Methods and Procedures: Patients undergoing bariatric procedures at our institution between 3/2012 and 3/2015 were identified using the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database. All patients under 18 years of age were excluded. Cases were stratified into four different categories- RYGB, LSG, LAGB, and LAGB revision (replacement, removal, or port revision). Data included patient demographics, comorbidities, length of stay, and 30-day complications. The primary outcomes of the study were operative time and 30-day overall complication rate. Secondary outcomes included length of stay, major complications and reoperation rates. Results: There were 2741 bariatric surgeries performed from 2012-2015. Of those, 2067 had resident involvement and 674 had PA involvement. 30-day complication rates for all surgery types, with and without residents, were 5.3 % and 6.1 %, respectively (p = .45). Complication rates for LSG (p = .716), LAGB (p = .694), LAGB revision (p = .493), and RYGB (p = .126) were also not significant. Operative duration for all surgery types was longer with residents (77.0 vs 60.6 min, p<.0001). Operative duration was longer with resident involvement for LSG (101.1 vs 76.6 min, p<.0001), LAGB (51.6 vs 42.4 min, p<.0001), and LAGB revision (63.0 vs 51.6 min, p = .007). After risk adjustment, OR time for RYGB was significantly longer as well (134.3 min vs 119.3 min, p = .038). Length of stay was also found to be significantly increased in the resident group (1.23 vs 1.09 days, p = .0007). Conclusion: Resident involvement as first assistant in the OR does not increase complication rates in bariatric surgery. Operative times and length of stay are prolonged, as shown in other studies, but no difference was seen in complication rates for cases involving a resident and cases involving a dedicated operative PA. Teaching advanced bariatric surgery techniques to residents is both safe and essential to their education

Aims: Gatstro-gastric fistula (GGF), a complication of roux-en-y gastric bypass (RYGB), has an occurrence rate of 1-2% and can result in weight regain, relapse of comorbidities, and marginal ulceration. Surgical management varies-revision of the bypass with concurrent remnant gastrectomy is often avoided for fear of complexity, while division of the fistula, remnant gastrectomy, and endoscopic repairs can result in recurrence of the GGF or marginal ulceration. Institutional data on GGF after RYGB and the step-by-step revision to an esophagojejunostomy are herein presented. Methods: This is a retrospective review of prospectively collected data at a single institution and video presentation. Results: Between 2005 and 2014, 13 patients presented with GGF after RYGB. The mean time to presentation was 4.4 years [range: 7 mos-16.4 years]. Surgical treatments included resection of GGF, remnant gastrectomy, and subtotal gastrectomy with either revision of gastrojejunostomy or esophagojejunostomy. Mean OR time was 191 minutes. Four patients required an additional reoperation for recurrent marginal ulcer (2), persistent GGF (1), and enterocutaneous fistula (1). Patients who underwent full resection of the gastric remnant and conversion to esophagojejunostomy did not develop postoperative complications. Video Presentation: A 47-year-old male s/p laparoscopic RYGB one year prior presented with 1 day of abdominal pain and was diagnosed with a GGF on CT scan. His weight loss was adequate and his BMI was 28.8. Marginal ulceration was presumed to be the source of his acute pain and the patient was taken to the OR for revisional surgery. Intraoperatively, the roux-limb and remnant stomach were divided. The GE junction was marked and divided proximally to the GGF and an endoscopic stapler created an end-to-side esophagojejunal anastomosis. The gastric remnant, gastrojejunostomy, and GGF were removed through the umbilical incision. Incidentally found internal and hiatal hernias were also repaired. Total operative time was 162 minutes. On 6 months follow-up the patient has no complications. Conclusion: Surgical treatment of GGF after RYGB should include revision to esophagojejunostomy with complete excision of the gastric remnant. In experienced hands, this operation is safe and effective and has a lower likelihood of recurrent GGF and marginal ulceration compared to other procedures

Aims: Laparoscopic sleeve gastrectomy (LSG) is a commonly performed primary bariatric procedure. Although bariatric surgery is becoming increasingly recognized as an effective treatment option for diabetes, there remain concerns about the operative risks faced by diabetic patients. This study's Objective: was to determine the safety of bariatric surgery in the subset of diabetic patients who do not require insulin (NIDDM). Methods: Patients with a body mass index (BMI) = 35 kg/m2 who underwent LSG in 2012 in the ACS-NSQIP database were identified. Emergency cases were excluded from analysis. Data included patient demographics, comorbidity, hospital length of stay, and 30-day complications. The primary outcome was 30-day overall complication rate and secondary outcomes included major complications and reoperation rates. Chi-square, Fisher's exact, and two-sample t tests were used to evaluate differences between groups. Results: Of 6062 LSG performed in 2012, 4726 (83.4 %) were non-diabetic and 941 (16.6 %) were NIDDM. NIDDM were more likely to be male (28.9 % vs. 19.3 %, p<0.001), older (47.6 years vs. 42.5 years, p<0.001), and had a higher BMI (46.4 kg/m2 vs. 45.7 kg/m2, p = 0.027) when compared to non-diabetics. In addition to diabetes, NIDDM had a higher rate of COPD (2.8 % vs. 0.6 %, p<0.001). The NIDDM group had a slightly longer mean operative time, as well (101.1 vs. 96.9 minutes, p = 0.014). The overall 30-day complication rate did not differ between groups (6.5 % NIDDM vs. 5.6 % non-diabetic, p = 0.305). In sub-analyses of specific complications, NIDDM had a slightly higher rate of blood transfusions (1.8 % vs. 1.0 %, p = 0.037). Other postoperative complications, including wound infection, intraabdominal infection, sepsis, renal injury, urinary tract infection, postoperative myocardial infarction, cardiac arrest, deep vein thrombosis, reoperation, and readmission did not differ between groups. Conclusion: Laparoscopic sleeve gastrectomy is a safe procedure for non-insulin dependent diabetics with regards to early post-operative complications