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.

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: 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