The avoidable delay in weight loss surgery for those with BMI over 50
BACKGROUND:Many insurance companies mandate medically supervised weight loss programs (MSWLPs) prior to bariatric surgery. This retrospective study aims to elucidate whether the average 6-month preoperative medical-management period decreases preoperative BMI for those with BMIâ€‰â‰¥â€‰50. METHODS:All adult patients with bariatric consultation at any time at the New York University Langone Health campuses during the period 2015 to 2021 were evaluated via electronic medical records. Only patients withâ€‰â‰¥â€‰BMI 50, without previous bariatric surgeries, and those with 6-month insurance-mandated medical visits were included. A paired t-test was performed on the difference in BMI and percent-weight loss among the subjects at least 6Â months before surgery and on the day of surgery. RESULTS:Of the 130 patients with BMIâ€‰â‰¥â€‰50, undergoing preoperative 6-month office weigh-ins, the mean difference in BMI was -Â 1.51 (Pâ€‰<â€‰0.01). The mean total body weight loss was 4.8% (Pâ€‰<â€‰0.01). There were no intraoperative complications nor 30-day complications or mortality in the group. CONCLUSIONS:We found that there was weight loss during the 6-month insurance-mandated medical management prior to surgery, but the amount (4.8%) did not reach the goal target of 10% of body weight. We found that there were no complications and question the need for prolonged delay to surgery.
Robotic mesh explantation (RoME): a novel approach for patients with chronic pain following hernia repair
BACKGROUND:Post-herniorrhaphy pain is common with an estimated 8-10% incidence of mesh-related complications, requiring mesh explantation in up to 6% of cases, most commonly after inguinal hernia repairs. Reoperation for mesh explantation poses a surgical challenge due to adhesions, scarring and mesh incorporation to the surrounding tissues. Robotic technology provides a versatile platform for enhanced exposure to tackle these complex cases. We aim to share our experience with a novel robotic approach to address these complex cases. METHODS:A descriptive, retrospective analysis of patients undergoing a robotic mesh explantation (RoME) for mesh-related chronic pain, or recurrent ventral hernia by two surgeons between the period of March 2016 and January of 2020. The patients were evaluated for resolution of mesh related abdominal pain as well as early post-operative complications. RoME was performed with concomitant hernia repair in cases of recurrences. RESULTS:Twenty-nine patients underwent a robotic mesh explantation (RoME) for mesh-related chronic pain, or recurrent ventral hernia between March 2016 and January of 2020. Nineteen patients (65.5%) had a prior inguinal hernia repair and 10 patients (34.5%) had a prior ventral hernia repair. Indications for mesh removal included chronic pain with or without hernia recurrence. Seventeen patients (58.6%) reported improvement or resolution of pain postoperatively (63% with a prior inguinal hernia repair and 50% of patients with a prior ventral hernia repair). Five patients (17.2%) required mesh reinforcement after explantation. Nineteen patients (65.5%) underwent mesh explantation with primary fascial closure or no mesh reinforcement. The mean follow-up was 36.4Â days. The most common postoperative complication was seroma formation (6.8%), with one reported recurrence (3.4%). CONCLUSION/CONCLUSIONS:Robotic mesh explantation in challenging cases due to the effect of chronic scarring, adhesions and mesh incorporation to the surrounding tissues is safe and provides an advantageous platform for concomitant hernia repair in these complex cases.
The avoidable delay in weight loss surgery for the super morbidly obese: A cross-sectional study [Meeting Abstract]
Introduction: Many insurance companies mandate a minimum of a 6-month preoperative medical intervention prior to bariatric surgery. It has been conventional experience that this does not make a difference in BMI prior to surgery. This cross-sectional study is an effort towards elucidating whether or not a 6-month preoperative medical intervention makes any difference in preoperative BMI.
Method(s): All adult patients with bariatric consultation at any time at the New York University Langone Health campuses during the period 2015 to 2021 were evaluated via electronic medical records. Only patients with>BMI 50 on initial visit and those without previous bariatric surgeries at other institutions were included. Along with BMI and weight, baseline characteristics were obtained during this perioperative period. A paired t-test was performed on the difference in BMI and percent-weight loss among the subjects at least 6 months before surgery and the same subjects right before surgery. Additionally, sub-group analysis was performed on those that had>5% weight loss.
Result(s): Of the 130 super-morbidly obese patients undergoing preoperative medical intervention, by the time of surgery there was a statistically significant mean difference in BMI of-1.51, standard deviation 3.26 with a p-value of<0.01. There was also a statistically significant mean difference in percent-weight loss of 0.048, standard deviation 0.11 with a p-value of<0.01. Furthermore, there were no observed intraoperative complications nor 30-day mortality.
Conclusion(s): We found that BMI and percent-weight loss is present and is statistically significant, but these small differences have little clinical significance given that the goal target of medical preoperative weight-loss is typically 5-10% body weight. This study provides additional data to suggest that mandatory preoperative medical interventions in the super morbidly obese may make no difference in BMI nor operative outcomes, and warrants further study in the form of cohort design
The Long-Term Effects of the Adjustable Gastric Band on Esophageal Motility in Patients Who Present for Band Removal
BACKGROUND:During the past decade, laparoscopic adjustable gastric banding (LAGB) was one of the most popular surgical procedures in treating morbid obesity. Long-term effects, specifically on esophageal motility, of LAGB have not been well described in the literature despite the high prevalence of reoperations and post-operative dysphagia. We aimed to characterize esophageal dysmotility after long-term follow-up using data of high-resolution esophageal manometry (HRM) performed in patients who presented for LAGB removal. The research was conducted in Academic Hospital Center in the USA. METHODS:Research was conducted with approval from the institution's Institutional Review Board. We included 25 consecutive patients who were requesting removal of the band or revisional bariatric surgery. All patients underwent HRM between 2011 and 2015. RESULTS:A Fisher's exact test two-sided p value 0.41 shows no statistically significant difference in proportions of normal motility or impaired motility between asymptomatic and symptomatic patients. CONCLUSIONS:Patients with a history of LABG can have esophageal dysmotility whether they are symptomatic or asymptomatic. Based on existing literature, we recommend pre-operative manometry in these patients requesting revisional surgery.
Retrospective review of predisposing factors for intraoperative pressure ulcer development
STUDY OBJECTIVE/OBJECTIVE:To evaluate the comorbidities and surgical factors involved in the genesis of intraoperative pressure ulcers. DESIGN/METHODS:Retrospective chart review. SETTING/METHODS:Anesthesiology department of a university medical center. MEASUREMENTS/METHODS:The charts of 222 patients with varying illness, who underwent an operation of at least two hours' duration, were analyzed retrospectively. Data on surgery type, case length, comorbidities, intraoperative surgical position, and area of ulceration were recorded. MAIN RESULTS/RESULTS:Risk factors for intraoperative pressure ulcer development include surgical times of 4 hours or longer; comorbidities affecting tissue perfusion (namely, diabetes, hypertension, and nonspecific cardiac issues); supine placement during surgery; and abdominal, noncardiac thoracic, and orthopedic operations. Regions of the body most at risk for ulceration include the coccygeal/sacral region, the buttocks, genitalia, and heels. CONCLUSIONS:Pressure ulcers are a costly, debilitating, and avoidable complication of surgery.