Adam C. Celio

Perioperative safety of laparoscopic versus robotic gastric bypass: a propensity matched analysis of early experience

BACKGROUND The role of robotic assistance for gastric bypass remains controversial. Using a large nationwide cohort, we compared early outcomes after robotic Roux-en-Y gastric bypass (Robot-RYGB) with the laparoscopic technique (LRYGB). OBJECTIVE This study aimed to use a bariatric-specific, large, nationwide cohort with several years of data to compare the early postoperative outcomes of the Robot-RYGB and LRYGB. SETTING Nationwide register-based cohort study. METHODS The Bariatric Outcomes Longitudinal Database from 2007 to 2012 was used to identify patients who underwent nonrevisional Robot-RYGB or LRYGB. Propensity matching was used to account for differences in age, body mass index, sex, American Society of Anesthesiologists classification, multiple preoperative co-morbidities, and procedural year. A second propensity score was calculated with adjustment of operative time in addition to the other adjusted variables. RESULTS We identified 137,455 patients who underwent Robot-RYGB (n = 2415) or LRYGB (n = 135,040) with a mean body mass index of 47.1 ± 8.4 kg/m2 and age of 45.4 ± 11.7 years. In the propensity-matched cohorts, there were 30-day differences in operative time (150.2 ± 72.5 versus 111.8 ± 47.6, P<.001); 30-day rates of reoperation (4.8% versus 3.1%, P = .002); 90-day rates of reoperation (8.8% versus 5.3%, P<.001), complication (15.8% versus 12.5%, P = .001), readmission (8.5% versus 6.4%, P = .005), stricture (3.5% versus 2.0%, P = .001), ulceration (1.2% versus .6%, P = .034), nausea or emesis (6.4% versus 4.36%, P = .001), and anastomotic leak (1.6% versus .2%, P<.001) when comparing Robot-RYGB with LRYGB. After including operative time in propensity matching, there were no significant differences in rates of 30-day readmission or ulceration or 90-day readmission or ulceration; all other differences remained significant. CONCLUSIONS Despite controlling for patient characteristics, patients undergoing Robot-RYGB developed higher rates of early morbidity compared with LRYGB, suggesting LRYGB may provide improved postoperative outcomes. Further studies are needed to definitively compare these 2 operative approaches.

The effect of close postoperative follow-up on co-morbidity improvement after bariatric surgery

BACKGROUND Patients undergoing gastric bypass (RYGB) surgery require follow-up for efficacy assessment, early detection of postoperative complications, and also for management of co-morbid conditions. Recent literature shows support for improved long-term weight loss with close patient follow-up. However, attrition rates after RYGB have been reported as high as 50%. OBJECTIVE The objective of this study was to assess the relationship between complete follow-up and improvement or remission of co-morbid conditions at 12 months after surgery. SETTING University Hospital, United States. METHODS Using the Bariatric Outcomes Longitudinal Database (BOLD) data set, patients with 12-month follow-up after RYGB were identified. Patients with complete follow-up were compared with patients who had missed either or both of their 3- and 6-month visits. Improvement and remission of type 2 diabetes, hypertension, and dyslipidemia were evaluated at 12-month postoperatively. RESULTS 46,381 patients (30.6% of all RYGB patients) were identified that had follow-up with minimum 12-month data. Complete follow-up was recorded for 75.6% of this group with 12-month data. Of the 18,629 patients with type 2 diabetes at baseline, 13,498 (72.4%) and 11,287 (60.6%) had improvement and remission, respectively, at 12 months. Improvement in hypertension and dyslipidemia was noted in 17,808 (62.8%) and 11,602 (55.2%) of patients, while 13,024 (45.9%) and 9119 (43.4%) had hypertension and dyslipidemia remission, respectively. After adjusting for baseline characteristics, complete follow-up in the first year after RYGB was independently associated with a higher rate of improvement or remission of co-morbid conditions. CONCLUSION Complete postoperative follow-up resulted in a higher rate of co-morbidity improvement and remission compared with incomplete postoperative care. Patients and practices should strive to achieve complete and long-term follow-up after RYGB surgery.

Bariatric Surgery: A Historical Perspective

Currently more than one third of Americans suffer from obesity. Of greater concern than one’s adiposity are obesity-related comorbidities such as diabetes, hypertension, asthma, infertility, and arthritis, among others. For nearly a century, diets, exercise, behavorial modifications, and drug therapies have proved to be an ineffective treatment. This chapter examines the evolution of bariatric surgery from its creation in the 1950s, with a focus on the effect of surgery on weight loss, comorbidity reduction, and patient safety. Bariatric surgery has been a remarkable success. For the first time, it is possible to curve severe obesity, diabetes, and hyperlipidemia in addition to the many other manifestations of obesity with remarkable safety. Equally important are the opportunities for research afforded by the measurement of outcomes. Until better treatments become available, bariatric surgery is the therapy of choice for patients with morbid obesity for weight control and comorbidity improvement.

Chronic immunosuppressant use in colorectal cancer patients worsens postoperative morbidity and mortality through septic complications in a propensity-matched analysis

Chronic immunosuppressant use increases the risk of septic complications after colectomy; however, adverse effects on other organ systems remain poorly understood. The aim of this study was to evaluate the multisystem organ effect(s) of chronic immunosuppressant(s) in colorectal cancer patients.