Bradley J. Needleman

Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy

AbstractBackgroundnIntraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near-infrared fluorescence cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC.MethodsPatients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot’s triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected.ResultsnEighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and body mass index (BMI) were 42.6xa0±xa013.7xa0years and 31.5xa0±xa08.2xa0kg/m2, respectively. ICG was administered 73.8xa0±xa026.4xa0min prior to incision. NIRF-C was significantly faster than IOC (1.9xa0±xa01.7 vs. 11.8xa0±xa05.3xa0min, pxa0<xa00.001). IOC was unobtainable in 20 (24.4xa0%) patients while NIRF-C did not visualize biliary structures in 4 (4.9xa0%) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1, 76.8, and 69.5xa0%, respectively, compared to 72.0, 75.6, and 74.3xa0% for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80xa0% of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C.nConclusionsNIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.

Laparoscopic sleeve gastrectomy in morbidly obese patients with end-stage heart failure and left ventricular assist device: medium-term results.

BACKGROUNDnMorbid obesity precludes patients with end-stage heart failure from becoming cardiac transplant candidates. This study evaluates the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) as a means to transplant candidacy in such patients.nnnMETHODSnMorbidly obese patients with end-stage heart failure, who were ineligible for cardiac transplantation and underwent LSG between 2008 and 2013, were reviewed retrospectively. Demographic characteristics, perioperative details, percentage of excess weight loss (%EWL), and status of transplant candidacy were analyzed.nnnRESULTSnSix patients (3 men) with end-stage heart failure and morbid obesity underwent LSG. Three patients (50%) had a left ventricular assist device (LVAD) in place at the time of surgery. Median age was 34 (31-66) years and mean preoperative body mass index (BMI) was 47.6±3.0 kg/m2. Median operative time was 90 (66-141) minutes, with a median length of stay of 7 (4-16) days. There were no perioperative deaths. One patient suffered a spontaneous flank hematoma. The same patient also had thrombosis of the LVAD pump at 3 weeks postoperatively, requiring an uneventful device exchange. At median follow-up of 22 (12-70) months, the mean %EWL was 51.4±10.3% with a decrease in BMI to 34.3±2.4 kg/m2 (P<.05). All patients had lost sufficient weight to become transplant eligible within 12 months of surgery. Two patients had undergone successful transplantation and another 2 were on the transplant list.nnnCONCLUSIONnLSG appears to be a safe, technically feasible, and effective method for obtaining adequate weight loss in morbidly obese patients with end-stage heart failure and mechanical circulatory support, subsequently improving their access to cardiac transplantation. This is the largest case series to date of this high-risk group of patients undergoing LSG.

Pharmacotherapy in Conjunction with a Diet and Exercise Program for the Treatment of Weight Recidivism or Weight Loss Plateau Post-bariatric Surgery: a Retrospective Review.

BackgroundBariatric surgery is an effective therapeutic option for management of obesity. However, weight recidivism (WR) and weight loss plateau (WLP) are common problems. We present our experience with the use of two pharmacotherapies in conjunction with our standard diet and exercise program in those patients who experienced WR or WLP.MethodsFrom June 2010 to April 2014, bariatric surgery patients who experienced WR or WLP after undergoing Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB), and who were treated with phentermine (Ph) or phentermine–topiramate (PhT), were reviewed retrospectively. Generalized estimating equations were used to compare patient weights through 90xa0days between initial surgery type and medication type. Patient weights, medication side effect, and co-morbidities were collected during the first 90xa0days of therapy.ResultsFifty-two patients received Ph while 13 patients received PhT. Overall, patients in both groups lost weight. Among those whose weights were recorded at 90xa0days, patients on Ph lost 6.35xa0kg (12.8xa0% excess weight loss (EWL); 95xa0% confidence interval (CI) 4.25, 8.44) and those prescribed PhT lost 3.81xa0kg (12.9xa0% EWL; CI 1.08, 6.54). Adjusting for baseline weight, time since surgery, and visit through 90xa0days, patients treated with Ph weighed significantly less than those on PhT throughout the course of this study (1.35xa0kg lighter; 95xa0% CI 0.17, 2.53; pu2009=u20090.025). There were no serious side effects reported.ConclusionsPhentermine and phentermine–topirimate in addition to diet and exercise appear to be viable options for weight loss in post-RYGB and LAGB patients who experience WR or WLP.

Laparoscopic Roux-en-Y gastric bypass for treatment of symptomatic paraesophageal hernia in the morbidly obese: medium-term results.

BACKGROUNDnThe ideal surgical approach for treatment of symptomatic paraesophageal hernias (PEH) in obese patients remains elusive. The objective of this study was to assess the safety, feasibility, and effectiveness of combined laparoscopic PEH repair and Roux-en-Y gastric bypass (RYGB) for the management of symptomatic PEH in morbidly obese patients.nnnMETHODSnFourteen patients with symptomatic PEH and morbid obesity (body mass index [BMI]>35 kg/m(2)) underwent laparoscopic PEH repair with RYGB between 2008 and 2011. Demographic characteristics and preoperative and perioperative details were analyzed. Patients were contacted in October 2013 for follow-up. BMI, reflux symptoms, and disease-specific quality of life (QoL) data were obtained.nnnRESULTSnThere were 11 females (79%). Median age and preoperative BMI were 48 years and 42 kg/m(2), respectively. Mean operative time was 180 minutes, with median length-of-stay of 4 days. There were no perioperative deaths, and 5 patients experienced postoperative complications including 1 gastrojejunostomy leak. Complete follow-up with a median follow-up interval of 35 months was available in 9 (64%) patients. The median % excess weight loss was 67.9%. Thirty-three percent required antisecretory medications for reflux control, compared to 89% preoperatively. Seventy-eight percent of patients reported good to excellent QoL outcomes assessed by the Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire. Overall, 89% of patients were satisfied with their operation and would undergo the procedure again.nnnCONCLUSIONnCombined laparoscopic PEH repair and RYGB is a safe, feasible, and effective treatment option for morbidly obese patients with symptomatic PEH, and offers good to excellent disease-specific quality-of-life outcomes at medium-term follow-up. To date, this is the largest series with the longest follow-up in this unique patient population.

Laparoscopic adjustable gastric banded plication: case-matched study from a single U.S. center

BACKGROUNDnLaparoscopic adjustable gastric banded plication (LAGBP) is a novel technique for weight loss surgery. This study evaluates the safety and short-term efficacy of LAGBP in a U.S. population. The setting was an academic medical center in the United States.nnnMETHODSnPatients who underwent LAGBP between 2012 and 2013 were reviewed retrospectively. Demographic characteristics, pre and perioperative details, body mass index (BMI), and percent excess weight loss (%EWL) were analyzed and compared to case-matched cohorts that had laparoscopic adjustable gastric banding (LAGB) or laparoscopic sleeve gastrectomy (LSG) during the same time period.nnnRESULTSnSeventeen patients (14 females) underwent LAGBP during the study period and were case-matched based on age, sex, race, and preoperative BMI with patients having LAGB and LSG. Mean age and preoperative BMI for LAGBP cohort were 42.5±11.6 years and 47.7±6.5 kg/m2, respectively. Mean operative time and estimated blood loss were 72±16 minutes and 23±23 mL, respectively, compared to 49±16 minutes (P=.002) and 15±23 mL for LAGB, and 66±18 minutes and 36±22 mL for LSG. There were no perioperative deaths. Hospital length of stay was 1.1±.3 days for LAGBP, versus .7±.3 days (P=.004) for LAGB, and 2.7±1.4 days (P<.001) for LSG. At 12-month follow-up, patients in the LAGBP and LAGB groups had undergone similar number of band adjustments (4.7 versus 5.1; P=.68). The %EWL was 46.1±14.8% for the LAGBP cohort, compared to 38.9±20.6% for LAGB, and 57.7±16% for LSG.nnnCONCLUSIONnLAGBP is technically feasible and safe, and offers weight loss results positioned between LAGB and LSG at 1 year. To date, this is the largest U.S. series to compare this novel technique to more traditional weight loss procedures.

Two-Year Outcomes for Medicaid Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass: a Case-Control Study

BackgroundMillions of patients will be added to Medicaid programs throughout the country due to expansion driven by the Affordable Care Act. Since 90xa0% of state Medicaid programs cover bariatric surgery, the outcomes of Medicaid patients will be important to study. We performed a retrospective analysis to compare outcomes between Medicaid and non-Medicaid bariatric surgery patients over a two-year period.MethodsAll patients who underwent a laparoscopic Roux-en-Y gastric bypass at The Ohio State University Medical Center from January 2008–April 2011 were identified. Of these 609 patients, 30 Medicaid patients were identified and compared to 90 randomly selected non-Medicaid patients (1:3 case-control). Preoperative data and postoperative outcome data (weight loss, comorbidity resolution, complications, and mortality) were obtained from electronic medical records. Descriptive statistical analyses were performed to compare categorical and continuous variables.ResultsMedicaid patients had a significantly higher average BMI (58.4 vs. 49.5; pu2009<u20090.001) and higher rates of comorbidities. Over a 90-day postoperative period, Medicaid patients experienced a higher wound complication rate (20.0 vs. 5.6xa0%; pu2009=u20090.03) and visited the ER more frequently (33.3 vs. 10.0xa0%; pu2009=u20090.007) but had similar rates of medical complications compared to non-Medicaid patients. The Medicaid cohort lost 52.1xa0% of its excess body weight vs. 64.6xa0% for the non-Medicaid cohort (pu2009=u20090.02) over a two-year period. There were no significant differences in comorbidity resolution, anastomotic complications, or mortality after 2xa0years of follow-up.ConclusionDespite being a higher risk cohort, Medicaid patients undergoing laparoscopic Roux-en-Y gastric bypass had similar long-term outcomes compared to non-Medicaid patients.

Impact of care coaching on hospital length of stay, readmission rates, postdischarge phone calls, and patient satisfaction after bariatric surgery

BACKGROUNDnBariatric surgery is well established as an effective means of treating obesity; however, 30-day readmission rates remain high. The Bariatric Care Coaching Program was developed in response to a perceived need for better communication with patients upon discharge from hospital and prior to being seen at their first postoperative visit. The lack of communication was apparent from the number of patient phone calls to clinic and readmissions to hospital.nnnOBJECTIVESnThe aim of this study was to evaluate the impact of the care coaching program on hospital length of stay (LOS), readmission rates, patient phone calls, and patient satisfaction.nnnSETTINGnThe study was conducted at The Ohio State University Wexner Medical Center.nnnMETHODSnA retrospective review was conducted on patients who had primary bariatric surgery from July 1, 2013 to June 30, 2015. The control group included patients who underwent surgery from July 1, 2013 to June 30, 2014, before development of the program, and the experimental group was composed of patients who received care coaching from July 1, 2014 to June 30, 2015. Demographics, postoperative complications, LOS, clinic phone calls, and hospital readmissions, prior to the first postoperative visit, were collected from medical records. Patient satisfaction scores were collected from the Hospital Consumer Assessment of Healthcare Providers and Systems Survey [HCAHPS]. Differences between study groups were assessed and P values <0.05 were considered statistically significant.nnnRESULTSnThere were 261 and 264 patients in the care-coach and control groups, respectively. The care-coached group had fewer patients with intractable nausea/vomiting (P = .0164) and a shorter mean LOS (P = .032). Subgroup analysis indicated that the difference in LOS was evident for laparoscopic sleeve gastrectomy (P = .002). There was no difference in readmission rates (P = .841) or phone calls to clinic (P = .407). HCAHPS scores demonstrated an improvement in patients perception of communication regarding medications (59th versus 27th percentile), discharge information (98th versus 93rd percentile), and likelihood of recommending the hospital (85th versus 74th percentile).nnnCONCLUSIONnThe Bariatric Care Coaching Program is an important new adjunct in the care of our bariatric inpatients. It has had the greatest impact on postoperative nausea/vomiting, LOS for sleeve gastrectomy, and patient satisfaction. Further studies are needed to evaluate how to use this program to reduce readmission rates and phone calls to the clinic.

Bariatric Surgery Candidates’ Peer and Romantic Relationships and Associations with Health Behaviors

BackgroundThe aim was to assess the romantic and peer relationships of bariatric surgery candidates and associations with health behaviors.MethodAdults seeking bariatric surgery (Nu2009=u2009120) completed surveys addressing health behaviors and social relationships at information sessions. Analysis was done to compare male/female differences in peer and romantic relationships and associations with health behaviors. Previously published reference (REF) data on the Relationship Structures questionnaire was used for comparison, and to split our sample into those ≤ or > REF mean for relationship anxiety and avoidance.ResultsOur sample reported higher avoidance and lower anxiety in their close friendships and romantic relationships compared to the REF sample. Men in our sample had higher peer and romantic relationships avoidance compared to the REF sample and had significantly higher close friendship avoidance than women in our sample. Participants with lower anxiety in their romantic relationships (≤ REF) had higher uncontrolled eating and physical activity; those with more anxiety in their romantic relationships (> REF) had a higher BMI.ConclusionsOur findings highlight the potential influence that social relationships may have on health behaviors within the bariatric surgery population. Further investigation is warranted to explore male bariatric surgery candidates’ relationships to inform understanding and intervention development.

The Impact of Bariatric Surgery on Short Term Risk of Clostridium Difficile Admissions

Background and AimsClostridium difficile infection (CDI) is major health care concern with reports linking it to obesity. Our aim was to investigate the little known impact of the two most common bariatric surgeries, Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG), on risk of CDI admissions.MethodsThis is a retrospective cohort study using the 2013 Nationwide Readmission Database. We examined inpatient CDI rates within 120xa0days after RYGB (nu2009=u200940,059) and VSG (nu2009=u200945,394). In a time to event analysis we also evaluated inpatient CDI rates up to 11xa0months post-surgery. We chose morbidly obese patients that underwent non-emergent ventral hernia repair (VHR) as additional surgical controls (nu2009=u20099673).ResultCDI rates were higher after RYGB than VSG in the first 30xa0days (odds ratio [OR]u2009=u20092.10; 95% confidence interval [CI], 1.05–4.20) with a similar but nonsignificant trend within 31–120xa0days. CDI rates were also higher after RYGB compared to VHR controls within 31–120xa0days after surgery (ORu2009=u20093.22, 95%CI: 1.31, 7.88, pu2009=u20090.01). In a time to event analysis with up to 11xa0months follow up, RYGB led to higher CDI compared to VSG (hazard ratio [HR]u2009=u20091.87; 95% CI, 1.12–3.13) with a trend towards higher CDI compared to VHR (HRu2009=u20091.95; 95% CI, 0.94–4.06). Similar CDI rates occurred after VSG vs VHR.ConclusionsRYGB may increase the risk of CDI hospitalization when compared to VSG and VHR controls. This data suggest VSG may be a better bariatric choice when post-surgical CDI risk is a concern.

Postoperative outcomes based on patient participation in a presurgery education and weight management program

BACKGROUNDnThe benefits of presurgery weight management programs (WMPs) for bariatric patients are mixed; some show a positive impact on percent excess weight loss (%EWL) at 12 months postsurgery, while others show no effect.nnnOBJECTIVESnThe purpose of this study was to compare pre- and postoperative 6- and 12-month outcomes between patients who attended a 12-week presurgery WMP and patients who did not participate.nnnSETTINGnOhio State Wexner Medical Center, University Hospital, United States.nnnMETHODSnA retrospective medical record analysis was conducted to compare preoperative and 6- and 12-month postoperative outcomes for patients who attend the presurgery WMP (nu202f=u202f56) and patients who did not (nu202f=u202f441) within a 2-year time period (Nu202f=u202f497). Descriptive statistics and independent t tests were conducted to determine mean differences between groups, while controlling for surgery type, for weight status outcomes (%EWL, change in body mass index) preoperatively and 6 and 12 months postsurgery, and length of stay and readmission rate.nnnRESULTSnPatients who attended the preoperative WMP had significantly higher %EWL at 12 months postsurgery compared with patients who did not attend the WMP. Additional findings indicated a positive, but nonsignificant effect, from the WMP on presurgery body mass index, and postsurgery %EWL at 6 months and body mass index change at 6 and 12 months postsurgery.nnnCONCLUSIONSnPatients attending the WMP had better 12-month %EWL and outcomes compared with those who did not attend the WMP, though this was not true for 6-month outcomes and differed based on surgery type.