Colette S. Inaba

Laparoscopic Adjustable Gastric Band Explantation and Implantation at Academic Centers

BACKGROUND The laparoscopic adjustable gastric band (LAGB) was approved for use in the US in 2001 and has been found to be a safe and effective surgical treatment for morbid obesity. However, there is a recent trend toward reduced use of LAGB nationwide. The objective of this study was to examine the prevalence and outcomes of primary LAGB implantation compared with revision and explantation at academic centers. STUDY DESIGN Data were obtained from the Vizient database from 2007 through 2015. The ICD-9-Clinical Modification and ICD-10-Clinical Modification were used to select patients with a primary diagnosis of obesity who had undergone LAGB implantation, revision, or explantation. Prevalence and outcomes of primary LAGB implantation compared with revision or explantation were analyzed. Outcomes measures included length of stay, ICU admission, morbidity, mortality, and cost. RESULTS From 2007 through 2015, a total of 28,202 patients underwent LAGB implantation for surgical weight loss. The annual number of LAGB implantation procedures decreased steadily after 2010. In the same time period, 12,157 patients underwent LAGB explantation. In 2013, the number of LAGB explantation procedures exceeded that of implantation. Laparoscopic adjustable gastric band revision rates remained stable throughout the study period. Mean length of stay, serious morbidity, and proportion of patients requiring ICU admission were higher for gastric band revision and explantation cases compared with primary LAGB implantation cases. There was no statistically significant difference in mortality or mean cost between the 2 groups. CONCLUSIONS Since 2013, the number of gastric band explantation procedures has exceeded that of implantation procedures at academic centers. Laparoscopic adjustable gastric band revision or explantation is associated with longer length of stay, higher rate of postoperative ICU admissions, and higher overall morbidity compared with LAGB implantation.

How safe is same-day discharge after laparoscopic sleeve gastrectomy?

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is associated with low morbidity and mortality and a short length of stay. Studies on the safety of same-day discharge after LSG are limited. OBJECTIVE To compare outcomes between same-day versus first-postoperative-day (POD1) discharge after LSG. SETTING Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program national database. METHODS The 2015 to 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was analyzed for elective LSG cases with same-day or POD1 discharge. Open, revisional, and converted cases were excluded. Multivariate analysis was performed to compare adjusted 30-day mortality, morbidity, readmission, and reoperation for same-day versus POD1 discharge. RESULTS We examined 85,321 LSG cases, including 4728 same-day discharges and 80,593 POD1 discharges. Compared with POD1 discharges, same-day discharges were associated with higher overall morbidity (1.31% versus .84%, respectively; adjusted odds ratio [AOR] 1.72; P = .0002), a higher readmission rate (2.14% versus 1.64%, respectively; AOR 1.40; P = 0.0034), and a higher reoperation rate (.61% versus .27%, respectively; AOR 2.35; P < .0001). There was no difference in mortality (.08% versus .04%, respectively; AOR 2.62; P = .0923). CONCLUSION Same-day discharge after LSG is associated with increased complications, readmissions, and reoperations compared with POD1 discharge. Further studies are needed to examine objective criteria for safe same-day discharge after LSG.

The effect of hospital teaching status on outcomes in bariatric surgery

BACKGROUND Studies have shown conflicting effects of resident involvement on outcomes after laparoscopic bariatric surgery. Resident involvement may be a proxy for a teaching environment in which multiple factors affect patient outcomes. However, no study has examined outcomes of laparoscopic bariatric surgery based on hospital teaching status. OBJECTIVE To compare outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) between teaching hospitals (THs) and nonteaching hospitals (NTHs). SETTING Retrospective review of a national database in the United States. METHODS The Nationwide Inpatient Sample database (2011-2013) was reviewed for obese patients who underwent LRYGB or LSG. Patient demographic characteristics and outcomes were analyzed according to hospital teaching status. Primary outcome measures included risk-adjusted inpatient mortality and serious morbidity. RESULTS We analyzed 32,449 LRYGBs and 26,075 LSGs. There were 35,160 (60.1%) cases performed at THs and 23,364 (39.9%) cases performed at NTHs. At THs, the distribution of LRYGB versus LSG cases was 20,461 (58.2%) versus 14,699 (41.8%), respectively; at NTHs, the distribution was 11,988 (51.3%) versus 11,376 (48.7%), respectively. For LRYGB, there were no significant differences between THs versus NTHs in mortality (AOR 1.14; P = 0.99), but there was an increase in odds of serious morbidity at THs (AOR 1.36; P<0.001). For LSG, there were no significant differences between THs versus NTHs for mortality (AOR 1.15; P = 0.99) or serious morbidity (AOR 1.03; P = 0.99). CONCLUSIONS There is an association between THs and increased serious morbidity for LRYGB, but hospital teaching status has no effect on morbidity or mortality after LSG. Further research is warranted to elucidate the reasons for these associations.

Defining the Role of Minimally Invasive Proctectomy for Locally Advanced Rectal Adenocarcinoma

Objective: National examination of open proctectomy (OP), laparoscopic proctectomy (LP), and robotic proctectomy (RP) in pathological outcomes and overall survival (OS). Background: Surgical management for rectal adenocarcinoma is evolving towards utilization of LP and RP. However, the oncological impacts of a minimally invasive approach to rectal cancer have yet to be defined. Methods: Retrospective review of the National Cancer Database identified patients with nonmetastatic locally advanced rectal adenocarcinoma from 2010 to 2014, who underwent neoadjuvant chemoradiation, surgical resection, and adjuvant therapy. Cases were stratified by surgical approach. Multivariate analysis was used to compare pathological outcomes. Cox proportional-hazard modeling and Kaplan–Meier analyses were used to estimate long-term OS. Results: Of 6313 cases identified, 53.8% underwent OP, 31.8% underwent LP, and 14.3% underwent RP. Higher-volume academic/research and comprehensive community centers combined to perform 80% of laparoscopic cases and 83% of robotic cases. In an intent-to-treat model, multivariate analysis demonstrated superior circumferential margin negativity rates with LP compared with OP (odds ratio 1.34, 95% confidence interval 1.02–1.77, P = 0.036). Cox proportional-hazard modeling demonstrated a lower death hazard ratio for LP compared with OP (hazard ratio 0.81, 95% confidence interval 0.67–0.99, P = 0.037). Kaplan–Meier analysis demonstrated a 5-year OS of 81% in LP compared with 78% in RP and 76% in OP (P = 0.0198). Conclusion: In the hands of experienced colorectal specialists treating selected patients, LP may be a valuable operative technique that is associated with oncological benefits. Further exploration of pathological outcomes and long-term survival by means of prospective randomized trials may offer more definitive conclusions regarding comparisons of open and minimally invasive technique.

Laparoscopic versus open resection of gastrointestinal stromal tumors: survival outcomes from the NCDB

BackgroundStudies comparing laparoscopic versus open resection of gastrointestinal stromal tumors (GIST) typically involve small comparative groups and often do not control for tumor size or stage of disease. The objective of this study was to compare adjusted survival outcomes for laparoscopic versus open GIST.MethodThe National Cancer Database (NCDB) from 2010 to 2014 was evaluated for gastric and small intestinal GIST resections. After stratification by disease stage and adjustment for patient demographics, comorbidity score, tumor size, and tumor location, 90-day mortality rates were compared based on laparoscopic versus open resection. Kaplan–Meier estimates of long-term survival were also compared. A Cox proportional hazards model was used to determine hazard ratios (HR) for survival.ResultsThere were 5096 cases analyzed, including 2910 (57%) stage I, 954 (19%) stage II, and 1232 (24%) stage III cases. The distribution of laparoscopic versus open cases was 1291 (44%) versus 1619 (56%) for stage I, 318 (33%) versus 636 (67%) for stage II, and 286 (23%) versus 946 (77%) for stage III. There was no significant difference in adjusted 90-day mortality between laparoscopic and open resection. Kaplan–Meier estimates of long-term survival demonstrated improved overall survival curves for laparoscopic resection for stage I and stage II disease, but no significant difference for stage III disease. Factors associated with statistically significant higher adjusted overall mortality included older age (HR 1.06; p < 0.001), black race (HR 1.33; p = 0.04), higher comorbidity score (HR 1.47; p < 0.001), and small intestinal versus gastric tumor location (HR 1.28; p = 0.03). The hazards model suggested improved overall survival for females (HR 0.59; p < 0.001) and laparoscopic approach (HR 0.80; p = 0.06).ConclusionLaparoscopic and open GIST resection have comparable 90-day mortality with possible improved long-term survival with laparoscopy for early-stage disease. These findings support the use of laparoscopy as a viable and potentially more effective approach to GIST resection.

Association of Centers for Medicare & Medicaid Services Overall Hospital Quality Star Rating With Outcomes in Advanced Laparoscopic Abdominal Surgery

Importance The Centers for Medicare & Medicaid Services (CMS) recently released the Overall Hospital Quality Star Rating to help patients compare hospitals based on a 5-star scale. The star rating was designed to assess overall quality of the institution; thus, its validity toward specifically assessing surgical quality is unknown. Objective To examine whether CMS high-star hospitals (HSHs) have improved patient outcomes and resource use in advanced laparoscopic abdominal surgery compared with low-star hospitals (LSHs). Design, Setting, and Participants Using the University HealthSystem Consortium database (which includes academic centers and their affiliate hospitals) from January 1, 2013, through December 31, 2015, this administrative database observational study compared outcomes of 72 662 advanced laparoscopic abdominal operations between HSHs (4-5 stars) and LSHs (1-2 stars). The star rating includes 57 measures across 7 areas of quality. Patients who underwent advanced laparoscopic abdominal surgery, including bariatric surgery (sleeve gastrectomy, Roux-en-Y gastric bypass), colorectal surgery (colectomy, proctectomy), or hiatal hernia surgery (paraesophageal hernia repair, Nissen fundoplication), were included. Risk adjustment included exclusion of patients with major and extreme severity of illness. Main Outcomes and Measures Main outcome measures included serious morbidity, in-hospital mortality, intensive care unit admissions, and cost. Results A total of 72 662 advanced laparoscopic abdominal operations were performed in patients at 66 HSHs (n = 38 299; mean [SD] age, 51.26 [15.25] years; 12 096 [31.5%] male and 26 203 [68.4%] female; 28 971 [75.6%] white and 9328 [24.4%] nonwhite) and 78 LSHs (n = 34 363; mean [SD] age, 49.77 [14.77] years; 9902 [28.8%] male and 24 461 [71.2%] female; 21 876 [67.6%] white and 12 487 [32.4%] nonwhite). The HSHs were observed to have fewer intensive care unit admissions (1007 [2.6%] vs 1711 [5.0%], P < .001) and lower mean cost (

Current Trends in the Use of Bowel Preparation for Colorectal Surgery

7866 vs

One-Year Mortality after Contemporary Laparoscopic Bariatric Surgery: An Analysis of the Bariatric Outcomes Longitudinal Database

8708, P < .001). No significant difference was found in mortality between HSHs and LSHs for any advanced laparoscopic abdominal surgery. No significant difference was found in serious morbidity between HSHs and LSHs for bariatric or hiatal hernia surgery. However, for colorectal surgery, serious morbidity was lower at HSHs compared with LSHs (258 [2.2%] vs 276 [2.9%], P = .002). Conclusions and Relevance This study found that HSHs treat fewer ethnic minorities and have similar outcomes as LSHs for advanced laparoscopic abdominal operations. However, HSHs may represent hospitals with improved resource use and cost.

Risk Factors for Gastrointestinal Leak after Bariatric Surgery: MBASQIP Analysis

Purpose of ReviewThis article reviews recent findings in the use of bowel preparation for preventing infectious complications after colorectal surgery.Recent FindingsWhereas mechanical bowel preparation (MBP) was formerly used routinely in combination with prophylactic non-absorbable oral antibiotics (OAs) and prophylactic intravenous antibiotics, there was a trend toward omitting OAs in the 1990s and early 2000s. Since the mid-2000s, the use of MBP has declined given evidence of the limited role of MBP alone in preventing infectious complications. However, recent studies have demonstrated favorable outcomes after MBP when used in combination with OAs.SummaryResults from recent studies have prompted surgeons to reexamine the appropriate regimen for preoperative bowel preparation. The principal question that should now be addressed by future research is whether OAs alone reduce surgical infectious complications after colorectal surgery.