Kevin R. Kasten

30-day readmissions after sleeve gastrectomy versus Roux-en-Y gastric bypass

BACKGROUND Laparoscopic sleeve gastrectomy (SG) is gaining popularity over laparoscopic Roux-en-Y gastric bypass (LRYGB) within the United States. Data on readmissions after bariatric procedures are mostly based on LRYGB, with limited evidence regarding etiology of readmissions after SG. OBJECTIVES The aim of this study was to compare 30-day readmission rate and etiology after SG and LRYGB. SETTING American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participating facilities METHODS Patients undergoing elective laparoscopic SG and LRYGB in 2012 and 2013 were identified from the ACS-NSQIP Participant Use Data File. Demographic characteristics, co-morbidities, and 30-day readmissions were analyzed. Multivariable logistic regression analysis evaluated variables with P<.1, using readmission as the dependent variable. RESULTS A total of 34,983 patients underwent bariatric surgery (46.0% SG, 54.0% LRYGB). Readmission was reported in 1773 (5.1%) patients. Readmission was more common after LRYGB compared with SG (6.1% versus 3.8%, P<.001, adjusted OR 1.59, 95% CI 1.44-1.76, P<.001). Nausea, vomiting, and dehydration were more commonly a reason for readmission after SG than LRYGB (30.4% versus 18.8%, P =<.001). Additionally, venous thromboembolism was a more frequent readmission cause for SG compared with LRYGB patients (7.2% versus 3.6%, P = .002). Postoperative pain, bleeding, intestinal obstructions, and wound occurrences were more commonly a readmission cause for LRYGB compared with SG. CONCLUSIONS Hospital readmissions are more common after LRYGB than SG. Reasons for readmission differ between procedures. Given the progressive increase in the proportion of bariatric patients undergoing SG, hospital programs that aim to decrease readmissions after bariatric surgery need to focus on prevention and control of postoperative nausea and dehydration.

Pulmonary embolism and gastrointestinal leak following bariatric surgery: when do major complications occur?

BACKGROUND Complications following bariatric surgery are uncommon but potentially life threatening. OBJECTIVES The aim of this study was to assess the timing of gastrointestinal leaks (GIL) and pulmonary embolism (PE) in patients undergoing bariatric surgery. SETTING Retrospective analysis of the nationwide American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2011. METHODS Data on patient demographic characteristics, baseline co-morbidities, procedural events, and postoperative occurrences were analyzed. Thirty-day morbidity was assessed. Median (interquartile range) and frequencies are reported. RESULTS We identified 71,694 bariatric surgery patients; median age was 45 years (range 36-54 yr), and median body mass index was 44.8 kg/m(2) (range 40.8-50.3 kg/m(2)). Laparoscopic Roux-en-Y gastric bypass was performed in 39,480 patients, laparoscopic adjustable band in 21,104, laparoscopic sleeve gastrectomy in 3225, open Roux-en-Y gastric bypass in 4243, duodenal switch in 1064, revisional surgery in 1182, and other procedures in 1396 patients. Of these patients, 95.2% had no complications. GIL was found in 441 (.6%), deep vein thrombosis in 184 (.3%), and PE in 134 (.2%). These complications occurred 10 (5-15), 13 (7-20), and 11 (4-19) days after surgery, respectively. GIL and PE developed after discharge in 275 (62.4%) and 96 (71.6%), respectively. Only 35 (26.1%) of the patients who developed PE had deep vein thrombosis. There were no differences in patient characteristics between the groups of early PE versus postdischarge PE. Patients diagnosed with in-hospital GIL were more obese with more severe systemic disease compared with patients with postdischarge diagnosis. CONCLUSIONS The majority of GILs and PEs after bariatric surgery occur after discharge. This finding goes against the routine use of contrast studies to rule out GIL. The risk of PE remains after discharge from bariatric surgery.

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.

All things not being equal: readmission associated with procedure type.

BACKGROUND There is an accelerated effort to reduce hospital readmissions despite minimal data detailing risk factors associated with this outcome. MATERIALS AND METHODS We analyzed National Surgical Quality Improvement Project data from January 1, 2011-December 31, 2011, evaluating all patients undergoing one of 34 targeted operative procedures across all surgical specialties. Multivariate regression models of risk for readmission were developed including targeted procedure codes, demographic variables, preoperative variables, intraoperative variables, and postoperative adverse events. Our main outcome measure was hospital readmission. RESULTS A total of 217, 389 patients met study inclusion criteria. Minimal associations existed between patient factors and risk of readmission. Adverse events including unplanned operating room return (odds ratio [OR] 8.5; confidence interval [CI] 8.0-9.0), pulmonary embolism (OR 8.2; CI 7.1-9.6), deep incisional infection (OR 7.5; CI 6.7-8.5), and organ space infection (OR 5.8; CI 5.3-6.3) were associated with increased risk of readmission. Our data suggest the type of procedure performed is significantly associated with risk of readmission. Furthermore, multivariate analysis revealed procedures, involving the pancreas, rectum, bladder, and lower extremity vascular bypass, were associated with the highest risk of readmission. CONCLUSIONS Postoperative complications demonstrated stronger association with readmission than patient factors. Focused analysis of higher risk procedures may provide insight into strategies for risk reduction.

What are the results of colonic volvulus surgery

BACKGROUND: Operative results of volvulus are largely unknown because of infrequent diagnosis. OBJECTIVE: We examined the results of operative intervention for colonic volvulus. DESIGN: We merged trackable data from the California Inpatient Database with Supplemental Files for Revisit Analyses between January 1, 2005, and December 31, 2007. SETTINGS: Trackable data from California discharge records. PATIENTS: We identified all of the patients with colonic volvulus who underwent 1 of 4 surgical procedures, including manipulation/fixation of the colon, right colectomy, left colectomy, or total colectomy. MAIN OUTCOME MEASURES: During the 36-month study period, we identified recurrence risk, recurrence requiring reoperation, time to reoperation, stoma formation, disposition on discharge, and in-hospital mortality. Fisher exact, &khgr;2, and ANOVA tests were used when appropriate. RESULTS: We identified 2141 patients with colonic volvulus who were undergoing intraoperative manipulation/fixation of the colon (n = 209 (12%)), right (n = 728 (41%)), left (n = 781 (44%)), or total colectomy (n = 56 (3%)). Patients treated with intraoperative manipulation/fixation were younger, more likely to be women, and more likely to have private insurance. Patients who underwent total colectomy had the highest risk of mortality (21%), highest risk of stoma creation (64%), and longest length of stay (18 days); were more likely to be readmitted (9%); and were the most likely to be discharged to a skilled nursing facility (48%). Patients treated with intraoperative manipulation/fixation had the lowest mortality, risk of stoma formation, length of stay, and likelihood of discharge to skilled nursing facility but the highest risk of subsequent procedures for volvulus (26%) over a follow-up ranging from 0 to 687 days. LIMITATIONS: This study was limited by retrospective study design, heterogeneous patient factors, and inability to identify the time of last follow-up. CONCLUSIONS: The majority of patients with volvulus underwent a resectional procedure. A subset without resection had favorable initial outcomes but remained at high risk for subsequent procedures. There may be a potential role for evaluating intraoperative manipulation/fixation in a small subset of patients with colonic volvulus.

Robotic-assisted abdominoperineal resection with obturator lymph node dissection: a multidisciplinary approach.

total mesorectal excision for rectal cancer produces locoregional failure rates under 15%, further lowered by the addition of chemoradiotherapy. the incidence of lateral pelvic lymph node involvement in rectal cancer approaches 15%. more than 60% of patients with suspected lateral pelvic nodal involvement had positive results for metastases on histologic examination following neoadjuvant chemoradiotherapy and surgical resection with lateral pelvic lymph node dissection. these studies suggest that lateral pelvic lymph node disease may be a relevant source of locoregional failure and, as such, advocate a role for lateral pelvic lymph node dissection in select patients. minimally invasive lateral pelvic lymph node dissection is a technically challenging procedure given the surrounding anatomy in a confined space. Colorectal surgeons in Korea and Japan routinely perform laparoscopic and robotic-assisted lateral pelvic lymph node dissection for rectal cancer. although rarely performed by colorectal surgeons in the united states, lateral pelvic lymph node dissection is routinely used by urologists during roboticassisted cystoprostatectomy. a multidisciplinary team approach may allow for adequate oncologic resection with the added benefit of minimally invasive surgery in an otherwise technically challenging operation. We used a multidisciplinary approach to a 54-yearold morbidly obese man with locally advanced rectal cancer 3 cm from the anal verge. in addition to regional nodal disease, diagnostic mRi revealed the presence of two 1-cm obturator nodes. Diagnostic imaging confirmed these nodes as Pet avid. Repeat pelvic mRi following completion of neoadjuvant therapy showed persistent obturator nodes greater than 1 cm. abdominoperineal resection was recommended for functional and curative concerns. urologic and colorectal surgeons successfully completed a robotic-assisted abdominoperineal resection with left lateral pelvic lymph node dissection (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/a153). the patients postoperative course was uncomplicated. ten lateral pelvic lymph nodes examined were negative for metastatic disease. at 1 year, the patient remains free of disease.

Considerations for Geriatric Patients Undergoing Colorectal Surgery

As the population ages, the number of elders undergoing surgery increases dramatically. Historically, surgical outcomes were thought to be notoriously high, however, recent data suggest otherwise in selectively fit individuals. The difficulty in caring for this population is its heterogeneity with diverse health status. Little is known about how to properly assess pre-operative risk of elders with colorectal problems. This chapter will evaluate the morbidity and mortality of the elderly population in various disease states, review current pre-operative assessment recommendations, and discuss future endeavors to better identify those patients at increased surgical risk.

Anorectal Abscess and Fistula

Anorectal abscess and fistula management is a cornerstone of any colorectal surgeon’s practice. Knowledge of anatomic structures and their relationship to each other is imperative to make the correct diagnosis and define the treatment plan. Many studies have demonstrated the value of a good physical exam and the surgeon’s judgment—these cannot be replaced with imaging studies and technology. Anorectal suppuration needs to be promptly managed most commonly with drainage only unless a fistula is identified and the anatomic relationship to the sphincter is clear. Many procedures have been described for the management of anal fistula but fistulotomy remains the most effective. In this chapter we review the current practice of managing anorectal abscess and fistulas.

Anatomy Considerations in Robotic Surgery

From Ancient Greece through modern surgical practice, anatomical knowledge has remained of utmost importance. Surgery, more than any other field, relies heavily on this framework to both diagnose and treat patients. Despite the fundamental basis for anatomic knowledge in surgery, many teaching institutions are placing less and less emphasis on gross anatomy coursework. For those without a strong fund of anatomic knowledge, unfamiliarity with minimally invasive visualization of structures may produce angst. As critical structures in abdominal procedures appear different in open, laparoscopic, and robotic approaches, one should always establish familiar orientation depending upon modality used. This chapter seeks to demonstrate relevant colorectal anatomy from a robotic perspective.