Matthew Lin

Laparoscopic sleeve gastrectomy is safe and efficacious for pretransplant candidates

BACKGROUND Morbid obesity is a relative contraindication for organ transplant because it is associated with higher postoperative morbidity and mortality. The safety and efficacy of laparoscopic sleeve gastrectomy (LSG) as a weight loss method for patients awaiting transplant has not been examined. METHODS A retrospective review was performed on morbidly obese patients awaiting liver or kidney transplant who underwent LSG from 2006 to 2012. Data included patient demographic characteristics, operative details, 30-day complications, percentage of excess weight loss, postoperative laboratory data, and status of transplant candidacy. RESULTS Twenty-six pretransplant patients underwent LSG. The mean age was 57 years, and 17 (65%) were women. Six patients had end-stage renal disease, and 20 patients had end-stage liver disease. The preoperative mean body mass index was 48.3 kg/m(2) (range 38-60.4 kg/m(2)). There were no deaths, and there were 6 postoperative complications: 2 superficial wound infections, 1 staple line leak, 1 postoperative bleed requiring blood transfusion, 1 transient encephalopathy, and 1 temporary renal insufficiency. The mean percentage of excess weight loss at 1, 3, and 12 months was 17% (n = 24/26), 26% (n = 23/26), and 50% (n = 18/20), respectively. All patients met our institutions body mass index cutoffs for transplantation by 12 months after the procedure. One patients renal function stabilized, and he was taken off the transplant list. Eight patients eventually underwent solid organ transplant. Six received liver transplants, 1 patient received a combined liver and kidney transplant, and 1 received a kidney transplant. The mean time between LSG and transplant was 16.6 months. CONCLUSIONS This is the largest case series involving LSG in patients awaiting solid organ transplantation. LSG is well tolerated, is technically feasible, and improves candidacy for transplantation.

A prospective, randomized controlled trial of single-incision laparoscopic vs conventional 3-port laparoscopic appendectomy for treatment of acute appendicitis.

BACKGROUND Proponents of single-incision laparoscopic surgery (SILS) claim patients have less pain, faster recovery, and better long-term cosmetic results than patients who undergo multiport laparoscopy. However, randomized comparisons are lacking. This study presents the results of a prospective randomized trial of SILS or 3-port laparoscopic appendectomy. STUDY DESIGN Adults with uncomplicated acute appendicitis were randomized 1:1 to either SILS or 3-port laparoscopic appendectomy. The primary end point was early postoperative pain (measured by opiate usage and pain score in the first 12 hours). Secondary end points were operative time, complication rate (including conversions), and recovery time (days of oral opiate usage and return to work). After 6 months, body image and cosmetic appearance were assessed using a validated survey. RESULTS The trial was planned for 150 patients, but was halted after 75 patients when planned interim analysis showed that SILS patients had more postoperative pain (pain score: 4.4 ± 1.6 vs 3.5 ± 1.5; p = 0.01) and higher inpatient opiate usage (hydromorphone use: 3.9 ± 1.9 mg vs 2.8 ± 1.7 mg; p = 0.01) than 3-port laparoscopy. Operative time for SILS averaged 40% longer (54 ± 17 minutes vs 38 ± 11 minutes; p < 0.01). Only 1 SILS case was converted to 3-port. There were no significant differences in length of stay, complications, oral pain medication usage after discharge, or return to work. After 6 months, body image and cosmetic appearance were excellent for both groups and indistinguishable by most measures. However, 3-port patients reported better physical attractiveness (4.0 ± 0.4 vs 3.8 ± 0.4; p = 0.04) and SILS patients reported better scars (score 18.4 ± 2.7 vs 16.4 ± 3.0; p < 0.01). Results are reported as mean ± SD. CONCLUSIONS Single-incision laparoscopic surgery appendectomy resulted in more pain and longer operative times without improving short-term recovery or complications. Long-term body image and cosmetic appearance were excellent in both groups.

Morbidity and Mortality Associated With Elective or Emergency Paraesophageal Hernia Repair

PACIFIC COAST SURGICAL ASSOCIATION Morbidity and Mortality Associated With Elective or Emergency Paraesophageal Hernia Repair For decades, the standard of care for a paraesophageal hiatal hernia (PEH) was surgical repair after diagnosis, irrespective of symptoms. This standard of care was based on the reported high risk of acute gastric volvulus, strangulation, bleeding, or obstruction associated with untreated PEH and on the high mortality associated with emergency repair.1,2 A paradigm shift occurred in 2002, when Stylopoulos et al,3 using Markov analysis, found that watchful waiting was superior to elective repair for patients older than 65 years of age with a minimally symptomatic PEH. As a result, many patients with a PEH deferred surgery and opted for watchful waiting. A predictable consequence of watchful waiting has been an increase in the number of patients presenting with an acute PEH, sometimes with catastrophic outcomes.4 We characterized outcomes of emergency PEH repair in the modern era compared with elective repair using data from the American College of Surgeons National Surgical Quality Improvement Program. Methods | We reviewed all PEH repairs reported to the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2012. Inclusion criteria were an age of 18 years or older at the time of surgery, an International Classification of Diseases, Ninth Revision (ICD-9) primary diagnosis code of diaphragmatic hernia (ie, ICD-9 code 551.3, 552.3, or 553.3), and a primary Current Procedural Terminology code indicating repair, as described by Mungo et al.5 Demographic data, comorbidities, and preoperative laboratory values were reviewed. The primary outcome was 30-day mortality. Secondary outcomes were hospital length of stay and serious morbidity (defined as return to the operating room, cardiac complication, sepsis, shock, ventilation >48 hours, unplanned reintubation, or cerebrovascular accident or stroke). Because this research involves only deidentified patient information, it did not require institutional review board approval from the University of California, San Francisco. Predictors of serious morbidity and 30-day mortality were identified in univariate logistic regression. Multivariate predictors were identified using backward-stepwise logistic regression. Statistical significance was defined as P < .05.

Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? a comparison of 30-day complications using the MBSAQIP data registry

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has become popular due to its technical ease and excellent short-term results. Understanding the risk profile of LSG compared with the gold standard laparoscopic Roux-en-Y gastric bypass (LRYGB) is critical for patient selection. OBJECTIVES To use traditional regression techniques and random forest classification algorithms to compare LSG with LRYGB using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Data Registry. SETTING United States. METHODS Outcomes were leak, morbidity, and mortality within 30 days. Variable importance was assessed using random forest algorithms. Multivariate models were created in a training set and evaluated on the testing set with receiver operating characteristic curves. The adjusted odds of each outcome were compared. RESULTS Of 134,142 patients, 93,062 (69%) underwent LSG and 41,080 (31%) underwent LRYGB. One hundred seventy-eight deaths occurred in 96 (.1%) of LSG patients compared with 82 (.2%) of LRYGB patients (P<.001). Morbidity occurred in 8% (5.8% in LSG versus 11.7% in LRYGB, P<.001). Leaks occurred in 1% (.8% in LSG versus 1.6% in LRYGB, P<.001). The most important predictors of all outcomes were body mass index, albumin, and age. In the adjusted multivariate models, LRYGB had higher odds of all complications (leak: odds ratio 2.10, P<.001; morbidity: odds ratio 2.02, P<.001; death: odds ratio 1.64, P<.01). CONCLUSION In the Metabolic and Bariatric Surgery Accreditation and Quality Improvements data registry for 2015, LSG had half the risk-adjusted odds of death, serious morbidity, and leak in the first 30 days compared with LRYGB.

Ertapenem Prophylaxis Associated With an Increased Risk of Clostridium difficile Infection Among Surgical Patients.

A case-control study was conducted to determine risk factors for hospital-onset Clostridium difficile infection among patients admitted to 2 surgical units. Ertapenem prophylaxis was significantly associated with C. difficile infection risk (odds ratio, 3.13 [95% CI, 1.13-8.68], P=.028) and may offer an antimicrobial stewardship target among surgical patients.

Expanded indications for bariatric surgery: should patients on chronic steroids be offered bariatric procedures?

BACKGROUND Patients who take chronic corticosteroids are increasingly referred for bariatric surgery. Little is known about their clinical outcomes. OBJECTIVE Determine whether chronic steroid use is associated with increased morbidity and mortality after stapled bariatric procedures. SETTING American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS All patients who underwent laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass and were reported to the ACS-NSQIP from 2011 to 2013 were reviewed. Patients were grouped based on type of surgery and history of chronic steroid use. Primary outcome measures were mortality and serious morbidity in the first 30 days. Regression analyses were used to determine predictors of outcome. RESULTS Of 23,798 patients who underwent laparoscopic sleeve gastrectomy and 38,184 who underwent Roux-en-Y gastric bypass, 385 (1.6%) and 430 (1.1%), respectively, were on chronic steroids. Patients on chronic steroids had a 3.4 times increased likelihood of dying within 30 days (95% confidence interval 1.4-8.1, P = .007), and 2-fold increased odds of serious complications (95% confidence interval 1.2-2.3, P = .008), regardless of surgery type. In multivariate regression, steroid usage remained an independent predictor of mortality and serious complications. CONCLUSION In a large, nationally representative patient database, steroid use independently predicted mortality and serious postoperative complications after stapled bariatric procedures. Surgeons should be cautious about offering stapled bariatric procedures to patients on chronic steroids.

Subcutaneous Fat Fibrosis Links Obesity to Insulin Resistance in Chinese Americans

Objective Type 2 diabetes presents at a lower body mass index (BMI) in Chinese individuals than in white individuals. We sought to determine the role of subcutaneous adipose tissue (SCAT)-intrinsic factors, vs BMI or adiposity per se, in the vulnerability of Chinese individuals to obesity-associated impairment of insulin sensitivity. Research Design and Methods Thirty-two Chinese and 30 white men and women from a cohort in the San Francisco Bay Area underwent anthropometric measurements, body composition (dual-energy X-ray absorptiometry) analyses, and measurement of fasting plasma glucose and insulin. Forty-eight also provided abdominal SCAT samples for transcriptional and biochemical analyses of tissue fibrosis. Results BMI correlated with total body fat in white (r = 0.74, P < 0.001) but not Chinese individuals, whereas BMI correlated with visceral adipose tissue (VAT) accrual in both ethnicities (r = 0.88 and 0.81, respectively; P < 0.01). Insulin resistance (homeostatic model assessment of insulin resistance) worsened with VAT mass, but not total body fat, in Chinese subjects (r = 0.63, P < 0.01), whereas it worsened with both in white individuals. By contrast, SCAT mRNA levels of genes encoding profibrotic proteins rose remarkably along with both BMI and VAT mass in Chinese but not white subjects. Similarly, SCAT levels of hydroxyproline, an indicator of tissue collagen content that correlated with increasing VAT mass, were higher in Chinese vs white subjects, particularly in the setting of relative insulin resistance. Conclusions Our findings dissociate BMI from adiposity in Chinese individuals and instead highlight SCAT fibrosis as a process linked to visceral adiposity and insulin resistance in this group.