Melissa C. Helm

Perioperative bleeding and blood transfusion are major risk factors for venous thromboembolism following bariatric surgery

BackgroundMorbidly obese patients are at increased risk for venous thromboembolism (VTE) after bariatric surgery. Perioperative chemoprophylaxis is used routinely with bariatric surgery to decrease the risk of VTE. When bleeding occurs, routine chemoprophylaxis is often withheld due to concerns about inciting another bleeding event. We sought to evaluate the relationship between perioperative bleeding and postoperative VTE in bariatric surgery.MethodsThe American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) dataset between 2012 and 2014 was queried to identify patients who underwent bariatric surgery. Gastric bypass (n = 28,145), sleeve gastrectomy (n = 30,080), bariatric revision (n = 324), and biliopancreatic diversion procedures (n = 492) were included. Univariate and multivariate regressions were used to determine perioperative factors predictive of postoperative VTE within 30 days in patients who experience a bleeding complication necessitating transfusion.ResultsThe rate of bleeding necessitating transfusion was 1.3%. Bleeding was significantly more likely to occur in gastric bypass compared to sleeve gastrectomy (1.6 vs. 1.0%) (p < 0.0001). For all surgeries, increased age, length of stay, operative time, and comorbidities including hypertension, dyspnea with moderate exertion, partially dependent functional status, bleeding disorder, transfusion prior to surgery, ASA class III/IV, and metabolic syndrome increased the perioperative bleeding risk (p < 0.05). Multivariate analysis revealed that the rate of VTE was significantly higher after blood transfusion [Odds Ratio (OR) = 4.7; 95% CI 2.9–7.9; p < 0.0001). Predictive risk factors for VTE after transfusion included previous bleeding disorder, ASA class III or IV, and COPD (p < 0.05).ConclusionsBariatric surgery patients who receive postoperative blood transfusion are at a significantly increased risk for VTE. The etiology of VTE in those who are transfused is likely multifactorial and possibly related to withholding chemoprophylaxis and the potential of a hypercoagulable state induced by the transfusion. In those who bleed, consideration should be given to reinitiating chemoprophylaxis when safe, extending treatment after discharge, and screening ultrasound.

Wisconsin's Enterra Therapy Experience: A multi-institutional review of gastric electrical stimulation for medically refractory gastroparesis

Background: Gastric electrical stimulation is a treatment for symptoms of diabetic or idiopathic gastroparesis refractory to medical management. We sought to evaluate the outcomes of gastric electrical stimulation in the state of Wisconsin during a more than 10‐year period. Methods: Data were collected prospectively from patients undergoing implantation of the gastric electrical stimulation to initiate gastric electrical stimulation therapy at two Wisconsin institutions from 2005–2017. The Gastroparesis Cardinal Symptom Index was administered during clinical encounters and over the phone preoperatively and postoperatively. Results: A total of 119 patients received gastric electrical stimulation therapy (64 diabetic and 55 idiopathic). All devices were placed laparoscopically. Mean follow‐up was 34.1 ± 27.2 months in diabetic and 44.7 ± 26.2 months in idiopathic patients. A total of 18 patients died during the study interval (15.1%). No mortalities were device‐related. Diabetics had the greatest rate of mortality (25%; mean interval of 17 ± 3 months post implantation). GCSI scores improved, and prokinetic and narcotic medication use decreased significantly at ≥1 year. Satisfaction scores were high. Conclusion: Gastric electrical stimulation therapy led to the improvement of symptoms of gastroparesis and a better quality of life. Patients were able to decrease the use of prokinetic and narcotic medications and achieve long‐term satisfaction. Diabetic patients who develop symptomatic gastroparesis have a high mortality rate over time.

Robotic skills can be aided by laparoscopic training

BackgroundGeneral Surgery is currently the fastest growing specialty with regards to robotic surgical system utilization. Contrary to the experience in laparoscopy, simulator training for robotic surgery is not widely employed partly because robotic surgical simulators are expensive. We sought to determine the effect of a robotic simulation curriculum and whether robotic surgical skills could be derived from those psychomotor skills attained in laparoscopic training.MethodsTwenty-seven trainees with no prior robotic experience and limited laparoscopy exposure were randomly assigned to one of three training groups: no simulator training, training on a fundamentals of laparoscopic surgery (FLS™) standard box trainer, and training on a robotic computer based simulator (da Vinci Skills Simulator™). Baseline robotic surgical skills were assessed on the clinical robot docked to a standard FLS trainer box on two tasks—intracorporeal knot tying and peg transfer. Subjects subsequently underwent four 1-h long training sessions in their assigned training environment over a course of several weeks. Robotic surgical skills were reassessed on the robot on the same two tasks used to assess skills prior to training.ResultsFLS training resulted in a greater score improvement than no training for both knot and peg scores. FLS training was also determined to result in greater score improvement than robotic simulator training for knot tying. There was no significant difference in peg transfer or knot tying scores when comparing robotic simulator training and no training.ConclusionsRobotic surgical skills can be in part derived from psychomotor skills developed in a laparoscopic trainer, especially for complex skills such as intracorporeal knot tying. Acquisition of robotic surgical skills may be enhanced by practice on a laparoscopic simulator using the FLS curriculum. This may be especially helpful when a robotic simulator is not available or is poorly accessible.

Preoperative immobility significantly impacts the risk of postoperative complications in bariatric surgery patients

BACKGROUND Preoperative immobility in general surgery patients has been associated with an increased risk of postoperative complications. It is unknown if immobility affects bariatric surgery outcomes. OBJECTIVES The aim of this study was to determine the impact of immobility on 30-day postoperative bariatric surgery outcomes. SETTING This study took place at a university hospital in the United States. METHODS The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 data set was queried for primary minimally invasive bariatric procedures. Preoperative immobility was defined as limited ambulation most or all the time. Logistic regression analysis was performed to determine if immobile patients are at increased risk (odds ratio [OR]) for 30-day complications. RESULTS There were 148,710 primary minimally invasive bariatric procedures in 2015. Immobile patients had an increased risk of mortality (OR 4.59, P<.001) and greater operative times, length of stay, reoperation rates, and readmissions. Immobile patients had a greater risk of multiple complications, including acute renal failure (OR 6.42, P<.001), pulmonary embolism (OR 2.44, P = .01), cardiac arrest (OR 2.81, P = .05), and septic shock (OR 2.78, P = .02). Regardless of procedure type, immobile patients had a higher incidence of perioperative morbidity compared with ambulatory patients. CONCLUSIONS This study is the first to specifically assess the impact of immobility on 30-day bariatric surgery outcomes. Immobile patients have a significantly increased risk of morbidity and mortality. This study provides an opportunity for the development of multiple quality initiatives to improve the safety and perioperative complication profile for immobile patients undergoing bariatric surgery.

Preoperative Functional Health Status is a Predictor of Postoperative Morbidity and Mortality following Bariatric Surgery

Abstract Background : Functional health status (FHS) is the ability to perform activities of daily living without caregiver assistance. Objectives : The primary aim of this study was to determine the impact of impaired preoperative functional health status on morbidity and mortality within 30-days of bariatric surgery. Setting : Academic Medical Center in the United States. Methods : The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 dataset was queried for primary minimally invasive bariatric procedures. The demographics and perioperative details of patients who were functionally independent were compared with patients with impaired FHS. Multivariable logistic regression analysis was performed to determine the odds of developing a perioperative complication or death for patients with impaired functional health. Results : 1,515 patients (1.0%) were reported as having impaired FHS and 147,195 patients (99.0%) were independent prior to surgery. Patients with impaired FHS experienced significantly longer length of hospital stays (2.4 vs. 1.8 days; p Conclusions : Patients with impaired FHS preoperatively have a significantly increased risk of short-term morbidity and mortality following bariatric surgery. The results of this study highlight the importance of establishing quality initiatives focused on improving short-term outcomes for patients with impaired functional health status.

Preoperative pain in patient with an inguinal hernia predicts long-term quality of life

Background. Patients presenting for inguinal hernia repair report a wide range of pain. We hypothesized that patients presenting with less preoperative pain would experience a greater improvement in long‐term quality of life after an inguinal hernia repair. Methods. A total of 54 patients underwent either laparoscopic or open inguinal hernia repair and completed the Short Form 12 (SF‐12) survey both preoperatively and 6 to 12 months after their repair. The physical and mental component scores (PCS and MCS) were calculated from the SF‐12. Patients also completed an analog surgical pain scale. t Tests and analyses of covariance were used. A preoperative surgical pain scale score of >12 was representative of moderate to severe pain. Results. Regardless of preoperative pain, there was improvement in long‐term PCS quality of life (45.4 ± 11.3 vs 50.1 ± 9.1; P < .0001) that was not noted when assessing MCS quality of life (55.0 ± 8.3 vs 54.7 ± 9.4; P = .76). Patients who reported no or a low amount of preoperative pain experienced improved PCS quality of life compared with patients who reported moderate to severe preoperative pain (P = .048). This relationship was not noted with MCS (P = .16). Conclusion. This study suggests that patients presenting for inguinal hernia repair with no or low pain are more likely to experience improved physical function quality of life as a result of the herniorrhaphy.