Monica T. Young

Bariatric surgery in the elderly: 2009–2013

BACKGROUND Ample evidence supports the safety and effectiveness of bariatric surgery in the general adult population but more information is needed in patients age 60 years and older (elderly). We previously examined the outcome of bariatric surgery performed in the elderly between 1999 and 2005 using the University HealthSystem Consortium (UHC) Clinical Database. The aim of this study was to analyze contemporary outcomes of bariatric surgery in the elderly and to compare them to previous data from 1999-2005. METHODS Using International Classification of Diseases, 9(th) Revision diagnosis and procedure codes, we obtained data from the UHC database for all elderly (age >60 yr) and adult nonelderly (age 19-60 yr) patients who underwent bariatric surgery for the treatment of morbid obesity between 2009 and 2013. Outcome measures, such as patient characteristics, LOS, morbidity, and observed-to-expected (risk-adjusted) mortality ratio were compared between elderly and nonelderly patients. RESULTS Bariatric surgery in the elderly made up 2.7% of all bariatric operations in 1999-2005. This represents an increase to 10.1% of all bariatric operations in 2009-2013. In-hospital mortality was .30% for the nonelderly and .70% for the elderly in 1999-2005, whereas contemporary in-hospital mortality has decreased to .11% for the nonelderly and .05% for the elderly. CONCLUSION Our results show that the number of bariatric procedures performed in the elderly is increasing and now represents 10% of all bariatric operations performed at academic centers. In-hospital mortality in bariatric surgery in the elderly has improved so much that it is now even better than in-hospital mortality in the nonelderly in 1999-2005.

A Decade Analysis of Trends and Outcomes of Male vs Female Patients Who Underwent Bariatric Surgery.

BACKGROUND Male obesity rates are now estimated to be equal to female obesity rates. Despite this, men constitute a minority of patients undergoing bariatric surgery. The aim of this study was to examine the national trends and outcomes of bariatric surgery in male patients compared with female patients. STUDY DESIGN The Nationwide Inpatient Sample database was reviewed for obese patients undergoing bariatric surgery between 2002 and 2011. Outcomes were analyzed according to sex. Main outcomes measures were patient demographics, length of stay, risk-adjusted inpatient morbidity and mortality, and hospital charge. RESULTS During the 10-year period, 810,999 patients underwent bariatric surgery; 19.3% were male and 80.7% were female. The percentage of male patients increased from 15.4% in 2002 to 21.7% in 2011. Mean age was significantly older for males (46 ± 11 years vs 43 ± 11 years; p < 0.01, respectively). Male patients had a higher proportion of moderate, major, and extreme severity of illness classifications and higher rates of comorbid conditions. Serious morbidity was significantly higher in male patients compared with female patients (7.58% vs 5.42%; p < 0.01). Mean hospital length of stay was longer for male patients (2.75 vs 2.61 days; p < 0.01) with a higher mean hospital charge (

Incisional Reinforcement in High-Risk Patients

38,682 vs

Laparoscopic and Thoracoscopic Esophagectomy with Colonic Interposition

34,294; p < 0.01). Compared with the female group, the male group had higher risk-adjusted in-hospital mortality (odds ratio = 2.16; 95% CI, 1.62-2.88; p < 0.01) and serious morbidity (odds ratio = 1.23; 95% CI, 1.17-1.29; p < 0.01). CONCLUSIONS The number of male patients undergoing bariatric surgery in the past decade continues to be a small fraction compared with the number of female patients. Men undergoing bariatric surgery tend to have higher severity of illness, with higher risk-adjusted serious morbidity and mortality rates. Additional studies are necessary to examine barriers in obtaining treatment for obese men.

Proctectomy and Rectopexy: Hybrid Robotic Approach

Hernia formation after surgical procedures continues to be an important cause of surgical morbidity. Incisional reinforcement at the time of the initial operation has been used in some patient populations to reduce the risk of subsequent hernia formation. In this article, reinforcement techniques in different surgical wounds are examined to identify situations in which hernia formation may be prevented. Mesh use for midline closure, pelvic floor reconstruction, and stoma site reinforcement is discussed. Additionally, the use of retention sutures, closure of the open abdomen, and reinforcement after component separation are examined using current literature. Although existing studies do not support the routine use of mesh reinforcement for all surgical incisions, certain patient populations appear to benefit from reinforcement with lower rates of subsequent hernia formation. The identification and characterization of these groups will guide the future use of mesh reinforcement in surgical incisions.

Single-Incision Robotic Surgery

Minimally invasive esophagectomy has become increasingly utilized as an alternative to open esophagectomy. Although the stomach is the preferred conduit for esophageal reconstruction, the colon can be used as an alternative when a gastric conduit is not feasible. We describe our surgical technique for a laparoscopic and thoracoscopic Ivor Lewis esophagectomy with colonic interposition. The esophagocolic anastomosis can be constructed with a circular stapler or a hand-sewn approach.

Use and Outcomes of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Gastric Bypass: Analysis of the American College of Surgeons NSQIP

Due to advances in technology and surgical technique, the da Vinci robot has become increasingly relevant in the field of colorectal surgery. This approach is particularly applicable to the technical challenges of pelvic dissection, which require precise movements in a confined space. Improved visualization can lead to lower conversion rate to open surgery, fewer complications, and shorter hospital stay (Baik et al., Ann Surg Oncol 16(6):1480–1487, 2009). This chapter will review the operative techniques of a hybrid robotic-assisted low anterior resection, abdominoperineal resection, and rectopexy.

Volume and outcome relationship in bariatric surgery in the laparoscopic era

Robotic surgery represents the latest advance in minimally invasive techniques. Single-incision robot-assisted surgery is the ultimate robotic surgery technology and has received enthusiastic acceptance in field of gallbladder surgery. However, apart from improved cosmesis, its reported benefits are thus far not widely known. Its application is limited largely to cholecystectomy, but it is gradually being applied to other procedures. As the results of further studies surface, a clearer picture of the role of reduced-port robotic surgery will emerge.