Nabeel R. Obeid

Single stage conversion from adjustable gastric banding to sleeve gastrectomy or Roux-en-Y gastric bypass: an analysis of 4875 patients

BACKGROUNDnThe previous popularity of adjustable gastric banding (AGB), along with inconsistent long-term results, has resulted in the need for conversion to other procedures. The perioperative safety of laparoscopic sleeve gastrectomy (SG) and gastric bypass (RYGB) as single-stage conversion procedures is unclear.nnnOBJECTIVESnTo compare the early safety of SG and RYGB when performed as single-stage conversion procedures at the time of AGB removal.nnnSETTINGnNationwide analysis of accredited centers.nnnMETHODSnThe Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file for 2015 was queried for all patients who underwent single-stage conversion to SG or RYGB. Multivariable logistic regression was performed to control for baseline differences, and odds ratios (ORs) with 95% confidence intervals are reported.nnnRESULTSnThere were 4865 patients who underwent a single-stage AGB conversion. SG was performed in 3364 (69.1%). The 30-day reoperation (1.6% versus 2.7%, P = .008), readmission (4% versus 5.7%, P = .006), reintervention (1.7% versus 2.7%, P = .024), and overall morbidity (2.9% versus 6.5%, P<.0001) were significantly less common in the SG group. After controlling for baseline characteristics, RYGB was independently associated with higher overall 30-day reoperation (OR 1.81, 1.19-2.75), readmission (OR 1.42, 1.07-1.88), reintervention (OR 1.59, 1.06-2.4), and overall morbidity (OR 2.17, 1.62-2.9).nnnCONCLUSIONSnAGB conversions are associated with low overall 30-day event rates. Patients undergoing RYGB as a single-stage conversion experience higher complication rates and the need for additional early procedures compared with SG.

Sleeve Gastrectomy: the first 3 Years: evaluation of emergency department visits, readmissions, and reoperations for 14,080 patients in New York State

IntroductionThe purpose of our study was to evaluate the indications for and incidence of both emergency department (ED) visits and hospital readmissions within the first postoperative year. We also sought to identify the rate of reoperation within the first 3xa0years following a SG operation in New York State (NYS).MethodsThe SPARCS database was examined for all SGs performed between 2011 and 2013. Using a unique identifier, patients were followed for at least 1xa0year. Patients were followed for reoperation and/or conversion to Roux-en-Y Gastric Bypass (RYGB), as well as for any other hospital-based encounter. Using primary diagnosis codes, the top five reasons for ED visits and readmission were identified.ResultsThere were 14,080 SG between 2011 and 2013. Among all patients, just over one-third of patients visited the ED (33.9%). One in every ten of these visits resulted in readmission (9.5%), with 12.5% of the total postoperative patient population undergoing readmission within their first year after SG surgery. ED visits were unrelated to surgery in just over half of the patients (nxa0=xa04977; 53.88%). However, ED visits for abdominal pain (nxa0=xa01029; 11.14%), vomiting (nxa0=xa0237; 2.57%), dehydration (nxa0=xa0224; 2.43%), and syncope (nxa0=xa0206; 2.23%) were attributed to surgery. The top five causes for readmission within the first year after SG were unrelated to surgery (nxa0=xa01101; 41.74%), complication related to bariatric surgery (nxa0=xa0211; 8%), dehydration (nxa0=xa0171; 6.48%), postoperative wound complication (nxa0=xa089; 3.37%), abdominal pain (nxa0=xa078; 2.96%). Overall, there was a low reoperation rate (0.32%); specifically, rates of sleeve revision and conversion to RYBG were 0.11 and 0.21%, respectively.ConclusionSG has increasing popularity in NYS. Although postoperative ED visits are high, SG has a low overall reoperation rate (0.32%), and of these patients, most undergo conversion to RYGB compared to sleeve revision. Overall 1-year readmission rates after SG are 12.5%.

Increasing bile duct injury and decreasing utilization of intraoperative cholangiogram and common bile duct exploration over 14 years: an analysis of outcomes in New York State

IntroductionDuring laparoscopic cholecystectomy (LC), common bile duct (CBD) visualization either directly or with cholangiography (IOC) is less routine. Cholangiography can be used to identify and possibly prevent bile duct injury (BDI), which is a dreaded complication of cholecystectomy. The purpose of our study was to evaluate the trend of IOC/CBD exploration and BDI during LC for benign disease.MethodsA state-wide database (SPARCS) was used to identify all LC for benign biliary non-obstructive and obstructive disease between 2000 and 2014 in the state of New York. ICD-9 and CPT codes were used to identify IOC/CBD exploration and BDI. Multivariable logistic regression models were used in examining the linear trend in the risk of complication, 30-day readmission, 30-day ED visits, and BDI among all cholangiogram patients after controlling for possible confounding factors.ResultsDuring 2000–2014, 391,945 patients underwent laparoscopic cholecystectomy. The trend of IOC/CBD exploration performed significantly decreased for LC overall (12.37–10.44%, relative riskxa0=xa00.98, pxa0<.0001) and particularly, in the outpatient setting (10.77–7.52%, relative riskxa0=xa00.96, p valuexa0<.0001). Among patients with IOC, overall complication rate, 30-day readmission rate, and 30-day ED visit rates increased. When looking at overall complication rate, there was an increase by about 4% per year (relative riskxa0=xa01.04, p valuexa0<.0001). After controlling for confounding factors, the complication risk and 30-day ED visit risk increased through years, while the 30-day readmission risk did not have significant change. Risk of BDI also increased significantly (pxa0=xa00.03).ConclusionIn an era of laparoscopy, the rate of IOC/CBD exploration during LC has significantly decreased, while BDI significantly increased.

Patterns of reoperation after failed fundoplication: an analysis of 9462 patients

BackgroundLittle is known about the choice of reoperation after failed fundoplication for gastroesophageal reflux disease. Both redo fundoplication and conversion procedure to Roux-en-Y gastric bypass (RYGB) are safe and effective. We aimed to characterize the rates of different revisional procedures and to identify risk factors associated with failed fundoplication.MethodsUsing a statewide database, we examined records for patients who underwent fundoplication between 2000 and 2010. The primary outcomes were the rate of each type of reoperation and the pattern of subsequent procedures. Demographics and comorbidities were used in a multivariable logistic regression model to identify risk factors associated with reoperation after fundoplication.ResultsA total of 9462 patients were included. Overall, 430 (4.5%) patients underwent reoperation. Of those, 46 (10.7%) patients underwent RYGB at first reoperation, with the remainder having a redo fundoplication. An additional five patients were converted to RYGB after undergoing a redo fundoplication (51 total patients converted to RYGB at any point, 11.9%). Eighty-three percent of patients converted to RYGB were obese, as opposed to 8% for redo fundoplication. A single redo fundoplication was done in 81% of patients, while 35 patients (8.1%) underwent two or more revisional procedures. On average, any reoperation was performed 2.9xa0years after fundoplication, with redo fundoplication 2.5xa0years and RYGB 6.5xa0years later. Age 30–49xa0years (vs.xa0>70xa0years; OR 2.01, pxa0=xa00.011) and 50–69xa0years (vs. >70xa0years; OR 1.61, pxa0=xa00.011), female gender (OR 1.56, pxa0=xa0<xa00.0001), and chronic pulmonary disease (OR 1.40, pxa0=xa00.0044) were associated with revisional surgery.ConclusionsFundoplication has a low reoperation rate within a mean 8.3xa0years of follow-up. Redo fundoplication is more commonly performed and at an earlier point than conversion to RYGB. Younger age, female gender, and chronic pulmonary disease are associated with reoperation after fundoplication.

Routine contrast imaging after bariatric surgery and the effect on hospital length of stay

BACKGROUNDnAlthough multiple studies demonstrate that routine postoperative contrast studies have a low yield in diagnosing patients with early gastrointestinal (GI) leak after bariatric surgery, the practice pattern is unknown. Additionally, routine imaging may hinder procedural pathways that lead to accelerated postoperative discharge.nnnOBJECTIVESnTo report on the nationwide use of routine upper GI studies (UGI) and evaluate the effect on hospital resource utilization.nnnSETTINGnNationwide analysis of accredited centers.nnnMETHODSnThe Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file for 2015 was used to identify patients who underwent routine UGI after nonrevisional Roux-en-Y gastric bypass or sleeve gastrectomy. Multivariable logistic regression models were developed to identify risk factors for early hospital discharge.nnnRESULTSnBariatric surgery was performed on 130,686 patients. Routine UGI was performed in 30.9% of Roux-en-Y gastric bypass and 43% of sleeve gastrectomy patients (P<.0001). Patients undergoing routine UGI were less likely to be discharged by postoperative day 1 (odds ratio .7, 95%; confidence interval .69-0.72). There was no difference in postoperative leak rate between the routine UGI versus nonroutine UGI group (.7% versus .8%, P = .208). Among patients who developed a GI leak, there was no significant difference in the rate of reoperation, readmission, and reintervention between the 2 groups. The time interval between index operation and any further management for the leak was longer in the routine UGI group.nnnCONCLUSIONSnRoutine UGI evaluation after bariatric surgery remains a common practice in accredited centers. This practice is associated with prolonged hospital length of stay, with no effect on the diagnosis of leak rate.

Fundamentals of Becoming a Safe and Independent Surgeon (From First Assistant to Skilled Educator)

General surgery residency training, governed by the Accreditation Council for Graduate Medical Education (ACGME) in collaboration with the American Board of Surgery (ABS), continues to evolve to meet the needs of the present-day healthcare climate and to address specific areas of deficiency so that graduating surgeons can be competent and proficient. Despite these efforts, the transition to independent surgical practice is difficult from a personal and professional perspective due to newfound operative autonomy and practice management. Key principles can be applied to alleviate these challenges and include formal transition to practice programs, finding a valuable mentor, setting up for early success by taking on low-complexity cases, developing collaborative relationships, and adhering to society guidelines.