William S. Laycock

A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs

Background: Although ventral hernia repair is increasingly performed laparoscopically, complication rates with this procedure are not well characterized. For this reason, we performed a prospective study comparing early outcomes after laparoscopic and open ventral hernia repairs. Methods: We identified all the patients undergoing ventral (including incisional) hernia repair at a single tertiary care center between September 1, 1999 and July 1, 2001 (overall n = 257). To increase the homogeneity of the sample, we excluded umbilical hernia repairs, parastomal hernia repairs, nonelective procedures, procedures not involving mesh, and repairs performed concurrently with another surgical procedure. Postoperative complications (in-hospital or within 30-days) were assessed prospectively according to standardized definitions by trained nurse clinicians. Results: Of the 136 ventral hernia repairs that met the study criteria, 65 (48%) were laparoscopic repairs (including 3 conversions to open surgery) and 71 (52%) were open repairs. The patients in the laparoscopic group were more likely to have undergone a prior (failed) ventral hernia repair (40% vs 27%; p = 0.14), but other patient characteristics were similar between the two groups. Overall, fewer complications were experienced by patients undergoing laparoscopic repair (8% vs 21%; p = 0.03). The higher complication rate in the open ventral hernia repair group came from wound infections (8%) and postoperative ileus (4%), neither of which was observed in the patients who underwent laparoscopic repair. The laparoscopic group had longer operating room times (2.2 vs 1.7 h; p = 0.001), and there was a nonsignificant trend toward shorter hospital stays with laparoscopic repair (1.1 vs 1.5 days; p = 0.10). Conclusions: The patients undergoing laparoscopic repair had fewer postoperative complications than those receiving open repair. Wound infections and postoperative ileus accounted for the higher complication rates in the open ventral hernia repair group. Otherwise, these groups were very similar. Long-term studies assessing hernia recurrence rates will be required to help determine the optimal approach to ventral hernia repair.

Open-label, sham-controlled trial of an endoscopic duodenojejunal bypass liner for preoperative weight loss in bariatric surgery candidates.

BACKGROUND The duodenojejunal bypass liner (DJBL) (EndoBarrier Gastrointestinal Liner) is an endoscopically placed and removable intestinal liner that creates a duodenojejunal bypass resulting in weight loss and improvement in type 2 diabetes mellitus. OBJECTIVE Weight loss before bariatric surgery to decrease perioperative complications. DESIGN Prospective, randomized, sham-controlled trial. SETTING Multicenter, tertiary care, teaching hospitals. PATIENTS Twenty-one obese subjects in the DJBL arm and 26 obese subjects in the sham arm composed the intent-to-treat population. INTERVENTIONS The subjects in the sham arm underwent an EGD and mock implantation. Both groups received identical nutritional counseling. MAIN OUTCOME MEASUREMENTS The primary endpoint was the difference in the percentage of excess weight loss (EWL) at week 12 between the 2 groups. Secondary endpoints were the percentage of subjects achieving 10% EWL, total weight change, and device safety. RESULTS Thirteen DJBL arm subjects and 24 sham arm subjects completed the 12-week study. EWL was 11.9% +/- 1.4% and 2.7% +/- 2.0% for the DJBL and sham arms, respectively (P < .05). In the DJBL arm, 62% achieved 10% or more EWL compared with 17% of the subjects in the sham arm (P < .05). Total weight change in the DJBL arm was -8.2 +/- 1.3 kg compared with -2.1 +/- 1.1 kg in the sham arm (P < .05). Eight DJBL subjects terminated early because of GI bleeding (n = 3), abdominal pain (n = 2), nausea and vomiting (n = 2), and an unrelated preexisting illness (n = 1). None had further clinical symptoms after DJBL explantation. LIMITATIONS Study personnel were not blinded. There was a lack of data on caloric intake. CONCLUSIONS The DJBL achieved endoscopic duodenal exclusion and promoted significant weight loss beyond a minimal sham effect in candidates for bariatric surgery. ( CLINICAL TRIAL REGISTRATION NUMBER NPT00469391.).

New technology for the division of short gastric vessels during laparoscopic Nissen fundoplication: A prospective randomized trial

Division of the short gastric vessels (SGV) is a standard component of laparoscopic Nissen fundoplications (LNF) at our institution. This study compares our original method of vessel control, multifire clip applier (MCA) and sharp division, to the Ultracision Harmonic Scalpel LCS (LCS). Twenty consecutive patients were evaluated in a randomized prospective fashion. Times for SGV division and estimated blood loss (EBL) were recorded. Cost data represent patient charges for use of either the MCA or LCS and the charge for operative time. Use of the LCS produced a significant reduction in the time required for SGV division and in the charges to the patient.

Early morbidity and mortality of laparoscopic sleeve gastrectomy and gastric bypass in the elderly: A NSQIP analysis

BACKGROUND Even though the U.S. population is aging, outcomes of bariatric surgery in the elderly are not well defined. Current literature mostly evaluates the effects of gastric bypass (RYGB), with paucity of data on sleeve gastrectomy (SG). The objective of this study was to assess 30-day morbidity and mortality associated with laparoscopic SG in patients aged 65 years and over, in comparison to RYGB. METHODS The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients aged 65 and over who underwent laparoscopic RYGB and SG between 2010 and 2011. Baseline characteristics and outcomes were compared. P value<.05 was considered significant. Odds ratios (OR) with 95% confidence interval (CI) were reported when applicable. RESULTS We identified 1005 patients. Mean body mass index was 44 ± 7. SG was performed in 155 patients (15.4%). The American Society of Anesthesiology physical classification of 3 or 4 was similar between the 2 groups (82.6% versus 86.7%, P = .173). Diabetes was more frequent in the RYGB group (43.2% versus 55.6%, P = .004). 30-day mortality (0.6% versus 0.6%, OR 1.1, 95% CI .11-9.49), serious morbidity (5.2% versus 5.6%, OR .91, 95% CI .42-0.96), and overall morbidity (9% versus 9.1%, OR 1.0, 95% CI .55-1.81) were similar. CONCLUSION In elderly patients undergoing laparoscopic bariatric surgery, SG is not associated with significantly different 30-day outcomes compared to RYGB. Both procedures are followed by acceptably low morbidity and mortality.

Laparoscopy may be lowering the threshold to operate on patients with suspected appendicitis

Background: Although several randomized trials have compared postoperative outcomes in patients undergoing open and laparoscopic appendectomy, few have examined whether laparoscopy has affected preoperative decision making. We hypothesized that surgeon enthusiasm for laparoscopic appendectomy would lower the threshold to operate on patients with possible appendicitis. To examine this question we designed a retrospective cohort study in the setting of a tertiary care medical center. Methods: We studied a consecutive series of 130 patients taken to the operating room with preoperative diagnoses of appendicitis between 1 January 1997 and 31 December 1999. We excluded pregnant patients, those under 18 or over 75, those admitted electively for chronic symptoms, and those undergoing appendectomy incidental to another procedure. Measures included the proportion of patients with normal appendices or acute appendicitis (perforated and nonperforated), as determined from the pathology report. Other clinical and demographic data were obtained by review of the medical records. Results: During the study period, 87 patients (67%) underwent open appendectomy and 43 patients (33%) underwent laparoscopic appendectomy. Women were more likely to receive the laparoscopic approach than men (43% vs 24% p = 0.021). Preoperative use of advanced imaging tests (computed tomography or ultrasound) was more prevalent in the laparoscopic group (40% vs 30%, p = 0.271). Patients undergoing the laparoscopic procedure were considerably less likely to have acute appendicitis than those undergoing an open one (67% vs 92%, p <0.001). However, among patients with confirmed appendicitis, those undergoing laparoscopic surgery were less likely to be perforated than those who had an open procedure (4.6% vs 25% p = 0.004). Conclusion: At our hospital, the availability of the laparoscopic approach to appendectomy may have lowered the threshold to operate on patients with possible appendicitis, as reflected in higher negative exploration rates and lower rates of perforated appendicitis.