Uptake of enhanced recovery practices by SAGES members: a survey

Abstract

Background

The SAGES Surgical Multimodal Accelerated Recovery Trajectory (SMART) Enhanced Recovery Task Force aims to increase awareness and provide tools for members to successfully implement enhanced recovery pathways (ERPs) to improve clinical outcomes and patient satisfaction. An initial step was to survey SAGES member on their knowledge, use, and impediments to enhanced recovery.

Methods

An online survey designed by SMART committee members to define SAGES member's awareness and use of enhanced recovery principles and practice was emailed to all SAGES members. Reminders were sent 2 and 3 weeks later, encouraging completion of the survey. The web-based survey included 48 questions and took an estimated 20 min to complete.

Results

A total of 229 members completed the survey. Respondents were primarily general/MIS surgeons (82.6%) working in an urban location (85.5%), with a bell-shaped age distribution (median 35–44). Almost half regularly used some elements of ERPs (48.7%), but 30% were unfamiliar with the concept. Wide variety in the specific ERP elements used and discharge criteria were reported. The majority had to create and implement their own plan (70.4%). Roadblocks to implementation were inconsistencies with partners/covering physicians (56.3%), nursing education (46.6%), and resources (34.7%). When implemented, members saw improvements in length of stay (88%), patient satisfaction (54.7%), postoperative pain (53.3%), time to return of bowel function (52.7%), and readmissions (16.7%). A need for education and standardization was especially seen in preoperative care, with 74.4% fasting patients from midnight the night before surgery. Wide variations were also reported in pain management practices. An overwhelming majority (89%) reported that having a protocol endorsed by a national organization, such as SAGES, would help with implementation.

Conclusions

From this survey of SAGES members, there is a need for education, tools, and standardized protocols to increase awareness, support implementation, and encourage wider utilization of ERP. The overwhelming majority stated having a protocol endorsed by a national organization, such as SAGES, would facilitate implementation.

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Five-year results of laparoscopic sleeve gastrectomy for the treatment of severe obesity

Abstract

Background

Since 2011, the most used bariatric technique in France has been the sleeve gastrectomy. There are still few studies exploring the medium and long-term results of this technique.

Objective

To describe medium–long-term (5 years) results of a cohort of CHU Montpellier experience in sleeve gastrectomy for morbid obesity.

Methods

All patients that underwent laparoscopic sleeve gastrectomy (LSG) from January 2005 to June 2013 were included in this study.

Results

A total of 1050 patients were operated. 72.86% were women. The mean preoperative BMI was 44.58 kg/m² (±7.71). A total of 183 patients (18.5%) were super-obese (BMI > 50 kg/m²). LSG was proposed as primary procedure, and also after failure of adjustable gastric banding in 169 patients (16.9%) or after vertical banded gastroplasty in 7 cases (0.7%). There were 38 postoperative gastric fistulas (3.8%) and 3 of them required some kind of bypass to be definitively treated. There were also 34 hemorrhages (3.4%) of which 21 were reoperated for hemostasis. Two gastric stenoses at the angulus (0.2%) were managed with dilation or RYGB. Overall reoperative rate was 6.8%. One patient died of pulmonary embolism. Most common late complication was GERD (39.1%). After 3, 4 and 5 years of LSG, the average of %EBL was, respectively, 75.95% (±29.16) (382 patients), 73.23% (±31.08) (222 patients) and 69.26% (±30.86) (144 patients). The success rate at 5 years was 65.97% (95 patients). The improvement or remission of comorbidities was found, respectively, in 88.4 and 57.2% of diabetic patients; 76.9 and 19.2% for hypertensive patients and 98 and 85% for patients with sleep apnea syndrome.

Conclusion

LSG is a bariatric surgery technique that presents a very good risk/benefit ratio. Five-year results are very convincing. GERD is the main long-term complication.

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Perioperative hemorrhagic complications after laparoscopic sleeve gastrectomy: four-year experience of a bariatric center of excellence

Abstract

Background

Bleeding and gastric fistula are the most common postoperative complications after laparoscopic sleeve gastrectomy (LSG). The long stapler line represents the most frequent source of bleeding, which ranges between 0 and 20%. The aim of this retrospective study was to analyze the 4-year experience of a high-volume center with respect to the prevention and management of perioperative LSG bleeding.

Methods

The prospectively maintained database from June 2012 to June 2016 was reviewed. Outcomes, especially perioperative bleeding (until patient discharge), its management, and follow-ups, were analyzed.

Results

Out of 870 LSG (603 females, 267 males), 31 cases (3.5%) of postoperative complications were registered: bleeding was the most frequent complication (1.9%). Hemoperitoneum was managed laparoscopically in 9/17 patients (52.9%) with only one conversion to laparotomy (11.1%). Conservative treatment successfully controlled bleeding in 8/17 patients (47.1%). However, four patients (50%) developed an infected hematoma; two of them were treated conservatively with a CT-guided drainage, and the other two were complicated by late gastric leak treated laparoscopically. No mortalities occurred in the investigated cases.

Conclusions

In a high-volume center, the expected incidence of bleeding after LSG is 1.7% even after the adoption of all preventive strategies. The intraoperative protocol for detecting silent bleeding was effective, and no cases of bleeding were observed since its application. Our findings showed that the conservative management of postoperative bleeding should be considered as a high-risk condition for late leakage.

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Laparoscopic common bile duct exploration: a safe and definitive treatment for elderly patients

Abstract

Background

Common bile duct (CBD) stone is one of the most common diseases among elderly people. In recent decades, there are numerous studies regarding the safety and efficacy of laparoscopic common bile duct exploration (LCBDE). Elderly patients are often regarded as high-risk patients because they are more likely to present with age-specific deterioration of organ function and coexisting chronic diseases, which may reduce their tolerance of laparoscopic surgery. Although laparoscopic surgery for choledocholithiasis is now widely accepted as the treatment for CBD stone, its appropriateness for the treatment of elderly patients or those with coexisting high-risk patients has not been well established. Therefore, the objective of this paper is to analyze the safety and efficacy of LCBDE in elderly patients.

Methods

Between January 2012 and November 2015, 376 patients underwent LCBDE in our center. Based on their ages, they were divided into two groups, and a retrospective study was performed. By making comparisons between younger group who were younger than 70 years (n = 253) and elderly group who were 70 years old or older (n = 123), the demographics, clinical characteristics, laboratory data, operative parameters and outcomes were analyzed.

Results

Before operation, elderly patients had more coexisting chronic diseases and risk factors, such as arterial hypertension, heart diseases, pulmonary diseases and previous abdominal surgery (P < 0.05). In both groups, LCBDE was equally successful with a high clearance rate (100 % in elderly patients vs. 98.8 % in younger group, P = 0.554). Besides, the operating time, intraoperative blood loss, postoperative hospital stay, total costs and overall complication showed no significant difference between two groups (P > 0.05). There was no major bile duct injury or death in either group.

Conclusion

Although elderly patients are frequently confronted with coexisting disorders, LCBDE can be considered as a safe and effective technique in choledocholithiasis treatment for elderly patients.

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Localizing small lung lesions in video-assisted thoracoscopic surgery via radiofrequency identification marking

Abstract

Background

To facilitate accurate localization of small lung lesions in thoracoscopic surgery, we employed a micro-radiofrequency identification tag designed to be delivered through the 2-mm working channel of a flexible bronchoscope. This report presents the results of preclinical studies of our novel localizing technique in a canine model.

Methods

To evaluate functional placement, three types of tags [Group A, tag alone (n = 18); Group B, tag + resin anchor (n = 15); and Group C, tag + NiTi coil anchor (n = 15)] were bronchoscopically placed in subpleural areas and subsegmental bronchi via our new delivery device; tags were examined radiographically on days 0–7 and day 14. In addition, eight tags, which were placed at a mean depth of 13.3 mm (range 9–15.7 mm) from visceral pleura in bronchi with a mean diameter of 1.46 mm (range 0.9–2.3 mm), were recovered by partial lung resection under video-assisted thoracoscopic surgery using a 13.56-MHz wand-shaped probe with a 30-mm communication range.

Results

Peripheral airway placement: Group C had a significantly higher retention rate than the other two groups (retention rate at day 14: Group A, 11.1 %; Group B, 26.7 %; Group C, 100.0 %; P < 0.0001). Central airway placement: Overall retention rate was 73.3 % in Group C, and placement was possible in bronchi of up to 3.3 mm in diameter. Outcomes of partial resection: Tag recovery rate was 100 %, mean time required for tag detection was 10.8 s (range 8–15 s), and mean surgical margin from the delivered tag was 9.13 mm (range 6–13 mm).

Conclusion

Radiofrequency identification marking enabled accurate localization with depth, which could ensure effective deep resection margins.

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Readmissions after laparoscopic cholecystectomy in a UK District General Hospital

Abstract

Introduction

Laparoscopic cholecystectomy is the gold standard for the treatment of symptomatic gallstones and its practice as day case where possible is considered the standard over the last decade. However, readmission after surgery is recognised as a new problem.

Aim

The aim of this cohort observational study was to investigate the readmission rate in a district general hospital and identify the causes of readmission in order to explore ways by which this can be reduced or managed more cost effectively.

Method

Records of patients who had laparoscopic cholecystectomy over 6 months were retrospectively searched. Patients returning to hospital due to symptoms within 30 days of elective and emergency laparoscopic cholecystectomy were included.

Results

Three hundred and twenty-eight laparoscopic cholecystectomies were performed within the 6-month period. Twenty-two patients returned within 30 days of surgery making a readmission rate of 6.7%. Reasons for inpatient admission were abdominal pain without any underlying cause 10 (45.5%), wound infection 5 (22.7%), leg swelling 2 (9%), retained stone 1 (4.5%), bile leak 1 (4.5%), pneumonia 1 (4.5%), iatrogenic bowel injury 1 (4.5%) and back pain 1 (4.5%). Readmission rate decreased with longer duration of stay in hospital during primary admission, and 64% of patients returned to the hospital within 7 days of procedure. 50% of patients who returned with abdominal pain without any identifiable cause had a longstanding history of conditions involving chronic pain.

Conclusion

While the feared intra-abdominal complications of cholecystectomy often come to mind when assessing patients presenting with abdominal pain after surgery, non-specific abdominal pain is consistently shown to be several times more likely. A combination of patient factors and pain control techniques account for this pain. Effective multimodal pain management approach and community primary health care support in the early post-operative period could reduce readmission, save cost and improve patient experience.

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