Mastering the learning curve significantly reduces operative time for laparoscopic treatment of complicated appendicitis

Laparoscopic appendectomy is the preferred operative method for acute appendicitistreatment. In terms of complicated appendicitis it can be effective in hands of an experiencedlaparoscopist that overwhelmed the learning curve for the method. Aim: Тhis retrospectivestudy examines whether the operative time for laparoscopic appendectomy for complicatedappendicitis is shortened after mastering the learning curve. Material and methods: A totalnumber of 196 patients were operated for the diagnosis of acute appendicitis, of whom 77were diagnosed with complicated appendicitis. They were subsequently divided in two groups(laparoscopic and open). Operative time in both groups was measured and the conversionand postoperative complications were noted. Results: Conversion rate was 2.3%. Operativetime was shorter in the laparoscopic group (67.4 ± 22.9 vs. 77.9 ± 17.9 minutes; p = 0.033).Overall postoperative morbidity was 25.97% with wound infection present only in the opengroup (p = 0.018). Intraabdominal abscess occurred in one patient from the laparoscopicgroup (0.38%). Length of hospital stay was shorter in the laparoscopic group (4.3 ± 2.2 vs. 5.7 ± 2.1, p = 0.0052).

The value of CT imaging and CRP quotient for detection of postbariatric complications

Background The diagnosis of major complications seems to be more challenging in obese patients. We aimed to show the relevance of routinely assessed clinical and paraclinical parameters as well as the relevance of CT scans in the diagnosis of major complications after bariatric procedures. Methods All patients who underwent operations (primary or revisional) in a 3-year period were retrospectively studied after bariatric surgery with a specific focus on the routinely assessed clinical parameters (tachycardia, temperature), paraclinical parameters on postoperative day (POD) 1 and 3 (C-reactive protein (CRP), leukocytes), and additional computed tomography (CT) scan results for the diagnosis of leakage, bleeding, intraabdominal abscess, superficial abscess, and other complications. Results A total of 587 patients were examined. In this cohort, 73 CT scans were performed due to suspected intraabdominal or pulmonary complication according to our hospital standard operating procedure. In total, 14 patients (2.4%) had a major complication (Clavien-Dindo grade IV/V). Of those, 10 patients (1.7%) had postoperative leakage. While the correct leakage diagnosis was only found in 33% of the patients by CT scan, the overall specificity of CT as a diagnostic tool for all kinds of complications remained high. Especially for abscess detection, CT scan showed a sensitivity and specificity of 100%. Multivariate analysis showed a significantly higher risk of leakage development characterized by a doubling of postoperative CRP level (odds ratio 4.84 (95% confidence interval 2.01–11.66, p < 0.001)). To simplify the use of CRP as a predictive factor for the diagnosis of leakage, a cut-off value of 2.4 was determined for the CRP quotient (POD3/POD1) with a sensitivity of 0.88 and a specificity of 0.89. Conclusion CT diagnostic after bariatric surgery has a high positive predictive value, especially for intraabdominal abscess formation. Nevertheless, CT scan for the diagnosis of leakage has a low sensitivity. Thus, a negative CT scan does not exclude the presence of a leakage. Using the described CRP quotient with a cut-off of 2.4, the risk of early leakage can be easily estimated. Furthermore, in any uncertain case of clinically suspected leakage, diagnostic laparoscopy should be performed.

Bariatric Surgery Conversions at a Revisional Referral Center: A Subset Analysis of Clinical Outcomes from a Rural Community Hospital Accredited Program

Introduction: Revisional bariatric surgery for complications and weight regain is associated with higher morbidity and mortality rates compared to primary bariatric surgery. The majority of procedures are done in an urban setting. Methods: A retrospective chart review with IRB approval was conducted in a rural community hospital accredited bariatric program. A total of 53 revisions were performed by a single surgeon from February 2019 to February 2020. A subset analysis of 18 bariatric surgery conversions was performed and its outcomes are presented. Primary outcomes were 30-day morbidity and mortality. Secondary outcomes included anastomotic or staple line leak, intraabdominal abscess and need for subsequent surgery. Results: Most patients were female (83.3%) and the median ASA class was 3. The mean age was 48.2 ± 13.3 years. Most conversions were performed laparoscopically (88.9%), with a minority done robotically (11.1%). There were no open procedures or conversions to open. The most common prior bariatric operation was a sleeve gastrectomy (SG) (44.4%) followed by vertical banded gastroplasty (VBG) (22.2%). The most common type of operation was laparoscopic SG conversion to Roux-en-Y gastric bypass (RYGB) (16.7%) followed by laparoscopic VBG conversion to RYGB (16.7%). History of tobacco use was present in 38.9% of patients. The most common preoperative comorbidity was severe gastroesophageal reflux disease (GERD) (88.9%). The 30-day morbidity was 33.3% and there was no mortality. There were no anastomotic or staple line leaks. Intraabdominal abscess developed in 11.1% of patients. The rate of marginal ulceration was 27.8%, with only one case (5.6%) requiring future gastrojejunostomy revision. The rate of subsequent surgery beyond 30 days was 22.2%. Conclusion: With an acceptable complication rate, no anastomotic or staple line leaks, and no mortality, minimally invasive bariatric surgery conversions are feasible and safe in a rural community hospital environment, with the most common indication being complications from a prior laparoscopic SG, and with the RYGB being the most common procedure as an end product of conversion.