ViSiGi 3D™ vs. Bougie Dilator for Sleeve Gastrectomy Calibration

ViSiGi 3D™ vs. Bougie Dilator for Sleeve Gastrectomy Calibration Nicholas Schiavone1 Richard Boorse M.D.1,2 1Department of Surgery, Lehigh Valley Health Network 2Research Scholar Program Mentor Abstract This paper is the start of a quality improvement project to decrease cost, length of stay, and various problems that are uncommon, but known to happen with laparoscopic sleeve gastrectomies. This will be accomplished by comparing the standard bougie used in laparoscopic sleeve gastrectomies with a newer technology called the ViSiGi 3DTM which is a suction calibration system. A database has been completed that tracks patient information and various important details from surgery to discharge that will allow for analysis of pros and cons of each calibration device pending approval from the IRB. Background Bariatric surgical procedures are rapidly becoming the most performed in the field of general surgery. Specifically the laproscopic sleeve gastrectomy is gaining popularity as an effective weight loss tool. Laparoscopic sleeve gastrectomy involves resection of 70% of the stomach leaving a narrow tube referred to as a “sleeve” (Fig. 1). The sleeve gastrectomy helps patients lose weight in two ways: the first being restricting volume of oral intake and the second being reduction in the “hunger hormone” ghrelin by removal of the gastric fundus where the hormone is produced. There are several important tools used in the completion of a laparoscopic sleeve gastrectomy, and this paper will focus on only one of them, the bougie. The bougie is plastic tubing that is inserted by the anesthetist through the mouth, down the esophagus, and rests against the pyloric sphincter in the stomach. This is then used as a guide for the surgeon to staple alongside of and form the new sleeve. The problem with a traditional weighted bougie (Fig. 2) is that the anesthetist needs to continually adjust and readjust the bougie so that the sleeve is uniform in shape and size. We started using a ViSiGi 3D calibration device (Fig. 3) and are planning to compare the results with those of a standard bougie. The advantages of a ViSiGi 3D calibration device are that not only does it serve the purpose of the standard bougie, it also compresses the stomach uniformly due to the suction acting on all surfaces of the stomach equally, it empties the stomach of all contents, as well as holding the stomach in place which removes the need for constant readjustment. The aim of this paper is to discuss the database that was created, and the process that was used to create it that will be used to compare and contrast the ViSiGi 3D calibration device to the standard weighted bougie. Methodology This study will be a retrospective chart review that will be broken up into two cohorts. The first cohort is comprised of the 100 sleeve gastrectomy cases preceding the use of the ViSiGi 3D suction calibration system in which a weighted bougie was used. The second cohort consisted of the first 100 sleeve gastrectomy cases using the ViSiGi 3D system. Both cohorts had procedures that were either stand-alone sleeve gastrectomies or a conversion of a band to a sleeve. All of the procedures were performed by either Dr. Boorse or Dr. Harrison using nearly identical techniques. Dispersed throughout these procedures were additional surgeries completed such as cholecystectomy, hiatal hernia repair, umbilical hernia repair, and/or lysis of adhesions which will be taken into consideration when determining the length of procedure. The first step in completing this project, following the completion of the 200 cases, was to make a database that outlined all the variables of interest, of which there were 110. These are listed in table 1. The importance of these variables is twofold. The first is that it will allow us, once we receive IRB approval, to analyze the data points which are truly important to our future paper. The second is that it has already allowed us to create an entire bariatric database that will be used to gather important data points on all future bariatric procedures performed at LVHN and will allow for continuous quality improvement analysis that is not limited to only laparoscopic sleeve gastrectomies. That data used in the database was gathered using a combination of EHMR as well as the newly implemented system of EPIC Hyperspace. Results There are no results at this time because the database has not yet been analyzed due to all the criteria not being fully collected at the time that this paper was written. Discussion However, there are several early impressions that the surgeons have made since using the ViSiGi 3d suction calibration system that we will be expecting to be confirmed once statistical analysis is performed. The first is a decrease in staple load fires. The second is that, due to the diminished need to constantly readjust the bougie, the overall length of procedure will decrease. The third is that leakage rates will be decreased. The fourth is that the overall length of stay will decrease. The fifth is that the rate of 30 day readmissions will decrease. We are hoping that, due to the aforementioned benefits, the cost will decrease more than the additional cost of the ViSiGi 3D. If any of the above is true the ViSiGi 3D may be made the new standard of care in the LVHN hospital network. Conclusion The goal of this paper was to give background on the differences between the standard bougie and the ViSiGi 3D suction calibration system, outline the database being used for storage of vital information pertaining to future quality improvement projects, as well as outline the goal for any future quality improvement projects that will be performed once all data has been collected. This paper is a promising start to a strong quality improvement project using the ViSiGi 3D suction calibration system during laparoscopic sleeve gastrectomies. It also provides the groundwork in the form of an all-encompassing bariatric database that will be used to compare all procedural outcomes with one another rather than just sleeve to sleeve comparisons. The future aim of Dr. Boorse and his colleagues is to statistically evaluate the pros and cons, if any, of using the ViSiGi 3D suction calibration system versus a standard bougie. Appendix Last Name First Name Date of Birth Medical Record Number Encounter Number Age Race Sex Smoking Status Pre Op Weight Pre Op BMI History of Pulmonary Embolism History of Deep Vein Thrombosis Cholelithiasis/Previous Cholecystectomy Sleep Apnea Diabetes Mellitus If “Yes” Type 1 or 2 Gastro Esophageal Reflux Disease Hypertension Hyperlipidemia Cardiac Disease Chronic Anticoagulation Meds Myocardial Infarction Musculoskeletal problems (i.e. arthritis, disc disease, or both) Anxiety Depression Barrett’s Esophagus Pre Op Hpylori Result EGD Result of Hiatal Hernia Surgery Date What Procedure The surgeon which performed the procedure Whether a ViSiGi bougie was used If “yes” what size Whether a Standard Bougie was used If “yes” what size How many of each staple was fired White, Blue, Green, Gold, Black Cost of Surgery Length of the Procedure What additional surgeries the patient had Cholecystectomy, hiatal hernia repair, umbilical hernia repair, and/or lysis of adhesions Admit Date Discharge Date Length of Stay If the length of stay was greater than 36 hours what was the reason Nausea, Fever, PO intolerance, Urinary Retention, Bleeding, and/or Other If an upper GI was performed If “yes” what were the findings Leak, Obstruction, Stricture, or Normal If the patient was readmitted within 30 days If “yes” what was the reason Nausea Vomiting, Dehydration, Superficial Site Infection, Deep Site Infection, Leak, Diarrhea, Respiration Failure, Pneumonia, Incisional Hernia, Deep Vein Thrombosis, C-Diff, Intestinal Obstruction, Stricture, Bleeding, Pain, Anastomotic Ulcer, Biliary Disease, and/or Other What was the weight lost at each successive post op visit? First initial, 1 month, 3 month, 6 month, 1 year, 2 year, 3 year, 4 year, and 5 year Comorbidity resolution I.e. Diabetes Mellitus, Hypertension, etc. If cholelithiasis developed post operatively what was the date it was diagnosed Intraoperative complications Conversion from laparoscopic to open What was the reason if there was one? Mortality If “yes” how soon after the surgery What was the cause? Figure 1. Diagram of sleeve gastrectomy Figure 2. example of standard weighted bougie dilator Figure 3. ViSiGi 3D suction calibration syste

Neuroleptic Malignant Syndrome in a Multiple Trauma Patient.

Neuroleptic malignant syndrome is a little-known adverse reaction to neuroleptic administration characterized by hyperpyrexia, leukocytosis, creatine kinase elevations, muscular rigidity, autonomic dysfunction, and alterations in level of consciousness. Neuroleptic malignant syndrome has an associated 20% mortality but can be reversed when treated with neuroleptic discontinuation and administration of bromocriptine and dantrolene. Early diagnosis in the trauma unit may prevent an extensive workup for presumed sepsis. To our knowledge, neuroleptic malignant syndrome has not previously been reported in a multiple trauma patients

Methemoglobinemia Secondary to Benzocaine Topical Anesthetic.

An 80-year-old white woman with a history of hypertension presented to the Emergency Department with bright red bleeding from the rectum. She was treated with 5 mg of midazolam and benzocaine topical anesthetic spray prior to undergoing colonoscopy and esophageal gastroduodenoscopy. Thirty minutes after endoscopy, the patient became cyanotic and dyspneic; she was suffering from methemoglobinemia, a rare complication secondary to the use of benzocaine topical anesthetic spray. After i.v. administration of methylene blue, 120 mg (2 mg/kg) in 100 cc of normal saline solution, the cyanosis and dyspnea resolved

Laparoscopic Colectomy: At What Cost?.

Summary: The purpose of this study was to compare laparoscopic to open colectomy with respect to: 1) morbidity and mortality, 2) adequacy of resection for cancer (margins and number of nodes), 3) operative time, 4) postoperative time for tolerating diet and discharge, and 5) total hospital charges. A historical control group of open colon surgery patients was used. Laparoscopic colectomy was completed in 18/24 patients and 6 were converted to open colectomy. There were no operative or perioperative mortalities. In procedures for cancer, all margins were free of tumor. The average number of nodes in the laparoscopic group (LC) was higher than in open colectomy (OC) group. The average operative time was slightly longer in the LC group compared to the OC group. Postoperative length of stay was shorter in the LC group, and considerably shorter in the elective LC group. Corrected average total hospital cost was lower in the LC group than in the OC group. Laparoscopic colectomy has acceptable morbidity and mortality, is cost-efficient and seems to provide ad-equate resection for cancer, although long-term data will be crucial to this issue

Laparoscopic colectomy: at what cost?

The purpose of this study was to compare laparoscopic to open colectomy with respect to: 1) morbidity and mortality, 2) adequacy of resection for cancer (margins and number of nodes), 3) operative time, 4) postoperative time for tolerating diet and discharge, and 5) total hospital charges. A historical control group of open colon surgery patients was used. Laparoscopic colectomy was completed in 18/24 patients and 6 were converted to open colectomy. There were no operative or perioperative mortalities. In procedures for cancer, all margins were free of tumor. The average number of nodes in the laparoscopic group (LC) was higher than in open colectomy (OC) group. The average operative time was slightly longer in the LC group compared to the OC group. Postoperative length of stay was shorter in the LC group, and considerably shorter in the elective LC group. Corrected average total hospital cost was lower in the LC group than in the OC group. Laparoscopic colectomy has acceptable morbidity and mortality, is cost-efficient and seems to provide adequate resection for cancer, although long-term data will be crucial to this issue

Laparoscopic Versus Conventional Appendectomy.

BACKGROUND: The results of recent series suggest remarkable advantages of laparoscopic appendectomy over the conventional open appendectomy. To determine if clear advantages could be established, the charts of all patients admitted to our institution with a presumptive diagnosis of acute appendicitis and subsequent appendectomy were retrospectively reviewed. STUDY DESIGN: From January 1990 through June 1992, there were 300 conventional open appendectomies and 66 laparoscopic appendectomies performed. Data from both groups were compared with respect to anesthesia time, operative time, postoperative morbidity, postoperative pain, time to regular diet, hospitalization period, cost, and return to normal activities. RESULTS: There were no significant differences between the laparoscopic and open appendectomy groups with respect to operative complications, postoperative morbidity, pain medication requirements, and time to regular diet. There were significantly longer anesthesia times, operative times, and operating room costs in the laparoscopic group. For complicated appendicitis, the laparoscopic technique resulted in infectious complications that required readmission in 45.5 percent of the patients. CONCLUSIONS: Laparoscopic appendectomy is a safe alternative to conventional open appendectomy for simple acute appendicitis. However, laparoscopic appendectomy is not superior to the conventional method with regard to operative time, postoperative morbidity, pain medication requirements, time to regular diet, length of stay, cost, or return to normal activity. Laparoscopic appendectomy may be contraindicated in complicated appendicitis (gangrene, perforated with abscess, or peritonitis) due to an increased rate of infectious complications requiring readmission