A retrospective chart review comparing transabdominal versus transoral remnant extraction in laparoscopic sleeve gastrectomy.

Scott M Golembeski, MD, Farah Husain, MD, FACS, Brain J Pottorf, MD. Exempla Saint Joseph Hospital. Colorado Permanente Medical Group

Background: Laparoscopic sleeve gastrectomy (LSG) is increasingly popular as a definitive bariatric operation because of the ongoing research supporting its safety, efficacy and long-term benefits. The technical aspects of this operation continue to evolve in hopes of minimizing perioperative complications. Natural orifice translumenal endoscopic surgery (NOTES) surgery has become an area of surgical research in hopes of reducing the morbidity associated with open and laparoscopic abdominal operations. This study compares postoperative complications between traditional transabdominal remnant extraction (TARE) and transoral remnant extraction (TORE) in patients undergoing laparoscopic sleeve gastrectomy (LSG).

Methods: A retrospective review of 145 patients undergoing LSG over a 15 month period with either TARE or TORE was conducted. Analyzed data included age, sex, preoperative body mass index (BMI), diabetes mellitus (DM) status, surgical site infection (SSI), and postoperative pain control. Pain control was assessed by whether or not the patient received a narcotic prescription refill. The operation was conducted in an identical fashion by a single surgeon excluding the extraction of the specimen.

Results: For the TARE and TORE procedures, respectively, patients presented a mean age of 51.4 years (sd=13.31) and 50.89 years (sd = 12.81); and a mean BMI of 42.8 kg/m2 (sd = 7.1) and 42 kg/m2 (sd = 6.0). There were 84% females and 12% males in the TARE condition and 55% females and 18% males in the TORE condition. Diabetes mellitus was present in 23.3% of the TARE and 48.6% of the TORE patients. Baseline differences across procedures were not statistically significant for age (p = 0.8249), BMI (p = 0.8639) or gender (p = 0.2228). The greater number of diabetic patients under the TORE procedure (109 percent more) was statistically significant (p ≤ 0.0001). The overall difference in post-operative prescription refills between TARE (32.9%) and TORE (16.7%) was statistically significant (p = 0.03382). The common odds of refill were higher in the TARE than TORE patients when controlling for age (odds ratio [OR] = 2.413, p = 0.03438), for BMI (OR = 2.454, p = 0.03391) and for presence of diabetes (OR = 2.011, p = 0.1076). The female odds of TARE refill to TORE refill were OR = 2.454 (p = .03391) and for males this value was OR = 0.2000 (p = 0.3024).There were 3 (4.0%) surgical site infections (SSI) in the TARE patients and 1 (1.4%) SSI in the TORE patients (OR = 3.0, p = 0.6200).

Conclusion: This study reports a comparison of TORE versus conventional LSG in the largest group of patients to date. Outcomes of this study support the feasibility and efficacy of TORE and suggest superiority compared to traditional LSG with regard to postoperative pain management. More post-operative pain prescription refills occurred under the TARE than TORE procedure, which was statistically significant. A fifty percent decline in post-operative pain medication refills was observed with TORE relative to TARE. Although SSI rates were not significantly greater in TARE when compared to TORE, the OR suggests a potential future area of study with a greater population.

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