© Borgis - Postępy Nauk Medycznych 9/2015, s. 638-641
*Artur Binda, Adam Ciesielski, Paweł Jaworski, Wiesław Tarnowski
Wpływ wybranych czynników na śródoperacyjną utratę krwi i czas trwania laparoskopowej, rękawowej resekcji żołądka
The impact of selected factors on intraoperative blood loss and operative time of laparoscopic sleeve gastrectomy
Department of General, Oncological and Digestive Tract Surgery, Medical Centre of Postgraduate Education, Warszawa
Head of Department: prof. Wiesław Tarnowski, MD, PhD
Streszczenie
Wstęp. Laparoskopowa, rękawowa resekcja żołądka jest jedną z najczęściej wykonywanych operacji bariatrycznych. Pomimo dużej popularności metody, istnieją wątpliwości co do wpływu wyjściowych parametrów masy ciała, płci operowanych pacjentów oraz przedoperacyjnej redukcji masy ciała na czas trwania operacji i śródoperacyjną utratę krwi.
Cel pracy. Celem pracy była ocena wpływu wyjściowych parametrów masy ciała, płci operowanych pacjentów oraz przedoperacyjnej redukcji masy ciała na czas trwania operacji i śródoperacyjną utratę krwi w trakcie laparoskopowej, rękawowej resekcji żołądka.
Materiał i metody. Ocenie poddano prospektywnie zbierane dane dotyczące 93 pacjentów operowanych w Klinice Chirurgii Ogólnej, Onkologicznej i Przewodu Pokarmowego CMKP z powodu otyłości chorobliwej w okresie od stycznia 2010 do kwietnia 2012 roku. U wszystkich pacjentów wykonano rękawową resekcję żołądka metodą laparoskopową. We wszystkich przypadkach linię zszywek wzmacniano szwem ciągłym. Oceniono wpływ płci operowanych pacjentów, spadku masy ciała przed operacją, wyjściowej wagi i BMI na śródoperacyjną utratę krwi i czas trwania operacji.
Wyniki. W ocenianym okresie rękawową resekcję żołądka metodą laparoskopową wykonano u 93 pacjentów. W żadnym przypadku nie doszło do konwersji. Średni czas trwania operacji wyniósł 123,1 ± 33,2 min (zakres: 60-270). Śródoperacyjna utrata krwi wyniosła średnio 46,3 ± 71,6 ml (zakres: 0-400). Nie odnotowano istotnego wpływu żadnego z ocenianych czynników na czas trwania operacji oraz na śródoperacyjną utratę krwi.
Wnioski. Wskaźnik masy ciała, waga, płeć operowanych pacjentów, spadek masy ciała przed operacją nie mają istotnego wpływu na czas trwania rękawowej resekcji żołądka i śródoperacyjną utratę krwi.
Summary
Introduction. Laparoscopic sleeve gastrectomy is one of the most commonly performed bariatric procedures. Despite the popularity of method, there still exist doubts as to the effect of the baseline characteristics of weight, sex of the patients undergoing surgeries and preoperative weight loss for the operative time and intraoperative blood loss.
Aim. The aim of the study was to evaluate the impact of initial body weight parameters, gender of patients, and preoperative weight loss on the operative time of the laparoscopic sleeve gastrectomy and intraoperative blood loss.
Material and methods. We have prospectively assessed data collected on 93 patients operated on due to morbid obesity in the period from January 2010 to April 2012. All of the patients underwent laparoscopic sleeve gastrectomy. In all cases, the staple line was reinforced with a continuous suture. The impact of gender of the surgical patients, weight loss before surgery, the initial weight and BMI on intraoperative blood loss and operative time were assessed.
Results. Laparoscopic sleeve gastrectomy was performed in 93 patients. In any case, there was no conversion. The mean duration of the surgery was 123.1 ± 33.2 min (range: 60-270). Intraoperative blood loss was an average of 46.3 ± 71.6 ml (range: 0-400). There was no significant effect of any of the assessed factors on the operative time and intraoperative blood loss.
Conclusions. Initial body mass index, weight, gender, weight loss before surgery do not have a material impact on the operative time of laparoscopic sleeve gastrectomy and intraoperative blood loss.
Introduction
The operative time and intraoperative blood loss affect the outcomes and costs of bariatric procedures. Extension of the processing time increases the amount of drugs used for anesthesia and total cost of procedure. These costs may rise as a result of the need for blood transfusions in the perioperative period. Prolonged surgeries for patients with high body weight increase the likelihood of rhabdomyolysis, with all its adverse consequences (1, 2). Identifying the factors affecting the duration of the surgery and intraoperative blood loss can contribute to improving the performance and reducing the cost of treatment. In recent years, this latter aspect is becoming increasingly important. Duration of a surgery and intraoperative blood loss can be affected by a variety of factors, such the baseline weight, the baseline body mass index or the gender of the patient operated on. Another important factor influencing both parameters is preoperative weight loss (3). Better exposure around the gastroesophageal junction and fundus, more comfortable operating conditions for the surgeon do not always translate, however, into shorter surgery time and less blood loss (4, 5).
Aim
The aim of the present study was to assess the influence of the initial body mass index, the body weight and the gender of patients undergoing surgeries and preoperative weight loss on the operative time of laparoscopic sleeve gastrectomy and intraoperative blood loss.
Material and methods
We have assessed prospectively collected data on 93 patients who underwent laparoscopic sleeve gastrectomy in the period from January 2010 to April 2012. Patients were qualified for the surgery on the basis of generally accepted criteria: BMI 35-39.9 kg/m2, with at least one comorbidity, or BMI ≥ 40 kg/m2. The condition for the surgery was to express an informed, written consent for surgery and having no contraindications to surgery under general anesthesia. The influence of the selected parameters on intraoperative blood loss and operative time was assessed. The study design used to write the following paper was approved by the Bioethics Committee of Medical Center of Postgraduate Education in Warsaw in accordance with Resolution No. 51/PW/2011 dated 08.03.2011.
Surgical technique
Patients underwent a laparoscopically performed procedure in the reverse Trendelenburg position at an angle of 450 to the floor. The surgeon stood between the lower limbs of the patient, the assist on the right and the left side of the patient. Pneumoperitoneum, at a pressure of 12 to 15 mmHg, was prepared using the Veress needle. Five trocars technique were used. Using LigaSure (Covidien) or the harmonic scalpel SonoSurg (Olympus), the greater omentum was cut off from the greater curvature, releasing, if necessary, all the adhesions between the posterior wall of the stomach and the pancreas. Using the EchelonFlex (Ethicon Endo-Surgery) or EndoGia (Covidien) staplers, the stomach was cut and the resection began at 4-6 cm from the pylorus. The width of the sleeve was calibrated with a 36Fr gastric bougie. The staple line was in each case reinforced by means of a continuous suture (PDS 3-0 or Maxon 3-0). The leak test was carried out using methylene blue. Suction drain was left along the staple line. After the surgery, the gastric bougie was removed and no nasogastric tube was introduced.
The evaluation of the selected factors
Intraoperative blood loss was assessed basing on the volume of blood in the suction pump, in milliliters, at the end of the procedure. In the case where no suction pump was used during the surgery, intraoperative blood loss was assessed to be 0 milliliters. The operative time was counted from the introduction of the first trocar (optical) to the last skin stitch. The influence of the following factors on both of the parameters was assessed: the initial weight, the initial BMI, gender of patient, and weight loss in the preoperative period. The impact of the initial body weight was assessed in two groups of patients: with a body weight of less than 125 kg and weighing ≥ 125 kg (average weight for the whole analyzed group was rounded to the nearest whole). The impact of the initial BMI was assessed in two groups of patients: those with a BMI less below 44 kg/m2 and BMI ≥ 44 kg/m2 (mean BMI for the whole analyzed group was rounded up to a whole).
Statistical methods
Comparisons between the groups used the Student’s t test. The analysis was performed using GraphPad Prism v.5.02 for Windows (GraphPad Software, San Diego California USA, www.graphpad.com). The value of P < 0.05 indicated statistically significant differences, while the P value in the range of 0.1-0.05 were considered to be trends.
Results
We analyzed data collected on 93 patients (63 women, 30 men) who underwent the laparoscopic sleeve gastrectomy during the period from January 2010 to April 2012. The average age of the patients was 43.0 ± 10.2 (range: 17-62). The average weight for the entire group before the surgery was 124.9 ± 19.4 kg (range: 82-180), in the group of women 118.8 ± 15.1 kg (range: 82-151) and 137.6 ± 21.3 kg (range: 106-180), p < 0.0001, in the group of men. The mean BMI was 43.7 ± 5.1 kg/m2 (range: 34.2-56.0), for women 43.9 ± 4.8 kg/m2 (range: 34.8-54.9) for men 43.5 ± 5.6 kg/m2 (range: 34.2-56), p = 0.7395. In four cases (4.3%), concomitant cholecystectomy was performed, due to symptomatic cholelithiasis, and in one case (1.08%) cruroplasty due to large hiatal hernia. The operative time was an average of 123.1 ± 33.2 min (range: 60-270). Intraoperative blood loss was an average of 46.3 ± 71. 6 ml (range: 0-400). No conversion was recorded.
Factors affecting the intraoperative blood loss
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Piśmiennictwo
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