Single Anastomosis Duodenal Switch versus Classic Duodenal Switch: Long-term Outcomes from a Prospective Comparative Cohort Study

PURPOSE

The literature on long-term outcomes of duodenal switch (DS) compared to single anastomosis duodenal switch (SADI-S) procedures is lacking. We evaluated the long-term outcomes of SADI-S compared to those after the classic DS procedure.

METHODS

This is a follow-up report from a single-institution prospective cohort study comparing long-term outcomes of SADI-S versus DS both as one- and two-stage procedures (ClinicalTrials.gov: NCT02792166). Data is depicted as count (percentage) or median (interquartile range).

RESULTS

Forty-two patients underwent SADI-S, of whom 11 had it as a second-stage procedure (26%). Of 20 patients who underwent DS, twelve had it as a second-stage procedure (60%). Both groups were similar at baseline. Median follow-up times for one-stage SADI-S and DS were 57 (24) and 57 (9) months, respectively (p = 0.93). Similar BMI reductions were observed after one-stage SADI-S (16.5 kg/m2 [8.5]) and DS (18.9 kg/m2 [7.2]; p = 0.42). At median follow-up of 51 (21) and 60 (15) months after second-stage SADI-S and DS, respectively (p = 0.60), surgical procedures yielded reductions in BMI of 20.5 kg/m2 (14.0) and 24.0 kg/m2 (13.9), respectively (p = 0.52). Follow-up rates were similar for one-stage (≥ 88%; p = 0.29) and second-stage procedures (≥ 83%; p = 0.16). Similar diabetes and hypertension remissions were found (p = 0.77; P = 0.54, respectively). Despite fat-soluble vitamin deficiencies at baseline, after supplementation, they were either eliminated or less prevalent long-term after SADI-S. Daily bowel movements were also less frequent.

CONCLUSIONS

Long-term weight and comorbidity outcomes after SADI-S are similar to those of DS both as one- and two-stage surgeries. SADI-S procedure may allow for similar beneficial outcomes with less burden from gastrointestinal symptoms and fat-soluble vitamin deficiencies.

Predictors of post-discharge pain and satisfaction with pain management after laparoscopic bariatric surgery: a prospective cohort study

BACKGROUND

Pain management after bariatric surgery remains challenging given the risk for analgesia-related adverse events (e.g., opioid use disorder, marginal ulcers). Identifying modifiable factors associated with patient-reported pain outcomes may improve quality of care. We evaluated the extent to which patient and procedural factors predict 7-day post-discharge pain intensity, pain interference, and satisfaction with pain management after bariatric surgery.

METHODS

This prospective cohort study included adults undergoing laparoscopic bariatric surgery at two university-affiliated hospitals and one private clinic. Preoperative assessments included demographics, Pain Catastrophizing Scale (score range 0-52), Patient Activation Measure (low [< 55.1] vs. high [≥ 55.1]), pain expectation (0-10), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) anxiety and depression scales. At 7 days post-discharge, assessments included PROMIS-29 pain intensity (0-10) and pain interference scales (41.6-75.6), and satisfaction with pain management (high [10-9] vs. lower [8-0]). Linear and logistic regression were used to assess the association of pain outcomes with potential predictors.

RESULTS

Three hundred and fifty-one patients were included (mean age = 44 ± 11 years, BMI = 45 ± 8 kg/m2, 77% female, 71% sleeve gastrectomy). At 7 days post-discharge, median (IQR) patient-reported pain intensity was 2.5 (1-5), pain interference was 55.6 (52.0-61.2), and 76% of patients reported high satisfaction with pain management. Pain intensity was predicted by preoperative anxiety (β + 0.04 [95% CI + 0.01 to + 0.07]) and pain expectation (+ 0.15 [+ 0.05 to + 0.25]). Pain interference was predicted by preoperative anxiety (+ 0.22 [+ 0.11 to + 0.33]), pain expectation (+ 0.47 [+ 0.10 to + 0.84]), and age (- 0.09 [- 0.174 to - 0.003]). Lower satisfaction was predicted by low patient activation (OR 1.94 [1.05-3.58]), higher pain catastrophizing (1.03 [1.003-1.05]), 30-day complications (3.27 [1.14-9.38]), and age (0.97 [0.948-0.998]).

CONCLUSION

Patient-related factors are important predictors of post-discharge pain outcomes after bariatric surgery. Our findings highlight the value of addressing educational, psychological, and coping strategies to improve postoperative pain outcomes.

Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study

INTRODUCTION

In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients.

METHODS

This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30 days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption.

RESULTS

We analyzed 351 patients (mean age 44 ± 11 years, BMI 45 ± 8.0 kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6 days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]).

CONCLUSION

This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.

Management of abdominal wall hernias in patients with severe obesity

Obesity is a risk factor for abdominal wall hernia development and hernia recurrence. The management of these two pathologies is complex and often entwined. Bariatric and ventral hernia surgery require careful consideration of physiologic and technical components for optimal outcomes. In this review, a multidisciplinary group of Society of American Gastrointestinal and Endoscopic Surgeons' bariatric and hernia surgeons present the various weight loss modalities available for the pre-operative optimization of patients with severe obesity and concurrent hernias. The group also details the technical aspects of managing abdominal wall defects during weight loss procedures and suggests the optimal timing of definitive hernia repair after bariatric surgery. Since level one evidence is not available on some of the topics covered by this review, expert opinion was implemented in some instances. Additional high-quality research in this area will allow for better recommendations and therefore treatment strategies for these complex patients.

Microsecond Isomer at the N=20 Island of Shape Inversion Observed at FRIB

Excited-state spectroscopy from the first experiment at the Facility for Rare Isotope Beams (FRIB) is reported. A 24(2)-μs isomer was observed with the FRIB Decay Station initiator (FDSi) through a cascade of 224- and 401-keV γ rays in coincidence with ^{32}Na nuclei. This is the only known microsecond isomer (1  μs≤T_{1/2}<1  ms) in the region. This nucleus is at the heart of the N=20 island of shape inversion and is at the crossroads of the spherical shell-model, deformed shell-model, and ab initio theories. It can be represented as the coupling of a proton hole and neutron particle to ^{32}Mg, ^{32}Mg+π^{-1}+ν^{+1}. This odd-odd coupling and isomer formation provides a sensitive measure of the underlying shape degrees of freedom of ^{32}Mg, where the onset of spherical-to-deformed shape inversion begins with a low-lying deformed 2^{+} state at 885 keV and a low-lying shape-coexisting 0_{2}^{+} state at 1058 keV. We suggest two possible explanations for the 625-keV isomer in ^{32}Na: a 6^{-} spherical shape isomer that decays by E2 or a 0^{+} deformed spin isomer that decays by M2. The present results and calculations are most consistent with the latter, indicating that the low-lying states are dominated by deformation.

Presentation, management, and outcomes of cauda equina syndrome up to one year after surgery, using clinician and participant reporting: A multi-centre prospective cohort study

Background

Cauda equina syndrome (CES) results from nerve root compression in the lumbosacral spine, usually due to a prolapsed intervertebral disc. Evidence for management of CES is limited by its infrequent occurrence and lack of standardised clinical definitions and outcome measures.

Methods

This is a prospective multi-centre observational cohort study of adults with CES in the UK. We assessed presentation, investigation, management, and all Core Outcome Set domains up to one year post-operatively using clinician and participant reporting. Univariable and multivariable associations with the Oswestry Disability Index (ODI) and urinary outcomes were investigated.

Findings

In 621 participants with CES, catheterisation for urinary retention was required pre-operatively in 31% (191/615). At discharge, only 13% (78/616) required a catheter. Median time to surgery from symptom onset was 3 days (IQR:1–8) with 32% (175/545) undergoing surgery within 48 h. Earlier surgery was associated with catheterisation (OR:2.2, 95%CI:1.5–3.3) but not with admission ODI or radiological compression. In multivariable analyses catheter requirement at discharge was associated with pre-operative catheterisation (OR:10.6, 95%CI:5.8–20.4) and one-year ODI was associated with presentation ODI (r = 0.3, 95%CI:0.2–0.4), but neither outcome was associated with time to surgery or radiological compression. Additional healthcare services were required by 65% (320/490) during one year follow up.

Interpretation

Post-operative functional improvement occurred even in those presenting with urinary retention. There was no association between outcomes and time to surgery in this observational study. Significant healthcare needs remained post-operatively.

Funding

DCN Endowment Fund funded study administration. Castor EDC provided database use. No other study funding was received.

Crossing N=28 Toward the Neutron Drip Line: First Measurement of Half-Lives at FRIB

New half-lives for exotic isotopes approaching the neutron drip-line in the vicinity of N∼28 for Z=12-15 were measured at the Facility for Rare Isotope Beams (FRIB) with the FRIB decay station initiator. The first experimental results are compared to the latest quasiparticle random phase approximation and shell-model calculations. Overall, the measured half-lives are consistent with the available theoretical descriptions and suggest a well-developed region of deformation below ^{48}Ca in the N=28 isotones. The erosion of the Z=14 subshell closure in Si is experimentally confirmed at N=28, and a reduction in the ^{38}Mg half-life is observed as compared with its isotopic neighbors, which does not seem to be predicted well based on the decay energy and deformation trends. This highlights the need for both additional data in this very exotic region, and for more advanced theoretical efforts.

Ambulatory sleeve gastrectomy: a prospective feasibility and comparative study of early postoperative morbidity

BACKGROUND

Given its short procedure time and low morbidity, there is enthusiasm to perform sleeve gastrectomy (SG) in an outpatient setting. However, most relevant studies include an overnight stay at a medical facility (≤ 24-h). Hence, we investigated the feasibility and safety of a same-day discharge (SDD) protocol for laparoscopic SG.

METHODS

In a prospective pilot study (02/01/2021-02/28/2022), all patients planned for SG were screened for eligibility. Patients met the inclusion criteria if they were ≤ 65 years old, without major comorbidity, and lived close to the hospital. Postoperatively, patients who met discharge criteria were sent home directly from the recovery room. Patients were called the same night and the next morning. Feasibility was defined as discharge on the day of surgery without emergency department (ED) visit or readmission within 24-h. Secondary outcomes, including 90-day morbidity, were compared to patients who met inclusion criteria but chose a same-day admission (SDA) approach during the same study period. Descriptive statistics are displayed as count (percentage) and median (interquartile range).

RESULTS

A total of 320 patients were planned for SG during the study period, 229 of whom met eligibility criteria and underwent SG with 56 agreeing to SDD-SG while 173 opted for SDA-SG. Baseline characteristics were all similar between both groups except for obstructive sleep apnea being more prevalent in SDA-SG group (38.2% vs. 16.1%; P < 0.001). Operative characteristics including procedure time were similar between both groups. Successful SDD-SG was achieved in 54(96%) of patients with a median of 6.0(1.0) hours of stay in the recovery room. Ninety-day morbidity was similar between SDD-SG and SDA-SG groups (1.8% vs. 6.9%, respectively; P = 0.196).

CONCLUSION

A SDD protocol for laparoscopic SG was feasible and safe in selected patients. Larger studies that evaluate patient reported outcomes and include bypass-type procedures may be needed to guide safe use of ambulatory bariatric surgery.

Diastematomyelia type I associated with intramedullary lipoma and dermoid cyst

Dysraphic entities like diastematomyelia are not uncommon. However, the co-existence of split cord malformation with two pathologically different lesions on the same hemicord is extremely rare. We report a case of a young child who presented with an unusual combination of diastematomyelia, intramedullary lipoma, and dermoid cyst.

Successful surgical weight loss with laparoscopic sleeve gastrectomy for morbid obesity prior to kidney transplantation

Morbid obesity in kidney transplant (KT) candidates is associated with increased complications and graft failure. Multiple series have demonstrated rapid and significant weight loss after laparoscopic sleeve gastrectomy (LSG) in this population. Long-term and post-transplant weight evolutions are still largely unknown. A retrospective review was performed in eighty patients with end-stage kidney disease (ESKD) who underwent LSG in preparation for KT. From a median initial BMI of 43.7 kg/m² , the median change at 1-year was -10.0 kg/m² . Successful surgical weight loss (achieving a BMI < 35 kg/m² or an excess body weight loss >50%) was attained in 76.3% and was associated with male gender, predialysis status, lower obesity class and lack of coronary artery disease. Thirty-one patients subsequently received a KT with a median delay of 16.7 months. Weight regain (increase in BMI of 5 kg/m² postnadir) and recurrent obesity (weight regain + BMI > 35) remain a concern, occurring post-KT in 35.7% and 17.9%, respectively. Early LSG should be considered for morbidly obese patients with ESKD for improved weight loss outcomes. Early KT after LSG does not appear to affect short-term surgical weight loss. Candidates with a BMI of up to 45 kg/m² can have a reasonable expectation to achieve the limit within 1 year.

Esophageal cancer after sleeve gastrectomy: a population-based comparative cohort study

BACKGROUND

Sleeve gastrectomy (SG) is the most common bariatric surgery; however, this approach may induce gastroesophageal reflux disease (GERD). Both obesity and GERD are independent risk factors for esophageal cancer, however the impact of SG on risk of esophageal cancer remains unknown.

OBJECTIVE

To evaluate the risk of esophageal cancer after reflux-prone bariatric surgery.

SETTING

Population-level, provincial administrative healthcare database, Quebec, Canada.

METHODS

We identified a population-based cohort of all patients with obesity who underwent reflux-prone surgery (SG and duodenal switch [DS]) or reflux-protective Roux-en-Y gastric bypass (RYGB) during 01/2006-12/2012 in Quebec, Canada. For every surgical patient, 2-3 nonsurgical controls with obesity matched for age, sex, and geography were also identified. Crude incidence rate ratios (IRRs) for esophageal cancer were calculated using person-time analysis. Hazard ratios (HRs) were obtained using multivariate cox regression.

RESULTS

A total of 4121 patients had reflux-prone procedures and 852 underwent RYGB. At a mean follow-up of 7.6 years, 8 cases of esophageal cancer were identified after bariatric surgery. Compared with RYGB, IRR for esophageal cancer in reflux-prone group was 1.45 (95%CI: .19-65.5) and HR = .83 (95%CI: .10-7.27). The crude incidence rate of esophageal cancer in the reflux-prone group was higher than that of nonsurgical controls (n = 12,159; IRR = 3.46, 95%CI: 1.00-12.5), but after adjustment the difference disappeared (HR = 2.47, 95%CI: .82-7.45).

CONCLUSIONS

Long-term incidence of esophageal cancer after reflux-prone bariatric surgery is not greater than RYGB. While crude incidence of esophageal cancer after reflux-prone surgery is higher than in nonsurgical patients with obesity, such difference disappears after accounting for confounders. Given the low incidence of esophageal cancer and slow progression of dysplastic Barrett esophagus, studies with longer follow-up are needed.

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S): short-term outcomes from a prospective cohort study

BACKGROUND

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modification of the classic duodenal switch (DS). These modifications are intended to address concerns about DS, including malnutrition, longer operative times, and technical challenges, while preserving the benefits.

OBJECTIVES

To evaluate safety and outcomes of SADI-S as it compares to classic DS procedure.

SETTING

Bariatric Surgery Center of Excellence, University Hospital, Montreal, Canada.

METHODS

In a single-institution prospective cohort study, we compared safety and outcomes of the SADI-S versus DS procedures (ClinicalTrials.gov: NCT02792166; registered: 06/2016). Data is depicted as count (percentage) or median (interquartile range).

RESULTS

There were 42 patients who underwent SADI-S, of whom 11 had it as a second-stage procedure (26%). There were 20 patients who underwent DS, of whom 12 had it as second-stage procedures (60%). Both groups were similar at baseline. The median age was 45 (14) years, 39 (63%) were female, the median body mass index (BMI) was 48.2 (7.7) kg/m², and 29 (47%) patients had diabetes. The operative time was shorter for 1-stage SADI-S versus DS surgery (211 [70] versus 250 [60] min, respectively; P = .05) but was similar for second-stage procedures (P = .06). The 90-day complication rates were 11.9% (N = 5/42) after SADI-S and 5.0% (N = 1/20) after DS surgery (P = .64). There were no mortalities. Median follow-ups for 1-stage SADI-S and DS were 17 (11) and 12 (24) months, respectively (P = .65). Similar BMI changes were observed after 1-stage SADI-S (17.9 kg/m² [8.7]) and DS (17.5 kg/m² [16]; P = .65). At median follow-ups of 10 (20) and 14 (16) months after second-stage SADI-S and DS, respectively (P = .53), surgical procedures yielded added 5.0 kg/m² (5.8) and 6.5 kg/m² (7.1) changes in BMI, respectively (P = .26). Complete remission rates for diabetes were 91% after SADI-S (n = 21/23) and 50% after DS (n = 3/6). Compared with the SADI-S procedure, DS surgery was associated with higher frequencies of deficiencies in some fat-soluble vitamins, especially vitamin D.

CONCLUSIONS

The SADI-S procedure is safe, and its short-term outcomes, including weight loss and the resolution of co-morbidities, are similar to those of DS. SADI-S surgery also has promising potential as a second-stage procedure after sleeve gastrectomy.

Surgeon and hospital volume outcomes in bariatric surgery: a population-level study

BACKGROUND

Outcomes after bariatric surgery are tied to surgical volume; however, this relationship is not clearly established for each procedure.

OBJECTIVES

To evaluate the impact of surgeon/hospital volumes on morbidity after bariatric surgery and identify volume cutoffs.

SETTING

Multi-centric population-level study, province of Quebec, Canada.

METHODS

We studied a population-based cohort of all morbidly obese patients who underwent bariatric surgery in Quebec, Canada during 2006 to 2012. We evaluated only the most common procedures in North America, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Multilevel, cross-classified logistic regressions were used to test the effects of annual surgeon volume (SV) and hospital volume (HV) on a composite 90-day postoperative outcome. Receiver operator curve was used to identify volume thresholds.

RESULTS

Overall, 821 patients had RYGB and 1802 underwent SG by 34 surgeons in 15 centers. For RYGB, 10-case increase in SV was associated with adjusted odds ratio of .82 (95% confidence interval: .71-.94). Similar increase in HV resulted in odds ratio of .86 (95% confidence interval: .77-.96). Annual SV threshold of 21 RYGBs and HV of 25 cases were identified (area under the curve = .60 and .61, respectively). For SV, being in the higher volume category translated into an absolute risk reduction of 12.5% for 90-day major morbidity. For SG, annual 10-case increase in SV and HV was not significantly associated with a decrease in 90-day postoperative morbidity.

CONCLUSION

SV and HV are significant independent predictors of 90-day major morbidity after RYGB. This study further supports establishing minimum surgical volume requirements for more complex anastomotic procedures like RYGB. However, the role of volume targets in SG remains unclear.

Variability in Bariatric Surgical Care Among Various Centers: a Survey of All Bariatric Surgeons in the Province of Quebec, Canada

BACKGROUND

Despite an increase in bariatric surgery across Quebec, Canada, access is still limited. Furthermore, there are differences in resources and multidisciplinary capabilities of providing centers that may impact quality of care and outcomes.

METHODS

We performed an online survey of all bariatric surgeons in the province of Quebec, Canada, using the LimeSurvey software.

RESULTS

Forty-six surgeons from 15 centers were surveyed. Response rate was 87% (n = 40). Only 13 (35%) surgeons have any formal fellowship training in bariatric surgery and 74% perform > 50 cases/year. All surgeons perform sleeve gastrectomy, 34% do duodenal switch, and 44% provide major revisions. Thirty-one surgeons (77%) identified access to operating room as the main cause for surgical delays. While most surgeons (52%) considered < 6 months as an acceptable wait-time, only 33% achieved this in their practice. Majority (70%) favored a centralized provincial referral system. Patient's geographical convenience, procedural choice, and multidisciplinary capabilities of providing centers are identified as important determinants for centralized referrals (93, 78, and 55%, respectively). Virtually, all supported accreditation/designation of centers and creation of Quebec Bariatric Network for quality control and research (85 and 98%, respectively).

CONCLUSION

Bariatric surgical patterns vary among designated centers in Quebec, Canada. Access to multidisciplinary care and surgeon's fellowship training may be contributing factors for the observed variability. Wait-lists are long and timely access to surgery remains an issue. There is near consensus for establishing a centralized referral system, designation of referral vs. primary centers, and creating Quebec Bariatric Network for research and quality control.

Early Postoperative Outcomes of Primary Bariatric Surgery in Patients on Chronic Steroid or Immunosuppressive Therapy

BACKGROUND

Previous research suggests that patients on chronic steroids may be at an increased risk of postoperative morbidity after major surgery. We aimed to evaluate the prognostic impact of chronic use of steroid or immunosuppression on 30-day morbidity and mortality rates after primary bariatric surgery.

METHODS

From American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent primary bariatric surgery between 2005 and 2013. Logistic regression was used to determine the prognostic impact of chronic use of steroid or immunosuppression on the 30-day postoperative outcomes.

RESULTS

One thousand two hundred seventy seven steroid/immunosuppressant-dependent (SD) and 112,892 non-dependent (ND) patients were analyzed. SD patients had a higher baseline risk profile compared to ND patients. Thirty-day mortality rates for SD and ND patients were 0.55 and 0.11 %, respectively (P < 0.001) which corresponds to an adjusted odds ration (OR) of 6.85 (95 % confidence interval (CI) 1.95-24.12). SD patients had a higher 30-day major morbidity compared to ND patients (5.01 versus 2.54 %; P < 0.001, respectively). After adjustment, this translated into an OR of 2.21 (95 % CI 1.29-3.79). Among SD patients, there was no significant difference in 30-day major morbidity after gastric bypass compared to sleeve gastrectomy (OR = 0.36; 95 % CI 0.08-1.66).

CONCLUSIONS

Chronic and active use of steroid or immunosuppressant medications is a strong predictor of 30-day postoperative morbidity and mortality following primary bariatric surgery. Among the steroid/immunosuppressant users, complication rates were similar for gastric bypass and sleeve gastrectomy patients. Further studies are needed to help guide the management or discontinuation of such medications in the perioperative period.

Trends in utilization of bariatric surgery, 2010-2014: sleeve gastrectomy dominates

BACKGROUND

Bariatric surgery is the most effective treatment for morbid obesity. Furthermore, the proportion of various types of bariatric procedures has significantly changed over the last two decades. Sleeve gastrectomy (SG) has been increasingly chosen as a primary bariatric procedure in recent years.

OBJECTIVES

This study aimed to analyze the changing pattern of bariatric surgery utilization from 2010 to 2014.

SETTINGS

Using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014.

METHOD

We identified patients aged≥18 years with a body mass index (BMI)≥35 kg/m² undergoing primary bariatric surgery. The trend of surgical procedures was analyzed from 2010 to 2014.

RESULTS

A total of 93,328 patients were included (age of 44.6±11.8 years and BMI of 46.2±7.9 kg/m²). Roux-en-Y gastric bypass (RYGB), adjustable gastric band, and SG comprised 58.4%, 28.8%, and 9.3% of the procedures in 2010 which changed to 37.6%, 3.1%, and 58.2% in 2014, respectively. Baseline BMI of SG patients decreased from 47.5 to 45.6 kg/m² (P< .001). The proportion of diabetic patients undergoing RYGB increased (30.4% to 33.2%, P<.001) but decreased among those having SG (26.6% to 22.8%, P = .001). The proportion of patients with hypertension having RYGB remained unchanged while decreased among SG patients (56.2% to 47.6%, P<.001). Female patients among the SG group increased from 73.2% to 77.7% (P< .001).

CONCLUSION

SG has been increasingly performed in the United States superseding adjustable gastric band and RYGB. The trend is in favor of females, lower BMI, and lower ratio of patients with diabetes and hypertension. More data are needed on outcomes of SG to assess its long-term effectiveness and credibility.

Fast track bariatric surgery: safety of discharge on the first postoperative day after bariatric surgery

BACKGROUND

Fast track recovery pathways have resulted in a multidisciplinary approach to enhance postoperative recovery.

OBJECTIVES

To assess feasibility and outcome of early discharge after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

SETTING

The American College of Surgeons National Surgical Quality Improvement Program database was analyzed to identify patients with body mass index≥35 kg/m² who underwent LSG or LRYGB in 2012 and 2013.

METHODS

Patients were allocated to early discharge (ED) when discharged on postoperative (POD) 1 and late discharge (LD) when discharged on POD 2 or 3. Baseline characteristics and 30-day outcomes were compared between the 2 groups.

RESULTS

Records of 15,468 LSG and 16,483 LRYGB patients were analyzed; 5220 patients with LSG (33.7%) and 2960 patients with LRYGB (18%) were discharged on POD 1. The early discharge group had significantly fewer co-morbidities and lower rate of complications and readmission. Thirty-day readmission rate in LSG was 2.8% in ED versus 3.6% in LD (P = .008), and in LRGYB, it was 4.3% in ED versus 5.8% in LD (P = .001). Based on multivariate analysis, early discharge was not an independent risk factor for a higher readmission rate after LSG or LRYGB. Predictors of late discharge were age>50 years, body mass index>50 kg/m², Hispanic or non-Hispanic black race/ethnicity, impaired functional status, diabetes on insulin, chronic steroid/immunosuppressant use, bleeding disorder, being on dialysis, chronic obstructive pulmonary disease, albumin<3.5 mg/dL, longer operative time, and concurrent cholecystectomy.

CONCLUSION

Discharge on POD 1 after LSG and LRYGB is feasible in a considerable proportion of patients. In this subgroup, early discharge is well tolerated and may be associated with lower complication and readmission rates.

Predictors of readmission after laparoscopic gastric bypass and sleeve gastrectomy: a comparative analysis of ACS-NSQIP database

BACKGROUND

Readmission rate is an indicator of quality in surgical practice. We aimed to determine the predictors of unplanned early readmissions following stapling bariatric surgeries.

METHODS

From the American College of Surgeons National Surgical Quality Improvement Program database, we identified morbidly obese patients, who underwent either laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) in 2012 and 2013. Demographic, comorbidities, operative and postoperative parameters of the readmitted (within 30 days) and non-readmitted patients were evaluated using a multivariate logistic regression analysis.

RESULTS

A total of 35,655 patients (17,101 LSG and 18,554 LRYGB) were analyzed. Of those, 1758 patients (4.9 %) were readmitted within 30 days of surgery. Multivariate analysis showed the following significant predictors for readmission: Non-Hispanic black ethnicity (OR: 1.56, 95 % CI:1.34-1.81), Hispanic ethnicity (OR: 1.29, 95 % CI:1.05-1.58), totally or partially dependent functional status (OR: 1.94, 95 % CI:1.06-3.55), higher preoperative creatinine (OR: 1.13, 95 % CI:1.04-1.22), lower serum albumin (OR: 0.78, 95 % CI:0.68-0.90), diabetes mellitus on insulin (OR: 1.28, 95 % CI:1.09-1.51), steroid or immunosuppressant use for a chronic condition (OR: 1.61, 95 % CI:1.11-2.33), history of cardiac disease with intervention (OR: 2.05, 95 % CI:1.10-3.83), bleeding disorders (OR: 1.71, 95 % CI:1.15-2.54), LRYGB versus LSG (OR: 1.63, 95 % CI:1.44-1.85), longer operative time (OR: 1.13, 95 % CI:1.07-1.20), concurrent splenectomy (OR: 4.10, 95 % CI:1.05-16.01), and occurrence of any postoperative complication during index admission (OR: 2.61, 95 % CI:1.99-3.42).

CONCLUSIONS

Ethnicity, baseline functional status, comorbidities, type and duration of surgical procedure, and postoperative complications occurred in the index admission can predict risk of early readmission following LRYGB and LSG.

Is Laparoscopic Bariatric Surgery a Safe Option in Extremely High-Risk Morbidly Obese Patients?

INTRODUCTION

Age, superobesity, and cardiopulmonary comorbidities define patients as high risk for bariatric surgery. We evaluated the outcomes following bariatric surgery in extremely high-risk patients.

MATERIALS AND METHODS

Among 3240 patients who underwent laparoscopic bariatric surgery at a single academic center from January 2006 through June 2012, extremely high-risk patients were identified using the following criteria: age ≥ 65 years, body mass index (BMI) ≥ 50 kg/m(2), and presence of at least two of six cardiopulmonary comorbidities, including hypertension, ischemic heart disease, congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and history of venous thromboembolism. Perioperative and intermediate-term outcomes were assessed.

RESULTS

Forty-four extremely high-risk patients underwent laparoscopic Roux-en-Y gastric bypass (n = 23), adjustable gastric banding (n = 11), or sleeve gastrectomy (n = 10). Patients had a mean age of 67.9 ± 2.7 years, a mean BMI of 54.8 ± 5.5 kg/m(2), and a median of two (range, two to five) cardiopulmonary comorbidities. There was no conversion to laparotomy. Thirteen (29.5%) 30-day postoperative complications occurred; only six were major complications. Thirty-day postoperative re-admission, re-operation, and mortality rates were 15.9%, 2.3%, and 0%, respectively. Within a mean follow-up time of 24.0 ± 18.4 months, late morbidity and mortality rates were 18.2% and 2.3%, respectively. The mean percentage total weight and excess weight losses after at least 1 year of follow-up were 26.7 ± 12.0% and 44.1 ± 20.6%, respectively.

CONCLUSIONS

Laparoscopic bariatric surgery is safe and can be performed with acceptable perioperative outcomes in extremely high-risk patients. Advanced age, BMI, and severe cardiopulmonary comorbidities should not exclude patients from consideration for bariatric surgery.

Bariatric and metabolic outcomes in the super-obese elderly

BACKGROUND

Numerous reports address bariatric outcomes in super-obese or elderly patients, but data addressing this high-risk combination is lacking.

OBJECTIVE

The objective of this study was to assess outcomes of bariatric surgery in the super-obese elderly.

SETTING

Academic institution, United States.

METHODS

All primary bariatric cases performed on patients aged 65 years or older with a body mass index (BMI) ≥ 50 kg/m(2) were retrospectively analyzed. Surgical approaches included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB).

RESULTS

Thirty patients (26 female, 4 male) with a mean age of 67.1 ± 2.7 years and BMI of 55.9 ± 3.9 kg/m(2), who had LRYGB (n = 16), LSG (n = 6), or LAGB (n = 8), were identified. There were no deaths, conversions, or intraoperative complications. Three patients were lost to follow-up after the 3-month visit. The early (<30 d) major morbidity rate was 10.0%. At a median follow-up of 37 (range, 6-95) months, the cohort had a mean BMI of 42.3 ± 6.7 kg/m(2), which corresponded to a mean percent excess weight loss of 44.5% ± 20.5% and mean percent total weight loss of 24.4% ± 12.2%. The most percent excess weight loss was achieved after LRYGB (54.1% ± 19.4%), followed by LSG (48.3% ± 10.2%) and then LAGB (26.2% ± 14.4%). Diabetic medication reduction in number and/or dosage was observed in 40% (6/15) patients, and 33% (5/15) of patients were completely off antidiabetic agents.

CONCLUSIONS

Although further research is needed, the present data suggest that successful weight loss and metabolic improvement can be achieved safely in the high-risk population of super-obese elderly.

Functional outcomes and quality of life after proximal gastrectomy with esophagogastrostomy using a narrow gastric conduit

BACKGROUND

The best surgical approach for tumors of the proximal stomach remains controversial. For proximal gastrectomy (PG), the evidence regarding quality of life (QoL) and functional outcomes is controversial. Moreover, there are limited data from non-Asian settings.

METHODS

All patients who underwent PG from September 2005 to July 2013 were identified from an institutional database. Demographic, perioperative and pathologic characteristics were retrieved. Symptom scores (0 = best/4 = worst) for reflux symptoms, dysphagia and validated QoL metrics (FACT scale, where a higher score is better) were assessed during early and late follow-up. Eligible patients for analysis were those with no evidence of recurrence.

RESULTS

Of 465 upper gastrointestinal cancer resections, 50 were PG for adenocarcinoma (42; 84%), neuroendocrine carcinoma (5; 10%) or other pathologies (3; 6%). R0 resection was achieved in 44 (89.8%) of 49 patients with malignant tumors. Median lymph node collection was 32 (range 7-57). QoL scores did not differ from preoperative to early follow-up but increased compared to both at late follow-up [preoperative, 125 (interquartile range 105-140); early follow-up, 122.5 (97-142); late follow-up, 147 (132-159); p < 0.05]. At early and late follow-up, 9 (21.4%) of 42 and 10 (33.3%) of 30 patients reported reflux symptoms, but most were mild. Endoscopic signs of esophagitis were found in 7 (29%) of 24 patients, but only two of these reported reflux symptoms. Conversely only three of eight patients with reflux symptoms had esophagitis on endoscopy.

CONCLUSIONS

Global QoL is not reduced early after PG, and increases compared to baseline at late follow-up. Although reflux symptoms are reported by a quarter of patients, most are mild, and there is little correlation with esophagitis. PG should remain a viable option in the management of proximal gastric tumors.

Diagnostic accuracy and utility of intraoperative microscopic margin analysis of gastric and esophageal adenocarcinoma

BACKGROUND

Positive resection margins are amongst the strongest predictors of cancer-related mortality for adenocarcinoma of the stomach and esophagus. Although intraoperative pathology consultation with frozen section of margins can predict final permanent section pathology, the accuracy of this approach is not known. We sought to determine the diagnostic accuracy of frozen section margin analysis in esophagogastric adenocarcinoma and the impact that it had on surgical therapy.

METHODS

Patients with resection of esophagogastric adenocarcinoma at a single centre from 1998 to 2008 were identified. Clinicopathologic data were collected. Frozen section results were compared to permanent section assessment, and sensitivity, specificity, positive, and negative predictive values were calculated. Patients with positive margins by frozen section were reviewed to assess the impact on surgical decision-making.

RESULTS

Of 220 patients who underwent surgery for adenocarcinoma of the esophagus and stomach (esophagus: 34/220, EGJ: 106/220, stomach 80/220), 56 % had an intraoperative consultation. Of these 122 patients, 66 % underwent frozen section. All errors on frozen section occurred on the interpretation of the proximal margin. The diagnostic accuracy of frozen section at the proximal margin was 93 % with sensitivity = 67 %, specificity = 100 %, positive predictive value = 100 %, and negative predictive value = 91 %. Signet ring cells were present in 83 % of false-negative readings. Surgical management was altered in 10 of the 13 of patients who had a true positive frozen section and 9 of these patients were converted to R0 resections.

CONCLUSIONS

Although very specific, negative results on frozen section require greater caution when signet ring cells are present. For esophagogastric adenocarcinoma, frozen section alters management and may increase the rate of complete resection.

Routine contrast esophagram has minimal impact on the postoperative management of patients undergoing esophagectomy for esophageal cancer

BACKGROUND

Routine contrast esophagram is frequently performed after esophagectomy in order to detect occult anastomotic leak (AL). This modality has a low sensitivity, and its routine use has been called into question. Accordingly, we sought to demonstrate the clinical impact of routine contrast esophagography in the management of patients undergoing esophagectomy for malignant disease.

METHODS

All patients undergoing esophagectomy from 2005 to 2011 for malignancy at a North American University hospital were identified from a prospectively collected database. Barium esophagram (BE) was performed within the first week postoperatively. Patients were dichotomized according to whether they had an AL, and the sensitivity and specificity of BE was determined. The clinical impact of the BE result, defined as cessation of enteral feeding, additional interventions, or delay in discharge, was determined.

RESULTS

Overall, 221 patients underwent esophagectomy. Thirty (13.6 %) developed an AL, of which 10 (30 %) had a positive BE, 12 (40 %) had a negative BE, and 8 (26.7 %) had no BE and were diagnosed clinically (1/8), by computed tomography (CT) (3/8), endoscopically (3/8), or at reoperation (1/7). AL in patients with a negative BE was confirmed clinically (4/12), by CT (6/12), endoscopically (1/12), or at reoperation (1/12). The sensitivity and specificity of BE was 45.5 and 97.8 %, respectively. BE altered postoperative management in 8/221 (3.6 %) patients, with 5/221 (2.3 %) undergoing therapeutic intervention. Conversely, 3/221 (1.4 %) patients demonstrated clinically insignificant AL, delaying discharge and feeding without intervention.

CONCLUSION

Contrast esophagram is not an effective screening modality for AL when employed routinely following esophagectomy.

Perioperative chemotherapy for upper gastrointestinal cancer: Correlation between response to treatment and outcome

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Background: Perioperative chemotherapy improves outcomes of surgery for upper GI cancer. Some patients have rapid recurrence. We hypothesized that any type of response to chemotherapy would predict better disease-free survival (DFS).

Methods: From May 2007 to Sep 2009, 43 patients with operable adenocarcinoma of the esophagus, stomach or gastroesophageal junction went on a multicenter phase II trial. 3 cycles of docetaxel/cisplatin/5FU were given pre and post surgery. We compared DFS between responders and nonresponders after 3 cycles. Clinical response was defined as improvement of ≥ 2 points on a dysphagia score (0: normal swallowing, to 4: total obstruction), metabolic response as ≥ 35% reduction of maximum SUV by PET scan. Lack of nodal involvement or significant histologic regression (less than 50% viable tumor) was considered pathologic response. Log-rank test was used for univariate analysis, Cox regression model for multivariate analysis. All p values are double sided, median follow-up from surgery is 808 days.

Results: Clinical response data for 29/40 patients: 26 responses (90%). Median DFS was 405 days for clinical responders vs. 210 days for nonresponders (p= 0.018). Metabolic response data for 28/40 patients : 22 responses (70%). Median DFS was 276 days in metabolic nonresponders, and has not been reached in responders (p = 0.009). 14 patients had no nodal involvement at resection (N0) and had longer DFS (median not reached) than the 26 with N+, who had median DFS of 562 days (p = 0.045). A nonsignificant trend (p = 0.192) was seen in favor of the 20 with significant tumor regression (DFS 565 days) compared to the 20se without it (median DFS not reached). All results were supported by multivariate analysis.

Conclusions: These preliminary results indicate that clinical, metabolic and pathologic responses may be individually predictive of longer DFS in patients receiving perioperative chemotherapy for upper GI adenocarcinoma. This requires confirmation in larger datasets. The optimal management of nonresponders is unclear at present. Acknowledgements: Biostatistics Unit (McGill University Health Centre) and Cedars Cancer Institute (Henry R Shibata Fellowship to Dr Alcindor).