Defining global benchmarks in elective secondary bariatric surgery comprising conversional, revisional and reversal procedures

Objective

Management of poor response and of long-term complications after bariatric surgery (BS) is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. Benchmarking uses best performance in a given field as reference point for improvement. Our aim was to define ‘‘best possible’’ outcomes for elective secondary BS.

Methods

The establishment of benchmarks in secondary BS followed a standardized methodology, based on recommendations of a Delphi consensus panel of experts. This multicenter study analyzed patients undergoing elective secondary BS in 18 high-volume centers on 4 continents from 06/2013 to 05/2019. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers. Benchmark cases had no: previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI>50kg/m2 or age>65 years. Descriptive statistics, multivariate logistic regression and data visualization were performed using the R software.

Results

Out of 44’884 elective bariatric procedures performed in the participating centers, 5’328 secondary BS cases were identified. The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8±10 years, 8.4±5.3 years after primary BS, with a body mass index 35.2±7kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.57% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.36) and after conversional or revisional procedures with gastrointestinal suture/stapling (OR 1.7). Benchmark cutoffs at 90-days postoperatively were ≤5.8% re-intervention and ≤8.8% re-operation rate. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation.

Conclusion

Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Gastrojejunal anastomotic stricture after Roux-en-Y gastric bypass: ambulatory management with the Savary-Gilliard dilator

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) is currently one of the most frequently performed procedures for the surgical treatment of morbid obesity. The success of this procedure's restrictive component requires a small gastrojejunostomy (GJ), which occasionally results in stenosis. The treatment of choice for this complication is balloon dilation. This study aimed to evaluate the feasibility and safety of ambulatory management for stenosis of the GJ using endoscopically guided Savary-Gilliard dilators.

METHODS

Between January 1998 and October 2003, 769 patients underwent RYGBP. The mean age of these patients was 38 +/- 12 years, and their mean body mass index (BMI) was 43 +/- 6 kg/m2. Of these 769 patients, 520 (68%) underwent open surgery and 249 (32%) underwent laparoscopic RYGBP. Patients suspected of GJ stenosis were referred for upper gastrointestinal endoscopy. Those who presented with stenosis were managed endoscopically with Savary-Gilliard dilators.

RESULTS

Stenosis at the GJ was confirmed in 53 patients (6.9%). A total of 71 dilations were performed for these patients, resulting in a mean of 1.3 dilations per patient. One dilation was needed for 41 patients (75.5%), two dilations for 9 patients (16.9%), three dilations for 3 patients (5.7%), and four dilations 1 patient (1.9%). The patients subjected to open RYGBP required a mean of 1.57 dilations, and those who had laparoscopic RYGBP required mean of 1.08 dilations. The mean time for the first dilation was 51 +/- 28 days after surgery (range, 20-178 days). All the dilations were performed in ambulatory settings. One patient (1.9%) was admitted after GJ dilation for pain. He was discharged without symptoms after 2 days with no need for invasive procedures.

CONCLUSIONS

The management and treatment of GJ stenosis after RYGBP can be effectively accomplished in ambulatory settings using endoscopically guided Savary-Gilliard dilators, with good and safe results.

[Communication and iatrogenesis through communication]

Human intercommunication means transfer of information through many channels, with codes that have biological and socio-cultural determinism. The biological determinism is identifiable through the development of the phonetics and ergomotricity functions, through the possibility of perception of the sensorial organs. The channels of human intercommunication can be verbal, linguistic (the most specialised channel), and nonverbal, extra linguistic channels (mimics, written model, drawing, walking), that are effectively implicated in defining a direct dialogue between the doctor and the patient, completing and emphasising the communication.

[Endovascular therapy of superior vena cava syndrome: clinical case]

The treatment of superior vena cava syndrome is usually oriented to the underlying cause, that can be too slow in emergency cases. We report a 49 years old woman with a multiple myeloma that was admitted due to a superior vena cava syndrome caused by a central venous catheter used for chemotherapy for 20 weeks. She was successfully treated with thrombolysis, angioplasty and stent placement. The patient died 7 months later due to the underlying disease. Long term catheters are the responsible for 20 to 30% of superior vena cava syndromes. Endovascular treatment of the syndrome is successful in 60 to 100% of cases with a symptomatic relapse in 4 to 45% of patients.

[The para-clinic investigation of temporo-mandibular joint changes in patients with acromegaly]

The Acromegaly is an endocrinological disease determined by the hypersecretion of STH in a certain period of the body evolution and it causes the hypertrophy of bones in general and of mandible and cranio-facial bones, determining a disorder due to this development of bones, associated with troubles in the activity of muscles and of the phospho-calcium metabolism. This study was made on a group of 33 acromegaly patients. Their temporo-mandibular joint was investigated by ortopantomography, tomography, computer tomography and scintigraphy. All of these exams shows the changes in temporo-mandibular joint due to the cells hyperactivity determined by the hypersecretion of STH.

[A statistical analysis of the variation in the cephalometric measures of acromegaly patients]

Acromegaly represents the endocrine disease which includes the somatic and metabolic disorders secondly resulting to the augmentation of the Growth Hormone secretion after the growth cartilages closing (in adult). In this study we want to describe the craniofacial cephalometric qualitative and quantitative disorders and to emphasize their implications in the onset and the evolution of the stomatognathic system dysfunctional syndrome. For proving this things, we made a statistical study using a statistics function named "standard deviation" which is a measure of how widely values are dispersed from the average value.

[The correlations between the electromyographic display and the aspects involved with masticatory muscle contraction and phosphorus-calcium metabolism]

The neuromuscular activity at the level of the stomatognathic system has a specific complexity, due to the multiple systemic functions, realizing the statistical and dynamical mandibular positions and the integration of the stomatognathic system at the level of the human body. Knowing that the neuroendocrine system represents an important factor for the over-systemic coordination of the stomatognathic muscular activity, we want to establish the implication and the neuroendocrine correlation in the stomatognathic muscular dysfunctions determined by some endocrine diseases.

Sucking pressure and its relationship to milk transfer during breastfeeding in humans

Breast sucking pressure has been only partially characterized in humans and its quantitative relationships with milk transfer and endocrine maternal responses are unknown. A method to record sucking pressure and milk transfer during complete sucking episodes is described. A tubing connected at one end to a pressure transducer was attached to the nipple so that the baby sucked both the nipple and the catheter during breastfeeding. The transducer's signals were fed into a commercial computer system designed to digitize and analyse physiological signals. A total of 27 recordings, 13 of which were from a single breast and 14 from both breasts were evaluated. Average values for the mean and maximum sucking pressures were -50 and -197 mmHg, respectively; the median intersuck interval was 0.7 s; and duration of the sucking episode was 7 min. Diverse sucking pressure patterns were observed due to different mixes of sucking bursts with steady sucking and stable versus decreasing pressure and frequency throughout each sucking episode. The amount of milk transferred to the baby was estimated from the difference in body weight immediately before and after each episode. Milk transfer from the second breast was 58% lower than from the first; this was associated with a significant decrease in grams of milk transferred per suck or per minute without significant changes in sucking pressure. The data suggest that there is a change in the maternal physiological response to sucking between the first and second breast. This report shows the feasibility of measuring the sucking pressure developed by human babies during complete nursing episodes, and offers great potential to explore the relationships between the physical parameters of sucking and maternal physiological responses, such as hormonal changes, milk yield and duration of lactational amenorrhoea.