Development of the "OS-SEV90 Score" to Predict Severe Postoperative Complications at 90 Days Following Bariatric Surgery

BACKGROUND

Bariatric surgery may be associated with severe postoperative complications (SPC). Factors associated with the risk of SPC have not been fully investigated.

OBJECTIVES

This study aimed to identify preoperative risk factors of SPC within 90 days and to develop a risk prediction model based on these factors.

METHODS

We conducted a retrospective single-center cohort study based on a prospectively maintained database of obese patients undergoing laparoscopic bariatric surgery from October 2005 to May 2019. All SPC occurring up to the 90th postoperative day were recorded according to the Dindo-Clavien classification. Associations between potential risk factors and SPC were analyzed using a logistic regression model, and the risk prediction ("OS-SEV90 score") was computed. Based on the OS-SEV90 score, the patients were grouped into 3 categories of risk: low, intermediate, and high.

RESULTS

Among 1963 consecutive patients, no patient died and 82 (4.2%) experienced SPC within 90 days. History of gastric or esophageal surgery (adjusted odds ratio (aOR) 3.040, 95% confidence interval; CI 1.78-5.20, p< 0.0001), past of thromboembolic event aOR 2.26, 95%; CI 1.12-4.55, p = 0.0225), and surgery performed by a junior surgeon (aOR 1.99, 95%; CI 1.26-3.13, p = 0.003) were all independently associated with risk for SPC, adjusting for ASA physical status system (ASA) score ≥ 3, severe OSA, psychiatric disease, asthma, a history of abdominal surgery, alcohol, cardiac disease, and dyslipidemia. "the OS-SEV90 score" based on these factors was constructed to classify patients into 3 risk groups: low (≤2), intermediate (3-4), and high (≥5). According to "the OS-SEV90 score," SPC increased significantly from 2.9% in the low-risk group, 7.7% in the intermediate-risk group, and 23.3% in the high-risk group.

CONCLUSIONS

A predictive model of SPC within 90 days "the OS-SEV90 score" has been developed using 9 baseline risk factors. The use of the OS-SEV90 score may help the multidisciplinary team to identify the specific risk of each patient and inform them about and optimize the comorbidities before the surgery. Further studies are warranted to validate this score in a new independent cohort before using it in clinical practice.

Guiding the non-bariatric surgeon through complications of bariatric surgery

Complications in bariatric surgery are varied; they are severe at times but infrequent. They may be surgical or non-surgical, and may occur early or late. The goal of this systematic review is to inform and help the attending physician, the emergency physician and the non-bariatric surgeon who may be called upon to manage surgical complications that arise after adjustable gastric band (AGB), sleeve gastrectomy (SG), or gastric bypass (GBP). Data from evidence-based medicine were extracted from the literature by a review of the Medline database and also of the most recent recommendations of the learned societies implicated. The main complications were classified for each intervention, and a distinction was made between early and late complications. Early complications after AGB include prosthetic slippage or perforation; SG can be complicated early by staple line leak or fistula, and BPG by fistula, stenosis and postoperative hemorrhage. Delayed complications of AGB include intragastric migration of the prosthesis, late prosthetic slippage and infection, while SG can be complicated by gastro-esophageal reflux, and BPG by anastomotic ulcer and internal hernia. The analysis of available data allowed us to develop decisional algorithms for the management of each of these complications.

Esophagopericardial fistula: an unexpected dreaded complication of treatment of leak following revisional sleeve gastrectomy by endoscopic internal drainage

Esophagopericardial fistula (EPF) is an uncommon but life-threatening complication of upper gastrointestinal tract surgery or endoscopy, which is related to anastomotic breakdown, chronic infection or esophageal traumatism. We first describe the first case of an EPF secondary to double pigtail drain migration: an endoscopic internal approach for the treatment of leak following revisional sleeve gastrectomy.

Multicentre study of neoadjuvant chemotherapy for stage I and II oesophageal cancer

Background

The benefit of neoadjuvant chemotherapy (NCT) for early-stage oesophageal cancer is unknown. The aim of this study was to assess whether NCT improves the outcome of patients with stage I or II disease.

Methods

Data were collected from 30 European centres from 2000 to 2010. Patients who received NCT for stage I or II oesophageal cancer were compared with patients who underwent primary surgery with regard to postoperative morbidity, mortality, and overall and disease-free survival. Propensity score matching was used to adjust for differences in baseline characteristics.

Results

Of 1173 patients recruited (181 NCT, 992 primary surgery), 651 (55·5 per cent) had clinical stage I disease and 522 (44·5 per cent) had stage II disease. Comparisons of the NCT and primary surgery groups in the matched population (181 patients in each group) revealed in-hospital mortality rates of 4·4 and 5·5 per cent respectively (P = 0·660), R0 resection rates of 91·7 and 86·7 per cent (P = 0·338), 5-year overall survival rates of 47·7 and 38·6 per cent (hazard ratio (HR) 0·68, 95 per cent c.i. 0·49 to 0·93; P = 0·016), and 5-year disease-free survival rates of 44·9 and 36·1 per cent (HR 0·68, 0·50 to 0·93; P = 0·017).

Conclusion

NCT was associated with better overall and disease-free survival in patients with stage I or II oesophageal cancer, without increasing postoperative morbidity.

Stenosis without stricture after sleeve gastrectomy

Sleeve gastrectomy (SG) is an increasingly popular restrictive bariatric procedure as attested by the 5,302 procedures performed in 2009, increasing worldwide to 13,557 in 2011 and to 24,190 in 2013. Among the early complications, gastric stricture is well described with a prevalence between 0.7 and 4.0% (Dhahri et al., 2010). The patient reported here had functional stenosis without any underlying anatomic stricture. This complication is rare and is the consequence of spiral stapling resulting in a gastric tube that is twisted from the start (Iannelli et al., 2014). Twisted sleeve gastrectomy resulting from spiral stapling exposes the patient to the risk of recurrent dysphagia, which has the appearance of stenosis on upper GI series but not on fibroscopy. Conversion to RY-GBP is one solution. At six months follow-up after conversion, our patient is symptom-free, with quality of life was rated excellent (a score greater than 9 on the BAROS questionnaire).

Mesh infection after inguinal hernia mesh repair

INTRODUCTION

Infection after repair of groin hernia is rare, even since the advent of mesh repair. The debate remains open about antibiotic prophylaxis.

AIM OF THE STUDY

Assess incidence of this kind of complication, determine criteria of diagnosis and strategy of therapy by examining the collective experience of 32 surgeons.

METHOD

Fifty surgeons were asked to report their experience with mesh repair of inguinal hernias and specifically mesh infection. Diagnosis and therapy for each mesh infection were detailed.

RESULTS

Forty-five cases were reported in 38 patients who had undergone open or laparoscopic mesh repair. Diagnosis was straightforward and established at a variable delay after mesh insertion: 51% during the first postoperative month; 26% more than one year after the procedure. Infection cured in 33 patients after mesh removal, in one step in 14 cases, but after many attempts for conservative therapy in 19 cases; the mean delay to cure was 12.5 months. Visceral resections had to be associated with mesh removal in 13% of cases.

CONCLUSIONS

This is the largest series of mesh infections after inguinal hernia repair reported in the literature. According to the evidence provided here, mesh removal appears to be the most appropriate treatment of this rare and serious complication.