Outcome comparison between primary and revisional bariatric surgery: A propensity-matched analysis

BACKGROUND

Revisional bariatric procedures for weight recurrence are rising but are considered higher risk and less effective than primary bariatric procedures. This study aimed to compare clinical outcomes between primary and revisional bariatric surgery for weight recurrence.

METHODS

Prospectively collected data from adult patients who underwent revisional or primary bariatric surgery from 2016 to 2020 in an academic institution were reviewed. Roux-en-Y gastric bypass and sleeve gastrectomy were performed primarily or as conversion procedures after laparoscopic adjustable gastric band, vertical banded gastroplasty, and sleeve gastrectomy. 1:1 propensity score matching was performed between revisional bariatric surgery and primary bariatric surgery, and logistic regression analysis was used to compare up to 2-year weight loss and comorbidity resolution outcomes.

RESULTS

A total of172 cases (86 revisional bariatric surgery versus 86 primary bariatric surgery) were included. Groups were matched for age, sex, preoperative body mass index, bariatric procedure, diabetes, hypertension, and obstructive sleep apnea. Procedure duration (203 ± 78 vs 154 ± 69 minutes; P < .001) and length of stay (2.3 ± 2.1 vs 1.7 ± 1 days; P = .02) were longer for revisional bariatric surgery versus primary bariatric surgery, respectively. Total weight loss was less in revisional bariatric surgery compared with primary bariatric surgery at 1 year (23 ± 10% vs 32 ± 9%; P < .001) and 2 years (21 ± 12.% vs 32 ± 10%; P < .001) of follow-up; however, no differences were detected in postoperative occurrences, emergency department visits, readmissions, reintervention and reoperation rates, and comorbidity resolution.

CONCLUSION

Although revisional bariatric surgery was associated with longer operation times, prolonged hospitalization, and lower weight loss than primary bariatric surgery, it was accomplished safely and led to substantial weight loss and comorbidity resolution. This information can guide patient counseling before revisional surgery for weight recurrence.

Educational and Patient Care Impacts of In Situ Simulation in Healthcare: A Systematic Review

ABSTRACT

This systematic review was performed to assess the effectiveness of in situ simulation education. We searched databases including MEDLINE and Embase for studies comparing in situ simulation with other educational approaches. Two reviewers screened articles and extracted information. Sixty-two articles met inclusion criteria, of which 24 were synthesized quantitatively using random effects meta-analysis. When compared with current educational practices alone, the addition of in situ simulation to these practices was associated with small improvements in clinical outcomes, including mortality [odds ratio, 0.66; 95% confidence interval (CI), 0.55 to 0.78], care metrics (standardized mean difference, -0.34; 95% CI, -0.45 to -0.21), and nontechnical skills (standardized mean difference, -0.52; 95% CI, -0.99 to -0.05). Comparisons between in situ and traditional simulation showed mixed learner preference and knowledge improvement between groups, while technical skills showed improvement attributable to in situ simulation. In summary, available evidence suggests that adding in situ simulation to current educational practices may improve patient mortality and morbidity.

Venous thromboembolism (VTE) prophylaxis after bariatric surgery: a national survey of MBSAQIP director practices

BACKGROUND

Venous thromboembolism (VTE) is the most common cause of death following metabolic/bariatric surgery (MBS), with most events occurring after discharge. The available evidence on ideal prophylaxis type, dosage, and duration after discharge is limited.

OBJECTIVES

Assess metabolic/bariatric surgeon VTE prophylaxis practices and define existing variability.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited centers.

METHODS

The members of the ASMBS Research Committee developed and administered a web-based survey to MBSAQIP medical directors and ASMBS members to examine the differences in clinical practice regarding the administration of VTE prophylaxis after MBS.

RESULTS

Overall, 264 metabolic/bariatric surgeons (136 medical directors and 128 ASMBS members) participated in the survey. Both mechanical and chemical VTE prophylaxis was used by 97.1% of the participants, knee-high compression devices by 84.7%, enoxaparin (32.4% 40 mg every 24 hours, 22.7% 40 mg every 12 hours, 24.4% adjusted the dose based on body mass index) by 56.5%, and heparin (46.1% 5000 units every 8 hours, 22.6% 5000 units every 12 hours, 20.9% 5000 units once preoperatively) by 38.1%. Most surgeons (81.6%) administered the first dose preoperatively, while the first postoperative dose was given on the evening of surgery by 44% or the next morning by 42.2%. Extended VTE prophylaxis was prescribed for 2 weeks by 38.7% and 4 weeks by 28.9%.

CONCLUSIONS

VTE prophylaxis practices vary widely among metabolic/bariatric surgeons. Variability may be related to limited available comparative evidence. Large prospective clinical trials are needed to define optimal practices for VTE risk stratification and prophylaxis in bariatric surgery patients.

Does Sleeve Shape Make a Difference in Outcomes?

INTRODUCTION

Sleeve gastrectomy (SG) is one of the most common procedures performed for weight loss. Many seek the "perfect sleeve" with the notion that the type of calibrating device affects sleeve shape, and this in turn will affect outcomes and complications. Two major concerns after SG are amount of weight loss and acid reflux. Our aim was to determine if the various calibration methods could impact sleeve shape and thereby allow for better outcomes of weight loss and reflux.

METHODS

A retrospective chart review was performed of 210 patients who underwent SG and had postoperative upper gastrointestinal (UGI) study from 2011 to 2015 in a single center by a single (fellowship-trained) bariatric surgeon. Data regarding demographics, calibrating devices and clinical outcomes at 1 year (weight loss and de novo acid reflux) were collected. UGIs were reviewed by two radiologists blinded to the clinical outcomes. Sleeve shape was classified according to a previously described classification as tubular, dumbbell, upper pouch, or lower pouch. The types of calibrating devices used to guide the sleeve size intraoperatively were endoscopy, large-bore orogastric tube, and fenestrated suction tube.

RESULTS

One hundred ninety-nine patients met inclusion criteria (11 had no esophagram). Demographics revealed age 45.76 ± 10.6 years, BMI 47 ± 8.6 kg/m², and 82% female. Calibration devices used were endoscopic guidance (7.6%), large bore orogastric tube (41.4%), and fenestrated suction tube (50.5%). Sleeve shape was reported as 32.6% tubular, 20.6% dumbbell, 39.2% lower pouch, and 7.5% upper pouch (100% interrater reliability). No correlation was seen with type of calibration used. Of patients, 62.0% had > 50% excess weight loss at 1 year. Twenty-three percent of patients remained on PPI at 1 year (of which 43.3% did not have reflux preoperatively). The lower pouch shape showed a trend toward less reflux and more weight loss.

CONCLUSION

This study showed no clear association between uniformity of sleeve shape and the type of calibration device used. The study showed a trend toward decreased reflux and improved weight loss with the lower pouch shape, regardless of calibration device.

The relation between serum vitamin D levels and blood pressure: a population-based study

Vitamin D deficiency has been proposed as an associating factor with increased blood pressure. We studied the relationship between serum vitamin D and blood pressure in a large representative sample of Iranian population. In this cross-sectional study, based on the data of 2508 adults (aged between 20 and 70 years) from the Iran Multicenter Osteoporosis Study (IMOS), the association between serum vitamin D and blood pressure was investigated. There was a significant difference between mean (±SD) vitamin D levels of the individuals with stage I hypertension and that of the three other groups (Normal: 32.9 (±27.5); Prehypertension: 34.4 (±27.2); Stage-I: 38.7 (±29.2); Stage-II: 34.7 (±24.0) ng/ml; P<0.05. In multivariate regression models, the weak positive association of vitamin D and systolic blood pressure values disappeared after age and Body Mass Index (BMI) adjustment. We found a statistically positive but weak association between vitamin D serum concentration and systolic blood pressure. Considering the difference noted between our results and previous studies, further research is needed to assess the potential effect of ethnicity and genetic factors on these findings.

Comparison of Knifelight Surgery versus Conventional Open Surgery in the Treatment of Carpal Tunnel Syndrome

Background

A variety of surgical treatment methods for carpal tunnel syndrome are introduced recently, including open surgery, endoscopic and the Knifelight. It is hypothesized that Knifelight method could decrease scar tenderness and time before return to daily activities for patients and is accompanied with less disturbance to fine sensory nerves.

Objectives

To compare the Knifelight instrument and open carpal tunnel release with respect to scar length, operation duration, recovery time needed before return to work and amount of pain three weeks after surgery in patients with neurophysiologically confirmed carpal tunnel syndrome.

Patients and Methods

Fifty nine patients with indication for carpal tunnel release randomly assigned into two groups: open (n=30) or Knifelight (n=29). The patients compared regarding scar length, operation duration, time to return to daily activities and amount of pain at three weeks after operation based on Visual Analog Scale.

Results

There was no significant differences regarding age and sex in the two groups. The scar length, operation duration and time before return to daily activities were significantly lower in the Knifelight group. Although the mean visual analogue scale of Knifelight group found to be lower than the other, it was not statistically significant.

Conclusions

The Knifelight technique is accompanied with advantages over the open surgery regarding operation time, scar length and time to return to daily activities. The pain relieve based on Visual Analog Scale was not statistically different from conventional open surgery.

Potentially preventable incidence of diabetes due to risk factor modification

BACKGROUND

Increasing diabetes incidence demands investigation of risk factors, prioritization and designing modification interventions. We calculated the potential modifiable incidence of diabetes due to reduction in risk factors.

METHODS

We used counterfactual analysis model to estimate avoidable burden of incident diabetes related to each risk factor. The potential impact fraction (PIF) index calculated utilizing the data of current prevalence, magnitude of impact and counterfactual status of risk factors. We considered the levels of evidence while giving higher priority to domestic data.

RESULTS

The estimated PIF regarding minimum feasible risk for the impaired fasting glucose (IFG), impaired glucose tolerance (IGT), combined IFG/IGT, low HDL, high triglyceride, high total cholesterol, hypertension, general obesity, central obesity and physical inactivity were 0.13, 0.10, 0.18, 0.01, 0.12, 0.03, 0.13, 0.03, 0.02 and 0.10, respectively.

CONCLUSION

While the combined risk factors of IFG and IGT should be noticed as the most important potential factor in prevention of diabetes and reducing its incidence burden, among the other risk factors, modification of hypertension, high triglyceride, and physical inactivity could have more impact.

Twelve year experience of laparoscopic gastric plication in morbid obesity: development of the technique and patient outcomes

BACKGROUND

Laparoscopic Gastric Plication (LGP) is a new restrictive bariatric surgery, previously introduced by the author. The aim of this study is to explain the modifications and to present the 12-year experience, regarding early and long term results, complications and cost.

METHODS

We used LGP for morbid obesity during the past 12 years. Anterior plication (10 cases), one-row bilateral plication while right gastroepiploic artery included (42 cases), and excluded from the plication (104 cases) and two-row plication (644 cases). The gastric greater curvature was plicated using 2/0 prolen from fundus at the level of diaphragm preserving the His angle to just proximal to the pylorus. The anatomic and functional volume of stomach was 50cc and 25cc respectively in two-row method. Ordered postop visits also included evaluation of weight loss, complications, change of diet and control of exercise.

RESULTS

LGP was performed in 800 cases (mean age: 27.5, range: 12 to 65 years, nine under 18). Female to male ratio was 81% to 19% and average BMI was 42.1 (35-59). The mean excess weight loss (EWL) was 70% (40% to 100%) after 24 months and 55% (28% to 100%) after 5 years following surgery. 134 cases (16.7%) did not completed long term follow-up. The average time of follow up was 5 years (1 month to 12 years). 5.5% and 31% of cases complained from weight regain respectively during 4 and 12 years after LGP. The mean time of operation was 72 (49-152) minutes and average hospitalization time was 72 hours (24 hours to 45 days). The cost of operation was 2000 $ less than gastric banding or sleeve and 2500 $ less than gastric bypass. Eight patients out of 800 cases (1%) required reoperation due to complications like: micro perforation, obstruction and vomiting following adhesion of His angle. Other complications included hepatitis pneumonia, self-limiting intra-abdominal bleeding and hypocalcaemia.

CONCLUSION

The percentage of EWL in this technique is comparable to other restrictive methods. The technique is safe with 1.6% complication (1% reoperated), and 31% regain during 12 years. The cost of operation is less than the other methods.