Revision surgery after sleeve gastrectomy: a nationwide study with 10 years of follow-up

BackgroundSleeve gastrectomy is the most common bariatric procedure worldwide. Several studies report good short- and midterm results. However, recent studies report alarming long-term outcomes, in particular about the revision rate.ObjectivesThe aim of this study is the assessment of the revisional rate after sleeve gastrectomy and the analysis of most common reasons for surgical conversion and early complications.SettingThis study is based on a national claims database comprehensive of all bariatric procedures performed in a 10-year period.MethodsThe French Programme De Médicalisation des Systèmes d’Information database was used to identify all patients who underwent sleeve gastrectomy between 2008 and 2018. Codes for diagnoses and procedures were used to describe the reason for and the morbidity of revision surgeries. Multivariate Cox proportional hazard regression analysis was performed to compare the risk of having a revision procedure.ResultsDuring the analyzed period, a total of 224,718 sleeve gastrectomies were performed. The rate of revision surgery after sleeve gastrectomy was 4.7%, 7.5%, and 12.2%, at 5, 7, and 10 years post procedure, respectively. A history of gastric banding was associated with a higher risk of revision (hazard ratio, 2.81; 95% CI, 2.66–2.95; P < .001). The most common revision procedure was gastric bypass (75.2%), followed by resleeve (18.7%). The main reasons for revision surgery were persistence of obesity (87.0%) and gastroesophageal reflux disease (5.2%). After revision surgery, we observed the following complications: 5.1% gastric leak, 18% bleeding, and reoperation rate of 6.4%.ConclusionsThis study suggests that a large number of patients who initially underwent a sleeve gastrectomy will undergo a revisional surgery. This information should be considered in the initial choice of the bariatric procedure, and patients should be informed of the mid- and long-term risks.     

Tomographic and histomorphometric evaluation of socket healing after tooth extraction using leukocyte- and platelet-rich fibrin: A randomized,single-blind,controlled clinical trial

The use of platelet concentrate in alveolar ridge preservation has been broadly studied. However, no randomized clinical trials with histomorphometric analysis and low risk of bias are available in the literature. We conducted a prospective, single-blind, parallel, randomized, controlled clinical trial to evaluate the efficacy of leukocyte- and platelet-rich fibrin (L-PRF) in socket preservation after tooth extraction. Additionally, the effect of L-PRF on bone formation was analyzed histologically using bone biopsy specimens obtained during implant placement.A total of 48 subjects who underwent a non-molar tooth extraction were randomly assigned to the L-PRF group (n = 24) or the control group (n = 24). Cone-beam computed tomographies were performed immediately after tooth extraction and at 3 months after tooth extraction, prior to implant surgery. A significant difference in bone resorption was registered 1 mm below the crest: 0.93 ± 0.9 mm for the L-PRF group and 2.27 ± 1.2 mm for the control group (p = 0.0001). Histomorphometric analysis showed a higher percentage of new bone formation in the L-PRF group compared with the control group. The values were 55.96 ± 11.97% and 39.69 ± 11.13%, respectively (p = 0.00001). These findings indicate that the administration of L-PRF should always be considered when socket preservation is planned (Clinicaltrials.gov NCT03408418).     

Role of joint distraction in osteoarthritis of the knee: Basic science,principles and outcomes

The burden of knee osteoarthritis (OA) is increasing worldwide. Advanced tibiofemoral joint OA in young patients is particularly a problem with inferior results seen with total knee arthroplasty in this patient population. Knee joint distraction (KJD) has been evaluated recently as a joint preserving procedure for young patients with advanced tibiofemoral osteoarthritis, to delay the need for a primary total knee arthroplasty (TKA). This will decrease the risk for revision TKA later in life. KJD temporarily unloads the knee joint and keeps the tibia and femur separated over a course of 6 weeks. Outcomes of KJD appear promising. Through this article, the authors hope to share from their collective experience as well as the available literature on the basic science, principles of surgery and outcomes of KJD.     

Outcomes of laparoscopic sleeve gastrectomy with and without antrectomy in severely obese subjects. Evidence from randomized controlled trials

BackgroundLaparoscopic sleeve gastrectomy (SG) has been proven safe and effective in achieving weight loss. However, the distance from the pylorus where resection should begin has been debated.ObjectivesTo compare the clinical outcomes of laparoscopic SG with antrum resection (AR) versus preservation (AP) for bariatric purposes by conducting a meta-analysis of randomized controlled trials (RCT).SettingAcademic hospital, United States.MethodsPubMed and Cochrane Library were queried for RCTs from establishment to August 2020. The following key search terms were used: “sleeve gastrectomy” AND (“antrectomy” OR “antrum”) AND (“randomized” OR “random”). The following data were extracted: author, publication year, country, sample size, follow-up duration, and clinical outcomes, including weight-related: excess weight loss (EWL), total weight loss (TWL), body mass index (BMI), operation time, length of hospital stay, complication rates, and resolution of obesity-related comorbidities.ResultsA total of 9 unique RCTs including 492 AR and 385 AP patients were screened and included in the final quantitative analysis. Patients who underwent SG with AR showed higher EWL and TWL at 6 months (EWL: P < .001; TWL: P = .006), and 1 year (EWL: P = .013; P < .001) postoperatively. The BMI was also lower in the AR group 3 months (P = .013) and 6 months (P = .003) postoperatively. However, the EWL and BMI at 2 years were comparable between both groups (P = .222 and P = .908, respectively). No statistical significance was observed in terms of operating time, staple line disruption, bleeding, complications with a Clavien-Dindo Grade >III, resolution of comorbidities (hypertension, diabetes, hyperlipidemia, arthritis/back pain), and de novo gastroesophageal reflux disease (P > .05). AP was associated with a slightly shorter postoperative hospital stay (4.0 versus 3.1 days, P = .039).ConclusionLaparoscopic SG with AR is associated with superior weight loss in the short-term compared with AP. However, mid-term follow-up beyond 1 year showed no significant differences in BMI or incidence of de novo gastroesophageal reflux disease.     

Innovative immunosuppression in kidney transplantation: A challenge for unmet needs

Due to the optimal results obtained in kidney transplantation and to the lack of interest of the industries, new innovative drugs in kidney transplantation are difficult to be encountered. The best strategy to find the new drugs recently developed or under development is to search in the sections of kidney transplantation still not completely covered by the drugs on the market. These unmet needs are the prevention of delayed graft function (DGF), the protection of the graft over the long time and the desensitization of preformed anti human leukocyte antigen antibodies and the treatment of the acute antibody-mediated rejection. These needs are particularly relevant due to the expansion of some kind of kidney transplantation as transplantation from non-heart beating donor and in the case of antibody-incompatible grafts. The first are particularly exposed to DGF, the latter need a safe desensitization and a safe treatments of the antibody mediated rejections that often occur. Particular caution is needed in treating these drugs. First, they are described in very recent studies and the follow-up of their effect is of course rather short. Second, some of these drugs are still in an early phase of study, even if in well-conducted randomized controlled trials. Particular caution and a careful check need to be used in trials launched 2 or 3 years ago. Indeed, is always necessary to verify whether the study is still going on or whether and why the study itself was abandoned.     

Mapping variability in allocation of Long-Term Care funds across payer agencies in OECD countries

IntroductionLong-term care (LTC) is organized in a fragmented manner. Payer agencies (PA) receive LTC funds from the agency collecting funds, and commission services. Yet, distributional equity (DE) across PAs, a precondition to geographical equity of access to LTC, has received limited attention. We conceptualize that LTC systems promote DE when they are designed to set eligibility criteria nationally (vs. locally); and to distribute funds among PAs based on needs-formula (vs. past-budgets or government decisions).ObjectivesThis cross-country study highlights to what extent different LTC systems are designed to promote DE across PAs, and the parameters used in allocation formulae.MethodsQualitative data were collected through a questionnaire filled by experts from 17 OECD countries.Results11 out of 25 LTC systems analyzed, fully meet DE as we defined. 5 systems which give high autonomy to PAs have designs with low levels of DE; while nine systems partially promote DE. Allocation formulae vary in their complexity as some systems use simple demographic parameters while others apply socio-economic status, disability, and LTC cost variations.Discussion and conclusionsA minority of LTC systems fully meet DE, which is only one of the criteria in allocation of LTC resources. Some systems prefer local priority-setting and governance over DE. Countries that value DE should harmonize the eligibility criteria at the national level and allocate funds according to needs across regions.     

我国老年长期护理服务质量及其影响因素分析——基于上海市的实证研究

利用上海市调研数据,以60岁及以上老人为研究对象,基于SERVQUAL模型和有序多分类逻辑回归方法分析我国老年长期护理服务质量及其影响因素。研究发现:老人对长期护理服务质量评价不高,且常用临床护理服务质量略低于基本生活照料服务质量。供给方因素中护理机构基础设施、管理水平、护理人员专业水平对长期护理服务质量的提升具有正向激励作用。需求方因素中老人养老金水平对长期护理服务质量的提高具有显著正向激励,而老人的失能程度对服务质量具有显著负向影响,且与男性老人相比,女性老人对长期护理服务质量评价显著更高。研究结果为精确地评估我国老年长期护理服务质量提供了科学依据,对提升失能老人的生活质量,促进我国长期护理服务产业的发展具有重要的政策启示。     

Histomorphometric evaluation of different grafting materials used for alveolar ridge preservation: a systematic review and network meta-analysis

In this systematic review and network meta-analysis including only randomized clinical trials (RCTs), different grafting materials used in alveolar ridge preservation after tooth extraction were analysed, focusing on histomorphometric new bone formation (NBF) in core biopsies obtained during implant placement. The PubMed, Embase, Cochrane Library, Web of Science, Scopus, and LILACS databases, as well as the grey literature, were searched for published and unpublished trials (from database inception to January 14, 2019). The primary outcome was the percentage of NBF. The secondary outcomes were the percentage of residual biomaterial and the percentage of soft tissue. An arm-based network meta-analysis was performed. The rank of intervention efficacy was obtained to measure the probability of each biomaterial being ranked first across all interventions. A total of 1526 studies were found, of which 38 were included for quantitative analysis. Three trials were rated as having a high risk of bias and 35 trials as having an unclear risk of bias. The network meta-analysis showed that nine grafting materials decreased NBF and 25 did not decrease NBF. The grafting material with the highest amount of NBF was plasma rich in growth factors. Due to the lack of studies with a low risk of bias, further RCTs are needed for definitive conclusions.