Examining the link between bariatric surgery, bone loss, and osteoporosis: a review of bone density studies

As the popularity of bariatric surgery to treat morbid obesity has risen, so has a concern of increased skeletal fragility secondary to accelerated bone loss following bariatric procedures. We reviewed cross-sectional and prospective literature reporting bone density outcomes following bariatric surgical treatment for morbid obesity. Prospective research provides evidence of hip and lumbar spine areal bone mineral density (aBMD) reductions primarily in women despite calcium and vitamin D supplementation. Femoral neck aBMD declines of 9–11% and lumbar spine aBMD reductions up to 8% were observed at the first post-operative year following malabsorptive procedures. Mean T- and Z-scores up to 25 years following surgery remained within normal and healthy ranges. Of those studies reporting development of osteoporosis following gastric bypass, one woman became osteoporotic after 1 year. Despite observed bone loss in the hip region post-surgery, data do not conclusively support increased incidence of osteoporosis or increased fracture risk in post-bariatric patients. However, given the limitations of dual energy X-ray absorptiometry technology in this population and the relative lack of long-term prospective studies that include control populations, further research is needed to provide conclusive evidence regarding fracture outcomes in this population.     

Increased Risk of Short-Term Complications and Venous Thromboembolism in Latarjet-Bristow Procedures Compared With Bankart Repairs

PurposeTo (1) determine the rate of surgical complications and venous thromboembolism (VTE) in patients undergoing arthroscopic Bankart repair, open Bankart repair, or Latarjet-Bristow; and (2) assess potential risk factors for surgical complications and VTE in patients undergoing shoulder stabilization procedures.MethodsThe NSQIP database was used to identify patients undergoing isolated surgery for shoulder instability from 2005 to 2017. Demographic data were collected and compared. Logistic regression was used to assess the risk factors for developing a postoperative complication, and regression analyses were used to evaluate the odds of postoperative complications between types of surgery.ResultsWe identified 7,233 patients for inclusion. Patients undergoing Latarjet-Bristow were more likely to be male and Black and to report current tobacco use. Overall, there was a low rate of surgical complications (0.4%) and VTE (0.2%). However, patients undergoing Latarjet-Bristow had nearly a 10-fold increase in the risk of surgical complications compared with an arthroscopic or open Bankart repair (1.9% versus 0.2%, P < .001), including deep surgical site infections, return to operating room within 30 days, and symptomatic VTE (deep venous thrombosis rate: arthroscopic Bankart repair, 0.1%; Latarjet-Bristow, 0.8%; P < .001). There were no differences in the odds of developing a surgical complication or VTE between patients undergoing arthroscopic or open Bankart repair.ConclusionThis study used a nationally representative, widely validated, peer-reviewed database to demonstrate that patients undergoing a Latarjet-Bristow procedure are at significantly higher risk for short-term postoperative complications, including deep surgical site infections, return to the operating room, and symptomatic VTE, than those undergoing Bankart repair. These findings should not discourage surgeons from proceeding with a coracoid transfer procedure when indicated for glenoid deficiencies, but should inform preoperative counseling and help guide perioperative care to optimize patient outcomes.Level of EvidenceIII, retrospective comparative trial     

Iatrogenic upper limb nerve injuries: a systematic review

Purpose: Peripheral nerve injuries are among the most frequent iatrogenic complications and are responsible for considerable morbidity and litigation. Most occur within surgical settings and upper limb nerves are most frequently involved. Methods: A systematic review of major iatrogenic upper limb nerve injuries was undertaken to evaluate the contemporary spectrum of such injuries. The electronic databases MEDLINE, PubMed, Cochrane Library and Google Scholar were searched for relevant articles listed between January 2000 and May 2010. Iatrogenic injuries to the brachial plexus, radial, axillary, ulnar, median, musculocutaneous and major cutaneous nerves were analysed, focusing on context, mechanisms of injury and incidence. Results: Iatrogenic upper limb nerve injuries are relatively common and can affect patients in any surgical specialty. Even patients undergoing diagnostic procedures under general anaesthesia are at risk. Orthopaedic surgery and plastic and reconstructive surgery figure prominently in these complications. The spectrum of iatrogenic peripheral nerve injuries has changed in parallel with technological advances in surgery, anaesthesia and medicine. Conclusions: Some iatrogenic upper limb peripheral nerve injuries may be unavoidable, but most cases are probably preventable by an adequate knowledge of surgical anatomy and an awareness of the types of procedures in which peripheral nerves are particularly vulnerable.     

Infective Complications after Abdominal Surgery in Patients Infected with Human Immunodeficiency Virus: Role of CD4+ Lymphocytes in Prognosis

n = 8); (2) clean-contaminated: cholecystectomy and biliary tract surgery ( n = 8); and (3) contaminated: appendectomy ( n = 8). Depending on their CD4 count, two groups were formed: one with 200 to 500 cells/ml ( n = 11) and the other with < 200 cells/ml ( n = 13). When surgical infection was suspected, surgical drainage and microbiologic cultures were undertaken. For statistical evaluation of the groups ANOVA and the chi-square test were used; p < 0.05 was considered significant. Altogether 14 patients (58.3%) had a wound infection, and the mean (± SD) CD4 count in those patients was decreased (221.7 ± 75.1) compared with that of the 10 patients in the uneventful group (386 ± 81.2). Surgical infection rates were 50% for clean procedures, 62.5% for clean-contaminated procedures, and 62.5% for contaminated surgery. The group of patients with CD4 counts of < 200 cells/ml had an increased incidence of surgical infection, regardless of the type of surgery ( p = 0.002). Thus the surgical infection rates in HIV patients undergoing abdominal surgery are dramatically increased. The CD4 and subsequently depressed neutrophil populations increase the risk of surgical infection during major procedures regardless of the type of surgery performed.     

In- and out-hospital mortality rate in surgical patients

Background: Death rates after surgery are increasingly analysed for clinical audit and quality assessment. Many studies commonly provide information only on deaths that occur during hospital stay, known as in-hospital death rates. By using hospital data set linked to death certificate registry, we recorded in- and out-hospital deaths within 30 and 60 post-operative days.

Methods: The study included all consecutive surgical procedures (denominator) under general or locoregional anaesthesia in adult patients admitted for elective or non-elective inpatient surgery. Patients undergoing planned day-case surgery or obstetrical procedures were excluded. The primary outcome was 30- and 60-day post-operative mortality rate (numerator) whether before or after discharge.

Results: The study material consisted of a sample of 36,494 surgical procedures corresponding to 28,202 patients. At 30-day, 384 (crude mortality rate of 1.1%) patients died, 314 (82%) during their hospitalisation and 70 (18%) after discharge. Factors that were associated with in-hospital mortality are ASA scores, emergency, duration of surgery and rate of admission to critical care unit. Within the 30–60 days interval, we recorded 231 supplemental deaths, 103 (45%) after discharge.

Conclusion: In-hospital mortality alone is an incomplete measure of mortality even within 30 days of care. To identify the missing deaths, hospital records need to be linked to data from death certificate. This connection with the national death registry will allow obtaining the rate of in-hospital and out-hospital death.     

Plastic surgery in the Norwegian undergraduate medical curriculum: students’ knowledge and attitudes. A nationwide case-control study

Objective: Changes in medical education have resulted in less available time for plastic surgery, which might jeopardise the availability of plastic surgery for patients. The aims of this study were to investigate the level of knowledge within and attitudes towards plastic surgery among medical students, and find predictors for a wish to pursue a career in plastic surgery.

Methods: A previously used questionnaire was sent to all clinical medical students. Law students were used as a control group.

Results: Thirty per cent of all clinical medical students in the country responded. The majority of students considered education in plastic surgery valuable/very valuable and 23% were considering it as a career. Nonetheless, about half of the students were unaware of the plastic surgical education at their faculty and reported non-academic sources of learning. Only 44% of medical students were able to name five common plastic surgical procedures and 8% were unable to name any. Law students were superior to medical students in the task (p?=?0.005). Forty-two per cent of medical students were successful in indicating on which body parts plastic surgeons operate, whereas law students were less successful (p?=?0.001). Male gender and positive valuing of clinical attachment could predict a wish for a career in plastic surgery.

Conclusion: In some aspects, medical students are only as knowledgeable as their non-medical peers. These results call for higher quality plastic surgery teaching, to secure referral of the correct patients and successful specialist recruitment to plastic surgery.     

Postoperative complications in combined gynecologic,plastic, and breast surgery: An analysis from National Surgical Quality Improvement Program

Patients undergoing the addition of a contralateral prophylactic mastectomy with unilateral breast cancer have an increased and potentially doubled post‐operative complication rate. One documented detriment from post‐operative complications is the potential delay in initiating adjuvant therapy. To determine if the addition of a gynecologic and/or plastic reconstructive procedure to breast surgery results in an increased risk of postoperative complications and re‐admissions, we evaluated outcomes in patients undergoing single vs multi‐site surgery in a large national surgical database. We utilized the National Surgery Quality Improvement Program (NSQIP) database to identify patients who underwent breast surgery between 2011 and 2015. We extracted patients who underwent prophylactic oophorectomy with or without hysterectomy as a comparison group. Chi square analysis was used to assess postoperative outcomes including complications, readmission, and reoperation. All statistics were performed in SPSS v. 24. During the study timeframe, 77 030 patients had a solitary or combined breast surgical procedure and a second cohort of 124 patients underwent gynecologic surgery. Breast cancer patients who did not have a simultaneous reconstruction or gynecologic procedure were older with more comorbidities. Patients undergoing coordinated procedures had a significantly longer length of stay, higher complication, readmission, and reoperation rates (P < 0.001 for all) as compared with patients who underwent single site surgery. Patients with surgery for breast cancer, either with a plastic or gynecologic procedure, have greater postoperative complications. Higher complication rates for those with coordinated operations may lead to delays in adjuvant therapy and discussions regarding the indications for simultaneous surgery are recommended.     

Procedure-specific Risks of Thrombosis and Bleeding in Urological Non-cancer Surgery: Systematic Review and Meta-analysis

Context

Pharmacological thromboprophylaxis involves a trade-off between a reduction in venous thromboembolism (VTE) and increased bleeding. No guidance specific for procedure and patient factors exists in urology.

Incidence of Venous Thromboembolism Following Major Emergency Abdominal Surgery

Background

In a retrospective cohort study, we looked at the incidence and risk factors of developing in-hospital venous thromboembolism (VTE) after major emergency abdominal surgery and the risk factors for developing a venous thrombosis.

Methods

Data were extracted through medical records from all patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 until 2016. The primary outcome was the incidence of venous thrombosis developed in the time from surgery until discharge from hospital. The secondary outcomes were 30-day mortality and postoperative complications. Multivariate logistic analyses were used for confounder control.

Results

In total, 1179 patients who underwent major emergency abdominal surgery during 2010–2016 were included. Thirteen patients developed a postoperative venous thromboembolism (1.1%) while hospitalized. Eight patients developed a pulmonary embolism all verified by CT scan and five patients developed a deep venous thrombosis verified by ultrasound scan. Patients diagnosed with a VTE were significantly longer in hospital with a length of stay of 34 versus 14 days, P < 0.001, and they suffered significantly more surgical complications (69.2% vs. 30.4%, P = 0.007). Thirty-day mortality was equal in patients with and without a venous thrombosis. In a multivariate analysis adjusting for gender, ASA group, BMI, type of surgery, dalteparin dose and treatment with anticoagulants, we found that a dalteparin dose ≥5000 IU was associated with the risk of postoperative surgical complications (odds ratio 1.55, 95% CI 1.11–2.16, P = 0.009).

Conclusion

In this study, we found a low incidence of venous thrombosis among patients undergoing major emergency abdominal surgery, comparable to the incidence after elective surgery.

     

Update on in hospital venous thromboembolism prophylaxis.

The surgical and hereditary risk factors for post-operative venous thromboembolism (VTE) are discussed and the heightened risk associated with particular risk factors quantified. Mechanical and pharmacological methods of prophylaxis are described, together with the different recommendations for use with general and regional anaesthesia. Prophylaxis may be started post-operatively and the duration of prophylaxis is discussed. The use of prophylaxis in vascular surgery is illustrated with case examples.     

Aspirin in the primary prophylaxis of venous thromboembolism in surgical patients

IntroductionVenous thromboembolism (VTE) is a common complication in surgical patients, especially those undergoing lower limb orthopaedic procedures as well as oncological resectional surgery. Numerous studies have evaluated the role of acetylsalicylic acid (ASA, aspirin) in primary VTE prevention, with contradictory results reflected in divergent guidelines. We reviewed current evidence for ASA as primary VTE prophylaxis.MethodsEnglish language studies meeting our inclusion criteria were retrieved from PubMed, EMBASE and Cochrane databases. Six studies (3 meta-analyses and 3 randomized trials) comparing ASA with placebo and 7 studies (1 meta-analysis, 5 randomized trials, and 1 prospective) comparing ASA with other anticoagulants were included in the final analysis. Retrospective studies and case reports were excluded.ResultsASA is more effective than placebo in primary VTE prevention. Although there is clinical equipoise when ASA is compared with other anticoagulants, studies specific to orthopaedic surgery suggest that ASA appears as effective as low molecular weight heparin (LMWH) and may reduce bleeding risk. Extended prophylaxis up to 4 weeks post surgery reduces VTE episodes.ConclusionsASA may be considered as a potential strategy in primary VTE prophylaxis in orthopaedic patients at high-risk of bleeding complications. Further studies comparing ASA with LMWH/oral anticoagulants in primary thromboprophylaxis following non-orthopaedic surgery are warranted.     

Esophageal perforation during laparoscopic sleeve gastrectomy: Complication of bougie insertion

Introduction and importanceEsophageal perforation (EF) is an uncommon complication of bariatric procedures, mostly related to the intraoperative use of bougie that is used for gastric calibration.Case presentationHere, we present a 33-year-old woman who underwent laparoscopy sleeve surgery (LSG). Due to perforation in the cervical site of the esophagus caused by bougie insertion, she developed subcutaneous emphysema on the first post-operative day. She immediately underwent reconstructive esophageal surgery under the probable diagnosis of having a cervical esophagus perforation. The patient’s condition was stable in the postoperative period and discharged after 10 days.Clinical discussionThe patients who present symptoms including subcutaneous emphysema, cervical pain, dysphagia, dysphonia, and fever post-surgery have to be considered for probably EF. The early optimal diagnosis works up and therapeutic approach should be performed as soon as possible to prevent mortality.ConclusionEP caused by a bougie insertion is an uncommon complication that is associated with high mortality rates if the diagnosis and treatment were delayed. The risk of using a bougie during surgery should not be underestimated and have to be inserted with extreme caution and careful guide of surgeon.     

Plastic surgeons’ self-reported operative infection rates at a Canadian academic hospital

BACKGROUND:

Surgical site infection rates are of great interest to patients, surgeons, hospitals and third-party payers. While previous studies have reported hospital-acquired infection rates that are nonspecific to all surgical services, there remain no overall reported infection rates focusing specifically on plastic surgery in the literature.

OBJECTIVE:

To estimate the reported surgical site infection rate in plastic surgery procedures over a 10-year period at an academic hospital in Canada.

METHODS:

A review was conducted on reported plastic surgery surgical site infection rates from 2003 to 2013, based on procedures performed in the main operating room. For comparison, prospective infection surveillance data over an eight-year period (2005 to 2013) for nonplastic surgery procedures were reviewed to estimate the overall operative surgical site infection rates.

RESULTS:

A total of 12,183 plastic surgery operations were performed from 2003 to 2013, with 96 surgical site infections reported, corresponding to a net operative infection rate of 0.79%. There was a 0.49% surgeon-reported infection rate for implant-based procedures. For non-plastic surgery procedures, surgical site infection rates ranged from 0.04% for cataract surgery to 13.36% for high-risk abdominal hysterectomies.

DISCUSSION:

The plastic surgery infection rate at the study institution was found to be <1%. This rate was equal to, or somewhat less than, surgical site infection rates. However, these results do not report patterns of infection rates germane to procedures, season, age groups or sex. To provide more in-depth knowledge of this topic, multicentre studies should be conducted.     

Prospective Identification of Risk Factors for Wound Infection After Lower Extremity Oncologic Surgery

Background: Surgical site infections (SSI) are frequent causes of morbidity and mortality after orthopaedic oncologic procedures. This study was conducted to identify the surgical site infection rate following a lower extremity or pelvic procedure and assess the risk factors for acquiring SSI by direct observation of orthopaedic oncology patients wounds at a comprehensive cancer center.Methods: One hundred ten consecutive patients were prospectively studied. The surveillance of surgical site infections was carried out by a surgeon-trained nurse from the Infectious Disease Service. Nineteen variables were analyzed as risk factors.Results: The overall SSI rate was 13.6% (15 of 110). Excluding those patients with known preoperative infections, the SSI rate was 9.5% (10 of 105). Two statistically significant risk factors for surgical site infection in these patients emerged in the multivariate analysis: blood transfusion (P = .007) and obesity (P = .016). Procedure category was significant in univariate analysis only. Preoperative length of stay, length of procedure, prior adjuvant treatment (chemotherapy or radiotherapy), prior surgery, and use of an implant or allograft were not statistically significant risk factors for wound infection. Antibiotic usage patterns did not influence SSI rate.Conclusions: Blood transfusion and obesity should be considered individual risk factors for the development of wound infection in patients having orthopaedic oncologic procedures.     

Nitrous oxide in abdominal surgery

Inhalation anaesthesia has traditionally been the method of choice for abdominal surgery. While most surgical interventions in the lower abdomen can be performed under regional anaesthesia, a general anaesthetic technique is frequently chosen for upper abdominal procedures. This explains the almost routine use of nitrous oxide (N₂O) for abdominal surgery.In addition to well-known contra-indications such as ileus and abdominal wall defects in infants, there is substantial scientific evidence against the application of N₂O in abdominal surgery. N₂O has an important role in the development of post-operative nausea and vomiting (PONV).     

Self-citation rate and impact factor in the field of plastic and reconstructive surgery

Background: Journal ranking based on the impact factor (IF) can be distorted by self-citation. The aim of this study is to investigate the present status of self-citation in the plastic surgery journals and its effect on the journals’ IFs.

Methods: IF, IF without self-citations (corrected IF), self-cited rate, and self-citing rate for 11 plastic surgery journals were investigated from 2009–2015, by reviewing the Journal Citation Report^®. The correlations of the IF with the self-cited rate and the self-citing rate were statistically assessed. In addition, Plastic and Reconstructive Surgery was compared with 15 top journals from other surgical specialties in 2015.

Results: IF was significantly correlated with the self-cited rate (R: 0.594, p?=?0.001) and the self-citing rate (R: 0.824, p?Plastic and Reconstructive Surgery in 2015 was higher than that of top journals from other surgical specialties. The IFs of Microsurgery and Journal of Cranio-Maxillo-Facial Surgery increased greatly in recent years, but they were inflated by high self-cited and self-citing rates.

Conclusions: The self-citation rate positively affects the IF in plastic surgery journals. A high concentration of self-citation of some journals could distort the ranking among plastic surgery journals in general.     

Early Peri-operative Outcomes Were Unchanged in Patients Undergoing Spine Surgery During the COVID-19 Pandemic in New York City

Background

Healthcare resources have been greatly limited by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic halting non-essential surgical cases without clear service expansion protocols.

Questions/Purposes

We sought to compare the peri-operative outcomes of patients undergoing spine surgery during the SARS-CoV-2 pandemic to a matched cohort prior to the pandemic.

Methods

We identified a consecutive sample of 127 adult patients undergoing spine surgery between March 9, 2020, and April 10, 2020, corresponding with the state of emergency declared in New York and the latest possible time for 1-month surgical follow-up. The study group was matched one-to-one based on age, gender, and body mass index with eligible control patients who underwent similar spine procedures prior to the SARS-CoV-2 outbreak. Surgeries performed for infectious or oncologic indications were excluded. Intra- and post-operative complication rates, re-operations, hospital length of stay, re-admissions, post-operative visit format, development of post-operative fever and/or respiratory symptoms, and SAR-CoV2 testing.

Results

A total of 254 patients (127 SARS-CoV-2 pandemic, 127 matched controls) were included. One hundred fifty-eight were male (62%), and 96 were female (38%). The mean age in the pandemic group was 59.8 ± 13.4 years; that of the matched controls was 60.3 ± 12.3. All patients underwent general anesthesia and did not require re-intubation. There were no significant differences in 1-month post-operative complication rates (16.5% pandemic vs. 12.6% control). There was one death in the pandemic group. No patients tested positive for the virus.

Conclusion

This study represents the first report of post-operative outcomes in a large group of spine surgical patients in an area heavily affected by the SARS-CoV-2 pandemic.

     

Meta-analysis of Enhanced Recovery After Surgery (ERAS) Protocols in Emergency Abdominal Surgery

Objectives

To evaluate enhanced recovery after surgery (ERAS) protocols in emergency abdominal surgery.

Methods

The electronic data sources were explored to capture all studies that evaluated the impact of ERAS protocols in patients who underwent emergency abdominal surgery. The quality of randomised and non-randomised studies was evaluated by the Cochrane tool and the Newcastle–Ottawa scale, respectively. Random or fixed effects modelling were utilised as indicated.

Results

Six comparative studies, enrolling 1334 patients, were eligible. ERAS protocols resulted in shorter post-operative time to first flatus (mean difference: −1.40, P < 0.00001), time to first defecation (mean difference: −1.21, P = 0.02), time to first oral liquid diet (mean difference: −2.30, P < 0.00001), time to first oral solid diet (mean difference: −2.40, P < 0.00001) and length of hospital stay (mean difference: −3.09, −2.80, P < 0.00001). ERAS protocols also resulted in lower risks of total complications (odds ratio: 0.50, P < 0.00001), major complications (odds ratio: 0.60, P = 0.0008), pulmonary complications (odds ratio: 0.38, P = 0.0003), paralytic ileus (odds ratio: 0.53, 0.88, P = 0.01) and surgical site infection (odds ratio: 0.39, P = 0.0001). Both ERAS and non-ERAS protocols resulted in similar risk of 30-day mortality (risk difference: −0.00, P = 0.94), need for re-admission (risk difference: −0.01, P = 0.50) and need for re-operation (odds ratio: 0.83, P = 0.50).

Conclusions

Although ERAS protocols are commonly used in elective settings, they are associated with favourable outcomes in emergency settings as indicated by reduced post-operative complications, accelerated recovery of bowel function and shorter post-operative hospital stay without increasing need for re-admission or re-operation. There should be an effort to incorporate ERAS protocols into emergency abdominal surgery settings.

     

Continuous spinal anaesthesia/analgesia for abdominal aortic aneurysm repair and post-operative pain management

The intra-operative management of two patients with chronic obstructive pulmonary disease and cardiovascular pathology, who underwent peripheral reconstructive vascular surgery under continuous spinal anaesthesia, is described. Furthermore, continuous intrathecal analgesia was also continued in the post-operative period and provided effective pain relief that was reflected by the favourable surgical outcome.