Complications After Ostomy Surgery: Emergencies and Obese Patients are at Risk—Data from the Berlin OStomy Study (BOSS)

World Journal of Surgery - Complications are common after ostomy surgery. Data from the Berlin OStomy Study were evaluated to determine risk factors for complications. Patients with a bowel ostomy...     

Bariatric Surgery Versus Lifestyle Intervention in Class I Obesity: 7–10-Year Results of a Retrospective Study

World Journal of Surgery - The American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation of Surgery for Obesity (IFSO) have both stated that bariatric surgery...     

Bone Remodeling of the Distal Femur After Uncemented Total Knee Arthroplasty—A 2-Year Prospective DXA Study

Loss of bone stock as a response to the bone trauma, immobilization, and stress shielding related to joint replacement surgery increases the risk of fracture of the distal femur after total knee arthroplasty. Previous studies of uncemented femoral components have reported very high levels of bone loss in the distal femur. This study investigates the adaptive bone remodeling of the distal femur after uncemented total knee arthroplasty. We performed a 2-year follow-up of 53 patients (mean age 61.5 [38–70] years, F/M?=?27/26, body mass index 29.5) who because of osteoarthritis received an uncemented total knee arthroplasty. All patients received a NexGen CR-Flex Porous Femoral Component. Measurements of bone mineral density of the distal femur using dual-energy X-ray absorptiometry were performed postoperatively and after 3, 6, 12, and 24 months. Bone mineral density (g/cm²) was measured in 3 regions of interest in the periprosthetic bone of the distal femur. Repeated measures analysis of variance and Tukey post hoc test for bone mineral density changed over time (p?<?0.05 were considered significant). In the distal femur, significant changes in bone mineral density were seen after 24 months of follow-up, and bone mineral density decreased by 23.6% in the anterior region behind the anterior flange of the prosthesis (p?<?0.001), 10.1% in the posterior region (p?<?0.001), and 5.5% in the most proximal region (p?<?0.001). We found highly significant bone mineral change in the distal femur after uncemented total knee arthroplasty, most pronounced in the anterior region, where a decrease in bone mineral density of almost 25%, was seen. Taking the expected age-related decay in bone mineral density in this age group into consideration, the decrease was substantial and must be considered to predispose to periprosthetic fractures.     

Fewer Nutrient Deficiencies After Laparoscopic Sleeve Gastrectomy (LSG) than After Laparoscopic Roux-Y-Gastric Bypass (LRYGB)—a Prospective Study

Background  

Deficiencies in micronutrients after bariatric operations are frequent, despite routine supplementation. Main outcome measures were pre- and postoperative frequency of nutrient deficiencies and success rate of their treatment.     

Weight-Related Quality of Life in Spanish Obese Subjects Suitable for Bariatric Surgery is Lower Than in Their North American Counterparts: a Case–Control Study

Background

Obesity impairs quality of life, but the perception of the impairment could be different from one country to another. The purpose was to compare weight-related quality of life (QOL) between cohorts from Spain and North America.

Methods

A cross-sectional case–control study was performed between two populations. Four hundred Spanish and 400 North American obese subjects suitable for bariatric surgery closely matched for race, gender, age, and body mass index (BMI) were included. Two non-obese control groups matched for gender, age, and BMI from each population were also evaluated (n?=?400 in each group). The participants completed the Impact of Weight on Quality of Life—Lite (IWQOL—Lite) questionnaire, a measure of weight-related QOL.

Results

Spanish morbidly obese patients showed poorer QOL than their North American counterparts in physical function, sexual life, work, and total score. By contrast, Spanish non-obese control subjects reported better QOL in all domains than their North American counterparts. Women, both in Spain and North America, reported reduced QOL compared to men on the domain of self-esteem. In addition, North American women reported reduced QOL on the sexual life domain compared to men. BMI correlated negatively with all domains of QOL except for self-esteem in both national groups.

Conclusions

Spanish obese subjects suitable for bariatric surgery report poorer weight-related quality of life than their North American counterparts, and obese women, regardless of nationality, perceive a reduced quality of life compared to men.     

Simultaneous Intra-gastric Balloon Removal and Laparoscopic Sleeve Gastrectomy for the Super-Super Obese Patients—a Prospective Feasibility Study

Background

The aim of the study was to prospectively evaluate the feasibility and clinical efficacy of a strategy of performing simultaneous balloon removal and sleeve gastrectomy in the super-super obese patients.

Methods

Forty consecutive super-super obese patients underwent intra-gastric balloon insertion followed by simultaneous balloon removal and sleeve gastrectomy 6 months later.

Results

Balloon insertion resulted in a reduction in mean body mass index from 69.3?±?1.4 to 62.3?±?1.3 kg/m². Simultaneous balloon removal and sleeve gastrectomy was achieved in 39 cases. There were no operative mortality and no leaks. Six months following sleeve gastrectomy, the mean BMI of the cohort had fallen to 54.1?±?1.2 kg/m².

Conclusions

Simultaneous balloon removal and sleeve gastrectomy in the super-super obese patients is feasible as a single-stage procedure with good perioperative outcomes.     

Evidence of Thromboembolism Prophylaxis in Bariatric Surgery—Results of a Quality Assurance Trial in Bariatric Surgery in Germany from 2005 to 2007 and Review of the Literature

Background  Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany). Methods  Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI). Results  Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m2 in 2005, 48.4 kg/m2 in 2006, and 48.0 kg/m2 in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m2 received low-molecular-weight heparin twice a day. Conclusion  In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.     

Improvement of Type 2 Diabetes Mellitus (T2DM) After Bariatric Surgery—Who Fails in the Early Postoperative Course?

Backround

Diabetes surgery in nonobese or moderately obese patients is an emerging topic. The identification of preoperative factors predicting diabetes outcome following bariatric surgery, especially for metabolic nonresponders, is imperative.

Methods

Between 2005 and 2011, 235 patients underwent bariatric surgery for morbid obesity. Eighty-two of 235 patients had type 2 diabetes mellitus (T2DM). Data from this subgroup were investigated with univariate and multivariate analyses to identify predictors for metabolic nonresponse after surgery.

Results

Diabetes did not improve in 17/82 patients within 3?months after surgery. No correlation between excess body weight loss and metabolic response was detected. In univariate analysis, preoperative duration of diabetes was significantly longer in the nonresponder group (9.146 vs. 6.270?years; *p?=?0.016), preoperative HbA1c levels were significantly higher among the nonresponders than among the responders (8.341 vs. 7.781?%; *p?=?0.033), and more patients in the nonresponder group were reliant on a multi-drug approach preoperatively (*p?=?0.045). In multivariate analysis, age, preoperative doses of insulin, and preoperative oral antidiabetics showed positive correlation to metabolic nonresponse after surgery (*p?=?0.04; *p?=?0.021; *p?=?0.021). Metabolic failure rate was lower after Roux-en-Y gastric bypass compared to other bariatric procedures (**p?=?0.008).

Conclusions

A long history of preoperative T2DM, high preoperative HbA1c levels, and a preoperative therapy consisting of diverse approaches to diabetes treatment may be factors predicting failure of diabetes improvement in the early postoperative course after bariatric surgery. Age, preoperative insulin, and oral antidiabetic medication can be regarded as independent, significant predictors for metabolic outcome after bariatric surgery.     

Gastrin Secretion After Bariatric Surgery—Response to a Protein-Rich Mixed Meal Following Roux-En-Y Gastric Bypass and Sleeve Gastrectomy: a Pilot Study in Normoglycemic Women

Background

Recent investigations have linked elevated gastrin levels to the improvement of type 2 diabetes mellitus (T2DM). Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are effective treatments for T2DM, but it is not known if this is related to postoperative alterations of gastrin secretion.

Methods

Twenty women previously operated with RYGB or SG and 13 female controls were enrolled and evaluated for body mass index, lipids, C-peptide, HbA1c, and anti-H. pylori IgG. Glucose, gastrin, insulin, and glucagon-like peptide 1 (GLP-1) concentrations were measured before and 30, 60, 90, and 120 min after ingestion of a protein-rich mixed meal.

Results

Six participants primarily selected were excluded due to usage of proton pump inhibitors, positive H.pylori IgG, or history of T2DM, yielding the following groups: RYGB (n?=?9), SG (n?=?8), and controls (n?=?10). There were no differences in age, body mass index, HbA1c, or C-peptide levels between groups. RYGB had significantly lower area under the curve (AUC) for glucose during the test compared to controls (p?=?0.013). RYGB showed lower serum gastrin levels compared to SG and controls (p?<?0.05 for all). There was a non-significant increased gastrin release in SG compared to controls (p?=?0.091). For SG and controls, there was a negative correlation between glucose and gastrin response (p?=?0.0043).

Conclusion

Gastrin secretion is diminished after RYGB. Hypergastrinemia was not present after SG, but a tendency of enhanced gastrin secretion was observed. These findings require further investigation in prospective studies.

     

Monitoring the Practice of Vascular Surgery: Findings from a National Registry (1996–2011)

Background

The goal of this article is to present for the first time to the international community the detailed findings and outcomes of the Spanish Vascular Registry (SVR) after 16 years of experience.

Methods

We examined the nationwide registry promoted by the Spanish Society of Angiology and Vascular Surgery (1996–2011). The changes in vascular surgical activity in Spain during the period of study were examined. We evaluated the number of services, medical specialists, consultations, admissions, and operations that occurred in Spain. We also assessed the trends in therapeutic activity and the medical and social impact of vascular pathology.

Results

A mean of 60 centers (range = 32–83) participated in the SVR (79.3 % of the total). In the last year of the study period, 94.3 % centers (100 % of teaching centers) participated. The mean number of activities per hospital per year was 5,298 consultations, 2,625 vascular explorations, 630 hospital admissions (61 % elective and 31 % emergency), and 742 surgical procedures. A total of 29,289 carotid stenosis procedures had been registered over 16 years. Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) procedures have increased in frequency over time. In 2011, CAS constituted 19.3 % of all carotid procedures. A total of 31,703 abdominal aortic aneurysm (AAA) operations were registered during the study period. Surgery for ruptured AAA remained stable over time. Since its appearance in the year 2000, endovascular treatment (EVAR) increased steadily over time. Currently, EVAR represents about half of all AAA surgery (50.2 %). The total rate of in-hospital operative deaths was 1.1 %, but in-hospital mortality for open arterial surgery was 4 %. Mortality has decreased of late.

Conclusions

The SVR has enabled us to understand the development and implementation of vascular surgery throughout Spain and to note the increased healthcare activity and the better overall results obtained as a consequence.     

Harvesting the Liver From a Donor With a Biventricular Assist Device (BiVAD)—An Unexpectedly Challenging Procedure: A Case Report

BackgroundOrgan procurement from deceased donors is usually a standard procedure. Nevertheless, the performing surgeon is often confronted with demanding situations, such as atherosclerotic or aneurysmatic aortic disease or even other pathologies, which may alter the surgical steps. We report on an interesting case of solid organ harvesting from a donor with a biventricular assist device (BiVAD) due to global heart failure.Case ReportA 42-year-old male donor with a BiVAD, enlisted for heart transplantation, died of intracerebral hemorrhage. Dressing the surgical field was challenging because the extracorporal portions of all 4 tubes and the pump device rested on the donor's body, covering his whole abdomen. To ensure enough space, the pump and tubes had been covered with sterile swabs and drapes. The second surgical assistant was tasked with holding the device slightly deviated to the left and the ankle elevated at 45°, to avoid any tube kinking. The dissection of the main vessels distally was performed using the standard technique. No encirclement of the proximal aorta beneath the diaphragm was necessary, as the cardiac output could be arrested by clamping the left ventricle's outflow tube. Once the perfusion was completed, the procedure continued in the standard fashion.ConclusionSo far, the literature has no data on organ harvesting from deceased donors with BiVAD. Although such a retrieval is quite challenging and requires an experienced team, the transplantation of the corresponding organs can be performed without any further special technical problems.