Can Bilateral Varicose Vein Surgery be Performed Safely in an Ambulatory Setting?

Objectives

Surgery for varicose veins is still the method of choice worldwide. When varicose veins require bilateral surgery, a single procedure often is the preferred choice by the patient. Today, unilateral varicose vein surgery is frequently performed as an outpatient procedure, while in many institutions bilateral surgery is done as an in-hospital procedure.

Design

Retrospective comparative study.

Methods

Between 1 October 2004 and 31 October 2006, 433 patients underwent surgery for the great saphenous vein as in-patient procedure (303 unilateral and 130 bilateral), period 1. From 1 November 2006 until 31 December 2009, 825 patients had ambulatory great saphenous vein surgery (550 unilateral and 275 bilateral), period 2. We have compared unilateral and bilateral varicose vein surgery (high ligation and stripping of the great saphenous vein) and in-hospital procedures with ambulatory surgery, with regard to postoperative complications, postoperative pain and midterm follow-up.

Results

Operation time and total length of stay in the institution following varicose vein surgery were significantly shorter for period 2 compared with period 1 for both unilateral and bilateral surgery, without other differences between the groups. There were few postoperative complications without differences between periods, and between unilateral and bilateral surgery (wound infection 0.5%, haematoma requiring drainage 0.2%, transient paraesthesia 1.1%, superficial localised thrombophlebitis 0.6% and deep vein thrombosis in one unilaterally operated case only).

Conclusions

Bilateral varicose vein surgery can be safely performed as an outpatient procedure, without increased risk of postoperative complications, increased postoperative discomfort or midterm adverse effects compared with unilateral surgery.     

Bariatric Surgery in Post-Transplantation Patients; Does Diabetes Influence Outcomes?

BackgroundType 2 diabetes (T2D) is frequently present in Metabolic and Bariatric Surgery (MBS) patients and is associated with increased morbidity and mortality. Organ transplantation patients also suffer from severe obesity and are now increasingly undergoing MBS.ObjectiveTo determine the association of T2D and perioperative outcomes after MBS in previous solid organ transplantation patientsSettingUniversity Hospital, United States.MethodsPatients with a history of solid organ transplantation undergoing sleeve gastrectomy and Roux-en-Y gastric bypass were identified from the 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Patients were then stratified by a history of T2D. Propensity-score matching was performed between the 2 cohorts. Outcomes were compared by Mann-Whitney U, Χ², and multivariable logistic regression analysis for overall and morbidity related to MBS.ResultsBefore matching 338 patients with a prior history of solid organ transplantation were identified including 132 (39%) with and 206 (61%) without diabetes. There were no significant differences in outcomes between the 2 cohorts at baseline, but these patients were significantly different at baseline. After matching, 85 patients with and without T2D were identified. Overall and morbidity related to MBS were similar (P > .5). Furthermore, multivariable logistic regression revealed T2D to not have an increased risk for overall (odds ratio .95, P = .09) or morbidity related to MBS (odds ratio .92, P = .87).ConclusionMBS in T2D patients with previous solid organ transplantation is overall safe with low rates of morbidity and mortality. Diabetes was not an independent predictor of adverse outcomes in this cohort of patients. Larger cohort studies are needed.     

Morbidly Obese Patients—Who Undergoes Bariatric Surgery?

Background  

Bariatric surgery particularly benefits patients with obesity-related comorbidities such as type 2 diabetes and obstructive sleep apnea. We aimed to examine whether the variables that influence treatment choice differ between morbidly obese patients undergoing bariatric surgery and those opting for conservative treatments.     

Why Patients Seek Bariatric Surgery: Does Insurance Coverage Matter?

Despite increasing prevalence of bariatric surgery, little is known about why patients seek out this treatment option. Heads Up is an observational study sponsored by a large benefits management group that examines surgical and nonsurgical approaches to weight management in obese adults. This study examined patients’ reasons for choosing surgery. The sample included 360 adult obese patients seeking bariatric surgery who were invited to volunteer for a surgical or a medical weight loss program by their insurer. Participants rank ordered their top three reasons as a deciding factor for choosing to consider surgery. The top three reasons were concerns regarding health (52 %), current obesity-related medical conditions (28 %), and improved physical fitness (5 %). Overall, 13 % endorsed insurance coverage as one of their top three choices. When insurance coverage is assured, health and functionality issues were the major reasons reported for obese adults choosing to undergo bariatric surgery.     

Weight Loss Associated with Bariatric Surgery Does Not Restore Short Telomere Length of Severe Obese Patients After 1 Year

Background

Telomere shortening is physiologically associated with ageing but it may be influenced by oxidative stress and chronic inflammation, linked to obesity. Thus, obesity might represent an additional cause of telomere attrition. We aim to study relative telomere length (RTL) in obese subjects with and without metabolic syndrome and to assess the effect of weight loss induced by bariatric surgery.

Methods

We evaluated RTL in 107 obese subjects (62 with metabolic syndrome and 45 without metabolic syndrome), compared to 130 age-matched non-obese subjects. We also measured RTL in a subgroup of 93 obese patients prior to and 3, 6, 9 and 12 months after surgery.

Results

RTL of obese subjects was significantly shorter (p?<?0.0001) than non-obese subjects but without differences between patients with and without metabolic syndrome (p?=?0.19). RTL was significantly shorter than baseline at 3, 6, 9 and 12 months after bariatric surgery.

Conclusions

These results confirm that obese subjects have shorter telomeres compared to non-obese subjects, but RTL is not influenced by the presence of metabolic syndrome. RTL shows an additional attrition during the immediate post-operative period, probably due to a catabolic state.     

Mohs Surgery in Patients Immunobullous Diseases: Should Prednisone be Increased Prior to Surgery?

Background: Mohs surgery is one of the most effective treatment options for skin cancers as it offers one of the highest chances for cure. Mohs surgery is a precise technique that removes a layer at a time. Although this may be advantageous, this treatment method is difficult in patients with immunobullous diseases. Currently the guidelines for Mohs surgery do not discuss the premanagement of immunobullous patients about to undergo Mohs surgery. Objective: To advocate for increasing prednisone dose in patients with immunobullous disease prior to undergoing Mohs surgery. Case Report: The authors present a case of an excision of a squamous cell carcinoma from a 94-year-old woman with a history of pemphigus vulgaris using Mohs micrographic surgery. Conclusion: Current preoperative guidelines for Mohs surgery do not address the issue of altering steroid medications for patients with immunobullous disease prior to the procedure. The authors suggest that patients with a history of immunobullous disease undergoing Mohs micrographic surgery should have an increase in steroid dose prior to surgery.A 94 year-old Caucasian woman with no prior history of A skin cancer presented for evaluation of a crusting Plaque on her mid-back that had been present for six months. The patient’s past medical history was significant for pemphigus vulgaris for the last 20 years for which she was on prednisone 2.5mg daily. The patient reported no allergies. She denied smoking and denied alcohol use. Review of systems was unremarkable and physical examination revealed a well-developed, well-nourished woman. Upon complete skin examination, the mid-back presented with a 5x4cm erythematous, waxy, and crusty plaque (Figure 1). The surrounding areas of skin were examined and no other suspicious lesions were noted. The lesion was biopsied and a diagnosis of squamous cell carcinoma (SCC) was established. Open in a separate windowFigure 1Left upper back—preoperativeOn the scheduled day of surgery, the patient did have a new oral ulcer on her left buccal mucosa. The patient did not exhibit any other active lesions. However, during curettage and the incision, her skin became positive for Nikolsky’s sign and the epidermis sloughed off immediately (Figure 2). The squamous cell carcinoma was then excised with wider margins using Mohs micrographic surgery (MMS) in one stage. Open in a separate windowFigure 2Left upper back—intraoperativeFurthermore, closing the lesion was very difficult (Figure 3). The defect was repaired utilizing 3-0 Vicryl and 4-0 Nylon, which were placed from opposite edges of the defect spanning the width of the opening to minimize tension at the wound edges. During microscopic examination of the frozen section, it was difficult to assess if the margins were still positive for cancer because the epidermis was not present anymore. A compression dressing consisting of xeroform was used to avoid the use of adhesive tape on surrounding tissue that had become prone to blistering. The authors’ goal was to avoid adhesives altogether, since they further traumatize the fragile skin. The patient returned for her two-week follow up for suture removal and was diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. This was subsequently cultured and treated with doxycycline. The patient returned one week thereafter for suture removal and healed well with no other complications. Open in a separate windowFigure 3Left upper back—postoperative     

Patients’ Experiences of Weight Regain After Bariatric Surgery

Obesity Surgery - Bariatric surgery is a successful obesity treatment; however, an estimated 1/5 of patients have regained more than 15% of their body weight 5&nbsp;years post-surgery. To...     

The Outcome of Bariatric Surgery in Patients Aged 75 years and Older

Background

Bariatric surgery has been shown to be safe and effective in patients aged 60–75 years; however, outcomes in patients aged 75 or older are undocumented.

Methods

Patients aged 75 years and older who underwent bariatric procedures in two academic centers between 2006 and 2015 were studied.

Results

A total of 19 patients aged 75 years and above were identified. Eleven (58%) were male, the median age was 76 years old (range 75–81), and the median preoperative body mass index (BMI) was 41.4 kg/m² (range 35.8–57.5). All of the bariatric procedures were primary procedures and performed laparoscopically: sleeve gastrectomy (SG) (n?=?11, 58%), adjustable gastric band (AGB) (n?=?4, 21%), Roux-en-Y gastric bypass (RYGB) (n?=?2, 11%), banded gastric plication (n?=?1, 5%), and gastric plication (n?=?1, 5%). The median operative time was 120 min (range 75–240), and the median length of stay was 2 days (range 1–7). Three patients (16%) developed postoperative atrial fibrillation which completely resolved at discharge. At 1 year, the median percentage of total weight loss (%TWL) was 18.4% (range 7.4–22.0). The 1-year %TWL varied among the bariatric procedures performed: SG (21%), RYGB (22%), AGB (7%), and gastric plication (8%). There were no 30-day readmissions, reoperations, or mortalities.

Conclusion

Our experience suggests that bariatric surgery in selected patients aged 75 years and older would be safe and effective despite being higher risk. Age alone should not be the limiting factor for selecting patients for bariatric surgery.