Can Composite Nutritional Supplement Based on the Current Guidelines Prevent Vitamin and Mineral Deficiency After Weight Loss Surgery?

Background

Nutritional deficiencies occur after weight loss surgery. Despite knowledge of nutritional risk, there is little uniformity of postoperative vitamin and mineral supplementation. The objective of this study was to evaluate a composite supplement based on the clinical practice guidelines proposed in 2008 regarding vitamin and mineral supplementation after Roux-en-Y gastric bypass. The composite included iron (Fe) and calcium as well.

Methods

A retrospective chart review of 309 patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) was evaluated for the development of deficiencies in iron and vitamins A, B₁, B₁₂, and D. Patients were instructed to take a custom vitamin and mineral supplement that was based on society-approved guidelines. The clinical practice guidelines were modified to include 1600 international units (IU) of vitamin D₃ instead of the recommended 800 IU.

Results

The compliant patients’ deficiency rates were significantly lower than those of the noncompliant patients for iron (p?=?0.001), vitamin A (p?=?0.01), vitamin B₁₂ (p?≈?0.02), and vitamin D (p?<?0.0001). Women’s menstrual status did not significantly influence the development of iron deficiency.

Conclusions

Use of a composite based on guidelines proposed by the AACE, TOS, and the ASMBS appears to be effective for preventing iron and vitamins A, B₁, B₁₂, and D deficiencies in the LRYGB patients during the first postoperative year. Separation of calcium and Fe does not need to be mandatory. Even with simplification, compliance is far from universal.

     

Improving Bariatric Patient Aftercare Outcome by Improved Detection of a Functional Vitamin B12 Deficiency

Background

Vitamin B12 deficiency is common after bariatric surgery. Vitamin B12 is a poor predictor of functional vitamin B12 status, since deficiencies might even occur within the reference limits. Therefore, vitamin B12 deficiencies with serum vitamin B12 levels are between 140 and 200 pmol/L remain undetected. Methylmalonic acid (MMA), however, will detect these deficiencies as accumulates due to functional intracellular vitamin B12 deficiencies. MMA is a relative expensive analysis and is therefore not generally available. To lower the costs, we only request MMA when vitamin B12 levels are between these levels. As a result, more biochemical deficiencies are found. However, it was not known whether bariatric patients with vitamin B12 levels between 140 and 200 pmol/L would benefit from supplementation.

Method

Bariatric patients with vitamin B12 levels between 140 and 200 pmol/L with (n?=?45) and without (n?=?45) intramuscular hydroxocobalamin injections were compared.

Results

Treated patients showed a significant increase of vitamin B12 levels (P?<?0.001) and a significant decrease in MMA levels (P?<?0.001). Biochemical improvement occurs in both patients with and without clinical symptoms. The control group showed a significant increase of MMA levels (P?<?0.001). To examine whether biochemical benefits of vitamin B12 supplementation are correlated with clinical improvement, patient records were checked for complaints. Complaints were disappeared after treatment, while no improvement was seen in untreated patients.

Conclusion

This study shows that all bariatric patients with vitamin B12 levels between 140 and 200 pmol/L benefit clinical and biochemical from vitamin B12 supplementation, regardless the MMA levels.

     

Investigating Nutritional Deficiencies in a Group of Patients 3 Years Post Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure has shown to be effective in achieving significant weight loss and resolving obesity-related co-morbidities. However, its nutrition consequences have not been extensively explored. This study aims to investigate weight loss and evolution of nutritional deficiencies in a group of patients 3 years post LSG.

Methods

Retrospective data of a group of patients, 3 years following LSG as a stand-alone procedure was collected. Data included anthropometry, nutritional markers (hemoglobin, iron studies, folate, calcium, iPTH, vitamins D, and B₁₂), and compliancy with supplementations.

Results

Ninety-one patients (male/female; 28:63), aged 51.9?±?11.4 years with a BMI of 42.8?±?6.1 kg/m² were identified to be 3 years post LSG. Percentage of weight loss at 1 and 3 years post-operatively was 29.8?±?7.0 and 25.9?±?8.8 %, respectively. Pre-operatively, the abnormalities included low hemoglobin (4 %), ferritin (6 %), vitamin B₁₂ (1 %), vitamin D (46 %), and elevated iPTH (25 %). At 3 years post-operatively, the abnormal laboratory values included low hemoglobin (14 % females, P?=?0.021), ferritin (24 %, P?=?0.011), vitamin D (20 %, P?=?0.018), and elevated iPTH (17 %, P?=?0.010). Compliancy with multivitamin supplementation was noted in 66 % of patients.

Conclusion

In these patients, LSG resulted in pronounced weight loss at 1 year post-operatively, and most of this was maintained at 3 years. Nutritional deficiencies are prevalent among patients prior to bariatric surgery. These deficiencies may persist or exacerbate post-operatively. Routine nutrition monitoring and supplementations are essential to prevent and treat these deficiencies.

     

Serum vitamin D level may be a novel potential risk factor for premature ejaculation: a comparative study

Purpose

To compare serum level of vitamin D [25(OH)D] in patients with life-long premature ejaculation (LPE) versus healthy controls.

Methods

Healthy married potent males were recruited from February 2017 to January 2018. Group A included 40 patients suffering from LPE who were compared versus 40 healthy controls (Group B). Participants suffering from hormonal disorders, obesity, neurological, psychological, or chronic diseases or taking medications that may affect ejaculatory function, serum level of vitamin D, or the accuracy of intra-vaginal ejaculation latency time (IELT) were excluded. LPE was self-reported by the patients with subsequent feelings of frustration and measured by premature ejaculation diagnostic tool (PEDT) and IELT using stopwatch handled by their partners. 25(OH)D was measured by obtaining 2 ml of venous blood. Statistical analysis was performed using Student t, Mann–Whitney, Chi square tests, logistic regression analysis, and Spearman correlation.

Results

Sixteen (20%) participants had vitamin D insufficiency/deficiency. All of them were in PE group. 25(OH)D correlated significantly with IELT (r²?=?0.349; p?<?0.001) and PEDT (r²?=?0.425; p?<?0.001). There was no statistically significant difference in age (p?=?0.341), BMI (p?=?1) or IIEF-5 (p?=?0.408) in both groups. 25(OH)D was significantly lower in patients than controls (35.75 vs. 58.92 ng/ml, p?<?0.001). ROC analysis revealed that the best cut-off value of 25(OH)D to detect patients suffering from LPE was 50.65 ng/ml with a sensitivity and specificity of 85% for both. 25(OH)D remained a significant risk factor for LPE in the logistic regression analysis (p?<?0.001).

Conclusions

The current study showed that vitamin D has significant association with LPE and correlates significantly with IELT and PEDT.

     

Hospital cost savings and other advantages of sutureless vs stented aortic valves for intermediate-risk elderly patients

Purpose

To evaluate and compare the clinical outcomes and hospital costs of using sutureless aortic valves vs conventional stented aortic valves.

Methods

Between 2007 and 2011, 52 elderly patients undergoing aortic valve replacement for aortic stenosis in our center had a sutureless valve inserted. From among 180 patients who had a stented valve inserted during the same period, 52 patients were matched to the sutureless group, based on age, gender, and operation type. We compared clinical outcomes and hospital costs between the two groups.

Results

The sutureless group had a higher Euroscore (logistic Euroscore I) risk (12.8 vs 9.7; p?=?0.02), with significantly shorter aortic cross-clamp (ACC) time (p?<?0.01), cardiopulmonary bypass (CPB) time (p?<?0.01), intensive care unit stay (p?<?0.01), intubation time (p?<?0.01), and overall hospital stay (p?=?0.05). The sutureless group also revealed a significant hospital cost saving of approximately 8200€ (p?=?0.01).

Conclusions

The clinical and hemodynamic outcomes of using the sutureless bioprosthesis were excellent. The reduced ACC and CPB times had a favorable effect on the duration of intubation and intensive care stay, resulting not only in faster recovery and discharge home, but also in a significant hospital cost reduction.

     

Pigmented villonodular synovitis: a crowdsourcing study of two hundred and seventy two patients

Purpose

We aimed to ascertain the feasibility of crowdsourcing via Facebook for medical research purposes; by investigating surgical, oncological and functional outcome and quality-of-life (QOL) in patients with pigmented villonodular synovitis (PVNS) enrolled in a Facebook community (1112 members).

Methods

Patients completed online open surveys on demographics, surgery and clinical outcomes (group 1); and patient-reported outcome measures (PROMs) including knee-injury osteoarthritis outcome score (KOOS), hip-disability osteoarthritis outcome score (HOOS), Toronto extremity salvage score (TESS) and SF-36 (group 2). Mean follow-up was 70 months (12–374). Consistency checks were performed with Cohen’s kappa statistic for intra-rater agreement.

Results

The first survey was completed by 272 patients (group 1) and 72 patients completed the second (group 2). In group 1, recurrence-rate was 58 % (69/118) after arthroscopic, 36 % (35/97) after open and 50 % (5/10) after combined synovectomy (p?=?0.003). In group 2, recurrence-rate was 67 % (26/39) after arthroscopic and 51 % (17/33) after open synovectomy (p?=?0.19). Recurrence-risk was increased for diffuse disease (OR?=?16; 95%CI?=?3.2–85; p?<?0.001). Mean function and QOL did not differ after arthroscopic or open synovectomy: KOOS 49 vs. 58 (p?=?0.24), HOOS 62 vs. 53 (p?=?0.56), TESS 78 vs. 82 (p?=?0.86), SF-36 61 vs. 66 (p?=?0.41). Cohen’s kappa statistic for intra-rater agreement was good to outstanding (κ?=?0.68–0.95; p?<?0.001).

Conclusion

Local recurrence-risk was higher for diffuse-type disease and arthroscopic synovectomy. Functional outcome and QOL were comparable for both types of surgery. Gathering data via crowdsourcing seems a promising and innovative way of evaluating rare diseases including PVNS.

     

Robotic or laparoscopic sacrohysteropexy versus open sacrohysteropexy for uterus preservation in pelvic organ prolapse

Introduction and hypothesis

The aim of this study was to compare robotic or laparoscopic sacrohysteropexy (RLSH) and open sacrohysteropexy (OSH) as a surgical treatment for pelvic organ prolapse (POP).

Methods

Among 111 consecutive patients who had undergone sacrohysteropexy for POP, surgical outcomes and postoperative symptoms were compared between the RLSH (n?=?54; robotic 14 cases and laparoscopic 40 cases) and OSH (n?=?57). groups The medical records of enrolled patients were reviewed retrospectively.

Results

Compared with the OSH group, the RLSH group had shorter operating time (120.2 vs 187.5 min, p?<?0.0001), less operative bleeding (median estimated blood loss 50 vs 150 ml; p?<?0.0001; mean hemoglobin drop 1.4 vs 2.0 g/dl; p?<?0.0001), and fewer postoperative symptoms (13 vs 45.6 %; p?<?0.0001). Patients’ overall satisfaction (94.4 vs 91.2 %; p?=?0.717) and required reoperation due to postoperative complications (3.7 vs 1.8 %; p?=?0.611) did not differ between groups.

Conclusions

RLSH could be a feasible and safe procedure in patients with POP and should be considered as a surgical option that allows preservation of the uterus. Prospective randomized trials will permit the evaluation of potential benefits of RLSH as a minimally invasive surgical approach.

     

Validation of the International Consultation on Incontinence Questionnaire–Vaginal Symptoms (ICIQ-VS) in two south- Asian languages

Introduction

The multifaceted nature of pelvic floor disorders means that a systematic evaluation is required for optimal treatment outcome. It is also generally acknowledged that a valid tool is necessary to objectively assess symptoms reported by affected women.

Methods

The International Consultation on Incontinence Questionnaire—Vaginal Symptoms (ICIQ-VS) questionnaire was translated to Sinhala and Tamil and a validation study carried out among women attending gynecology clinics at North Colombo Teaching Hospital, Ragama, and the district general hospitals Mannar and Vavuniya.

Results

Content validity was assessed by the level of missing answers, which was < 4% and 2% for each item in Sinhala and Tamil, respectively. Construct validity was assessed by the ability of the questionnaire to differentiate between patients and controls. Both differentiated patients from controls on vaginal symptoms score (VSS) (p?<?0.001), sexual symptoms score (SSS) (p?<?0.01), and quality of life (QoL) (p?<?0.001). There was a strong positive correlation between Pelvic Organ Prolapse Quantification (POP-Q) scores and VSS (Sinhala r _s ?=?0.64, p?<?0.001, Tamil r _s ?=?0.65, p?<?0.001), and QoL (Sinhala r _s ?=?0.49, p?<?0.001, Tamil r _s ?=?0.60, p?<?0.001). Internal consistency as assessed using Cronbach’s coefficient alpha: 0.78 (0.76–0.78) and 0.83 (0.80–0.84) in Sinhala and Tamil, respectively. Test–retest reliability was assessed by weighted kappa scores (Sinhala 0.58–0.88 and Tamil 0.76–0.90). Both questionnaires were sensitive to change and showed that VSS and QoL improved following surgery (Wilcoxon matched-pairs signed-rank test p?<?0.001).

Conclusion

The validated Sinhala and Tamil translations of ICIQ-VS will be useful for assessing vaginal and sexual symptoms among women speaking Sinhala and Tamil.

     

Postoperative atrial fibrillation is less frequent in pulmonary segmentectomy compared with lobectomy

Objective

The aim of this study was to elucidate the characteristics and predictors of postoperative atrial fibrillation (POAF) from the standpoint of surgical mode.

Methods

Retrospective analysis was carried out on 607 patients who underwent lobectomy or segmentectomy for clinical stage IA lung cancer. We investigated the clinical factors to determine the predictors of the development of POAF.

Results

Of the 607 patients, 443 underwent lobectomy, and 164 underwent segmentectomy. POAF developed in 37 patients. Of these, 34 (7.7%) were in the lobectomy group, and 3 (1.8%) in the segmentectomy group. In the univariate analysis for predictors of POAF, age (p?<?0.01), history of ischemic heart disease (p?=?0.03), FEV1.0% (p?<?0.01) and surgical mode (p?=?0.01) showed significant differences between the groups. The multivariate analysis revealed that increasing age (p?<?0.01, HR 1.059, CI 1.015–1.106), surgical mode (p?=?0.02, HR 5.734, CI 1.350–24.361) and FEV1.0%?<?70% (p?=?0.03, HR 2.182, CI 1.067–4.461) were independent predictors of POAF.

Conclusion

POAF was significantly less following segmentectomy compared with lobectomy.

     

Comparison of functional outcomes of robotic and open partial nephrectomy in patients with pre-existing chronic kidney disease: a multicenter study

Background

We compared renal functional outcomes of robotic (RPN) and open partial nephrectomy (OPN) in patients with chronic kidney disease (CKD), a definite indication for nephron-sparing surgery.

Methods

A multicenter retrospective analysis of OPN and RPN in patients with baseline ≥?CKD Stage III [estimated glomerular filtration rate (eGFR) <?60 mL/min/1.73 m²] was performed. Primary outcome was change in eGFR (ΔeGFR, mL/min/1.73 m²) between preoperative and last follow-up with respect to RENAL nephrometry score group [simple (4–6), intermediate (7–9), complex (10–12)]. Secondary outcomes included eGFR decline >?50%.

Results

728 patients (426 OPN, 302 RPN, mean follow-up 33.3 months) were analyzed. Similar RENAL score distribution (p?=?0.148) was noted between groups. RPN had lower median estimated blood loss (p?<?0.001), and hospital stay (3 vs. 5 days, p?<?0.001). Median ischemia time (OPN 23.7 vs. RPN 21.5 min, p?=?0.089), positive margin (p?=?0.256), transfusion (p?=?0.166), and 30-day complications (p?=?0.208) were similar. For OPN vs. RPN, mean ΔeGFR demonstrated no significant difference for simple (0.5 vs. 0.3, p?=?0.328), intermediate (2.1 vs. 2.1, p?=?0.384), and complex (4.9 vs. 6.1, p?=?0.108). Cox regression analysis demonstrated that decreasing preoperative eGFR (OR 1.10, p?=?0.001) and complex RENAL score (OR 5.61, p?=?0.03) were independent predictors for eGFR decline >?50%. Kaplan–Meier analysis demonstrated 5-year freedom from eGFR decline >?50% of 88.6% for OPN and 88.3% for RPN (p?=?0.724).

Conclusions

RPN and OPN demonstrated similar renal functional outcomes when stratified by tumor complexity group. Increasing tumor age and tumor complexity were primary drivers associated with functional decline. RPN provides similar renal functional outcomes to OPN in appropriately selected patients.

     

Low Levels of Vitamin D have a Deleterious Effect on the Articular Cartilage in a Rat Model

Background

Vitamin D appears to play an important role in bone and cartilage metabolism since its receptors are widely found in human articular chondrocytes. Thus, effects of variation of vitamin D may directly impact cartilage and bone biology.

Questions/Purposes

The aims of this study are to compare (1) articular cartilage structure and composition and (2) trabecular and cortical bone microstructure in rats with normal versus insufficient vitamin D levels.

Methods

Twenty-five mature, male Sprague-Dawley rats were allocated to two groups: (1) control arm (vitamin D replete—12 rats) and (2) an experimental arm (vitamin D deficient—13 rats). Vitamin D deficiency was induced using a vitamin D-deficient diet and UV light restriction. Rats were sacrificed after 4 weeks vitamin D deficiency was confirmed. The right knee was harvested for analysis of both the medial (MFC) and lateral femoral condyles (LFC). A region of interest was established on both condyles to correlate subchondral bone architecture and the overlying cartilage. Histological analysis was performed and graded using the modified Mankin score. Subchondral and cortical bony architecture was evaluated with micro-CT.

Results

After 4 weeks, the vitamin D-deficient group had statistically significant changes in cartilage structure in both the MFC and LFC [1.55?±?0.6 vs. 4.23?±?4.1 (p?=?0.035) and 1.55?±?0.6 vs. 3.53?±?2.4 (p?=?0.009), respectively]. Micro-CT analysis revealed no correlation between subchondral bone values and the overlying cartilage Mankin score (p?=?0.460). No significant difference was evident between the subchondral bone of the control and study group.

Conclusions

Low levels of vitamin D have a deleterious effect on the cartilage.Given the high prevalence of vitamin D deficiency in the general population, these findings raise important questions about the potential role of vitamin D in articular cartilage health.

     

Platelet Counts and Liver Enzymes After Gastric Bypass Surgery

Background

Obesity is associated with chronic inflammation, liver steatosis and increased liver enzymes such as gamma-glutamyltransferase (GGT) and alanine aminotransferase (ALT), markers for non-alcoholic fatty liver disease (NAFLD) and liver fat content. Increased platelet counts (PCs) are a biomarker reflecting inflammation and the degree of fibrosis in NAFLD. We investigated alterations in PCs, GGT, ALT, C-reactive protein (CRP) and ferritin after Roux-en-Y gastric bypass (RYGBP).

Methods

One hundred twenty-four morbidly obese non-diabetic patients were evaluated before (baseline) and 12 months after (follow-up) RYGBP.

Results

Body mass index (BMI) was reduced from 43.5 kg/m² (baseline) to 31.1 kg/m² (follow-up), and p?<?0.001 and weight declined from 126.2 to 89.0 kg. PCs decreased from 303?×?10⁹ to 260?×?10⁹/l, p?<?0.001. GGT was reduced from 0.63 to 0.38 μkat/l, p?<?0.001. ALT decreased from 0.69 to 0.59 μkat/l, p?=?0.006. CRP was lowered from 7.3 to 5.4 mg/l p?<?0.001 and ferritin from 106 to 84 μg/l p?<?0.001. The alterations in PCs correlated with the changes in CRP (r?=?0.38, p?=?0.001), BMI (r?=?0.25, p?=?0.012), weight (r?=?0.24, p?=?0.015) and inversely correlated with ferritin (r?=?21, p?=?0.036).

Conclusions

PCs, GGT and ALT (markers for NAFLD), and CRP and ferritin (markers for inflammation) decreased in morbidly obese after RYGBP. The decrease in PCs correlated with alterations in CRP, BMI, weight and ferritin. The lowering of liver enzymes may reflect a lowered liver fat content and decreased general inflammation.

     

Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients

Introduction

In laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE.

Methods

A retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression.

Results

After exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (p?<?0.004) and jaundice (p?=?0.019) before surgery and longer operative times (OT, p?<?0.001); they were less likely to have incidental intraoperative diagnosis (p?=?0.031) or to have biliary colic as the reason for surgery (p?=?0.031). In the final multivariate model, leukocytosis (p?=?0.013) and OT (p?<?0.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (p?<?0.001).

Conclusion

The risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.

     

Effects of Sleeve Gastrectomy and Gastric Bypass on Postprandial Lipid Profile in Obese Type 2 Diabetic Patients: a 2-Year Follow-up

Background

Bariatric surgery (BS) is known to favorably impact fasting lipid profile. Fasting and postprandial lipids were evaluated before and 2 years after BS in obese type 2 diabetic (T2DM) patients.

Methods

A prospective study was conducted in 19 obese T2DM patients: ten undergoing sleeve gastrectomy (SG) and nine undergoing Roux-en-Y gastric bypass (RYGB). Before and 2 years after BS, clinical parameters and the response of lipid and incretin hormones to a mixed meal (MM) were assessed.

Results

The two groups had similar characteristics at baseline. After BS, weight loss was similar in the two groups (p?≤?0.01). Fasting glucose, insulin, and triglycerides decreased while HDL cholesterol increased in a similar way (p?<?0.05); in contrast, fasting LDL cholesterol decreased only after RYGB (p?<?0.05). Post-meal glucose concentrations decreased while early insulin response significantly improved after both procedures (p?<?0.001 for both). Postprandial triglycerides decreased after both procedures (p?<?0.05) while postprandial LDL cholesterol decreased only after RYGB (p?<?0.05). Meal-GLP-1 increased postoperatively in both groups although to a greater extent after RYGB (p?<?0.001 vs. SG). GIP decreased after both procedures, especially after RYGB (p?=?0.003). At multivariate analysis, GLP-1 peak was the best predictor of LDL reduction (β?=??0.552, p?=?0.039) while the improvement of HOMA-IR (β?=?0.574, p?=?0.014) and weight loss (β?=?0.418, p?=?0.036) predicted triglycerides reduction.

Conclusions

Both surgical procedures markedly reduce fasting and postprandial triglycerides and increase HDL cholesterol levels. LDL cholesterol decreases only after RYGB through a mechanism likely mediated by the restoration of GLP-1.

     

Prognostic Value of Lymph Node Status and Extent of Lymphadenectomy in Pancreatic Neuroendocrine Tumors Confined To and Extending Beyond the Pancreas

Background

The impact of lymph node (LN) status and lymphadenectomy (LA) on survival in pancreatic neuroendocrine tumors (pNETs) remains controversial. We evaluated the impact of tumor extension and grade on nodal metastasis and survival.

Methods

Surgical pNET patients were queried in the Surveillance Epidemiology and End Results (SEER) database (1998–2012, N?=?981). Factors associated with LN status were analyzed by logistic regression and by Cox analyses.

Results

For T1–T2 tumors, N status was associated only with tumor size. N status (p?=?0.001), grade (p?<?0.001), age (p?=?0.001), and sex (p?=?0.007) predicted overall survival (OS). For T3–T4, grade (p?<?0.001), sex (p?=?0.004), size (p?=?0.013), and age (p?=?0.007) but not N status (p?=?0.789) predicted OS. For T1–T2, disease-specific survival (DSS; p?=?0.003) and OS (p?=?0.008) were longer for N0 vs N1, while N0 vs NX had similar OS (p?=?0.59) and DSS (p?=?0.80). While a difference was seen in DSS for NX vs N1 (p?=?0.04), no significant difference in OS was seen (p?=?0.08). For T3–T4, N status did not affect DSS (p?=?0.365) or OS (p?=?0.454). For all T groups and any N status, extended LA (≥10 nodes resected) was not associated with OS.

Conclusion

While in T1–T2 pNET N1 status is a predictor of negative OS, similar outcome between NX and N0 supports limited LN resection in selected patients. Extended LA is unlikely to be helpful in T3–T4.

     

Readmission Following Gastric Cancer Resection: Risk Factors and Survival

Background

This study utilized a multi-institutional database to evaluate risk factors for readmission in patients undergoing curative gastrectomy for gastric adenocarcinoma with the intent of describing both perioperative risk factors and the relationship of readmission to survival.

Methods

Patients who underwent curative resection of gastric adenocarcinoma from 2000 to 2012 from seven academic institutions of the US Gastric Cancer Collaborative were analyzed. In-hospital deaths and palliative surgeries were excluded, and readmission was defined as within 30 days of discharge. Univariate and multivariable logistic regression analyses were employed and survival analysis conducted.

Results

Of the 855 patients, 121 patients (14.2 %) were readmitted. Univariate analysis identified advanced age (p?<?0.0128), American Society of Anesthesiology status ≥3 (p?=?0.0045), preexisting cardiac disease (p?<?0.0001), hypertension (p?=?0.0142), history of smoking (p?=?0.0254), increased preoperative blood urea nitrogen (BUN; p?=?0.0426), concomitant pancreatectomy (p?=?0.0056), increased operation time (p?=?0.0384), estimated blood loss (p?=?0.0196), 25th percentile length of stay (<7 days, p?=?0.0166), 75th percentile length of stay (>12 days, p?=?0.0256), postoperative complication (p?<?0.0001), and total gastrectomy (p?=?0.0167) as risk factors for readmission. Multivariable analysis identified cardiac disease (odds ratio (OR) 2.4, 95 % confidence interval (CI) 1.6–3.3, p?<?0.0001), postoperative complication (OR 2.3, 95 % CI 1.6–5.4, p?<?0.0001), and pancreatectomy (OR 2.2, 95 % CI 1.1–4.1, p?=?0.0202) as independent risk factors for readmission. There was an association of decreased overall median survival in readmitted patients (39 months for readmitted vs. 103 months for non-readmitted). This was due to decreased survival in readmitted stage 1 (p?=?0.0039), while there was no difference in survival for other stages. Stage I readmitted patients had a higher incidence of cardiac disease than stage I non-readmitted patients (58 vs. 24 %, respectively, p?=?0.0002).

Conclusions

Within this multi-institutional study investigating readmission in patients undergoing curative resection for gastric cancer, cardiac disease, postoperative complication, and concomitant pancreatectomy were identified as significant risk factors for readmission. Readmission was associated with decreased overall median survival, but on further analysis, this was driven by differences in survival for stage I disease only.

     

Which factors should be considered in choosing pessary type and size for pelvic organ prolapse patients in a fitting trial?

Introduction and hypothesis

This study explored whether the optimal pessary type and size can be predicted using the specific pelvic organ prolapse quantification system (POP-Q) measurements in women with pelvic organ prolapse in a fitting trial.

Methods

We conducted a prospective study in women who had undergone pessary fitting. A total of 78 patients with stage II, III or IV symptomatic pelvic organ prolapse completed a detailed history. Data were analysed using nonparametric tests, continuity correction chi-squared tests and multivariate logistic regression.

Results

Differences in total vaginal length (TVL; p?<?0.01) and vaginal introitus width/TVL ratio (p?=?0.012) were observed between patients with and without a history of hysterectomy. Patients with a history of hysterectomy and patients with a larger vaginal introitus had more success with the Gellhorn pessary than with the ring pessary with support (p?=?0.005 and p?=?0.01, respectively). Factors determining the size of the ring pessary with support were the genital hiatus (GH) width (p?=?0.044), TVL (p?=?0.011), vaginal introitus width (p?<?0.001), and vaginal introitus width/TVL ratio (p?=?0.025). Factors determining the size of the Gellhorn pessary were the GH width (p?=?0.025), GH width/TVL ratio (p?=?0.013), vaginal introitus width (p?=?0.003), vaginal introitus width/TVL ratio (p?=?0.001), stage of apical prolapse (p?=?0.006) and stage of posterior prolapse (p?=?0.003).

Conclusions

Patients with a history of hysterectomy or with a larger vaginal introitus were more likely to achieve success with the Gellhorn pessary. The GH width and the vaginal introitus width influenced the size of both pessaries chosen. The TVL was predictive of the optimal size of the ring pessary with support but was not predictive of the optimal size of the Gellhorn pessary. Finally, the size of the Gellhorn pessary was associated with POP stage.

     

Comparison Between Billroth-II with Braun and Roux-en-Y Reconstruction After Laparoscopic Distal Gastrectomy

Purpose

This study aims to compare the effectiveness of Billroth-II with Braun and Roux-en-Y reconstruction after laparoscopic distal gastrectomy.

Methods

From April 2010 to August 2012, 66 patients underwent laparoscopic distal gastrectomy (Billroth-II with Braun reconstruction, 26; Roux-en-Y, 40). The patients’ data were collected prospectively and reviewed retrospectively.

Results

The mean operation and reconstruction times were statistically shorter for Billroth-II with Braun reconstruction than Roux-en-Y (198.1?±?33.0 vs. 242.3?±?58.1 min, p?=?0.001). One case of postoperative stricture was observed in each group. One case each of intra-abdominal abscess and delayed gastric emptying occurred in the Billroth-II with Braun group. At 1 year postoperatively, gastric residue and reflux esophagitis were not significantly different between the groups. Gastritis and bile reflux were more frequently observed in the Billroth-II with Braun group (p?=?0.004 and p?<?0.001, respectively). At 2 years postoperatively, gastric residue was not significantly different, but gastritis, bile reflux, and esophagitis were more frequent in the Billroth-II with Braun group (p?=?0.029, p?<?0.001, and p?=?0.036, respectively).

Conclusion

The postoperative effectiveness of Roux-en-Y reconstruction may be superior to Billroth-II with Braun reconstruction after laparoscopic distal gastrectomy.

     

Outcomes of Sleeve Gastrectomy in Septuagenarians

Background

Few previous studies have assessed the safety of bariatric surgery in septuagenarians.

Methods

A retrospective analysis of all patients 70 years or older who underwent laparoscopic sleeve gastrectomy at our institution between 2012 and 2017 was performed. This group was compared to a matched cohort of younger LSG patients (18–50 years) who were operated during the same time period.

Results

Thirty septuagenarian LSG patients were compared to 60 younger patients. Gender distribution, preoperative weight, and preoperative body mass index (BMI) were comparable, although patients in the older age group suffered from more preoperative comorbidities (100 vs. 51.7%, p?<?0.001). Operative time was longer (77.2 vs. 57.3 min, p?=?0.005) and more hiatal hernias were repaired (46.7 vs. 8.3%, p?<?0.001) in the older age group. Intraoperative complications occurred more in the older age group (6.7 vs. 0%, p?=?0.04) but the overall complication rate (13.3 vs. 5.0%, p?=?0.17) and the postoperative complication rate (10.0 vs. 5.0%, p?=?0.38) were comparable. After a mean follow-up period of 31.3 and 33.5 months, the percentage of total body weight loss was 24.6 and 28.3% for the older and younger patients, respectively (p?=?0.11). Rates of improvement/remission of comorbidities were comparable between the groups.

Conclusions

In a carefully selected group of severely obese patients ≥?70 years old, LSG may be safe, with acceptable postoperative complication rates, weight loss results, and improvement in comorbidities.

     

Exercise during energy restriction mitigates bone loss but not alterations in estrogen status or metabolic hormones

Summary

Energy restriction causes bone loss, increasing stress fracture risk. The impact of exercise during energy restriction on bone and endocrine factors is examined. Exercise with energy restriction did not influence endocrine factors, but did mitigate some bone loss seen with energy restriction in sedentary rats.

Introduction

Chronic dietary energy restriction (ER) leads to bone loss and increased fracture risk. Strictly controlled trials of long-term ER with and without vigorous exercise are required to determine whether exercise loading can counterbalance ER-induced bone loss. The aim of this current project is to elucidate the impact of exercise and ER on bone mass, estrogen status, and metabolic hormones.

Methods

Twenty-four virgin female Sprague-Dawley rats (n?=?8/group) were divided into three groups—ad libitum fed?+?exercise (Adlib?+?EX), 40 % energy restricted?+?exercise (ER?+?EX), and 40 % energy restricted?+?sedentary (ER?+?SED). Energy availability between ER groups was equal. Treadmill running was performed 4 days/week at 70 % VO_2max for 12 weeks.

Results

Fat and lean mass and areal bone mineral density (aBMD) were lower after 12 weeks (p?<?0.05) for ER?+?EX vs Adlib?+?EX, but ER?+?EX aBMD was higher than ER?+?SED (p?<?0.0001). Serum leptin and a urinary estrogen metabolite, estrone-1-glucuronide (E1G), were lower at week 12 (p?=?0.0002) with ER, with no impact of exercise. Serum insulin-like growth factor I (IGF-I) declined (p?=?0.02) from baseline to week 12 in both ER groups. ER?+?EX exhibited higher cortical volumetric bone mineral density (vBMD) at the midshaft tibia (p?=?0.006) vs ER?+?SED.

Conclusion

Exercise during ER mitigated some, but not all, of the bone loss observed in sedentary ER rats, but had little impact on changes in urinary E1G and serum IGF-I and leptin. These data highlight the importance of both adequate energy intake and the mechanical loading of exercise in maintaining bone mass.