Surgery versus surgery and postoperative radiotherapy in squamous cell carcinoma of the buccal mucosa: A comparative study

Background: The efficacy of postoperative radiotherapy for squamous cell carcinoma of the buccal mucosa was evaluated. Methods: One hundred seventy-six patients treated between 1989 and 1993 were analyzed. One hundred fifteen patients were treated with surgery alone (Group 1), and 61 patients were treated with a combination of surgery and postoperative radiotherapy (Group 2). Results: Actuarial 3-year locoregional control in Groups 1 and 2 was 11% and 48% for patients with stage III + IV cancer (P=.001) and 71% and 75% for patients with stage I + II cancer (P=.74), respectively. On multivariate analysis for locoregional failure, surgical margin, bone invasion, high grade, and node involvement were significant factors in Group 1, whereas in Group 2 only tumor thickness was a significant factor. For local failure, margin, bone invasion, and stage in Group 1 and tumor thickness in Group 2 appeared as significant factors. For nodal failure, clinical nodal (cl N0 vs. N+) stage and grade in Group 1 and pathologic nodal stage (pN0 + 1 vs. pN2) in Group 2 were observed as significant factors. On subset analysis, postoperative radiotherapy was observed to have a significant advantage for surgical margins of 2 mm or less in both early pT (T1 + T2) (P=.019) and late pT (T3 + T4) (P=.016) stages. The local failure rate was higher if the time between surgery and radiotherapy was greater than 30 days. Conclusions: Postoperative radiotherapy was effective in decreasing locoregional failure in patients with close surgical margins, tumor thicker than 10 mm, high-grade tumors, positive node, and bone invasion. The effect of interval between surgery and postoperative radiotherapy on local failure was margin-dependent.     

Inducción con timoglobulina: ¿incrementa el riesgo hemorrágico en receptores renales sensibilizados?

ObjectiveIt has been described that thymoglobulin could increase the risk of infections and malignancies, in comparison to basiliximab. Leukopenia and thrombocytopenia are also more common within the first days after transplantation among thymoglobulin patients. Our objective was to analyze bleeding complications in this subset of patients.Material and methodsBleeding complications were evaluated among 515 renal transplants carried out at our institution between 2012 and 2018. We compared patients treated with thymoglobulin (Group 1, N = 91) with those treated with basiliximab (Group 2, N = 424).ResultsWe found differences in platelet decrease:95142.2 (55,339.6) in Group 1 and 52,364.3 (69,116.6) in Group 2 (P=.001), number of patients with severe thrombocytopenia (<75,000/mm3) (20.8% vs. 3.7%, P=.001), number of blood units transfused (3.25 (0.572) vs. 2.2 (0.191, P=.028) and percentage of patients that required surgery due to bleeding (18.2% vs. 7.7%, P=.046). In a multiple lineal regression multivariable analysis (dependent variable was number of blood units transfused), only age [OR 0.037, 95% CI (0.003-0.070)] and type of immunosuppression [OR 1.592, 95% CI (1.38-2.84)] showed statistical significance.ConclusionsThe use of thymoglobulin in the perioperative transplantation period could increase bleeding complications. In our series, in the group of patients with thymoglobulin, severe thrombocytopenia was 6 times more frequent, and active bleeding that required surgery was also 2.5 times more frequent. One way to continue with the use of this immunosuppression agent, might be to adjust the dose instead of discontinuing it. The use of thymoglobulin should be a factor to consider in the postoperative period of these patients.     

Hypoalbuminemia as a risk factor for complications in revisional/conversional bariatric surgery: an MBSAQIP analysis

BackgroundHypoalbuminemia (HA) is a risk factor for serious complications after elective bariatric surgery. Patients undergoing revisional/conversional bariatric surgery may represent a higher-risk group who often have underlying co-morbid medical illnesses and more complex surgery.ObjectivesThis study investigated the postoperative complications in patients with HA undergoing revisional/conversional bariatric surgery.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), years 2015–2019.MethodsThe MBSAQIP database was used to evaluate patients undergoing non-banding revisional/conversional bariatric surgery between 2015 and 2019. Patients were categorized by serum albumin (≤3.5 g/dL). Variables were assessed via bivariate analysis and multivariable regression. Propensity score matching was conducted to compare gastric bypass (RYGB) to sleeve gastrectomy (VSG).ResultsOne hundred forty-seven thousand four hundred thirty patients underwent revisional/conversional procedures. After applied exclusions, 58,777 patients were available for analysis. The HA group had a significantly (P < .05) higher prevalence of being black (22.95% versus 17.76%), renal insufficiency (1.08% versus .36%), smoking history (9.47% versus 6.91%), chronic obstructive pulmonary disease (COPD) (2.54% versus 1.33%), and history of deep vein thrombosis (DVT) (4.03% versus 2.3%). Postoperative complications associated with HA included perioperative blood transfusion (3.1% versus 1.27%; P < .001), 30day readmission (10.87 versus 6.77%; P < .001), 30day reoperation (4.9% versus 3.18%; P < .001), and 30day mortality (.40% versus .14%; P < .0001). HA was a significant predictor of 30day readmission in the RYGB versus VSG matched cohort (odds ratio [OR], 1.30; 95% confidence interval [CI], [1.14, 1.48]; P < .001).ConclusionsHA is a risk factor requiring attention for patients undergoing revisional/conversional bariatric surgery and optimization of nutritional status or medical comorbidities associated with HA prior to bariatric surgery may help avoid postoperative complications.     

Practice Makes Perfect? Patient Response to a PreBariatric Surgery Behavior Modification Program

Background: Although bariatric surgery has been identified as an effective treatment for weight loss in the morbidly obese, some patients regain weight postoperatively. A pre-treatment program focused on changing lifestyle behaviors could facilitate improved post-surgical outcomes. The purpose of this study was to determine patient satisfaction and perceived usefulness of a preoperative program. Method: Participants completed a bariatric surgery program that incorporated a 6-week behavior modification component before the surgery date. A selfreport questionnaire was sent to individuals who had completed the program. The questionnaire assessed demographics, satisfaction with the pre-surgery program, and patients' perceived usefulness of the program. Results: Of 124 questionnaires sent, 70 were returned (56%). Participants had a mean age of 46.3 years. The majority of participants were Caucasian (97.1%), female (78.6%), and employed (68.6%). Mean preoperative BMI was 55.3; mean postoperative BMI was 36.3. Participants were 1 year post-surgery (mean 48.8 weeks). Patients were very satisfied with the overall program (mean Likert score 4.51), as well as with the behavior modification groups (mean 4.44). They found the groups to be very useful in making postoperative changes (mean 4.45). Patient satisfaction and perceived usefulness were not significantly correlated with the degree of weight lost (r=.05, P=.69; r=.05, P=.71). Conclusions: Patients found the preoperative behavior modification program useful in helping them make the necessary post-surgical lifestyle changes.     

Open vs Laparoscopic Roux-en-Y Gastric Bypass: Comparison of Operative Morbidity and Mortality

Background: Open Roux-en-Y gastric bypass (RYGBP) has proven to be an effective method for weight control for the morbidly obese patient. With technologic and surgical skill advancement in the application of laparoscopic surgery, laparoscopic RYGBP has also been found to be of value in surgical control of obesity. Risk/benefit ratios in comparison of the 2 methods are undergoing definition by experience. Methods: 779 patients who underwent RYGBP between March 1, 2000 and June 30, 2002 were evaluated retrospectively. 328 patients underwent laparoscopic RYGBP (Group A) and 451 underwent open RYGBP (Group B). All charts and hospital records of these patients were reviewed. Questionnaires were mailed to all patients who had undergone RYGBP. Follow-up was 5-29 months. Results: 89 patients in Group A and 162 patients in Group B experienced significant morbidity. There were no surgical deaths in Group A and one surgical death in Group B.Weight loss profiles were the same. Significant differences in morbidity were noted with respect to gastrojejunal stenosis (Group A = 11.6%, Group B = 4.7%, P=.0012), occurrence of ventral incisonal hernia (A=0%, B=10%, P<.00013), and wound problems (abdominal wall hematoma A=1.5%%, B=0%, P=.013; wound infection A=1.2%, B=6.2%, P=.00037). Gastrojejunal perforation was not significantly different (A=1.5%, B=0.89%, P=.50), as was true of small bowel obstruction (A=2.7%, B=3.3%, P=.68). Conclusions: Each operative approach has associated problems.Wound care problems and ventral hernias are more common in Group B (open) and anas tomotic stenoses are more common in Group A (laparoscopic). Anastomotic leaks and small bowel obstruction are troublesome but not statistically different in occurrence.     

Revision of Failed Gastric Restrictive Operations to Roux-en-Y Gastric Bypass: Impact of Multiple Prior Bariatric Operations on Outcome

Background: Morbid obesity is now an epidemic with considerable associated morbidity for which bariatric surgery has been the only effective treatment. Despite its success, occasional patients require revision because of weight regain or mechanical complications. The impact of multiple prior bariatric operations on complications and weight loss after revision to Roux-en-Y gastric bypass (RYGBP) was evaluated. Methods: All patients undergoing revisional surgery to RYGBP by the senior author from 1997 through 2004 were retrospectively reviewed at a multi-center academic institution. Patients who had previously undergone multiple revisional operations (MR) were compared to patients who had undergone primary ("first-time") revision (PR). Demographics, indications for revision, complications, and weight loss were reviewed. Results: 66 patients underwent open revision to RYGBP after failed bariatric operations, with 12 in the MR group and 54 in the PR group. Mean preoperative BMI was 46.1 and 45.2 (P=0.8), respectively. Operative time (227 vs 162 min, P=0.07), blood loss (517 vs 313 ml, P=0.09) and hospital length of stay (11.5 vs 6.7 days, P=0.2) were higher in the MR group. Major perioperative complications occurred in 16.7% of MR patients compared to 9.3% of PR patients (P=0.6). Percent of excess weight loss (%EWL) has been 54.3% in the MR group and 60.6% in the PR group (P=0.6). Average follow-up is 26 and 23 months, respectively. Conclusion: Although operative times, blood loss, and LOS were greater in MR patients, RYGBP can be performed in patients with multiple previous bariatric operations with acceptable weight loss and complication rates.     

The Impact of Bariatric Surgery on Menstrual Patterns

Background: Obesity and anovulation are common medical problems in the United States. Anovulation in obese patients primarily manifests with irregular, sporadic or absent menstrual bleeding. Weight loss of at least 5% has been shown to reverse obesity-related anovulation. The aim of this study was to assess the impact of bariatric surgery on infertility in morbidly obese women and to identify factors associated with return of normal menses following bariatric surgery. Methods: A survey of patients was collected from the bariatric surgery data-base at the Hospital of the University of Pennsylvania. 410 women under the age of 40 were sent questionnaires. 195 patients completed the questionnaire, and 29 patients had incorrect addresses without a forwarding address, resulting in a 51.2% response rate. Patients who reported menstrual cycle lengths >35 days were considered abnormal. 92 of the 195 responders were considered anovulatory preoperatively, based on menstrual history. Results: There was no significant difference in postoperative BMI, BMI decrease or age at surgery between the survey responders and non-responders. There was a significant difference between these 2 groups in time since surgery (P=.01). Both groups had a decrease in BMI of >18 kg/m². The mean menstrual cycle length preoperatively among those categorized as ovulatory and anovulatory was 27.3 and 127.5 days, respectively. Of the 98 patients who were anovulatory preoperatively, 70 patients (71.4%) regained normal menstrual cycles after surgery. Those patients who regained ovulation had greater weight loss than those who remained anovulatory (61.4 kg vs 49.9 kg, P=0.02). Conclusions: Anovulation resulting in abnormal menses is a common problem in morbidly obese premenopausal women. The menstrual cycle disorders may completely resolve after bariatric surgery. Thus, infertility due to anovulation among morbidly obese women could potentially be viewed as an additional indication for bariatric surgery.     

Risk of complications after bariatric surgery among individuals with and without type 2 diabetes mellitus

BackgroundType 2 diabetes mellitus is highly prevalent in obese individuals. Bariatric surgery, promoted for reducing the medical problems of morbid obesity, has been increasingly recognized for its particular efficacy in treating diabetes. However, before bariatric surgery can be recommended for the treatment of diabetes, its safety in the diabetic population must be known. We assessed the odds of complications after bariatric surgery in patients with and without diabetes.MethodsThis was a retrospective cohort study. Using an administrative database from 7 Blue Cross/Blue Shield plans, we identified 22,288 subjects who had undergone bariatric surgery from 2002 to 2008. From this cohort, we selected 6754 pairs of surgical patients (1 with and 1 without diabetes) matched by age, gender, health plan, and year of surgery. With conditional logistic regression analysis, we determined the relative odds of postoperative complications for ≤12 months after surgery in the 2 groups.ResultsThe mean age of the surgical patients was 46 years, and 79% were women. Postoperative complications were rare and comparable in those with and without diabetes. The most common complications were nausea, vomiting, and abdominal pain (8.8%), the need for a gastric revision procedure (5.0%), and upper endoscopy (2.3%). Select cardiac, infectious, and renal complications occurred more frequently in the diabetic group. The incidence of cardiac complications was greater in the 2–3-month and 4–6-month postoperative periods (odds ratio [OR] 1.7, P < .001), the incidence of infectious complications was greater in the 0–1-month (OR 1.3, P < .02) and 4–6-month (OR 1.8, P < .001) periods, and the incidence of renal complications was greater in the 2–3-month postoperative period (OR 4.6, P = .01).ConclusionsOur findings support the safety of bariatric surgery in obese individuals with diabetes, although management strategies to avert postoperative cardiac, infectious, and renal complications in this population might be warranted.     

The Effects of Acute Preoperative Weight Loss on Laparoscopic Roux-en-Y Gastric Bypass

Background: Minimal acute pre-operative weight loss significantly reduces liver size and intra-abdominal adipose tissue. We hypothesize that these changes will reduce intra-operative complications and reduce the difficulty of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: This is a retrospective chart review of consecutive patients who had undergone isolated LRYGBP between July 2003 and March 2005. All patients participated in our institution's medically supervised Weight Management Program before surgery. Results: 48 patients (Weight Loss Group) had an average percent loss of excess weight (%EWL) of 4.6; whereas 47 patients (No Weight Loss Group) gained an average of 4.8% of excess weight over an average period of 2.4 and 3 months (P=0.09), respectively. There were no differences between the two groups in age, gender, ASA class, co-morbidities, or BMI at operation. The Weight Loss Group had less intra-operative blood loss (102 vs 72 ml, P=.03). The surgeon was also less likely to report an enlarged liver in the Weight Loss Group (P=.02). Finally, the operation was less likely to deviate from the standard LRYGBP when patients lost weight (P=.02). No differences were seen in operative time, length of hospital stay, wound infections, or major complications. Conclusion: Acute preoperative weight loss is associated with less intra-operative blood loss and reduces the need for intraoperative deviation from the standard LRYGBP. A larger series with a greater reduction in excess weight is necessary to determine the maximal benefits of acute preoperative weight loss.     

Postoperative care fragmentation in bariatric surgery and risk of mortality: a nationwide study

BackgroundReadmission after bariatric surgery may to lead to fragmentation of care if readmission occurs at a facility other than the index hospital. The effect of readmission to a nonindex hospital on postoperative mortality remains unclear for bariatric surgery.ObjectivesTo determine postoperative mortality rates according to readmission destinations.SettingNationwide analysis of all surgical facilities in France.MethodsMulticenter, nationwide study of adult patients undergoing bariatric surgery from January 1, 2013, through December 31, 2018. Data from all surgical facilities in France were extracted from a national hospital discharge database.ResultsIn a cohort of 278,600 patients who received bariatric surgery, 12,760 (4.6%) were readmitted within 30 days. In cases of readmission, 23% of patients were admitted to a nonindex hospital. Patients readmitted to a nonindex facility had different characteristics regarding sex (men, 23.6% versus 18.2%, respectively; P < .001), co-morbidities (Charlson Co-morbidity Index, .74 versus .53, respectively; P < .001), and travel distance (38.3 km versus 26.9 km, respectively; P < .001) than patients readmitted to the index facility. The main reasons for readmission were leak/peritonitis and abdominal pain. The overall mortality rate after readmission was .56%. The adjusted odds ratio (OR) of mortality for the nonindex group was 4.96 (95% confidence interval [CI], 3.1–8.1; P < .001). In the subgroups of patients with a gastric leak, the mortality rate was 1.5% and the OR was 8.26 (95% CI, 3.7–19.6; P < .001).ConclusionReadmissions to a nonindex hospital are associated with a 5-fold greater mortality rate. The management of readmission for complications after bariatric surgery should be considered as a major issue to reduce potentially preventable deaths.     

Laparoscopic Major Hepatectomy: Do Not Underestimate the Impact of Specimen Extraction Site

Background

In laparoscopic major hepatectomy, analysis of outcomes according to specimen extraction site remains poorly described. The aim was to compare postoperative outcomes according to specimen extraction site.

Methods

From 2000 to 2017, all laparoscopic major hepatectomies were reviewed and postoperative outcomes were analyzed according to specimen extraction site: subcostal (Group 1), midline (Group 2), or suprapubic (Group 3) incision.

Results

Among 163 patients, 15 (9.2%) belonged to Group 1, 49 (30.1%) in Group 2, and 99 (60.7%) in Group 3. The proportion of right-sided, left-sided, or central hepatectomies, mortality, and overall and severe complications were comparable between groups. Group 1 had larger tumors (61 vs. 38 vs. 47 mm; P = 0.014), higher operative time (338 vs. 282 vs. 260 min; P < 0.008), higher adjacent organ resection rate (46.6 vs. 16.3 vs. 7.1%; P < 0.001), and tended to increase pulmonary complications (40.0 vs. 12.2 vs. 18.2%; P = 0.064). In Group 2, a previous midline incision scar was more frequently used for specimen extraction site (65.3 vs. 26.6 and 30.3%, Group 1 and 3; P < 0.001). Postoperative incisional hernia was observed in 16.4% (n = 23) and was more frequent in Group 2 (26.6 vs. 6.6% and 10.1%, Group 1 and Group 3; P = 0.030). Finally, Group 2 (HR 2.63, 95% CI 1.41–3.53; P = 0.032) was the only independent predictive factor of postoperative incisional hernia.

Conclusions

While using a previous incision makes sense, the increased risk of postoperative incisional hernia after midline incision promotes the suprapubic incision.

     

Body Composition and Metabolic Changes following Bariatric Surgery: Effects on Fat Mass, Lean Mass and Basal Metabolic Rate: Six Months to One-Year Follow-up

Background: With the failure of traditional weight loss plans, bariatric surgery has become the treatment of choice for morbid obesity. The primary objective of this study was to track body composition and metabolic changes for 1 year following bariatric surgery. Methods: 19 bariatric patients (14 female, 5 male) began the study and completed 12 months of testing, which included data collection within 1 week preoperatively and 1, 3, 6 and 12 months postoperatively. 2 female subjects were lost to the study between 6 months and 1 year, resulting in 17 subjects (12 female, 5 male) completing the entire 12-month follow-up. Variables measured in this study included weight, lean body mass (LBM), fat mass (FM), % body fat and basal metabolic rate (BMR). Results: Analysis of variance (ANOVA) using the general linear model indicated significant (P<.05) losses for weight, FM, and % fat for all time periods. Significant losses in LBM were observed in all time periods except 6-12 months, where no change in LBM (60.6 vs 61.1 kg) was observed. A significant decrease (P<.05) in BMR (2091 vs 1758) was observed only from pre-surgery to 1 month post-surgery. Thereafter, there was no significant change in BMR (1758 vs 1647 vs 1651 vs 1674) respectively. Changes in LBM were correlated with changes in BMR at both 6-12 months (r=.545, P=.024) and preoperatively to 12 months postoperatively (r=.608, P=.01). There were no significant changes in the BMR/LBM ratio over the 12-month period (28.3 vs 25.0 vs 27.3 vs 27.2 vs 27.4), indicating no adaptation of the body to an energy-conserving mechanism. Conclusion: Bariatric surgery appears to have been highly successful over the 12-month follow-up period, with 50.9 kg weight loss, 38.3 kg (75.2%) FM loss, and 12.6 kg (24.8%) LBM loss. The 417 kcal loss in BMR (2091 to 1674), while significant, was not greater than what would be predicted from loss of LBM.     

Extracorporeal life support in lung and heart–lung transplantation for pulmonary hypertension in adults

After bilateral lung and heart–lung transplantation in adults with pulmonary hypertension, hemodynamic and oxygenation deficiencies are life‐threatening complications that are increasingly managed with extracorporeal life support (ECLS). The primary aim of this retrospective study was to assess 30‐day and 1‐year survival rates in patients managed with vs without post‐operative venoarterial ECLS in 2008–2013. The secondary endpoints were the occurrence rates of nosocomial infection, bleeding, and acute renal failure. Of the 93 patients with pulmonary hypertension who received heart‐lung (n=29) or bilateral lung (n=64) transplants, 28 (30%) required ECLS a median of 0 [0–6] hours after surgery completion and for a median of 3.0 [2.0–8.5] days. Compared to ECLS patients, controls had higher survival at 30 days (95.0% vs 78.5%; P=.02) and 1 year (83% vs 64%; P=.005), fewer nosocomial infections (48% vs 79%; P=.0006), and fewer bleeding events (17% vs 43%; P=.008). The need for renal replacement therapy was not different between groups (11% vs 17%; P=.54). Venoarterial ECLS is effective in treating pulmonary graft dysfunction with hemodynamic failure after heart‐lung or bilateral lung. However, ECLS use was associated with higher rates of infection and bleeding.     

Impression management or real change? Reports of depressive symptoms before and after the preoperative psychological evaluation for bariatric surgery

Background Many bariatric surgery programs require that candidates undergo a preoperative mental health evaluation. Candidates may be motivated to suppress or exaggerate psychiatric symptoms (i.e., engage in impression management), if they believe doing so will enhance their chances of receiving a recommendation to proceed with surgery. Method 237 candidates for bariatric surgery completed the Beck Depression Inventory-II (BDI-II) as part of their preoperative psychological evaluation (Time 1). They also completed the BDI-II approximately 2–4 weeks later, for research purposes, after they had received the mental health professional’s unconditional recommendation to proceed with surgery (Time 2). Results There was a small but statistically significant increase in mean BDI-II scores from Time 1 to Time 2 (11.4 vs 12.7, P < .001). Clinically significant changes, defined as a change from one range of symptom severity to another, were observed in 31.2% of participants, with significant increases in symptoms occurring nearly twice as often as reductions (20.7% vs 10.5%, P < .008). Demographic variables were largely unrelated to changes in BDI-II scores from Time 1 to Time 2. Conclusion Approximately one-third of bariatric surgery candidates reported a clinically significant change in depressive symptoms after receiving psychological “clearance” for surgery. Possible explanations for these findings include measurement error, impression management, and true changes in psychiatric status.     

Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity

Few data exist concerning preoperative nutritional status in patients undergoing bariatric surgery. We retrospectively analyzed the preoperative values of serum albumin, calcium, 25-OH vitamin D, iron, ferritin, hemoglobin, vitamin B₁₂, and thiamine in 379 consecutive patients (320 women and 59 men; mean body mass index 51.8±10.6 kg/m²; 25.8% white, 28.4% African American, 45.8% Hispanic) undergoing bariatric surgery between 2002 and 2004. Preoperative deficiencies were noted for iron (43.9%), ferritin (8.4%), hemoglobin (22%; women 19.1%, men 40.7%), thiamine (29%), and 25-OH vitamin D (68.1%). Low ferritin levels were more prevalent in females (9.9% vs. 0%; P=0.01); however, anemia was more prevalent in males (19.1% vs. 40.7%; P<0.005). Patients younger than 25 years were more likely to be anemic than patients over 60 years (46% vs. 15%; P<0.005). This correlated with iron deficiency, which was more prevalent in younger patients (79.2% vs. 41.7%; P<0.005). Whites (78.8%) and African Americans (70.4%) had a higher prevalence of vitamin D deficiency than Hispanics (56.4%), P=0.01. Whites were the least likely group to be thiamine deficient (6.8% vs 31.0% African Americans and 47.2% Hispanics; P<0.005). Nutritional deficiencies are common in patients undergoing Roux-en-Y gastric bypass, and these deficiencies should be detected and corrected early to avoid postoperative complications. Presented at the Forty-Fifth Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004.     

Early postoperative complications after gastric bypass revisional surgery in patients with previous sleeve gastrectomy versus primary gastric bypass

BackgroundRevisional bariatric surgery (RS) is indicated if there is weight regain or insufficient weight loss, no improvement or reappearance of co-morbidities, or previous bariatric surgery complications. It has been associated with higher postoperative morbidity.ObjectiveTo evaluate the early postoperative complications (<30 d) of Roux-en-Y gastric bypass RS (RYGB-RS) after primary sleeve gastrectomy (SG-1) compared with primary RYGB (RYGB-1) at a bariatric surgery referral center.SettingDepartment of General and Digestive Surgery of General Universitary Hospital of Alicante, Spain.MethodsRetrospective cohort study comparing RYGB-RS after SG-1 and RYGB-1 between January 2008 and March 2021. Postoperative complications, hospital stay, mortality, and readmissions were analyzed.ResultsSix hundred and twenty-eight RYGB surgeries (48 RYGB-RS, 580 RYGB-1) were studied. The mean age of patients undergoing RYGB-RS was 50 years, compared with 46 years in the RYGB-1 group (P = .017). Mean initial body mass index was 44.2 kg/m² (RYGB-RS) versus 47.6 kg/m² (RYGB-1; P = .004). Cardiovascular risk factors were higher in the RYGB-1 group (P < .05). Indications for RS were weight regain or insufficient weight loss (72.9%), weight regain or insufficient weight loss plus gastroesophageal reflux disease (14.6%), and gastroesophageal reflux disease (12.5%). There were no differences in the frequency of complications (RYGB-RS 22.9% vs RYGB-1 20.5%) or in their severity (Clavien–Dindo ≥IIIa; RYGB-RS 10.4% vs RYGB-1 6.4%; P > .05). There were no differences in emergency room visits (RYGB-RS at 12.5% vs RYGB-1 at 14.9%) or in readmissions (RYGB-RS at 12.5% vs RYGB-1 at 9.4%).ConclusionNo differences were observed between primary RYGB and revisional RYGB in early morbidity, mortality, emergencies, or readmissions. Revisional bariatric surgery is a safe procedure at referral centers and must be done by expert hands.     

Racial disparity in causes for readmission following bariatric surgery

BackgroundReadmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood.ObjectiveOur study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients.SettingAcademic hospital.MethodsWe performed a retrospective analysis of the 2015–2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching.ResultsMore than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%–4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism–related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001).ConclusionReadmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.     

What happens to patients who do not follow-up after bariatric surgery?

Loss of follow-up is a concern when tracking long-term clinical outcomes after bariatric surgery. The results of patients who are "lost to follow-up" are not known. After bariatric surgery, the lack of follow-up may result in less weight loss for patients. This study investigated the hypothesis that there are differences between patients who do not automatically return for their annual follow-up and those that do return. Patients who were greater than 14 months postoperative after laparoscopic gastric bypass were contacted if they had not returned for their annual appointment. They were seen in clinic and/or a phone interview was performed for follow-up. These patients (Group A) were compared with patients who returned to see us for their annual appointment (Group B) without us having to notify them. There were 105 consecutive patients, with 48 patients who did not automatically return for their annual appointment. Only six of these patients could not ultimately be contacted. There was no difference in preoperative body mass index between the two groups. Percentage excess body weight loss was greater in Group B (76 vs. 65%; P < 0.003). More patients had successful weight loss (defined as within 50% of ideal body weight) in Group B (50 [88%] vs. 28 [67%]; P < 0.02). We found that a significant number of patients will not comply with regular follow-up care after laparoscopic gastric bypass unless they are prompted to do so by their bariatric clinic. These patients have worse clinical outcome (i.e., less weight loss). Caution should be taken when examining the results of any bariatric study where there is a significant loss to follow-up.     

Effect of the COVID-19 pandemic on bariatric surgery in North America: a retrospective analysis of 834,647 patients

BackgroundCOVID-19 has transformed surgical care, yet little is known regarding implications for bariatric surgery.ObjectiveWe sought to characterize the effect of COVID-19 on bariatric surgery delivery and outcomes.SettingThe Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 885 centers in North America.MethodsThe MBSAQIP database was evaluated with 2 cohorts described: the COVID-19 and the pre–COVID-19, with patients receiving surgery in 2020 and 2015–2019, respectively. Yearly operative trends were characterized, and bivariate analysis compared demographics and postoperative outcomes. Multivariable modeling evaluated 30-day readmission, reintervention, and reoperation rates and factors associated with undergoing Roux-en-Y gastric bypass.ResultsWe evaluated 834,647 patients, with 155,830 undergoing bariatric surgery during the 2020 pandemic year. A 12.1% reduction in total cases (177,208 in 2019 versus 155,830 in 2020; P < .001) and 13.8% reduction in cases per center occurred (204.2 cases per center in 2019 versus 176.1 cases per center in 2020; P < .001). Patients receiving bariatric surgery during the pandemic were younger and had fewer co-morbidities. Use of sleeve gastrectomy increased (74.5% versus 72.5%; P < .001), and surgery during COVID-19 was associated with reduced Roux-en-Y gastric bypass procedure selection (odds ratio = .83; 95% CI: .82–.84; P < .001). Length of stay decreased significantly (1.4 ± 1.4 days versus 1.6 ± 1.4 days; P < .001), yet postoperative outcomes were similar. After adjusting for co-morbidities, patients during COVID-19 had decreased 30-day odds of readmission and reintervention and a small increase in odds of reoperation.ConclusionThe COVID-19 pandemic dramatically changed bariatric surgery delivery. Further studies evaluating the long-term effects of these changes are warranted.     

Prior Nonarthroplasty Surgery Increases Risk of Complication in Primary Total Knee Arthroplasty

BackgroundPrior ipsilateral knee surgery may increase the risk for complications after total knee arthroplasty (TKA). It remains unclear if the extent of previous surgery affects those risks disparately. The purpose of this study is to evaluate prior nonarthroplasty bony procedure (BP) and soft tissue only procedure (STP) as a potential risk factor for complications after TKA and determine the association with charges or reimbursement of the primary TKA.MethodsPatients who underwent primary TKA with previous knee surgery were identified using a national Medicare database and matched 1:5 to controls without prior knee surgery. Rates of postoperative medical and surgical complications were calculated in addition to hospital-associated charges and reimbursements. Logistic regression analysis was used to control for confounding factors.ResultsPatients who underwent BP (n = 835) had increased risk of readmission (58.6% vs 45.3%, odds ratio (OR) 1.72, 95% confidence interval (CI) 1.59-1.85, P < .001) and emergency room visits (14.5% vs 10.4%, OR 1.44, 95% CI 1.29-1.61, P = .001). Patients who underwent STP (n = 6766) had increased risk of readmission (58.1% vs 45.2%, OR 1.69, 95% CI 1.64-1.73, P < .001), emergency room visits (12.6% vs 0.7%, OR 1.33, 1.28-1.39, P < .001), revision (1.8% vs 1.4%, OR 1.33, 95% CI 1.21-1.47, P = .006), cerebrovascular accident (2.3% vs 1.7%, OR 1.33, 95% CI 1.22-1.46, P = .002), and venous thromboembolism (3.8% vs 3.2%, OR 1.21, 95% CI 1.13-1.29, P = .009). Prior surgery was associated with increased charges and reimbursements.ConclusionPrior ipsilateral knee surgery is associated with significantly increased risks of postoperative complications after primary TKA. Interestingly, previous STP but not BP increased the risk of short-term revision and venous thromboembolism.