Total Knee Arthroplasty in the Elderly. Is There an Age Limit?

The goal of this study was to compare the results of the total knee arthroplasty (TKA) in 2 study groups only differing by age. We have analyzed 218 TKA cases (138 women and 80 men) with at least 2 years follow-up. Mean age was 70 years (SD, 7.38 years; range, 43 to 98 years). An age cutoff point at 75 years defined the 2 study groups: 167 cases younger than 75 years and 51 older. Results were evaluated using the Hospital for Special Surgery Score. Mean score was raised from 53.43 (SD, 9.186) preoperatively to 85.57 (SD, 10.763) in 2 years follow-up (P < .001). The final score did not show significant differences between both groups (86.11 for the younger group and 83.8 for the older group). Differences in pain on walking, pain at rest, walk, range of motion, climbing stairs, transfer, muscle strength, or instability were not found between the patients younger and older than 75 years. We did not find any differences in TKA, functional score, or pain between the 2 studied groups.     

Management of Ulcerative Colitis in the Morbidly Obese Patient: Is Bariatric Surgery Indicated?

Ulcerative colitis and obesity share a systemic chronic inflammatory response manifested by increased inflammatory markers. There are data suggesting a benefit in both diseases after inflammatory markers are decreased. We present a 39-year-old morbidly obese male with a history of ulcerative colitis who manifested significant symptomatic improvement after an 86.8% excess weight loss following gastric bypass surgery. We believe that this result may have been due to a reduction of inflammatory markers secondary to considerable weight loss. Although to our knowledge there are no publications showing a direct relationship between symptomatic improvement of ulcerative colitis and weight loss in the obese patient, we believe that weight loss surgery could become a promising tool in the treatment of ulcerative colitis when associated with morbid obesity.     

Bariatric Surgery in Adolescence. Is this the Best Age to Operate?

Background: Bariatric surgery in morbidly obese adolescents is controversial. Many argue that morbidly obese individuals should be of adult age before undergoing bariatric operations, despite the progressive and debilitating course of this increasingly common disease. Materials and Methods: 19 consecutive adolescent patients, aged 13-17, underwent vertical banded gastroplasty-Roux-en-Y gastric bypass between May 1990 and August 2001. Average BMI was 49 kg/m², range 38-67. All had one or more co-morbidities. Follow-up was obtained up to 10 years. Results: Postoperative BMI at the maximum time of follow-up, mean 5.5 years (range 1-10 years), was 28 (range 23 to 45). Only one patient did not lose enough weight and was considered a failure. There were two revisions and no mortality or morbidity. All co-morbidities disappeared. Family and patients were pleased with the surgery. Conclusions: Early surgical intervention should be offered to a greater number of adolescents to minimize the emotional and physical consequences of morbid obesity.     

What is the Future of Surgical Treatment of Obesity; What Will be the Place of the American Society for Bariatric Surgery?

There is focused awareness of severe obesity, its health risk and possible solutions. Yet there remains confusion and skepticism among the medical profession over therapeutic action. Basic questions unanswered project futility toward solving the problem, while the general public is driven toward unsound solutions which are costly. A cloud of cynicism pervades for those seeking to control this problem surgically. The problem will persist. Its health risks increasingly will demand attention, and solution will be sought by surgical means which is the only control for comorbidity, but does not cure severe obesity. Pressure to totally control excess weight results in undesirable sideeffects. Careful judgement must be used. New insight is desperately needed to understand severe obesity, its etiology and pathophysiology. This insight is likely to come from careful observations of those engaged in its control. Surgical control, profound in its success, provides a model that should lead to more complete understanding of severe obesity, as in the example of “Burns-The Universal Trauma Model.” Those experienced and engaged in this work show courage in this orphan field of endeavour. They lead the way as general surgeons and gastrointestinal surgeons with broad application of knowledge for this model. This society will continue to focus the expertise and the opportunities in this area. The future predicted is exciting and demanding.     

Heart Transplantation With Older Donors: Should There Be an Age Cutoff?

PurposeHeart transplantation remains limited by donor availability. Currently, only some programs accept older donors, and their use remains contentious. We compared outcomes of heart transplant recipients who received donor hearts ≥55 years with those who received donor hearts <55 years.MethodsRecords of first-time adult heart transplant recipients between 2010 and 2019 were reviewed. Endpoints included 30-day and 1-, 3-, and 5-year survival; freedom from cardiac allograft vasculopathy; freedom from nonfatal major adverse cardiac events; and freedom from any rejections. The effect of donor age ≥55 years was analyzed with Cox proportional hazards modeling, 1:2 propensity score matching, and Kaplan-Meier survival analysis.ResultsSixty-six patients received donor hearts ≥55 years and 766 received donor hearts <55 years. In the unmatched cohort, there was no significant difference in survival between the 2 groups at 30 days (93.9% vs 97.3%, P = .127), 1 year (87.9% vs 91.6%, P = .325), 3 years (86.4% vs 86.5%, P = .888), or 5 years (78.8% vs 83.8%, P = .497). The ≥55 years group had a significantly lower freedom from cardiac allograft vasculopathy and fatal major adverse cardiac events. In propensity-matched patients, recipients of donors ≥55 years had similar survival and freedom from cardiac allograft vasculopathy but significantly lower 1-year (76.7% vs 88.3%, P = .026), 3-year (68.3% vs 84.2%, P = .010), and 5-year (63.3% vs 83.3%, P = .002) freedom from nonfatal major adverse cardiac events when compared to recipients of younger donors.ConclusionsCarefully selected older donors can be considered for a carefully selected group of recipients with acceptable outcomes.     

Who Should Be Doing Laparoscopic Bariatric Surgery?

Background: The training and credentialing of surgeons for laparoscopic bariatric surgery is controversial. We sought to determine if there is an association between surgeons' practice and choice of open or laparoscopic bariatric surgery. Methods: Members of the ASBS were surveyed via email. Associations were tested with Cochran-Mantel-Haenszel or Pearson's chi-square. Results: 104/472 members responded; 65% were in private practice; 47% did 1-5 operations/week, 48% offered open procedures only, and 76% undertook gastric bypass. Respondents believe that laparoscopic procedures: should mimic open ones (77%), are safe (63%), should be evaluated by clinical trials (48%), and that expertise in bariatric surgery is more important than laparoscopic experience. 75% believe that courses and preceptorships are important. Regarding laparoscopic operations, surgeons doing only open procedures believe that: 1) the ASBS should be the main credentialing body; 2) surgeons should do >25 open before laparoscopic ones; and 3) clinical trials are needed (P<0.02, all). Surgeons with laparoscopic training or practices believe that laparoscopic surgery is safe and effective (P<0.002). Both laparoscopic and open surgeons believe bariatric surgeons should be the only surgeons doing laparoscopic bariatric procedures (P<0.008). Conclusions:There is consensus that laparoscopic bariatric surgery should be undertaken only by surgeons with strong interest in bariatric surgery. Laparoscopic bariatric surgeons should incorporate lessons learned from open surgery. Both laparoscopic and open bariatric surgeons should seek added expertise via courses and preceptorships.The skepticism of surgeons with 'open' practices could be addressed by clinical trials. The ASBS should maintain its leadership position and foster emerging technologies.     

Systematic Review of Obesity Surgery Mortality Risk Score—Preoperative Risk Stratification in Bariatric Surgery

Bariatric surgery is the best long term treatment for morbid obesity. However, it carries risks of considerable morbidity and potential mortality. There is no published review on pre-operative identification of high-risk patients in bariatric surgery. This systematic review analyses obesity surgery mortality risk score (OS-MRS) as a tool for pre-operative prediction of mortality risk in bariatric surgery. Medline and Embase was systematically searched using the medical subjects headings (MeSH) terms 'bariatric surgery' and 'mortality' with further free text search and cross references. Studies that described OS-MRS to predict mortality risk after bariatric surgery were included in this review. Six studies evaluated 9,382 patients to assess the validity of OS-MRS to predict the mortality risk after bariatric surgery. Patient's age ranged from 19 to 67 years, and the body mass index ranged from 30 to 84. There were 83 deaths among the 9,382 patients (0.88 %) with individual studies reporting a mortality range from 0 % to 1.49 %. There were 13 deaths among 4,912 (0.26 %) class A patients, 55 deaths among 4,124 (1.33 %) class B patients and 15 deaths among 346 (4.34 %) class C patients. Mortality in classes A, B and C was significantly different from each of the other two classes (P < 0.05, χ(2)). This systematic review confirms that OS-MRS stratifies the mortality risk in the three-risk classification subgroups of patients. The OS-MRS can be used for pre-operative identification of high-risk patients undergoing primary Roux-en-Y gastric bypass surgery.     

Assessing Marijuana Use in Bariatric Surgery Candidates: Should It Be a Contraindication?

Research has demonstrated negative effects of both alcohol and tobacco use after bariatric surgery. However, no research to date has examined effects of cannabis use after bariatric surgery, even though cannabis is the most commonly used illicit drug in the USA. Literature review reveals that many practitioners generalize from data regarding alcohol abuse to all substances. Further, many screening protocols fail to differentiate between varying levels of cannabis use. The current report aims to (1) review the relevant literature on marijuana use and its potential consequences among bariatric patients, (2) discuss relevant problems and gaps in this literature, and (3) make preliminary recommendations regarding the assessment and treatment planning of bariatric candidates who disclose marijuana use.     

Radiologic Assessment of the Upper Gastrointestinal Tract: Does It Play an Important Preoperative Role in Bariatric Surgery?

Background: The role of upper GI series (UGIS) before bariatric surgery is controversial. The aim of this study was to evaluate the diagnostic yield and cost of routine UGIS prior to bariatric surgery. Methods: The medical records of consecutive obese patients who underwent UGIS before bariatric surgery between April 2001 and October 2002 were reviewed. UGIS reports were reviewed by 2 experienced gastroenterologists, and the findings were divided into 4 groups based on predetermined criteria: group 0 (normal study), group 1 (abnormal findings that neither changed the surgical approach nor postponed surgery), group 2 (abnormal findings that changed the surgical approach or postponed surgery), and group 3 (results which were an absolute contraindication to surgery). Clinically important findings included lesions in groups 2 and 3. The cost of an upper GI series ($154.80) was estimated from the published 2002 New York State Medicare reimbursement schedule. Results: During the 18-month study period, 171 patients were evaluated by UGIS prior to bariatric surgery. One or more lesions were identified in 48.0% of patients, with only 5.3% having clinically important findings. The prevalence of radiologic findings using the classification system above was as follows: group 0 (52.0%), group 1 (42.7%), group 2 (5.3%), and group 3 (0.0%). The most common findings identified were esophageal reflux (21.6%) and hiatal hernias (18.7%). The cost of performing routine UGIS on all patients before bariatric surgery was $2,941.20 per clinically important finding detected. Conclusions: Routine preoperative upper GI series before bariatric surgery had a low diagnostic yield, rarely revealing pathology that changed the surgical approach or postponed surgery.     

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     

Parathyroid Surgery in the Elderly: Should Minimally Invasive Surgery Be Abandoned?

Background

Single adenoma is the cause of 80 % of primary hyperparathyroidism (PHPT) resulting in wide acceptance of minimally invasive parathyroidectomy (MIP). The incidence of PHPT increases with age. Little information is available regarding the prevalence of multiglandular disease (MGD) in older patients.

Methods

The records of 537 patients that underwent parathyroid surgery between January 2005 and October 2012 at two endocrine surgery referral centers were retrospectively reviewed. Comparison was performed between patients younger than 65 and older than 65 years of age. Clinical variables included preoperative laboratories and imaging, extent of neck exploration, number of glands excised, and intraoperative parathyroid hormone levels during surgery.

Results

There were 374 (70 %) patients in the younger age group (YG) and 163 (30 %) patients in the older age group (OG). The mean age was 50 ± 0.5 and 71 ± 0.4 years, respectively. There was no difference between the groups in terms of gender or laboratory results. MGD was significantly more common in the OG (24 % vs. 12 %; p = 0.001) and similarly MIP was less commonly completed in the OG (49 % vs. 68 %; p < 0.001). Cure rates were comparable between the OG and YG (93 % vs. 95 %; p = 0.27). In the OG, patients with MGD had significantly smaller glands as compared to patients with single adenomas in this group (331 ± 67 vs. 920 ± 97 mg; p = 0.006, respectively).

Conclusions

MGD in PHPT was found to be more prevalent in older patients. Planning a bilateral neck exploration should be considered in older patients, especially when a relatively small gland is suggested by imaging or encountered during surgery.