Perception and Awareness of Bariatric Surgery in Canada: a National Survey of General Surgeons

Background

The objective of this study was to assess Canadian general surgeons’ knowledge of bariatric surgery and perceived availability of resources to manage bariatric surgery patients.

Methods

A self-administered questionnaire was developed using a focus group of general surgeons. The questionnaire was distributed at two large general surgery conferences in September and November 2012. The survey was also disseminated via membership association electronic newsletters in November and December 2012.

Results

One hundred sixty-seven questionnaires were completed (104 practicing surgeons, 63 general surgery trainees). Twenty respondents were bariatric surgeons. Among 84 non-bariatric surgeons, 68.3 % referred a patient in the last year for bariatric surgery, 79 % agreed that bariatric surgery resulted in sustained weight loss, and 81.7 % would consider referring a family member. Knowledge gaps were identified in estimates of mortality and morbidity associated with bariatric procedures. The majority of surgeons surveyed have encountered patients with complications from bariatric surgery in the last year. Over 50 % of surgeons who do not perform bariatric procedures reported not feeling confident to manage complications, 35.4 % reported having adequate resources and equipment to manage morbidly obese patients, and few are able to transfer patients to a bariatric center. Of the respondents, 73.3 % reported residency training provided inadequate exposure to bariatric surgery, and 85.3 % felt that additional continuing medical education resources would be useful.

Conclusions

There appears to be support for bariatric surgery among Canadian general surgeons participating in this survey. Knowledge gaps identified indicate the need for more education and resources to support general surgeons managing bariatric surgical patients.

     

The Effect of Roux-en-Y Gastric Bypass Surgery in Morbidly Obese Patients on Pharmacokinetics of (Acetyl)Salicylic Acid and Omeprazole: the ERY-PAO Study

Background

Data on the absorption of orally administered drugs following Roux-en-Y gastric bypass (RYGB) surgery in obese patients are limited and inconclusive. As it is difficult to predict changes in absorption, studies on frequently used drugs in this population are necessary. Acetylsalicylic acid (ASA) and omeprazole are two commonly prescribed drugs in obese patients.

Methods

In this repeated measures study, omeprazole and salicylic acid (SA) serum concentrations were measured before and after RYGB in 34 morbidly obese subjects. Time to maximum concentration (Tmax), lag time (Tlag), maximum concentration (Cmax), and area under the serum concentration versus time curve (AUC) were calculated for both drugs to determine possible differences in drug absorption after the procedure.

Results

For SA, Tmax significantly decreased after RYGB, while both Cmax and AUC_0–24 significantly increased. For omeprazole, both Tmax and Tlag significantly decreased after RYGB, while Cmax significantly increased. Mean AUC_0–12 significantly decreased post-surgery. The difference in AUC_0–12 before and after surgery varied between subjects.

Conclusions

Our study shows a faster absorption of both ASA and omeprazole after RYGB. The exposure to ASA is higher post-surgery, but the standard dose of 80 mg does not need to be modified, considering its range in effective dose. The exposure to omeprazole is, on average, decreased after surgery. Clinicians should be aware to increase the dose of omeprazole if symptoms suggest inadequate response.

     

A Pre-Hospital Patient Education Program Improves Outcomes of Bariatric Surgery

Background

We designed an assessment and education program which was delivered to patients prior to first outpatient appointment for bariatric surgery. We hypothesised that this program would streamline care and would lead to improved weight loss following bariatric surgery.

Methods

The program incorporates a structured general practitioners (GP) review, a patient information evening and an on-line learning package. It was introduced in September 2012. Patient flow through the program was recorded. Outcomes of the new program were compared with contemporaneously treated patients who did not undertake the pre-hospital program.

Results

All 636 patients on the waiting list for first appointment at the Alfred Health bariatric surgery clinic were invited to participate. There were 400 patients ultimately removed from the waiting list for first appointment. Of the remaining 236 patients, 229 consented to participate in the new program. The mean BMI was 47.8?±?9.2. The fail to attend first appointment rate dropped from 12 to 2.1 %. At 12 months post-bariatric surgery, patients who undertook the new program (n?=?82) had a mean excess weight loss (EWL) of 41.1?±?20.3 % where as those treated on the standard pathway (n?=?61) had a mean EWL 32?±?18.0 % (p?=?0.012).

Conclusions

The introduction of a pre-hospital education program has led to an improvement in attendance rates and early weight loss post-bariatric surgery.

     

Maximizing Weight Loss After Roux-en-Y Gastric Bypass May Decrease Risk of Incident Organ Cancer

Background

Recent studies have suggested that metabolic surgery reduces cancer risk. This study aims to determine if incident cancer is associated with the extent of weight loss after Roux-en-Y gastric bypass (RYGB).

Methods

Patients at a large tertiary bariatric surgery center were retrospectively reviewed to identify patients with no history of cancer at the time of RYGB. Diagnoses in the electronic health record, a tumor registry, and chart review were used to identify postoperative incident solid organ cancer. The overall incidence of organ cancer was estimated using Kaplan-Meier analysis. The percent total body weight loss (%TWL) in the 48 months after surgery but prior to cancer was compared between those that developed organ cancer versus those that did not using repeated measures linear regression.

Results

The 2943 patients had a mean age of 45.6 years (SD?=?11.1), 81 % were female, and a mean baseline body mass index (BMI) of 47.2 kg/m² (SD?=?7.9). Median follow-up after surgery was 3.8 years (range?=?[<1, 12]). Incident organ cancer developed and was verified in 54 of the 2943 patients (1.8 %). Kaplan-Meier estimates for cancer at 3, 5, and 10 years postsurgery were 1.3, 2.5, and 4.2 %. After adjusting for age, BMI, sex, diabetes, hypertension, and dyslipidemia, patients that developed organ cancer achieved less weight loss (?1.5 % TWL, 95 % CI?=?[?2.9 %, ?0.1 %], p?=?0.034).

Conclusions

Greater weight loss after metabolic surgery may be associated with lower organ cancer risk.

     

Implementing a robotics curriculum at an academic general surgery training program: our initial experience

The robotic surgical platform is being utilized by a growing number of hospitals across the country, including academic medical centers. Training programs are tasked with teaching their residents how to utilize this technology. To this end, we have developed and implemented a robotic surgical curriculum, and share our initial experience here. Our curriculum was implemented for all General Surgical residents for the academic year 2014–2015. The curriculum consisted of online training, readings, bedside training, console simulation, participating in ten cases as bedside first assistant, and operating at the console. 20 surgical residents were included. Residents were provided the curriculum and notified the department upon completion. Bedside assistance and operative console training were completed in the operating room through a mix of biliary, foregut, and colorectal cases. During the fiscal years of 2014 and 2015, there were 164 and 263 robot-assisted surgeries performed within the General Surgery Department, respectively. All 20 residents completed the online and bedside instruction portions of the curriculum. Of the 20 residents trained, 13/20 (65 %) sat at the Surgeon console during at least one case. Utilizing this curriculum, we have trained and incorporated residents into robot-assisted cases in an efficient manner. A successful curriculum must be based on didactic learning, reading, bedside training, simulation, and training in the operating room. Each program must examine their caseload and resident class to ensure proper exposure to this platform.     

An increasing proportion of perinephric to subcutaneous fat is associated with adverse perioperative outcomes of robotic partial nephrectomy

To investigate the association of perinephric fat (PF) thickness and the ratio of perinephric to subcutaneous fat (PF:SF) thickness on perioperative outcomes following robotic partial nephrectomy (RPN), 240 patients undergoing RPN with preoperative computed tomography (CT) axial imaging were included. Perinephric and subcutaneous fat thickness was measured at the level of the renal vein and umbilicus, respectively. The association between PF thickness and PF:SF ratio and perioperative outcomes was determined by Spearman correlation and logistic regression. 121 men and 119 women with a median age of 55 years, BMI of 32, tumor size of 2.6 cm, and RENAL nephrometry score of 6 were included. On preoperative imaging, median PF thickness was 2.2 cm, SF thickness was 3.1 cm, and PF:SF ratio was 0.63. There were statistically significant positive correlations between PF thickness (Spearman correlation coefficient = 0.26, p = 0.001) and PF:SF ratio (Spearman correlation coefficient = 0.33, p < 0.0001) with longer operative duration of RPN. In addition, an increasing PF:SF ratio was associated with a greater risk of perioperative complications (OR = 1.82, 95 % CI 1.1–3.0, p = 0.02). No association was observed with respect to ischemia time, blood loss, length of stay, or margin status. PF thickness is associated with longer OR duration, and a greater PF:SF ratio correlated with increased OR duration and complications following RPN. These easily measured indices of fat distribution are likely more accurate in predicting perioperative outcomes after RPN than BMI alone.     

External fixation reconstruction of the residual problems of benign bone tumours

The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov’s contribution that allows deformity correction and reconstruction of bone defects. We present a retrospective study of 20 patients who suffered from a variety of benign tumours for which external fixators (EF) were used to treat deformity, bone loss, and limb-length discrepancy. A total of 26 bony segments in twenty patients (10 males, 10 females; mean age 17 years; range 7–58 years) were treated with EF for residual problems from the tumour itself (primary treatment) in 8 patients and for complications related to the primary surgery (secondary treatment) in 12 patients. Histological diagnoses were Ollier’s disease (n = 4), Fibrous Dysplasia (n = 5), Congenital multiple exostosis (n = 5), giant cell tumour (n = 2) and one case for chondromyxoid fibroma, desmoid fibroma, chondroma and unicameral bone cyst. Various types of external fixators used to treat these problems. These were Ilizarov, unilateral fixator, multiaxial correction frame (Biomet, Parsippany, NJ), Taylor spatial frame (Memphis, TN) and smart correction multiaxial frame. The mean follow-up time was 69.5 months (range 35–108 months). The mean external fixation time was 159.5 days (range 27–300 days). The mean external fixation index was 67.4 days/cm (12–610) in 26 limbs who underwent distraction osteogenesis. The mean length of distraction was 4.9 cm (range 0.2–14 cm). At final follow-up, all patients had returned to normal activities. Complications were in the form of knee arthrodesis in one patient, pin tract infection in six and residual shortening in eight patients. The use of EF and the principles of distraction osteogenesis, in the management of problems associated with benign bone tumours and related surgery yields successful results especially in young patients. With this approach, the risk for recurrence of shortening and deformity may be minimized with overcorrection or over-lengthening as dictated by preoperative planning.     

Minimally invasive single-session double-level rotational osteotomy of the forearm bones to correct fixed pronation deformity in congenital proximal radioulnar synostosis

BackgroundCongenital proximal radioulnar synostosis is the most common congenital disease of the elbow joints and forearms.MethodsThis was a prospective study of 12 consecutive children (14 forearms) who presented to the National Institute of Neuromotor System in Egypt between September 2012 and September 2013 with severe congenital proximal radioulnar synostosis, having a mean pronation deformity of 70.7° (range 60°–85°), and who underwent operative correction by single-session double-level rotational osteotomy and percutaneous intramedullary K-wires of both the radius and ulna. Ten forearms were type III, and four were type II according to Cleary and Omer classification. The mean age at the time of surgery was 5 years and 2 months (range 4 years and 10 months to 6 years and 5 months). They were evaluated for functional results after rotational corrective osteotomy at a mean interval of 30.4 months (range 24–36 months) by physical examination and radiographs.ResultsAll children had a mean pronation deformity correction of 59.8° (range 30°–90°) reaching a final position of 20°–30° of pronation in the affected dominant extremities and 20° of supination in the affected non-dominant extremities after osteotomy. All children showed improvement in functional activities, with no loss of correction or non-union in any child, and no circulatory disturbances, neuropathies, or hypertrophic scars.ConclusionMinimally invasive single-session double-level rotation osteotomy of the proximal ulna and distal radius with percutaneous intramedullary K-wire fixation is a safe, technically simple and efficient procedure which corrects pronation deformity.     

Nanotechnology Treatment Options for Osteoporosis and Its Corresponding Consequences

Unfortunately, osteoporosis, as a worldwide disease, is challenging human health with treatment only available for the symptoms of osteoporosis without managing the disease itself. Osteoporosis can be linked as the common cause of fractures and increased mortality among post-menopausal women, men, and the elderly. Regrettably, due to osteoporosis, incidents of fractures are more frequent among the presented populations and can be afflictive for carrying out everyday life activities. Current treatments of osteoporosis encompass changing lifestyles, taking orthopedic drugs, and invasive surgeries. However, these treatment options are not long lasting and can lead to complications after post-surgical life. Therefore, to solve this impairment, researchers have turned to nanotechnologies and nanomaterials to create innovative and alternative treatments associated with the consequences of osteoporosis. This review article provides an introduction to osteoporotic compression vertebral fractures (OVCFs) and current clinical treatments, along with the rationale and efficacy of utilizing nanomaterials to modify and improve biomaterials or instruments. The methods of applying bioactive agents (bone morphogenetic protein-2 (BMP-2), parathyroid hormone 1–34 (PTH 1–34)), as well as 3D printing will be presented from an osteoporosis treatment perspective. Additionally, the application of nanoparticles and nanotube arrays onto the current surgical treatments and orthopedic drug administration methods addressed will show that these systems reinforce a better mechanical performance and provide precise and slow-releasing drug delivery for better osseointegration, bone regeneration, and bone strength. In summary, nanomaterials can be seen as an alternative and more effective treatment for individuals with osteoporosis.