Safety and Efficacy of Revisional Surgery as a Treatment for Malnutrition after Bariatric Surgery.

BACKGROUND: Malnutrition after bariatric operation is a rare but potentially life-threatening complication. The safety and efficacy of revisional bariatric operation in malnourished patients are not well elucidated. STUDY DESIGN: We performed a retrospective chart review of patients who underwent revisional bariatric operation for severe malnutrition at our institution between 2008 and 2020. Associations of demographic and clinical characteristics with dichotomous outcomes of interest were examined using Fisher's exact tests, Cochran-Armitage tests for trend, and two-sample t -tests when appropriate. RESULTS: Fifty-three patients underwent revisional bariatric operation for malnutrition from 2008 and 2020. The median follow-up was 24 months. The anatomy before revision was Roux-en-Y gastric bypass (n = 40, 75%), biliopancreatic diversion with duodenal switch (n = 6, 11%), sleeve gastrectomy (n = 4, 8%), and mini gastric bypass (n = 3, 6%). The percentage of patients requiring supplemental or total nutritional support decreased from 89% preoperatively (47% on enteral feedings and 42% on total parenteral nutrition (TPN) with or without tube feeding) to 13.2% at the last encounter after revision (7.5% still requiring enteral feedings and 5.7% on TPN). There was an association between the number of prior abdominal operations and postoperative pneumonia (p 0.03) and need for blood transfusion (p 0.01). There were no associations between major complications or last encounter nutrition and any preoperative variables other than age at the time of operation. There were 2 mortalities during a median follow-up of 24 months, and both occurred more than 1 year postoperatively. CONCLUSION: Revisional operation for severely malnourished bariatric operation patients is effective in the discontinuation of supportive nutrition. Postoperative complications are increased but not prohibitive.

Fourteen Crutches for Mediocrity. The logismoi that jeopardize good research and publication.

Publications are used widely as a measure of academic quality. Many investigators have difficulty publishing in this competitive field. After coming across a religious lecture on the "Fourteen Crutches for Mediocrity", our team adapted this approach to life to the science of publishing: (1) what is the problem of doing it?; (2) there are worse!; (3) everybody does it!; (4) why exaggerate?; (5) I will do it tomorrow!; (6) maybe if …; (7) it is not used anymore!; (8) be a cousin not a brother!; (9) I need to be thanked!; (10) don't eat your own head, let it be!; (11) I can't possibly accomplish it!; (12) I don't feel like doing it!; (13) I am fed up!; (14) I am not worthwhile! These crutches jeopardize good research and thoughtful learned publications.

Postpancreatectomy Acute Pancreatitis (PPAP): Definition and Grading From the International Study Group for Pancreatic Surgery (ISGPS).

OBJECTIVE: The ISGPS aimed to develop a universally accepted definition for PPAP for standardized reporting and outcome comparison. BACKGROUND: PPAP is an increasingly recognized complication after partial pancreatic resections, but its incidence and clinical impact, and even its existence are variable because an internationally accepted consensus definition and grading system are lacking. METHODS: The ISGPS developed a consensus definition and grading of PPAP with its members after an evidence review and after a series of discussions and multiple revisions from April 2020 to May 2021. RESULTS: We defined PPAP as an acute inflammatory condition of the pancreatic remnant beginning within the first 3 postoperative days after a partial pancreatic resection. The diagnosis requires (1) a sustained postoperative serum hyperamylasemia (POH) greater than the institutional upper limit of normal for at least the first 48 hours postoperatively, (2) associated with clinically relevant features, and (3) radiologic alterations consistent with PPAP. Three different PPAP grades were defined based on the clinical impact: (1) grade postoperative hyperamylasemia, biochemical changes only; (2) grade B, mild or moderate complications; and (3) grade C, severe life-threatening complications. DISCUSSIONS: The present definition and grading scale of PPAP, based on biochemical, radiologic, and clinical criteria, are instrumental for a better understanding of PPAP and the spectrum of postoperative complications related to this emerging entity. The current terminology will serve as a reference point for standard assessment and lend itself to developing specific treatments and prevention strategies.

Fourteen Crutches for Mediocrity. The logismoi that jeopardize good research and publication.

Publications are used widely as a measure of academic quality. Many investigators have difficulty publishing in this competitive field. After coming across a religious lecture on the "Fourteen Crutches for Mediocrity", our team adapted this approach to life to the science of publishing: (1) what is the problem of doing it?; (2) there are worse!; (3) everybody does it!; (4) why exaggerate?; (5) I will do it tomorrow!; (6) maybe if …; (7) it is not used anymore!; (8) be a cousin not a brother!; (9) I need to be thanked!; (10) don't eat your own head, let it be!; (11) I can't possibly accomplish it!; (12) I don't feel like doing it!; (13) I am fed up!; (14) I am not worthwhile! These crutches jeopardize good research and thoughtful learned publications.

The Long-Term Impact of Bariatric Surgery on Development of Atrial Fibrillation and Cardiovascular Events in Obese Patients: An Historical Cohort Study.

Objective: To determine whether early Roux-en-Y gastric bypass surgery (RYGB) reduces the risk of Major adverse cardiovascular events (MACE) in patients with obesity. Patients and Methods: We conducted a study of patients with class II and III obesity [body mass index (BMI) > 35 kg/m2] from Olmsted County, Minnesota, who underwent obesity clinic consultation between the years 1993-2012, and had either RYGB surgery within 1 year (RYGB-1Y group), or medically managed (No-RYGB group). The composite endpoint of MACE (all-cause mortality, stroke, heart failure admission and acute myocardial infarction) was the primary endpoint, with new-onset AF as the secondary endpoint. Results: Of the 1,009 study patients, 308 had RYGB-1Y and 701 were medically managed (No-RYGB). Overall, the age was 44.0 ± 12.4 (mean ± SD) years; BMI was 45.0 ± 6.8 kg/m2. The RYGB-1Y group had a lower rate of MACE (adjusted hazard ratio (HR), 0.62; 95% CI, 0.44-0.88; P = 0.008) and lower mortality (adjusted HR, 0.51; 95% CI, 0.26-0.96; P = 0.04) than the No-RYGB group. The RYGB-1Y surgery was not associated with lower AF occurrence (HR, 0.66; 95% CI, 0.40-1.10; P = 0.11). Conclusion: An early RYGB approach for BMI reduction was associated with lower rates of MACE.

Clinical practice guidelines for the management of liver metastases from extrahepatic primary cancers 2021.

BACKGROUND: Hepatectomy is standard treatment for colorectal liver metastases; however, it is unclear whether liver metastases from other primary cancers should be resected or not. The Japanese Society of Hepato-Biliary-Pancreatic Surgery therefore created clinical practice guidelines for the management of metastatic liver tumors. METHODS: Eight primary diseases were selected based on the number of hepatectomies performed for each malignancy per year. Clinical questions were structured in the population, intervention, comparison, and outcomes (PICO) format. Systematic reviews were performed, and the strength of recommendations and the level of quality of evidence for each clinical question were discussed and determined. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations. RESULTS: The eight primary sites were grouped into five categories based on suggested indications for hepatectomy and consensus of the guidelines committee. Fourteen clinical questions were devised, covering five topics: (1) diagnosis, (2) operative treatment, (3) ablation therapy, (4) the eight primary diseases, and (5) systemic therapies. The grade of recommendation was strong for one clinical question and weak for the other 13 clinical questions. The quality of the evidence was moderate for two questions, low for 10, and very low for two. A flowchart was made to summarize the outcomes of the guidelines for the indications of hepatectomy and systemic therapy. CONCLUSIONS: These guidelines were developed to provide useful information based on evidence in the published literature for the clinical management of liver metastases, and they could be helpful for conducting future clinical trials to provide higher-quality evidence.

Efficacy of Conversion of Roux-en-Y Gastric Bypass to Roux Jejuno-Duodenostomy for Severe Medically Refractory Postprandial Hypoglycemia.

Treatment of medically refractory postprandial hypoglycemia after Roux-en-Y Gastric bypass (RYGB) is often unsuccessful. Various operations have been described with poor results. We describe a novel procedure and retrospective review of 8 patients who underwent Roux jejuno-duodenostomy for postprandial hypoglycemic symptoms refractory to dietary modification and medications. Mean follow-up was 35 months. Complete resolution occurred in two of the patients, marked improvement in four, and no improvement in two. The mean frequency of hypoglycemic symptoms decreased from 30 to 7 episodes per week (p = 0.015). One complication was noted with no mortality. Mean weight decreased postoperatively by 0.8 kg (p = 0.93). Conversion to a Roux jejuno-duodenostomy appears to be a safe and effective treatment with maintenance of post-RYGB weight loss in most such cases.

An International Collaborative Study on Surgical Education for Quality Improvement (ASSURED): A Project by the 2017 International Society of Surgery (ISS/SIC) Travel Scholars International Working Group.

BACKGROUND: There is a huge difference in the standard of surgical training in different countries around the world. The disparity is more obvious in the various models of surgical training in low- and middle-income countries (LMICs) compared to high-income countries. Although the global training model of surgeons is evolving from an apprenticeship model to a competency-based model with additional training using simulation, the training of surgeons in LMICs still lacks a standard pathway of training. METHODS: This is a qualitative, descriptive, and collaborative study conducted in six LMICs across Asia, Africa, and South America. The data were collected on the status of surgical education in these countries as per the guidelines designed for the ASSURED project along with plans for quality improvement in surgical education in these countries. RESULTS: The training model in these selected LMICs appears to be a hybrid of the standard models of surgical training. The training models were tailored to the country's need, but many fail to meet international standards. There are many areas identified that can be addressed in order to improve the quality of surgical education in these countries. CONCLUSIONS: Many areas need to be improved for a better quality of surgical training in LMICs. There is a need of financial, technical, and research support for the improvement in these models of surgical education in LMICs.