National trends in using revisional surgeries post-sleeve gastrectomy due to reflux and weight recurrence: a matched case-control analysis.

BACKGROUND: Several options exist for surgical conversion after sleeve gastrectomy (SG), but a definitive safety profile for each option by indication for conversion remains unclear. OBJECTIVES: To determine and compare 30-day risk profiles of SG conversion to Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), and single-anastomosis duodenoileostomy (SADI). METHODS: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program national database entries from 2020 to 2022 were used to identify 25,760 adult patients who underwent SG conversion to RYGB, BPD-DS, or SADI. Subgroup analyses were performed among 6106 conversions completed for weight-related complications (RYGB: 3053 patients; BPD-DS: 1826 patients; SADI: 1227 patients). Multivariable analysis and 1:1 nearest-neighbor matching were used to further characterize the 30-day risk profile of each conversion. RESULTS: Patients with RYGB conversions had a lower preoperative body mass index compared with those with BPD-DS + SADI conversions (39.8 versus 46.1, P < .001) and significantly lower rates of medical comorbidities. The distribution of conversion indication for each MBS configuration varied, where most RYGB conversions were for reflux (56.1%) whereas most BPD-DS + SADI conversions were for weight-related complications (87.3%; P < .001). On 1:1 matched analysis of conversions for weight recurrence, odds of 30-day complications (odds ratio .73, P = .019) and readmission (odds ratio .77, P = .031) were lower in BPD-DS + SADI conversions compared with RYGB. There were no significant differences in odds of 30-day reintervention or reoperation between conversion to RYGB and BPD-DS + SADI. Major differing drivers of complications between conversion types included hemorrhage (RYGB 1.98% versus BPD-DS + SADI .87%; P = .001). CONCLUSIONS: For weight recurrence after SG, conversion to BPD-DS + SADI does not have greater 30-day complications than RYGB and may be a safe conversion option.

From Bands to Bypasses: Navigating Safety of Band Conversions to Roux-en-Y Gastric Bypass and Single Anastomosis Duodenoileostomy Versus Sleeve Gastrectomy.

INTRODUCTION: Revisional bariatric surgery is associated with higher perioperative complications over primary procedures. Adjustable gastric bands (AGB) continue to be the most frequently converted bariatric configuration. This study examines trends in current clinical indication and safety profile of the most frequently pursued AGB conversions. MATERIALS AND METHODS: MBSAQIP data from 2020 to 2022 was retrospectively analyzed in a cohort study examining 30-day postoperative outcomes after AGB conversion to sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or single anastomosis duodenoileostomy (SADI). Descriptive statistics were used, including multivariable and 2:1 nearest neighbor matching analysis. RESULTS: This study included 19,335 AGB conversions, of which most were to SG (n = 11,736) followed by RYGB (n = 7442) and SADI (n = 157). While a majority were completed for weight loss, there were differences in distribution of primary indication for each conversion cohort, such as higher proportion of RYGB conversion for gastroesophageal reflux disease (18.7%) compared to SG (7.92%) and SADI (5.10%). Multivariable analysis demonstrates conversion to RYGB has significantly higher odds of 30-day major complications (OR 1.75, p < 0.001), reoperation (OR 2.08; p = 0.001), readmission (OR 1.69; p = 0.001), and emergency department visits (OR 1.50; p = 0.001) over SG. These risks and odds of reintervention (OR 1.75; p < 0.001) remained significantly higher after conversion to RYGB versus SG on matched analysis. None of these risks is significantly different between conversions to SADI versus SG in either multivariable or matched analysis. CONCLUSIONS: Compared to AGB conversion to SG, single-stage conversion to RYGB had increased odds of perioperative complications while risks of conversion to SADI were not significantly different.

Impact of Preoperative Weight Loss on 30-Day Complication Rate after Bariatric Surgery.

BACKGROUND: The aim of this study is to evaluate the impact of preoperative weight loss on surgical outcomes and operating room (OR) times after primary bariatric procedures, including laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (RYGB). STUDY DESIGN: A retrospective cohort study uses the 2021 MBSAQIP dataset. Preoperative total weight loss (TWL)% was calculated. Patients were then divided in to 4 groups: those with no weight loss, lost <0 to <5%, lost ≥5% to <10%, or lost ≥10% TWL preoperatively. These groups were then stratified into those with BMI less than 50 kg/m 2 and those with BMI 50 kg/m 2 or more and 30-day outcomes and OR times were compared. RESULTS: Analysis included 171,010 patients. For BMI less than 50 kg/m 2 , preoperative weight loss led to no consistent improvement in surgical outcomes. Although >0% to <5% TWL led to a decrease in intra- and postoperative occurrences after RYGB and a decrease in reoperation rates after LSG, these observations were not seen in those with higher degree of weight loss. In patients with BMI 50 kg/m 2 or more, preoperative weight loss showed a consistent improvement in reintervention rates after LSG, and readmission rates after RYGB. There was no improvement in other outcomes, however, irrespective of degree of preoperative weight loss. CONCLUSIONS: In patients undergoing primary bariatric surgery, preoperative weight loss does not lead to a consistent improvement in outcomes or OR times. In those with BMI 50 kg/m 2 or more, there may be improvement in select outcomes that is procedure-specific. Overall, these data do not support a uniform policy of preoperative weight loss, although selective use in some high-risk patients may be appropriate.

Outcomes and Management of Re-Establishing Bariatric Patients.

BACKGROUND: Lifelong follow-up after metabolic and bariatric surgery (MBS) is necessary to monitor for patient outcomes and nutritional status. However, many patients do not routinely follow-up with their MBS team. We studied what prompted MBS patients to seek bariatric care after being lost to follow-up and the subsequent treatments they received. STUDY DESIGN: A retrospective cohort study of patients after MBS who had discontinued regular MBS follow-up but represented to the MBS clinic between July 2018 and December 2022 to re-establish care. Patients with a history of a sleeve gastrectomy (SG), Roux-En-Y gastric bypass (RYGB), and adjustable gastric banding (AGB) were included. RESULTS: We identified 400 patients (83.5% women, mean age 50.3 ± 12.2 years at the time of re-establishment of bariatric care), of whom 177 (44.3%) had RYGB, 154 (38.5%) had SG, and 69 (17.2%) had AGB. Overall, recurrent weight gain was the most common reason for presentation for all three procedures (81.2% in SG, 62.7% in RYGB, and 65.2% in AGB; p < 0.001). Patients who underwent SG were more likely to undergo a revision MBS compared with patients who underwent RYGB (16.9% vs 5.8%, p < 0.001), whereas patients who underwent RYGB were more likely to undergo an endoscopic intervention than patients who underwent SG (17.5% vs 7.8%, p < 0.001). The response to antiobesity medication agents, specifically glucagon-like peptide-1 receptor agonists drugs, was better in patients who underwent RYGB, than that in patients who underwent SG. CONCLUSIONS: This study highlights recurrent weight gain as the most common reason for patients after MBS seeking to re-establish care with the MBS team. SG had a higher rate of revision MBS than RYGB, whereas endoscopic interventions were performed more frequently in the RYGB group. Antiobesity medication agents, especially glucagon-like peptide-1 receptor agonists drugs, were more effective in patients who underwent RYGB.

Clinical outcomes following treatment of deep surgical site infection after fixation of calcaneal fractures: A retrospective case-control study.

INTRODUCTION: Deep surgical site infection (SSI) may be a complication of open reduction and internal fixation (ORIF) of calcaneal fractures. This study aimed to describe the characteristics of patients with deep SSI following ORIF of calcaneal fractures via extensile lateral approach (ELA). We compared clinical outcomes of these patients, with a minimum follow-up of one year after successful treatment of deep SSI with a matched control group. METHODS: In this retrospective case-control study, demographic data, fracture characteristics, bacterial pathogens, medical treatments and surgical approaches were collected, also the outcome was evaluated by the visual analog scale (VAS) for pain, foot function index (FFI) and AOFAS ankle-hindfoot score. The differences in Böhler and Gissane's angles between infected and contralateral feet were measured. By matching a control group of uninfected cases, clinical outcomes were compared between 2 groups using the Mann-Whitney U test. RESULTS: Among 331 calcaneus fractures in 308 patients (mean age, 38.0 ± 13.1; male/female ratio, 5.5), 21 had deep SSI (6.3 %). There were 16 (76.2 %) males and 5 (23.8 %) females with a mean age of 35.1 ± 11.7 years. Thirteen (61.9 %) patients had unilateral fractures. The most common Sanders Type was found to be type II. The most frequent type of detected microorganisms was Staphylococcus species. Intravenous antibiotic therapy, mostly clindamycin, imipenem and vancomycin, based on the microbiological results, was prescribed with a mean±SD duration of 28.1 ± 16.5 days. The mean number of surgical debridements was 1.8 ± 1.3. Implants needed to be removed in 16 (76.2 %) cases. Antibiotic-impregnated bone cement was applied in three (14.3 %) cases. The clinical outcomes of 15 cases (follow up, 35.5 ± 13.8; range, 12.6-64.5 months) were 4.1 ± 2.0, 16.7 ± 12.3 and 77.5 ± 20.8 for VAS for pain, FFI % and AOFAS ankle-hindfoot score, respectively. Comparing with the control group (VAS for pain, 2.3 ± 2.7; FFI %, 12.2 ± 16.6, and AOFAS, 84.6 ± 18.0), only VAS pain was statistically lower in this group (p-value: 0.012). The differences in Böhler and Gissane's angles between both feet of infected cases were - 14.3 ± 17.9 and - 7.7 ± 22.5 (worse in the infected side), respectively. CONCLUSION: Proper on-time approaches to deep infection following ORIF of calcaneal fractures may lead to acceptable clinical and functional outcomes. Sometimes aggressive approaches with intravenous antibiotic therapy, multiple sessions of surgical debridement, removal of implants and antibiotic impregnated cement are necessary to eradicate deep infection. LEVEL OF EVIDENCE: Level III.

The Effect of Single-Anastomosis Sleeve Ileal (SASI) Bypass on Patients with Severe Obesity in Three Consecutive Years.

BACKGROUND: Sparse data are available regarding the efficacy and safety of single anastomosis sleeve ileal (SASI) bypass surgery, where most available studies utilized short-term follow-ups. Therefore, this study was conducted to evaluate the safety and outcomes of this procedure in three consecutive years after the surgery. MATERIALS AND METHODS: This retrospective study was carried out with 116 patients who underwent SASI from October 2016 to September 2021. Anthropometric, clinical, and biochemical data were recorded before, 1, 2, and 3 years after surgery. RESULTS: The 1, 2, and 3-year percentage of excess weight loss (%EWL) were 87.37%, 90.7%, and 80.6%, respectively. Remission or improvement was recorded for diabetes mellitus in 90.9%, hypertension in 80.0%, hyperlipidemia in 100%, sleep apnea in 100%, and irregular menstruation in 58.06 at 3 years after surgery. No mortality and 5.1% early major postoperative complications were recorded. Eight patients (6.8%) had reversal surgery due to EWL > 100%. CONCLUSIONS: The SASI bypass is an effective bariatric surgery that achieved sequential weight loss and improvement in medical comorbidities three years after the surgery; however, standardization of SASI procedure technique is needed to ameliorate nutritional deficiencies.

Optimal Length of Biliopancreatic Limb in Single Anastomosis Sleeve Gastrointestinal Bypass for Treatment of Severe Obesity: Efficacy and Concerns.

PURPOSE: The present study aimed to compare two newly introduced procedures, single anastomosis sleeve jejunal (SASJ) with ileal (SASI) bypass in terms of weight loss, remission of obesity-associated medical problems, complications, and nutritional status. MATERIALS AND METHODS: This retrospective study was carried out with 162 patients who underwent single anastomosis sleeve gastrointestinal bypass from October 2017 to September 2021, either single anastomosis sleeve jejunal bypass (SASJ) or single anastomosis sleeve ileal bypass (SASI). The main outcome measures were weight loss and improvement in obesity-associated medical problems, nutritional status, and complications at 12 months post-surgery. RESULTS: At 12 months, both groups showed significant weight loss and remission in obesity-associated medical problems. There were significant differences in body mass index (BMI), total weight loss (TWL), and excess weight loss (EWL) between SASI and SASJ bypass (P < 0.05). Improvements in associated medical problems after the two procedures were similar except for hypertension. The reversal surgery rate of the SASI group was significantly higher than that of the SASJ group (5.5% vs. 0.0%, p = 0.03). CONCLUSIONS: SASJ and SASI bypass achieved satisfactory weight loss and improvement in obesity-associated medical problems that were comparable between the two groups. SASI bypass was followed by a significant difference in the rate of reversal surgery at 1 year due to a short common channel, which was not observed after SASJ bypass.

Lung Injuries Associated with Scapular Fractures in Adult Traumatic Patients.

Background: Scapular fractures are among the orthopedic injuries, which are associated with other injuries, such as lung injuries. This study aimed to evaluate the prevalence of lung injuries associated with scapular fractures in traumatic patients referred to a main trauma center in the south of Iran. Methods: The present retrospective cross-sectional study was conducted from April 2016 to June 2019 on adult traumatic patients, who were referred to one of the main trauma centers in the south of Iran, and their data were recorded in the hospital information system. The patients with chest computed tomography, and those whose scapula fractures were reported and confirmed by a radiologist were included in this study. All patients' data were extracted from their medical files and then analyzed. Results: A total of 100 patients were enrolled, and the majority (78%) of the cases were male. The mean±SD age of the patients was 40.71±14.071 years, and 55% of the cases had lung injuries (P=0.158). Furthermore, most of the causes of scapular fracture were due to car-motorcycle accidents (30%) and car overturning (27%). Lung contusion (31%) and hemothorax (30%) were the most types of lung injuries. The mean±SD duration of hospitalization was estimated at 4.94±7.90 days. The mean age (OR=-0.207, P=0.039) and intensive care unit admission rate (OR=0.267, P=0.007) were statistically different in patients with and without lung injuries. Conclusion: Although scapula fractures were not significantly associated with lung injuries in this study, the occurrence of 55% of the lung injuries was clinically important, which should be considered by emergency physicians.

The Effect of Cigarette Smoke Exposure on Efferocytosis in Chronic Obstructive Pulmonary Disease; Molecular Mechanisms and Treatment Opportunities.

Cigarette smoking-related inflammation, cellular stresses, and tissue destruction play a key role in lung disease, such as chronic obstructive pulmonary disease (COPD). Notably, augmented apoptosis and impaired clearance of apoptotic cells, efferocytosis, contribute to the chronic inflammatory response and tissue destruction in patients with COPD. Of note, exposure to cigarette smoke can impair alveolar macrophages efferocytosis activity, which leads to secondary necrosis formation and tissue inflammation. A better understanding of the processes behind the effect of cigarette smoke on efferocytosis concerning lung disorders can help to design more efficient treatment approaches and also delay the development of lung disease, such as COPD. To this end, we aimed to seek mechanisms underlying the impairing effect of cigarette smoke on macrophages-mediated efferocytosis in COPD. Further, available therapeutic opportunities for restoring efferocytosis activity and ameliorating respiratory tract inflammation in smokers with COPD were also discussed.