Assessment of guidelines for bariatric and metabolic surgery: a systematic review and evaluation using appraisal of guidelines for research and evaluation II (AGREE II).

BACKGROUND: In recent years, multiple guidelines on bariatric and metabolic surgery were published, however, their quality remains unknown, leaving providers with uncertainty when using them to make perioperative decisions. This study aims to evaluate the quality of existing guidelines for perioperative bariatric surgery care. METHODS: A comprehensive search of MEDLINE and EMBASE were conducted from January 2010 to October 2022 for bariatric clinical practice guidelines. Guideline evaluation was carried out using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. RESULTS: The initial search yielded 1483 citations, of which, 26 were included in final analysis. The overall median domain scores for guidelines were: (1) scope and purpose: 87.5% (IQR: 57-94%), (2) stakeholder involvement: 49% (IQR: 40-64%), (3) rigor of development: 42.5% (IQR: 22-68%), (4) clarity of presentation: 85% (IQR: 81-90%), (5) applicability: 6% (IQR: 3-16%), (6) editorial independence: 50% (IQR: 48-67%), (7) overall impressions: 48% (IQR: 33-67%). Only six guidelines achieved an overall score >70%. CONCLUSIONS: Bariatric surgery guidelines effectively outlined their aim and presented recommendations. However, many did not adequately seek patient input, state search criteria, use evidence rating tools, and consider resource implications. Future guidelines should reference the AGREE II framework in study design.

Relation of body mass index to long-term survival and cardiac remodelling for patients undergoing mitral valve replacement surgery.

BACKGROUND AND AIMS: Studies have demonstrated that obesity is paradoxically associated with reduced mortality following cardiac surgery. However, these studies have treated various types of cardiac surgery as a single entity. With mitral valve (MV) surgeries being the fastest-growing cardiac surgical interventions in North America, the purpose of this study was to identify the impact of body mass index (BMI) on long-term survival and cardiac remodelling of patients undergoing MV replacement (MVR). METHODS AND RESULTS: In this retrospective, single-center study, 1071 adult patients who underwent an MVR between 2004 and 2018 were stratified into five BMI groups (<20, 20-24.9, 25-29.9, 30-34.9, >35). Cox proportional hazard regression models were used to determine the association between BMI and all-cause mortality. Patients who were underweight had significantly higher all-cause mortality rates at the longest follow-up (median 8.2 years) than patients with normal weight (p = 0.01). Patients who were in the obese group had significantly higher readmission rates due to myocardial infarction (MI) at the longest follow-up (p = 0.017). Subgroup analysis revealed a significant increase in long-term all-cause mortality for female patients who were underweight. Significant changes in left atrial size, mitral valve peak and mean gradients were seen in all BMI groups. CONCLUSIONS: For patients undergoing mitral valve replacement, BMI is unrelated to operative outcomes except for patients who are underweight.

Endoscopic Submucosal Dissection Versus Surgery or Endoscopic Mucosal Resection for Metachronous Early Gastric Cancer: a Meta-analysis.

BACKGROUND: Resection options for early gastric cancer (EGC) include endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and surgery. In patients with metachronous EGC following previous resection, the optimal resection technique is not well elucidated. We conducted a systematic review and meta-analysis of studies comparing ESD to EMR, or ESD to surgery, in patients with metachronous EGC. METHODS: We conducted an electronic search of studies reporting on outcomes and AEs following ESD versus either EMR or surgery for patients with metachronous EGC. Pooled odds ratios (OR) of included studies were obtained using DerSimonian and Laird random effects models. Funnel plots were produced and visually inspected for evidence of publication bias. The quality of the evidence was assessed using GRADE. RESULTS: A total of 9367 abstracts were screened and 10 observational studies were included. The odds of complete resection were higher amongst patients undergoing ESD compared to EMR (OR 5.88, 95% confidence intervals, CI, 1.79-19.35), whereas the odds of complete resection were no different between ESD and surgery (OR 0.57, 95% CI 0.04-8.24). There were no differences in the odds of local recurrence with ESD versus surgery (OR 5.01, 95% CI 0.86-29.13). Post-procedural bleeding did not differ significantly between ESD and EMR (OR 0.70, 95% CI 0.16-3.00). There was no evidence of publication bias. DISCUSSION: For metachronous EGC, ESD or surgery is preferred over EMR depending on local expertise and patient preferences, largely due to a higher risk of incomplete resection with EMR. REVIEW REGISTRATION: PROSPERO CRD42021270445.

The role of routine groin ultrasonography in the management of inguinal hernia.

BACKGROUND: Groin ultrasonography (US) has been used as an adjunct to inguinal hernia diagnosis, but there is limited evidence as to whether its use affects surgical decision-making. The primary aim of this study was to examine whether groin US affects surgical management of inguinal hernia; the secondary goal was to estimate the frequency of groin US ordered before surgical consultation. METHODS: We performed a retrospective chart review of 400 consecutive patients aged older than 18 years referred to 1 of 4 general surgeons in Calgary, Alberta, for inguinal hernia between January 2014 and January 2015. Bilateral groin examinations were entered as separate entries into the database. Outcomes assessed included the frequency of groin US examinations performed within 1 year before the general surgery consultation, presence of inguinal hernia on clinical examination (CE), presence of inguinal hernia on groin US, and whether the hernia proceeded to herniorrhaphy. RESULTS: A total of 476 groins in the 400 patients (354 [88.5%] male; mean age 53.5 yr [standard deviation 15.2 yr]) were evaluated for a hernia during the study period. Groin US was performed before general surgery consultation in 336 cases (70.6%). Overall, 364 (76.5%) of the hernias were clinically palpable; of the 364, 220 (60.4%) had preconsultation US, even in the presence of a positive CE finding. Of the 112 groins that did not have a clinically palpable hernia, 103 (92.0%) underwent preconsultation US. Of the 476 groins, 315 (66.2%) underwent inguinal hernia repair: 310 (85.2%) of the 364 with clinically palpable hernias and 5 (4.8%) of the 103 with clinically negative findings but positive groin US findings. Surgical decision-making based on CE findings occurred in 390 cases (81.9%) overall, whereas surgery based on groin US findings alone occurred in 5 of 336 cases (1.5%). CONCLUSION: Routine groin US was frequently performed before general surgery consultation, whether a hernia was detectable on clinical examination or not. Positive groin US results alone infrequently affected whether the patient proceeded to surgery. Clinical examination findings played a larger role in surgical decision-making than groin US results. Eliminating the practice of routine groin US may provide considerable health care cost savings.

The effects of body mass index on long-term outcomes and cardiac remodeling following mitral valve repair surgery.

BACKGROUND: Previous literature has demonstrated equivalent or improved survival post mitral valve (MV) surgery amongst patients with obesity when compared to their normal-weight counterparts. This relationship is poorly understood and the impact of body mass index (BMI) on cardiac remodeling has not been established. METHODS: In this retrospective, single-center study, we sought to identify the impact that BMI may have on long-term outcomes and cardiac remodeling post-MV repair. Outcomes were compared between patients of varying BMI undergoing MV repair between 2004 and 2018. The primary outcome was mortality and secondary outcomes included stroke, myocardial infarction, reoperation of the MV, rehospitalization, and cardiac remodeling. RESULTS: A total of 32 underweight, 249 normal weight, 249 overweight, 121 obese, and 50 morbidly obese patients were included in this study. Underweight patients had increased mortality at longest follow-up. Patients with morbid obesity were found to have higher rates of readmission for heart failure. Only underweight patients did not demonstrate a significant reduction in LVEF. Patients with normal weight and overweight had a significant reduction in left atrial size, and patients with obesity had a significant reduction in MV area. CONCLUSIONS: An obesity paradox has been identified in cardiac surgery. While patients with obesity have higher rates of comorbidities preoperatively, their rates of mortality are equivalent or even superior to those with lower BMI. The results of our study confirm this finding with patients of high BMI undergoing MV repair demonstrating equivalent rates of morbidity to their normal BMI counterparts. While the obesity paradox has been relatively consistent in the literature, the understanding of its cause and long-term impacts are not well understood. Further focused investigation is necessary to elucidate the cause of this relationship.

The effects of body mass index on outcomes for patients undergoing surgical aortic valve replacement.

BACKGROUND: Most of the studies of obesity and postoperative outcome have looked predominantly at coronary artery bypass grafting with fewer focused on valvular disease. The purpose of this study was to compare the outcomes of patients undergoing aortic valve replacement stratified by body mass index (BMI, kg/m^2). METHODS: The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry captured 4780 aortic valve replacements in Alberta, Canada from January 2004 to December 2018. All recipients were stratified by BMI into five groups (BMI: < 20, 20-24.9, 25-29.9, 30-34.9, and > = 35). Log-rank test and Cox regression were used to examine the crude and adjusted survival differences. RESULTS: Intra-operative clamp time and pump time were similar among the five groups. Significant statistical differences between groups existed for the incidence of isolated AVR, AVR and CABG, hemorrhage, septic infection, and deep sternal infection (p < 0.05). While there was no significant statistical difference in the mortality rate across the BMI groups, the underweight AVR patients (BMI < 20) were associated with increased hazard ratio (1.519; 95% confidence interval: 1.028-2.245) with regards to all-cause mortality at the longest follow-up compared with normal weight patients. CONCLUSION: Overweight and obese patients should be considered as readily for AVR as normal BMI patients.

Idiopathic intracranial hypertension and bariatric surgery: a systematic review

Background: Idiopathic intracranial hypertension (IIH) is a rare condition typically affecting women with obesity who are of child-bearing age. Patients commonly present with headaches, visual disturbances, pulsatile tinnitus and papilledema. The association between IIH and obesity has been well established in the literature, suggesting that weight loss may contribute to improving IIH. For patients with severe obesity for whom conservative management is not successful, bariatric surgery is an effective modality for weight loss. We aimed to systematically review the literature to determine the efficacy of bariatric surgery in the treatment of IIH Methods: We conducted a comprehensive search of MEDLINE, Embase, Scopus, the Cochrane Library and Web of Science (limited to studies in humans published in English between January 1946 and July 2015). Results: Twelve primary studies (n = 39 patients) were included in the systematic review. All patients had a preoperative diagnosis of IIH. Preoperative body mass index (BMI) was 47.4 ± 3.6 kg/m2 ; BMI improved to 33.7 ± 2.1 kg/m2 and 33.9 ± 11.6 kg/m2 at 6 and 12 months postoperatively, respectively. Lumbar puncture opening pressures decreased from 34.4 ± 6.9 cmH2O to 14.0 ± 3.6 cmH2O after surgery. Common symptoms of IIH improved after bariatric surgery: headaches (100% preoperatively v. 10% postoperatively), visual complaints (62% v. 44%), tinnitus (56% v. 3%) and papilledema (62% v. 8%). Conclusion: Bariatric surgery appears to lead to considerable improvement in IIH. Idiopathic intracranial hypertension is not a well-publicized comorbidity of obesity, but its presence may be considered as an indication for bariatric surgery.

Contexte: L'hypertension intracrânienne (HTIC) idiopathique est une affection rare qui touche surtout les femmes atteintes d'obésité en âge de procréer. Les symptômes courants sont des maux de tête, des troubles de la vue, des acouphènes pulsatiles et un oedème papillaire. Le lien entre l'HTIC idiopathique et l'obésité est bien établi dans la littérature, ce qui suggère que la perte de poids pourrait améliorer le tableau clinique de l'HTIC. Pour les patients atteints d'obésité sévère pour lesquels le traitement conservateur ne fonctionne pas, la chirurgie bariatrique est un moyen efficace de perdre du poids. Cette revue systématique de la littérature vise à déterminer l'efficacité de la chirurgie bariatrique dans le traitement de l'HTIC idiopathique. Méthodes: Nous avons interrogé MEDLINE, Embase, Scopus, la Bibliothèque Cochrane et Web of Science (limites : études portant sur les humains publiées en anglais entre janvier 1946 et juillet 2015). Résultats: Douze études primaires (n = 39 patients) ont été incluses dans la revue systématique. Tous les patients avaient un diagnostic préopératoire d'HTIC idiopathique. L'indice de masse corporelle (IMC) préopératoire était de 47,4 ± 3,6 kg/m2 ; l'IMC est passé à 33,7 ± 2,1 kg/m2 6 mois après l'opération, puis à 33,9 ± 11,6 kg/m2 12 mois après l'opération. Les pressions d'ouverture des ponctions lombaires sont passées de 34,4 ± 6,9 cmH2O à 14,0 ± 3,6 cmH2O après l'opération. Les symptômes courants de l'HTIC idiopathique se sont améliorés après la chirurgie bariatrique : maux de tête (100% avant opération c. 10% après), troubles de la vue (62% c. 44%), acouphènes pulsatiles (56% c. 3%) et œdème papillaire (62% c. 8%). Conclusion: La chirurgie bariatrique semble améliorer considérablement les symptômes d'HTIC idiopathique. Cette affection n'est pas une comorbidité bien connue de l'obésité, mais sa présence peut être une indication pour la chirurgie bariatrique comme traitement.

Does body mass index affect the rate of adverse outcomes in total hip and knee arthroplasty? A retrospective review of a total joint replacement database

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are reliable surgical options to treat pain and disability resulting from degenerative conditions around the hip and knee. Obesity is a modifiable risk factor that contributes to significant morbidity. The purpose of this study was to retrospectively compare outcomes in primary hip and knee arthroplasty for patients with increased body mass index (BMI) and those with normal BMI, using data from the registry of the Alberta Bone and Joint Health Institute (ABJHI). Methods: We retrospectively reviewed the data compiled in the ABJHI registry between March 2010 and July 2016. We reviewed outcomes with respect to length of stay, discharge destination, 30-day readmission, postoperative infection, postoperative transfusion requirements, postoperative adverse events and in-hospital postoperative mechanical complications. Results: A total of 10 902 patients (6076 women, 4826 men) who underwent THA and 16 485 patients (10 057 women, 6428 men) who underwent TKA were included in the study. For both THA and TKA, patients with increased BMI had an increased number of in-hospital medical events, had an increased rate of deep infection, were less likely to be discharged home (p < 0.001) and had decreased transfusion requirements (p < 0.001) than patients whose weight was in the normal range. Increased BMI increased the rate of 30-day readmission and length of stay in the THA cohort but not in the TKA cohort. Increased BMI had no effect on acute postoperative dislocation or periprosthetic fractures. Patients with a BMI of 30 kg/m2 or greater required a THA 1.7 years earlier than patients of normal weight, patients whose BMI was 35 kg/m2 or greater required a THA 3.4 years earlier, and patients whose BMI was 40 kg/m2 or greater required a THA 5.8 years earlier. In the TKA cohort, patients with a BMI of 30 kg/m2 or greater required a TKA 2.7 years earlier than patients whose weight was in the normal range, patients with a BMI of 35 kg/m2 or greater required a TKA 4.6 years earlier, and patients whose BMI was 40 kg/m2 or greater required a TKA 7.6 years earlier. Conclusion: Our study quantifies the effects of obesity in primary hip and knee arthroplasty. It provides a greater understanding of the risks in the obese population when contemplating joint arthroplasty.

Contexte: La prothèse totale de la hanche (PTH) et la prothèse totale du genou (PTG) sont des options chirurgicales fiables pour traiter la douleur et l'invalidité résultant de maladies dégénératives de la hanche et du genou. L'obésité est un facteur de risque modifiable qui contribue significativement à la morbidité. Le but de cette étude était de comparer de manière rétrospective le résultat des interventions primaires pour prothèses de la hanche et du genou selon que les patients avaient un indice de masse corporelle (IMC) normal ou élevé à partir des données du registre de l'Alberta Bone and Joint Health Institute (ABJHI). Méthodes: Nous avons analysé de manière rétrospective les données compilées par le registre de l'ABJHI entre mars 2010 et juillet 2016. Nous avons passé en revue les paramètres suivants : durée du séjour hospitalier, destination post-congé, réadmissions dans les 30 jours, infections postopératoires, besoins transfusionnels postopératoires, complications postopératoires et complications mécaniques postopératoires perhospitalières. Résultats: En tout, 10 902 patients (6076 femmes, 4826 hommes) ayant subi une PTH et 16 485 patients (10 057 femmes, 6428 hommes) ayant subi une PTG ont été inclus dans l'étude. Tant pour la PTH que pour la PTG, les patients ayant un IMC élevé ont présenté un plus grand nombre de complications médicales en cours d'hospitalisation; ils ont aussi présenté un nombre plus élevé d'infections profondes, étaient moins susceptibles de pouvoir retourner chez eux au moment de leur congé (p < 0,001) et ont eu moins besoin de transfusions (p < 0,001) comparativement aux patients dont le poids se situait dans l'éventail des valeurs normales. L'IMC élevé a été en corrélation avec une augmentation du taux de réadmission à 30 jours et de la durée du séjour dans la cohorte soumise à une PTH, mais non dans la cohorte soumise à une PTG. L'IMC élevé n'a exercé aucun effet sur la dislocation postopératoire aiguë ou les fractures périprothétiques. Les patients ayant un IMC de 30 kg/m2 ou plus ont eu besoin d'une PTH 1,7 an plus tôt que les patients de poids normal, les patients ayant un IMC de 35 kg/m2 ou plus ont eu besoin d'une PTH 3,4 ans plus tôt, et les patients ayant un IMC de 40 kg/m2 ou plus ont eu besoin d'une PTH 5,8 ans plus tôt. Dans la cohorte soumise à la PTG, les patients ayant un IMC de 30 kg/m2 ou plus ont eu besoin d'une PTG 2,7 ans plus tôt que les patients de poids normal, les patients ayant un IMC de 35 kg/m2 ou plus ont eu besoin d'une PTG 4,6 ans plus tôt, et les patients ayant un IMC de 40 kg/m2 ou plus ont eu besoin d'une PTG 7,6 ans plus tôt. Conclusion: Notre étude quantifie les effets de l'obésité sur le recours aux interventions primaires pour prothèse de la hanche et du genou. Elle permet de mieux comprendre les risques auxquels est exposée la population obèse lorsqu'une intervention pour prothèse articulaire est envisagée.

Evaluating the safety of bariatric surgery for weight loss in class I obesity: A propensity-matched analysis of North American data.

BACKGROUND: Bariatric surgery is an effective treatment for severe obesity. However, there has been an evolving role for bariatric surgery as a primary treatment in the management of class I obesity. OBJECTIVES: We aimed to assess the safety of surgery by directly comparing surgical outcomes of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in class I obesity (body mass index [BMI] 30-35 kg/m2) with those with class II obesity (BMI 35-40 kg/m2) and higher (BMI >40 kg/m2) using an analysis of a large-scale matched-patient cohort analysis. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, United States and Canada. METHODS: We performed a retrospective analysis using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, which collects patient information from >790 bariatric surgery centers in North America. Patients included in our analysis underwent surgery in the years 2015 and 2016 and had either LRYGB or LSG for weight loss. RESULTS: Initial analysis included 274,091 patients. Propensity-matching resulted in 9104 patients for analysis in each of the class I and class II and higher groups. The overall major complication rate between the 2 matched groups was 3.9% for class I and 3.5% for class II and higher (P = .11). We did not find that class I obesity was associated with an increased risk of 30-day complication or death. CONCLUSIONS: In our analysis of propensity-matched patients undergoing LSG and LRYGB for weight loss, class I obesity did not have statistically higher risk of postoperative complication rates compared with class II and higher.

Early Routine Use of Upper GI Contrast Series Post Paraesophageal Hernia Repair: A Single Institution Consecutive Case Series.

INTRODUCTION: There is conflicting evidence with regard to the routine use of upper gastrointestinal contrast series in detecting early complications post paraesophageal hernia repair (PEHR). METHODS: All cases booked for a PEHR between January 2007 and September 2015 were identified using hospital records. Standard demographic, operation, and imaging data were extracted. RESULTS: We retrospectively identified 391 PEHR cases between January 2007 and September 2015. The mean age at the index operation was 66.7 years with a female predominance. The majority of index operations were elective and completed for a large paraesophageal hernia. Contrast studies were reported as normal in 70.6%, a leak in 0.3%, an obstruction in 27.9%, and early recurrence in 1.0%. Reoperation was required in 1.8% of cases. CONCLUSION: Routine upper gastrointestinal contrast studies post-PEHR changed management in 0.8% of cases and were unhelpful in determining the need for early reoperation in 57.1% of cases requiring reoperation.

Predicting venous thromboembolism following laparoscopic bariatric surgery: development of the BariClot tool using the MBSAQIP database.

BACKGROUND: Bariatric surgery is an effective treatment for severe obesity; however, postoperative venous thromboembolism (VTE) remains a leading cause of morbidity and mortality. The objective of this study is to develop a tool to stratify individuals undergoing laparoscopic bariatric surgery according to their 30-day VTE risk. METHODS: This is a retrospective cohort study of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. This registry collects data specific for metabolic or bariatric surgery with 30-day outcomes from 791 centers. Individuals undergoing primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were included. Characteristics associated with 30-day VTE were identified using univariate and multivariable analyses. A predictive model, BariClot, was derived from a randomly-generated derivation cohort using a forward selection algorithm. BariClot's robustness was tested against a validation cohort of subjects not included in the derivation cohort. The calibration and discrimination of two previously published VTE risk tools were assessed in the MBSAQIP population and compared to BariClot. RESULTS: A total of 274,221 patients underwent LRYGB or LSG. Overall, 1106 (0.4%) patients developed VTE, 452 (0.2%) developed pulmonary embolism, and 43 (0.02%) died due to VTE. VTE was the most commonly identified cause of 30-day mortality. A prediction model to assess for risk of VTE, BariClot, was derived and validated. BariClot consists of history of VTE, operative time, race, and functional status. It stratifies individuals into very high (> 2%), high (1-2%), medium (0.3-1%), and low risk groups (< 0.3%). This model accurately predicted events in the validation cohort and outperformed previously published scoring systems. CONCLUSIONS: BariClot is a predictive tool that stratifies individuals undergoing bariatric surgery based on 30-day VTE risk. Stratifying low- and high-risk populations for VTE allows for informed clinical decision-making and potentially enables further research on customized prophylactic measures for low- and high-risk populations.

Sleeve gastrectomy and hypertension: a systematic review of long-term outcomes.

INTRODUCTION: Bariatric surgery has been shown to be a safe and durable intervention for patients struggling with obesity and metabolic syndrome, including hypertension. Buchwald et al. reported hypertension resolution rates in 67.1% and improvement in 78.5% following aggregate bariatric surgery. The laparoscopic sleeve gastrectomy (LSG) is becoming increasingly utilized as a primary bariatric surgery, but lacks long-term outcome data. There are a growing number of studies reporting outcome data beyond 5 years. OBJECTIVE: This study aims to systematically evaluate the efficacy of laparoscopic sleeve gastrectomy on hypertension amongst obese patients. MATERIALS AND METHODS: A comprehensive literature search was conducted through Medline, Embase, Scopus, Web of Science, Dare, Cochrane library, and HTA database. The search terms used were broad: sleeve gastrectomy AND hypertension OR blood pressure. Adult patients undergoing LSG with follow-up hypertension outcome results of at least 5 years were included. Revisional surgeries were excluded. Two independent reviewers were used. RESULTS: Fourteen studies were included in this systematic review, which included 3550 subjects in total. Mean age was 41.1 ± 10.7 years. Mean pre-operative BMI and weight were 47.7 ± 8.83 kg/m2 and 272.8 ± 48.4 lb, respectively. Pre-operative prevalence of hypertension was 36.5% (range 6.7-91%) which dropped to 14.79% (range 0-33.3%) at approximately 5-year follow-up. Hypertension resolved in 62.17% (range 0-100%) of patients and improved in 35.7% (range 13.3-76.9%) at a mean of 5.35 years of follow-up. CONCLUSION: From this systematic review, LSG is an effective intervention for bariatric patients with hypertension. In addition to the observed reduction in the incidence of hypertension, it is likely that LSG may lead to additional health system benefits such as cost savings due to reductions in antihypertensive medications. Further prospective studies should include estimates of cost savings associated with reductions in chronic antihypertensive medication usage.

A Shorter Circular Stapler Height at the Gastrojejunostomy during a Roux-En-Y Gastric Bypass Results in Less Strictures and Bleeding Complications.

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is prone to a number of complications, most notably at the gastrojejunostomy (GJ) staple line. The circular stapler technique is a common method used to create the GJ anastomosis. Although recent studies have shown a decreased rate of anastomotic strictures with shorter stapler heights, the optimal circular stapler height to use remains controversial. We therefore completed a retrospective cohort study within the Alberta Provincial Bariatric Program (APBP) to compare outcomes between the 3.5 mm and 4.8 mm stapler heights. We identified 215 patients who had a LRYGB done between the years 2015 and 2017. 143 patients had the GJ constructed with a 3.5 mm circular stapler height, with the remaining 72 patients having the GJ fashioned with a 4.8 mm stapler height. The rate of anastomotic stricturing was lower in the 3.5 mm stapler group compared to the other cohort (3.5 versus 13.9%, resp., p=0.008). Likewise, the overall rate of bleeding complications was lower in the 3.5 mm stapler group compared to the 4.8 mm group (6.3 versus 15.3%, resp., p=0.04). The rate of anastomotic stricturing and postoperative bleeding is lower with the use of a 3.5 mm circular stapler compared to a 4.8 mm circular stapler when forming the GJ.

Diagnostic accuracy of transabdominal ultrasonography for gallbladder polyps: systematic review.

BACKGROUND: Previous research has shown variable but generally poor accuracy of transabdominal ultrasonography in the diagnosis of gallbladder polyps. We performed a systematic review of the literature with the aim of helping surgeons interpret and apply these findings in the preoperative assessment and counselling of their patients. METHODS: We searched PubMed, MEDLINE and the Cochrane database using the keywords "gallbladder," "polyp," "ultrasound," "pathology" and "diagnosis" for English-language articles published after 1990 with the full-text article available through our institutional subscriptions. Polyps were defined as immobile features that on transabdominal ultrasonography appear to arise from the mucosa and that lack an acoustic shadow, and pseudopolyps were defined as features such as inflammation, hyperplasia, cholesterolosis and adenomyomatosis that convey no risk of malignant transformation. RESULTS: The search returned 1816 articles, which were narrowed down to 14 primary sources involving 15 497 (range 23-13 703) patients who had preoperative transabdominal ultrasonography, underwent cholecystectomy and had postoperative pathology results available. Among the 1259 patients in whom a gallbladder polyp was diagnosed on ultrasonography, 188 polyps were confirmed as true polyps on pathologic examination, and 81 of these were found to be malignant. Of the 14 238 patients for whom a polyp was not seen on ultrasonography, 38 had a true polyp on pathologic examination, none of which were malignant. For true gallbladder polyps, transabdominal ultrasonography had a sensitivity of 83.1%, specificity of 96.3%, positive predictive value of 14.9% (7.0% for malignant polyps) and negative predictive value of 99.7%. CONCLUSION: Transabdominal ultrasonography has a high false-positive rate (85.1%) for the diagnosis of gallbladder polyps. Further study of alternative imaging modalities and reevaluation of existing management guidelines are warranted.

CONTEXTE: Des recherches antérieures ont montré la précision variable, mais généralement médiocre, de l'échographie transabdominale pour le diagnostic des polypes de la vésicule biliaire. Nous avons procédé à une revue systématique de la littérature scientifique afin d'aider les chirurgiens à interpréter et à appliquer ces résultats lors de l'évaluation préopératoire, et à conseiller leurs patients. MÉTHODES: Nous avons interrogé les réseaux PubMed, MEDLINE et la base de données Cochrane à partir des mots clés « gallbladder ¼, « polyp ¼, « ultrasound ¼, « pathology ¼ et « diagnosis ¼ (vésicule biliaire, polype, échographie, pathologie et diagnostic) pour recenser les articles en langue anglaise publiés après 1990, pour lesquels le texte intégral était accessible par abonnement institutionnel. À l'échographie, les polypes étaient définis comme des structures fixes semblant émaner de la muqueuse et dépourvues d'ombre acoustique, et les pseudopolypes étaient définis par des caractéristiques telles que l'inflammation, l'hyperplasie, la cholestérolose et l'adénomyomatose ne comportant pas de risque de transformation maligne. RÉSULTATS: La recherche a généré 1816 articles qui ont été ramenés à 14 sources principales regroupant 15 497 (éventail, 23-13 703) patients ayant subi une échographie transabdominale préopératoire et une cholécystectomie, et pour lesquels on disposait des résultats de l'examen anatomopathologique postopératoire. Sur les 1259 patients chez qui des polypes intravésiculaires ont été diagnostiqués à l'échographie, 188 polypes ont été jugés vrais à l'examen anatomopathologique, et 81 d'entre eux se sont révélés malins. Parmi les 14 238 patients chez lesquels aucun polype n'avait été détecté à l'échographie, 38 étaient porteurs d'un vrai polype à l'examen anatomopathologique et aucun ne s'est révélé malin. En ce qui concerne les vrais polypes intravésiculaires, l'échographie transabdominale a une sensibilité de 83,1 %, une spécificité de 96,3 %, une valeur prédictive positive de 14,9 % (7,0 % dans le cas des polypes malins) et une valeur prédictive négative de 99,7 %. CONCLUSION: L'échographie transabdominale présente un taux de résultats faux positifs élevé (85,1 %) pour le diagnostic des polypes de la vésicule biliaire. Il faudra approfondir la recherche sur d'autres techniques d'imagerie et réévaluer les lignes directrices actuelles de prise en charge.

LINX® magnetic esophageal sphincter augmentation versus Nissen fundoplication for gastroesophageal reflux disease: a systematic review and meta-analysis.

BACKGROUND: The LINX® magnetic sphincter augmentation system (MSA) is a surgical technique with short-term evidence demonstrating efficacy in the treatment of medically refractory or chronic gastroesophageal reflux disease (GERD). Currently, the Nissen fundoplication is the gold-standard surgical treatment for GERD. We are the first to systematically review the literature and perform a meta-analysis comparing MSA to the Nissen fundoplication. METHODS: A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science and the Cochrane Library) using search terms "Gastroesophageal reflux or heartburn" and "LINX or endoluminal or magnetic" and "fundoplication or Nissen" was completed. All randomized controlled trials, non-randomized comparison study and case series with greater than 5 patients were included. Five hundred and forty-seven titles were identified through primary search, and 197 titles or abstracts were screened after removing duplicates. Meta-analysis was performed on postoperative quality of life outcomes, procedural efficacy and patient procedural satisfaction. RESULTS: Three primary studies identified a total of 688 patients, of whom 273 and 415 underwent Nissen fundoplication and MSA, respectively. MSA was statistically superior to LNF in preserving patient's ability to belch (95.2 vs 65.9%, p < 0.00001) and ability to emesis (93.5 vs 49.5%, p < 0.0001). There was no statistically significant difference between MSA and LNF in gas/bloating (26.7 vs 53.4%, p = 0.06), postoperative dysphagia (33.9 vs 47.1%, p = 0.43) and proton pump inhibitor (PPI) elimination (81.4 vs 81.5%, p = 0.68). CONCLUSION: Magnetic sphincter augmentation appears to be an effective treatment for GERD with short-term outcomes comparable to the more technically challenging and time-consuming Nissen fundoplication. Long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation.

The Effect of Bariatric Surgery on the Spectrum of Fatty Liver Disease.

Nonalcoholic fatty liver disease is becoming one of the most common causes of liver disease in the western world. The most significant risk factors are obesity and the metabolic syndrome for which bariatric surgery has been shown to be an effective treatment. However, the effects of bariatric surgery on nonalcoholic fatty liver disease, specifically liver fibrosis and cirrhosis, are not well established. We review published bariatric surgery outcomes with respect to nonalcoholic liver disease. On the basis of this review we suggest that bariatric surgery may provide a viable treatment option for the treatment of nonalcoholic fatty liver disease, including patients with fibrosis and compensated cirrhosis, and that this topic should be a target of future investigation.

A Case Study of Severe Esophageal Dysmotility following Laparoscopic Sleeve Gastrectomy.

Following bariatric surgery, a proportion of patients have been observed to experience reflux, dysphagia, and/or odynophagia. The etiology of this constellation of symptoms has not been systematically studied to date. This case describes a 36-year-old female with severe esophageal dysmotility following LSG. Many treatments had been used over a course of 3 years, and while calcium channel blockers reversed the esophageal dysmotility seen on manometry, significant symptoms of dysphagia persisted. Subsequently, the patient underwent a gastric bypass, which seemed to partially relieve her symptoms. Her dysphagia was no longer considered to be associated with a structural cause but attributed to a "sleeve dysmotility syndrome." Considering the difficulties with managing sleeve dysmotility syndrome, it is reasonable to consider the need for preoperative testing. The question is whether motility studies should be required for all patients planning to undergo a LSG to rule out preexisting esophageal dysmotility and whether conversion to gastric bypass is the preferred method for managing esophageal dysmotility after LSG.

Intragastric Balloon for Management of Severe Obesity: a Systematic Review.

Older models of intragastric balloons (IGBs) had unacceptably high complication rates and inconsequential weight loss. With FDA approval of newer models, we aimed to systematically examine the literature regarding the efficacy of IGB therapy for obesity. A comprehensive electronic database search was completed. Title searching was restricted to the following keywords: bariatric, gastric, gastric bypass, gastric band, sleeve gastrectomy, and intragastric balloon. Twenty-six primary studies (n = 6101) were included. At balloon removal, mean change in weight and BMI were 15.7 ± 5.3 kg and 5.9 ± 1.0 kg/m(2). The most common complications were nausea/vomiting (23.3 %) and abdominal pain (19.9 %). Serious complications were rare: mortality (0.05 %) and gastric perforation (0.1 %). IGBs are associated with marked short-term weight loss with limited serious complications.

A Systematic Review and Meta-Analysis of Outcomes for Type 1 Diabetes after Bariatric Surgery.

Background. The utility of bariatric surgery in type 1 diabetes remains controversial. The aim of the present study is to evaluate glycemic control outcomes in obese patients with type 1 diabetes after bariatric surgery. Methods. A comprehensive search of electronic databases was completed. Inclusion criteria included human adult subjects with BMI ≥35 kg/m(2) and a confirmed diagnosis of type 1 diabetes who underwent a bariatric surgical procedure. Results. Thirteen primary studies (86 patients) were included. Subjects had a mean age of 41.16 ± 6.76 years with a mean BMI of 42.50 ± 2.65 kg/m(2). There was a marked reduction in BMI postoperatively at 12 months and at study endpoint to 29.55 ± 1.76 kg/m(2) (P < 0.00001) and 30.63 ± 2.09 kg/m(2) (P < 0.00001), respectively. Preoperative weighted mean total daily insulin requirement was 98 ± 26 IU/d, which decreased significantly to 36 ± 15 IU/d (P < 0.00001) and 42 ± 11 IU/d (P < 0.00001) at 12 months and at study endpoint, respectively. An improvement in HbA1c was also seen from 8.46 ± 0.78% preoperatively to 7.95 ± 0.55% (P = 0.01) and 8.13 ± 0.86% (P = 0.03) at 12 months and at study endpoint, respectively. Conclusion. Bariatric surgery in patients with type 1 diabetes leads to significant reductions in BMI and improvements in glycemic control.