Primary Aldosteronism: Does Underlying Pathology Impact Clinical Presentation and Outcomes Following Unilateral Adrenalectomy?

INTRODUCTION: Patients undergoing unilateral adrenalectomy for primary aldosteronism (PA) may have a solitary adenoma, unilateral hyperplasia, or multiple adenomas on final pathology. This study investigated whether the underlying pathological diagnosis was associated with differences in clinical presentation and postoperative outcomes. METHODS: A retrospective cohort study of patients undergoing unilateral adrenalectomy for PA from 2004 to 2015 at our institution was performed. Baseline clinical and laboratory parameters, as well as postoperative biochemical and hypertension cure rates, were compared across the three aforementioned pathological groups. RESULTS: Of 206 patients who met criteria for inclusion, 152 (73.8%) had a single adenoma, 33 (16%) had unilateral hyperplasia, and 21 (10.2%) had multiple unilateral adenomas. Patients with unilateral hyperplasia were more likely to be male (81.2% vs 57.9%, P = .03), undergo left-sided adrenalectomy (78.8% vs 47.4%, P < .01), and had a lower median adrenal venous sampling lateralization index (9.8 vs 19.8, P = .04) compared to those with solitary, but not multiple unilateral adenomas. No differences were seen in age, duration of hypertension, preoperative plasma aldosterone levels, plasma renin activities, 24-h urinary aldosterone excretion, serum potassium concentrations, and the number of preoperative antihypertensive medications across all three pathological groups. All patients achieved biochemical cure following adrenalectomy, and no significant differences in the rates of hypertension cure or improvement were observed in comparisons across pathological subtype. CONCLUSIONS: Clinical presentation and postoperative outcomes are similar regardless of underlying pathology in patients with PA. Because one in four patients may harbor unilateral hyperplasia or multiple adenomas, total unilateral adrenalectomy should be performed as the operation of choice over adrenal-sparing approaches.

The Omental Plug: A Novel Management Approach of Concomitant Ventral Hernias During Bariatric Surgery.

BACKGROUND: Severe obesity leads to a higher incidence of ventral hernias, thus complicating up to 8% of bariatric procedures. The optimal management of these hernias continues to be a controversial topic. We present our novel approach of utilizing an omental plug for concomitant ventral hernia management during metabolic surgery. METHODS: To prevent early bowel incarceration and obstruction during bariatric surgery, we sutured the omentum circumferentially to the edges of the hernia defect and to the hernia sac itself with absorbable suture. RESULTS: Four patients were managed with this novel omental plug technique. All patients were female. The mean age was 53 years (range 39 to 68 y), the mean body-mass index was 54.75 kg/m 2 (range 49 to 59 kg/m 2 ), and the mean follow-up was 4.6 months (range 1.5 to 6.5 mo). There were no hernia-related complications through the follow-up period. CONCLUSION: The omental plug technique is a feasible, inexpensive, and safe alternative for ventral hernias with the potential prevention of bowel incarceration during bariatric surgery. This approach allows deferring the definitive hernia repair for a later stage.

Duodenal switch versus Roux-en-Y gastric bypass: a perioperative risk comparative analysis of the MBSAQIP Database (2015-2019).

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD/DS) is a procedure that has long been considered to have a higher early postoperative morbidity than Roux-En-Y gastric bypass (RYGB). However, patients who undergo BPD/DS have more baseline co-morbidities that may affect the reported early postoperative morbidity. OBJECTIVE: To compare 30-day postoperative morbidity and mortality between BPD/DS and RYGB propensity score-matched cohorts obtained from the MBSAQIP database. SETTING: Analysis of data obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: Retrospective analysis of 21-variable propensity score-matched patients in the BPD/DS and RYGB groups obtained from the MBSAQIP database between 2015 and 2019. Variables included age, sex, body mass index, American Society of Anesthesiologists (ASA) class, and pertinent medical co-morbidities. Data were analyzed for 30-day postoperative morbidity, mortality, reoperation, reintervention, and readmissions. RESULTS: Before matching, RYGB and BPD/DS cohorts contained 134 188 and 5079 patients, respectively. After multivariable propensity score matching, each cohort contained 5050 patients. The RYGB group had a higher rate of surgical-site infections than the BPD/DS group (1% versus .5%, P = .007) and a higher rate of blood product transfusions (1.1% versus .6%, P = .018). The rate of other early postoperative complications was similar between the 2 groups (P > .05). There was no statistically significant difference in the 30-day mortality, readmission rate, reoperation rate, or reintervention rate between the 2 groups (P > .05). CONCLUSION: When matched for baseline body mass index and co-morbidities, BPD/DS does not lead to a higher 30-day postoperative morbidity and mortality than RYGB. Patients can be counseled that in the short term, BPD/DS is as safe as RYGB.

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.