Timing of Autologous Tissue Breast Reconstruction Does Not Affect Free Flap Failure.

ABSTRACT: This study aimed to determine whether there is a difference in free flap failure based on the decision to undergo immediate versus delayed autologous tissue breast reconstruction after mastectomy. The National Surgical Quality Improvement Program database was queried for breast free flap procedures performed between 2015 and 2020. This study demonstrates that the decision to undergo immediate versus delayed autologous tissue breast reconstruction does not have a significant association with free flap failure. This remains true regardless of whether patients undergo unilateral mastectomy with reconstruction or whether patients choose to also undergo contralateral prophylactic mastectomy with reconstruction.

Post-mastectomy Breast Reconstruction With Gas vs Saline Tissue Expanders: Does the Fill Type Matter?

The most common reconstruction technique following mastectomy is a 2-stage technique that involves tissue expansion followed by definitive implant-based reconstruction (IBR). Tissue expanders (TEs) have classically used saline for initial fill; however, TEs with an initial gas fill (GTE)-including the CO2-based AeroForm (AirXpanders, San Francisco, CA) TE and TEs initially filled with atmospheric air-have been increasingly used in the past decade. We aimed to compare the outcomes in breast reconstruction for tissue expanders initially filled with saline vs gas. PubMed was queried for studies comparing gas- and saline-filled tissue expanders (STEs) used in IBR. A meta-analysis was performed on major postoperative outcomes and the required expansion and definitive reconstruction time. Eleven studies were selected and included in the analysis. No significant differences existed between tissue expansion with GTEs vs STEs for 11 of the 13 postoperative outcomes investigated. Out of the complications investigated, only the risk of infection/cellulitis/abscess formation was significantly lower in the GTE cohort (odds ratio 0.62; 95% CI, 0.47 to 0.82; P = .0009). The time to definitive reconstruction was also significantly lower in the GTE cohort (mean difference [MD], 45.85 days; 95% CI, -57.80 to -33.90; P < .00001). The total time to full expansion approached significance in the GTE cohort (MD, -20.33 days; 95% CI, -41.71 to 1.04; P = .06). A cost analysis considering TE cost and infection risk determined that GTE use saved a predicted $2055.34 in overall healthcare costs. Surgical outcomes for both fill types were predominantly similar; however, GTEs were associated with a significantly decreased risk of postoperative infection compared to saline-filled TEs. GTEs could also reduce healthcare expenditures and require less time until definitive reconstruction after placement.

Complication Profiles of Smooth vs Textured Tissue Expanders in Breast Reconstruction: A Systematic Review and Meta-Analysis.

BACKGROUND: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a type of non-Hodgkin lymphoma first linked with breast implants in 2011. The correlation between BIA-ALCL and textured devices has led to increased use of smooth devices. However, much of the data surrounding smooth and textured devices investigates breast implants specifically and not tissue expanders. OBJECTIVES: We performed a systematic review and a meta-analysis to compare surgical outcomes for smooth tissue expanders (STEs) and textured tissue expanders (TTEs). METHODS: A search was performed on PubMed, including articles from 2016 to 2023 (n = 419). Studies comparing TTEs and STEs and reported complications were included. A random-effects model was utilized for meta-analysis. RESULTS: A total of 5 articles met inclusion criteria, representing 1709 patients in the STE cohort and 1716 patients in the TTE cohort. The mean duration of tissue expansion with STEs was 221.25 days, while TTEs had a mean time of tissue expansion of 220.43 days.Our meta-analysis found no differences in all surgical outcomes except for explantation risk. STE use was associated with increased odds of explantation by over 50% compared to TTE use (odds ratio = 1.53; 95% CI = 1.15 to 2.02; P = .003). CONCLUSIONS: Overall, STEs and TTEs had similar complication profiles. However, STEs had 1.5 times higher odds of explantation. The incidence of BIA-ALCL is low, and only a single case of BIA-ALCL has been reported with TTEs. This indicates that TTEs are safe and may lower the risk of early complications requiring explantation. Further studies are warranted to further define the relationship between tissue expanders and BIA-ALCL.

Leukopenia is an independent risk factor for early postoperative complications following incision and drainage of anorectal abscess.

AIM: Few data are available regarding the management of anorectal abscess in patients with leukopenia. The aim of this study was to investigate the impact of leukopenia among patients undergoing incision and drainage for anorectal abscess. METHOD: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. Perianal fistulas and supralevator abscesses were excluded. Patients were grouped based on white blood cell (WBC) count: WBC < 4.5 cells/µl, WBC = 4.5-11.0 cells/µl and WBC > 11.0 cells/µl. The 30-day overall complications and outcomes were compared using regression models, accounting for demographics and comorbidities. RESULTS: Ten thousand two hundred and forty (70.3% male) patients were identified. Univariate analysis showed that, compared with patients with leukocytosis (WBC > 11.0 cells/µl) and normal WBC count (WBC = 4.5-11.0 cells/µl), patients with leukopenia (WBC <4.5 cells/µl) had higher rates of overall (p < 0.001), pulmonary (p < 0.001) and haematological complications (p < 0.001). They also had higher rates of readmission (p < 0.001), reoperation (p = 0.005), discharge to a care facility (p = 0.003), increased length of hospital stay (p = 0.004) and death (p < 0.001). Multivariable analysis identified leukopenia as an independent risk factor for overall complications [odds ratio (OR) 2.31, 95% CI 1.65-3.24; p < 0.001], pulmonary complications (OR 5.65, 95% CI 1.88-16.97; p = 0.002), haematological complications (OR 4.30, 95% CI 2.94-6.28; p < 0.001), unplanned readmission (OR 2.20, 95% CI 1.43-3.40; p < 0.001), reoperation (OR 1.80, 95% CI 1.10-2.93; p = 0.019) and death (OR 2.77, 95% CI 1.02-7.52; p = 0.046). Discharge to a care facility and length of stay were not significant on multivariable analysis. CONCLUSION: Leukopenia is associated with increased risk for pulmonary and haematological complications, readmissions, reoperations, discharge to a care facility and death after incision and drainage for anorectal abscess.

The Utility of Flap Coverage for Limb Salvage in Patients With Severe Prosthetic Joint Infections of the Knee Requiring Implant Exchange.

BACKGROUND: Prosthetic joint infection (PJI) is a challenging complication of knee arthroplasty, which can require amputation in severe cases. This study analyzes the utility of flap reconstruction in PJIs requiring hardware removal and extensive soft tissue debridement. METHODS: This was a retrospective analysis of patients who were treated according to a multistage extremity salvage protocol between 2018 and 2022. The protocol involved at least 3 planned surgeries including (1) hardware removal with antibiotic spacer placement and soft tissue debridement, (2) spacer exchange with flap coverage, and (3) hardware reimplantation with simultaneous or delayed extensor mechanism reconstruction. All patients had large periprosthetic tissue defects that would necessitate an amputation if not reconstructed. Primary outcomes were extremity salvage and successful defect coverage. RESULTS: Fifty-two patients (25 female) underwent 62 reconstructions (52 primary, 10 salvage). Flap techniques included pedicled muscular (n = 32), fasciocutaneous (n = 4), combined muscular and fasciocutaneous (n = 2), and free flaps (n = 24). Overall rate of successful defect coverage was 95% (98% in primary and 80% in salvage reconstructions). At a median follow-up of 11 months, 41 patients completed the treatment protocol with a 68% (n = 28) extremity salvage rate (reimplantation arthroplasty, n = 15; permanent knee fusion, n = 13). On the multivariate model including demographic factors, defect size, and flap type, no single factor independently predicted limb salvage. CONCLUSIONS: Alongside intensive orthopedic surgical treatment, flap coverage may aid in extremity salvage in severe knee PJIs by reestablishing healthy soft tissue coverage and allowing reimplantation arthroplasty. We recommend a multispecialty approach including plastic surgeons for this challenging condition.

Examination of Outcome Disparities in Reports of Prepectoral and Subpectoral Direct-to-Implant Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: There are mixed results in surgical complications regarding the usage of prepectoral versus subpectoral implant placement in direct-to-implant breast reconstruction. This study aimed to provide a comprehensive synthesis of surgical complications between the subpectoral and prepectoral reconstructive method. METHODS: PubMed, Embase, and Cochrane were searched for literature published up until December 2022. Studies that compared subpectoral and prepectoral breast reconstruction and reported at least one postoperative complication were included. The following 8 major outcomes were included: revision and reoperation, capsular contracture, explantation, seroma, hematoma, infection, skin necrosis, and animation deformity. Systematic review and meta-analysis were performed to compare outcomes of the 2 techniques. Subgroup analysis was performed to compare whether practice differences in different countries may have an impact on outcomes. RESULTS: A total of 18 studies were identified in our literature search. Two thousand three hundred sixty patients were included, representing a total of 3135 breasts. Our analysis demonstrated that prepectoral reconstruction had significantly lower odds of developing postoperative hematoma [odds ratio (OR), 0.62; P = 0.05], seroma (OR, 0.67; P = 0.01), infection (OR, 0.64; P = 0.03), revision and reoperation (OR, 0.44; P < 0.00001), and animation deformity (OR, 0.01; P < 0.00001), compared with the subpectoral method. Subgroup analysis showed that differences between 3 countries (United States, Korea, Italy) are low (all subgroup heterogeneity test P > 0.1). CONCLUSIONS: While both subpectoral and prepectoral are safe methods for breast reconstruction, the prepectoral technique may lead to lower odds of developing multiple major postoperative complications.

Evaluation of modified frailty index for predicting post-operative outcomes after lower-extremity free-flap reconstruction.

BACKGROUND: Risk stratification for complex procedures such as microsurgical reconstruction of the lower extremities is an important part of preoperative planning and counseling. The aim of this study was to determine the effectiveness of the modified five-item frailty index (5-mFI) score, a validated tool for assessing risk in surgical patients, in predicting postoperative complications after lower extremity (LE) free flap reconstruction. METHODS: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was conducted from 2010 to 2020 on patients who underwent LE free-flap reconstruction. 5-mFI scores were calculated and patients were categorized as 5-mFI ≥2 or <2. The primary endpoint was the presence of 30-day overall complications. The secondary endpoints included 30-day readmission, need for reoperation, and need to discharge to a care facility. Comparisons were made using one-way analysis of variances, Pearson's chi-squared test, or Fisher's extract test. Multivariable logistic regression models were performed for sex, age, BMI, smoker status, operative time, and ASA classification. RESULTS: Total of 294 (61.6% males) patients were identified. Univariate analysis showed 5-mFI ≥2 had higher rates of overall complications (p = .043) and hematologic complications (p = .033). In this population, there were also higher rates of reoperation (p = .003) and discharge to care facility (p < .001). Multivariable regression models further substantiated that 5-mFI ≥2 was independently associated with increased overall complications [2.46, CI: 1.10-5.59, p = .031], hematologic complications [2.55, 1.02-6.35, p = .046], reoperation [4.55, 1.54-13.3, p = .006], and discharge to facility [2.86, 1.27-6.45, p = .011]. CONCLUSIONS: There is a strong association of 5-mFI ≥2 with adverse post-operative outcomes in male patients undergoing LE free-flap reconstruction. This can be a valuable adjunct in the counsel of patients for whom lower extremity salvage is feasible.

Biochemical assessment of adrenal insufficiency after adrenalectomy for non-cortisol secreting tumors: clinical correlation and recommendations.

BACKGROUND: Data regarding changes in cortisol axis after adrenalectomy for non-cortisol secreting tumors and their correlation with adrenal insufficiency are limited. Our aim was to analyze these changes and their clinical correlations to guide management after adrenalectomy for non-Cushing's tumors. METHODS: Following IRB approval, postoperative cortisol axis changes were analyzed in patients who underwent unilateral adrenalectomy for non-Cushing's tumors. A morning serum cortisol of ≥ 10 µg/dl was accepted as a sufficient adrenal response. RESULTS: 223 adrenalectomies were analyzed. In 63% of patients, POD1 serum cortisol was ≥ 10 µg/dl and in 37% < 10 µg/dl. No patient with a POD1 cortisol ≥ 10 µg/dl developed AI symptoms, whereas symptoms of AI were observed in 4% of those with < 10 µg/dl. In patients with a POD1 cortisol of < 10 µg/dl, the rate of steroid replacement therapy initiation was 100%, 8%, and 25% when the decision was based on serum cortisol, clinical symptoms, and serum cortisol plus ACTH stimulation test results, respectively. In 90% of asymptomatic patients, hypocortisolemia resolved uneventfully within a week on repeat morning cortisol testing. 75% of patients with hypocortisolemia on POD1 demonstrated an adequate cortisol response to ACTH stimulation test. CONCLUSION: Although postoperative hypocortisolemia was observed in 37% of patients undergoing unilateral adrenalectomy for non-cortisol secreting tumors, majority did not develop symptoms of adrenal insufficiency. All three steroid initiation approaches appeared safe, with management based on clinical symptoms or selective ACTH stimulation testing sparing more patients from steroids compared to steroid initiation based on POD 1 cortisol levels alone.

Literature Review: Robotic-Assisted Harvest of Deep Inferior Epigastric Flap for Breast Reconstruction.

INTRODUCTION: Robotic-assisted surgery is gaining popularity because of reported improvement in aesthetic outcomes while reducing the occurrence of complications compared with conventional surgical methods. Deep inferior epigastric perforator (DIEP) flap harvesting has a long track record as a viable procedure for autologous reconstruction of the breast. In this literature review, we describe the feasibility of using the robotic platform in DIEP flap harvest. METHODS: The Preferred Reporting Items for Systemic Reviews and Meta-Analysis methodology was to guide the literature review. PubMed and Scopus databases were searched from inception to June 6, 2022. The Medical Subject Heading terms and keywords used to conduct this search are as described: "Robotic AND deep inferior epigastric perforator AND Breast reconstruction." RESULTS: Seven publications, detailing a total of 56 robotic-assisted DIEP flap harvest procedures, were selected for review. Four publications used the transabdominal preperitoneal approach, whereas 2 exclusively used a totally extraperitoneal approach, and 1 compared the 2 approaches. The measured outcomes included technical feasibility of flap harvest in cadavers, viable flap harvest in live patients, harvest time and pedicle dissection time, pedicle length, fascial incision length, donor site pain, need for postoperative narcotic, donor site morbidity, and hernia formation. Overall, the reviewed articles demonstrated successful DIEP flap harvesting without the need for conversion to the conventional open procedure. Postoperative complications were minimal. Robotic DIEP flap harvest was shown to be safe and there were no reports of donor-site morbidity in the studies reviewed. The main advantages of the robotic approach include decreased postoperative pain and length of hospital stay, along with improved aesthetic outcomes. The main disadvantages are increased operative time and cost. CONCLUSIONS: Although at its current iteration, the robotic-assisted DIEP flap is feasible, it may not be practical in all settings. Furthermore, the true benefit of the robotic platform is yet to be determined, as more long-term studies are necessary.

Is bariatric surgery safe in the elderly population?

BACKGROUND: Bariatric surgery has proven to be the most effective treatment for morbid obesity in all age groups and is considered superior to medical treatment. The aim of our study was to report the outcomes of bariatric surgery in patients over 65 years of age at our institution. METHODS: A retrospective review of a prospectively collected database was conducted of all patients > 65 years who underwent a bariatric procedure between 2005 and 2015 at our institution. We compared this group to a control group of patients < 65 years of age who were operated on during the last 5 years, from 2011 to 2015. Data analyzed included age, preoperative BMI, postoperative complications, and comorbidities. RESULTS: Of 1613 patients studied, 1220 patients were under 65 years of age, and in Group B, 393 were >65 years of age at time of surgery. There was a significant difference in proportion of male patients among groups; 42 % in Group B were male compared to 30 % in Group A (p < 0.001). Caucasians represented the majority in both groups. Both groups had comparable preoperative BMI 42.27 kg/m2 for the younger Group A population versus 41.64 kg/m2 for Group B (p = 0.074). Group B had more comorbidities than Group A: hypertension (p < 0.001), sleep apnea (p < 0.001), and hypercholesterolemia (p < 0.001). No difference was found between groups in history of depression (p = 0.409) or type II diabetes (p = 0.961). Distribution of procedures was significantly different between groups, with more LSG in Group A (p < 0.001). Elderly patients had longer length of stay (LOS) by one day on average (LOS = 3 days, p < 0.001), but a lower readmission rate (10 % vs. 7 %) (p = 0.023). Complication rates were comparable in both groups, except for incidence of de novo GERD, which was higher in Group B (5 % vs. 8 %) (p = 0.005). CONCLUSIONS: Elderly patients are usually sicker in terms of comorbidities than the younger population. However, age does not seem to represent a risk of surgical complications after bariatric surgery.

Modified Frailty Index Predicts Postoperative Complications Following Parastomal Hernia Repair.

BACKGROUND: The 5-factor frailty index (5-mFI), validated frailty index with Spearmen rho correlation of .95 and C statistic >.7 for predicting postoperative complications, can be preoperatively used to stratify patients prior to parastomal hernia repairs. METHODS: Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. 5-mFI scores were calculated by adding one point for each comorbidity present: diabetes mellitus, congestive heart failure (CHF), hypertension requiring medication, severe chronic obstructive pulmonary disease (COPD), non-independent functional status. Primary endpoint was 30-day overall complications; secondary endpoints were 30-day readmission, reoperation, and discharge to care facility. RESULTS: 2924 (52.2% female) patients underwent elective parastomal hernia repair. Univariate analysis showed 5-mFI > 2 had higher rates of overall (P = .008), pulmonary (P = .002), cardiovascular (P = .003)), hematologic (P = .003), and renal (P = .002) complications and higher rates of readmission (P = .009), reoperation (P = .001), discharge to care facility (P < .001), and death (P < .001). Multivariate analysis identified a 5-mFI of 2 or more as an independent risk factor for overall complications [OR: 1.40, 1.03-1.78; P = .032], pulmonary complications [2.97, 1.63-5.39; P < .001], hematological complications [1.60, 1.03-2.47; P = .035], renal complications [2.04, 1.19-3.46; P = .009], readmission [1.54, 1.19-1.99; P < .001], and discharge to facility [2.50, 1.66-3.77; P < .001]. Reoperation was not signification on multivariate analysis. CONCLUSIONS: Parastomal hernia repair patients with 5-mFI score of >2 had higher risk of renal, cardiovascular, pulmonary, and hematologic complications, readmissions, longer hospitalization, discharge to care facility, and mortality, and can be useful during preoperative risk stratification.

Analyzing Google Search Trends for Migraine Surgery and Nurtec in Response to Public Announcements.

Background: Nurtec, a versatile migraine medication, has gained popularity. However, the awareness of migraine surgery remains uncertain. Methods: Following a descriptive approach, this cross-sectional study used Google Trends data as of December 1, 2023, to analyze internet search patterns. Approval from Vanderbilt University's institutional review board and adherence to Strengthening the Reporting of Observational Studies in Epidemiology guidelines were confirmed. Monthly relative search volume (RSV) data for "migraine surgery," "Nurtec," and "Rimegepant" were collected from January 1, 2004, to November 11, 2023, within the United States. Statistical analysis involved determining mean monthly RSV values and percentage changes for critical periods. Results: For "Nurtec," a significant surge in RSV occurred from March 2020 to April 2020 (344%). Additional peaks were observed from June 2020 to July 2020 (66%), October 2020 to December 2020 (169%), May 2021 to June 2021 (33%), and May 2023 to June 2023 (14%). "Migraine surgery" exhibited a notable 400% increase in RSV, from March 2005 to May 2005. However, post-2006, RSV for "migraine surgery" consistently remained low without noticeable peaks. Conclusions: The analysis of RSV trends for "Nurtec" and "migraine surgery" from 2004 to 2023 reveals the impact of pivotal events and marketing strategies on public interest. The distinct peaks in "Nurtec" RSV align with Food & Drug Administration approvals and marketing campaigns, highlighting the medication's accessibility. Conversely, the consistently low RSV for "migraine surgery" indicates limited awareness, emphasizing the need for enhanced promotion and education regarding surgical interventions.

Detection of Sentinel Lymph Nodes Using Indocyanine Green After Failing Scintigraphy in Merkel Cell Carcinoma.

Merkel cell carcinoma (MCC) is a rare but highly aggressive skin cancer that carries a high rate of lymph node involvement and death. The National Comprehensive Cancer Network recommends sentinel lymph node (SLN) biopsy for the staging of the disease. Scintigraphy using radioactive isotopes (RI) such as technetium 99m (Tc99) remains the gold standard for the detection of SLNs, however, recently indocyanine green (ICG) fluorescence imaging has been used to aid in the detection of SLNs.We present the case of a patient who presented with MCC of the face and two SLNs successfully identified with ICG fluorescence despite the fact that they were not detected by intraoperative scintigraphy using Tc99. The use of ICG fluorescence imaging in MCC is safe and improves the ability to detect SLNs when combined with RI.

Evaluation and Management of Complications of Endovascular Aneurysm Repair of the Thoracic Aorta.

Thoracic endovascular aortic repair (TEVAR) has become the standard of care for descending thoracic aortic pathology as the procedure has a historically low rate of reintervention and a high rate of success. However, TEVAR can be associated with complications such as endoleak, upper extremity limb ischemia, cerebrovascular ischemia, spinal cord ischemia, and post-implantation syndrome. An 80-year-old man with a history of complex thoracic aortic aneurysms underwent repair of a large thoracic aneurysm with a frozen elephant trunk procedure in 2019 at an outside institution. The proximal aortic graft extended to the arch and the innominate and left carotid artery were implanted into the distal portion of the graft. The endograft, extending from the proximal graft to the descending thoracic aorta, was fenestrated to maintain left subclavian artery flow. In an attempt to gain a seal at the fenestration, a Viabahn graft (Gore, Flagstaff, AZ, USA) was inserted. A type III endoleak was identified postoperatively at the fenestration, and a second Viabahn graft was required to gain a seal during the initial hospitalization. In 2020, an endoleak persisted at the fenestration on follow-up imaging, but the aneurysmal sac was stable. No intervention was recommended. The patient later presented to our institution with three days of chest pain. A type III endoleak at the level of the subclavian fenestration persisted with significant enlargement of the aneurysm sac. The patient underwent an urgent repair of the endoleak. This consisted of covering the fenestration with an endograft and left carotid to subclavian bypass. Subsequently, the patient developed a transient ischemic attack (TIA) due to kinking and extrinsic compression by the large aneurysm sac of the proximal left common carotid artery, requiring a right carotid to left carotid-axillary graft bypass. This report with a literature review discusses TEVAR complications and outlines methods to approach them. TEVAR complications and their management should be firmly understood to improve overall treatment outcomes.

Liver Venous Deprivation for Rapid Liver Hypertrophy Before Major Hepatectomy: A Case Report.

Liver venous deprivation (LVD) is an emerging, minimally invasive strategy to induce rapid liver hypertrophy of the future liver remnant (FLR) before a major hepatectomy. LVD (aka "double vein embolization") entails same-session percutaneous embolization of the portal and hepatic veins of the planned liver resection. This report discusses LVD's utilization and technical challenges in managing a 49-year-old male with recurrent multifocal colorectal liver metastases (CRLM). The patient initially underwent neoadjuvant FOLFOX chemotherapy followed by a simultaneous laparoscopic sigmoid colectomy and liver surgery (microwave ablation of segment V and wedge resections of segment one and IVb), followed by completion of chemotherapy. The patient had an R0 resection with clear colon and liver surgical margins. Nine months after the initial surgery, the patient had a rise in tumor markers, and surveillance imaging demonstrated recurrence of liver metastases in segments I and V. LVD was performed by interventional radiology, which led to a 28% increase in FLR (segments II, III, and IV); initially measuring 464 cm3 before LVD and measuring 594 cm3 on post-procedure day 21. The patient underwent right hemi-hepatectomy and caudate resection on post-procedure day 29. The patient did not have any complications and was discharged on postoperative day 6. The patient remains disease-free with no evidence of recurrence at 12 months follow-up.

Predictors and outcomes of acute kidney injury after bariatric surgery: analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry.

BACKGROUND: Acute kidney injury (AKI) after surgery increases long-term risk of kidney dysfunction. The major risk factor for AKI after bariatric surgery is having preoperative renal insufficiency. Little is known about the outcomes and risk factors for developing AKI in patients undergoing bariatric surgery with normal renal function. OBJECTIVE: We aimed to describe factors that may increase risk of AKI after primary bariatric surgery in patients without history of kidney disease. SETTING: Academic hospital, United States. METHODS: We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry for patients aged ≥18 years undergoing laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2015 to 2019. Patients with diagnosis of chronic kidney disease were excluded. The primary outcome was incidence of AKI. Secondary outcomes included 30-day complications, readmissions, reoperations, and mortality. Univariate and multivariate analyses were performed to identify differences between patients with and without AKI. RESULTS: A total of 747,926 patients were included in our analysis (laparoscopic sleeve gastrectomy = 73.1%, LRYGB = 26.8%). Mean age was 44.40 ± 11.94 years, with female predominance (79.7%). AKI occurred in 446 patients (.05%). Patients with postoperative AKI had higher rates of complications, readmissions, reoperations, and mortality. Significant predictors of AKI were male sex, history of venous thromboembolism, hypertension, limitation for ambulation, and LRYGB. High albumin levels and White race were protective factors. CONCLUSIONS: New-onset AKI was associated with adverse 30-day outcomes in patients undergoing bariatric surgery. Male sex, venous thromboembolism, hypertension, limited ambulation, and LRYGB were independent predictors of AKI. Prospective studies are needed to better describe these results.

Midterm benefits of metabolic surgery on symptom remission and medication use in patients with pseudotumor cerebri.

BACKGROUND: Pseudotumor cerebri is a serious obesity-related disorder that can result in severe complications. The aim of this study was to compare metabolic surgery with medical management of pseudotumor cerebri at a single bariatric center. METHODS: After institutional review board approval, a retrospective review was conducted of individuals with severe obesity and pseudotumor cerebri (nonbariatric group) and patients with preoperative pseudotumor cerebri (bariatric group). The variables included demographic characteristics, comorbidities, and pseudotumor cerebri-related risk factors. Symptoms, medication use, and body mass index were analyzed during a 4-year follow-up. RESULTS: A total of 86 patients with pseudotumor cerebri were included in the analysis. In the nonbariatric group (n = 77), the mean age was 34.1 ± 10.5 years and initial body mass index 37.2 ± 6.5 kg/m2. Initially, the most common symptom was headache (90.9%; n = 70), with a mean lumbar opening pressure of 341.94 ± 104.50 mm H2O. In the bariatric group (n = 9), the mean age was 36.1 ± 8.9 years and preoperative body mass index 46.1 ± 5.5 kg/m2. The most common preoperative symptom was headache (100%; n = 9), with a lumbar opening pressure of 320 ± 44.27 mm H2O. During the 4-year follow-up, both groups presented with a significant decrease in pseudotumor cerebri-related symptoms at 3 months (P < .0001). Additionally, pseudotumor cerebri medication use significantly decreased after 3 months in the bariatric group (P = .0406), whereas in the nonbariatric group decreased at 18 months (P = .023). Bariatric patients presented with a significant decrease in body mass index in ≤3 months of surgery (P = .0380), which was not observed in nonbariatric patients (P = .6644). CONCLUSION: Metabolic surgery seems to provide a greater decrease in pseudotumor cerebri symptoms and medication use in a shorter period of time compared with medical management alone.

The impact of bariatric surgery on hospitalization due to peripheral artery disease and critical limb ischemia: a nationwide analysis.

BACKGROUND: Severe obesity could be an independent risk factor for peripheral artery disease (PAD) and critical limb ischemia (CLI). Bariatric surgery reduces cardiac risk factors, decreasing cardiovascular morbidity and mortality in subjects with severe obesity. OBJECTIVES: We aimed to describe the impact of bariatric surgery on risk of hospitalization due to PAD and CLI. SETTING: Academic hospital. METHODS: The National Inpatient Sample data collected from 2010 to 2015 were examined. Patients were classified as treatment and control groups. Treatment was defined as patients with a previous history of bariatric surgery, and control was defined as patients with a body mass index ≥35 without a history of bariatric surgery. The primary outcome was hospitalization due to PAD; secondary outcomes were CLI, revascularization, major amputation, length of hospital stay (LOS), and total cost of hospitalization. Univariate and multivariate analyses were performed to assess the differences between groups. RESULTS: There were a total of 2,300,845 subjects: 2,004,804 controls and 296,041 treatment patients. Hospitalization rate for PAD was significantly lower compared to the control group (.10% versus .21%, P < .0001), which was confirmed after adjusting for covariables (control versus treatment: odds ratio= 1.20, confidence interval: 1.15-1.47). Subgroup analysis showed patients without a history of bariatric surgery had a higher prevalence of CLI (59.3% versus 52.4%, P < .0219) and a higher mean LOS (6.7 versus 5.7 days, P = .0023) and cost of hospitalization (78.756 versus 72.621$, P = .0089), with no significant differences in other outcomes. After multivariate analysis, only LOS and total costs were significantly different. CONCLUSIONS: Bariatric surgery may decrease the risk of hospitalization due to PAD, similarly to the LOS and total cost of hospitalization. Prospective studies should be performed to describe this relationship.

Does bariatric surgery change the risk of acute ischemic stroke in patients with a history of transient ischemic attack? A nationwide analysis.

BACKGROUND: Stroke is the second leading cause of death worldwide and fifth in the United States, and it represents the major cause of disability in older adults. OBJECTIVE: We aimed to determine the risk of acute ischemic stroke (AIS) in individuals with obesity with a history of transient ischemic attack (TIA) compared with patients with a history of bariatric surgery. SETTING: Academic hospital, United States. METHODS: Using the Nationwide Inpatient Sample (NIS) database from 2010 to 2015, we retrospectively identified patients with obesity and past medical history of TIA and divided them into 2 groups: a treatment group of patients who underwent bariatric surgery, and a control group of patients with obesity. We compared incidence of new AIS in both groups using a univariate analysis and multivariate regression model. Covariates included were lifestyle (smoking status, alcohol habits, cocaine use), family history of stroke, co-morbidities (diabetes, hypertension, hyperlipidemia, atrial fibrillation) and long-term medical treatment (antiplatelet/antithrombotic treatment). RESULTS: A total of 91,640 patients met inclusion criteria, of which treatment patients were 12.3% (n = 11,284) and control patients 87.6% (n = 80,356). The average age of the treatment group was 62.9 ± 17.08 years, and the average of the control was 59.6 ± 12.74 years. The rate of AIS in the treatment group was significantly lower compared with the control group (2.8% versus 4.2%, P < .0001). After adjusting for covariables, the risk difference of AIS was still significant between groups (odds ratio = 1.33, P < .0001), showing that patients in the treatment group were less likely to have AIS compared with the control group. CONCLUSIONS: After analyzing nationwide information, we conclude bariatric surgery helps decrease risk of AIS in patients with a history of TIA. However, this comparison is limited by the nature of the database; further studies are needed to better understand these results.