The SAGES masters program presents the 10 seminal articles for laparoscopic sleeve gastrectomy.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program includes eight distinct clinical pathways. The Bariatric Surgery Pathway focuses on three anchoring procedures, including the laparoscopic sleeve gastrectomy (LSG) which is the most commonly performed bariatric procedure in the United States. In this article, we present and discuss the top 10 seminal articles regarding the LSG. METHODS: The literature was systematically searched to identify the most cited papers on LSG. The SAGES Metabolic and Bariatric Surgery committee reviewed the most cited article list, and using expert consensus elected the seminal articles deemed most pertinent to LSG. These articles were reviewed in detail by committee members and are presented here. RESULTS: The top 10 most cited sentinel papers on LSG focus on operative safety, outcomes, surgical technique, and physiologic changes after the procedure. A summary of each paper is presented, including expert appraisal and commentary. CONCLUSIONS: The seminal articles presented support the widespread acceptance and use of the LSG by bolstering the understanding of its mechanism of action and by demonstrating its safety and excellent patient outcomes. All bariatric surgeons should be familiar with these 10 landmark articles.

The Dynamic Platelet Transcriptome in Obesity and Weight Loss.

OBJECTIVE: Adiposity is associated with oxidative stress, inflammation, and glucose intolerance. Previous data suggest that platelet gene expression is associated with key cardiometabolic phenotypes, including body mass index but stable in healthy individuals over time. However, modulation of gene expression in platelets in response to metabolic shifts (eg, weight reduction) is unknown and may be important to defining mechanism. Approach and Results: Platelet RNA sequencing and aggregation were performed from 21 individuals with massive weight loss (>45 kg) following bariatric surgery. Based on RNA sequencing data, we measured the expression of 67 genes from isolated platelet RNA using high-throughput quantitative reverse transcription quantitative PCR in 1864 FHS (Framingham Heart Study) participants. Many transcripts not previously studied in platelets were differentially expressed with bariatric surgical weight loss, appeared specific to platelets (eg, not differentially expressed in leukocytes), and were enriched for a nonalcoholic fatty liver disease pathway. Platelet aggregation studies did not detect alteration in platelet function after significant weight loss. Linear regression models demonstrated several platelet genes modestly associated with cross-sectional cardiometabolic phenotypes, including body mass index. There were no associations between studied transcripts and incident diabetes or cardiovascular end points. CONCLUSIONS: In summary, while there is no change in platelet aggregation function after significant weight loss, the human platelet experiences a dramatic transcriptional shift that implicates pathways potentially relevant to improved cardiometabolic risk postweight loss (eg, nonalcoholic fatty liver disease). Further studies are needed to determine the mechanistic importance of these observations.

Proteins Altered by Surgical Weight Loss Highlight Biomarkers of Insulin Resistance in the Community.

Objective- Mechanisms of early and late improvements in cardiovascular risk after bariatric surgery and applicability to larger, at-risk populations remain unclear. We aimed to identify proteins altered after bariatric surgery and their relations to metabolic syndrome and diabetes mellitus. Approach and Results- We identified 19 proteins altered in 32 nonfasting plasma samples from a study of patients undergoing bariatric surgery who were evaluated preoperatively (visit 1) versus both early (visit 2; ≈3 months) and late (visit 3; ≈12 months) postoperative follow-up using predefined protein panels (Olink). Using in silico methods and publicly available gene expression repositories, we found that genes encoding 8 out of 19 proteins had highest expression in liver relative to other assayed tissues, with the top biological and disease processes, including major obesity-related vascular diseases. Of 19 candidate proteins in the surgical cohort, 6 were previously measured in >3000 FHS (Framingham Heart Study) participants (IGFBP [insulin-like growth factor binding protein]-1, IGFBP-2, P-selectin, CD163, LDL (low-density lipoprotein)-receptor, and PAI [plasminogen activator inhibitor]-1). A higher concentration of IGFBP-2 at baseline was associated with a lower risk of incident metabolic syndrome (odds ratio per log-normal unit, 0.45; 95% CI, 0.32-0.64; P=7.7×10-6) and diabetes mellitus (odds ratio, 0.63; 95% CI, 0.49-0.79; P=0.0001) after multivariable adjustment. Conclusions- Using a directed protein quantification platform (Olink), we identified known and novel proteins altered after surgical weight loss, including IGFBP-2. Future efforts in well-defined obesity intervention settings may further define and validate novel targets for the prevention of vascular disease in obesity.

Effect of reversible intermittent intra-abdominal vagal nerve blockade on morbid obesity: the ReCharge randomized clinical trial.

IMPORTANCE: Although conventional bariatric surgery results in weight loss, it does so with potential short-term and long-term morbidity. OBJECTIVE: To evaluate the effectiveness and safety of intermittent, reversible vagal nerve blockade therapy for obesity treatment. DESIGN, SETTING, AND PARTICIPANTS: A randomized, double-blind, sham-controlled clinical trial involving 239 participants who had a body mass index of 40 to 45 or 35 to 40 and 1 or more obesity-related condition was conducted at 10 sites in the United States and Australia between May and December 2011. The 12-month blinded portion of the 5-year study was completed in January 2013. INTERVENTIONS: One hundred sixty-two patients received an active vagal nerve block device and 77 received a sham device. All participants received weight management education. MAIN OUTCOMES AND MEASURES: The coprimary efficacy objectives were to determine whether the vagal nerve block was superior in mean percentage excess weight loss to sham by a 10-point margin with at least 55% of patients in the vagal block group achieving a 20% loss and 45% achieving a 25% loss. The primary safety objective was to determine whether the rate of serious adverse events related to device, procedure, or therapy in the vagal block group was less than 15%. RESULTS: In the intent-to-treat analysis, the vagal nerve block group had a mean 24.4% excess weight loss (9.2% of their initial body weight loss) vs 15.9% excess weight loss (6.0% initial body weight loss) in the sham group. The mean difference in the percentage of the excess weight loss between groups was 8.5 percentage points (95% CI, 3.1-13.9), which did not meet the 10-point target (P = .71), although weight loss was statistically greater in the vagal nerve block group (P = .002 for treatment difference in a post hoc analysis). At 12 months, 52% of patients in the vagal nerve block group achieved 20% or more excess weight loss and 38% achieved 25% or more excess weight loss vs 32% in the sham group who achieved 20% or more loss and 23% who achieved 25% or more loss. The device, procedure, or therapy-related serious adverse event rate in the vagal nerve block group was 3.7% (95% CI, 1.4%-7.9%), significantly lower than the 15% goal. The adverse events more frequent in the vagal nerve block group were heartburn or dyspepsia and abdominal pain attributed to therapy; all were reported as mild or moderate in severity. CONCLUSION AND RELEVANCE: Among patients with morbid obesity, the use of vagal nerve block therapy compared with a sham control device did not meet either of the prespecified coprimary efficacy objectives, although weight loss in the vagal block group was statistically greater than in the sham device group. The treatment was well tolerated, having met the primary safety objective. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01327976.

Intermediate results of a prospective randomized controlled trial of traditional four-port laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy.

BACKGROUND: Minimally invasive techniques have become an integral part of general surgery, with recent investigation into single-incision laparoscopic cholecystectomy (SILC). This study presents a prospective, randomized, multicenter, single-blind trial of SILC compared with four-port cholecystectomy (4PLC) with the goal of assessing safety, feasibility, and factors predicting outcomes. METHODS: Patients with biliary colic and documented gallstones or polyps or with biliary dyskinesia were randomized to SILC or 4PLC. Data measures included operative details, adverse events, and conversion to 4PLC or laparotomy. Pain, cosmesis, and quality-of-life scores were documented. Patients were followed for 12 months. RESULTS: Two hundred patients were randomized to SILC (n = 117) or 4PLC (n = 80) (3 patients chose not to participate after randomization). Patients were similar except for body mass index (BMI), which was lower in the SILC patients (28.9 vs. 31.0, p = 0.011). One SILC patient required conversion to 4PLC. Operative time was longer for SILC (57 vs. 45 min, p < 0.0001), but outcomes, including total adverse events, were similar (34% vs. 38%, p = 0.55). Cosmesis scores favored SILC (p < 0.002), but pain scores were lower for 4PLC (1 point difference in 10-point scale, p < 0.028) despite equal analgesia use. Wound complications were greater after SILC (10% vs. 3%, p = 0.047), but hernia recurrence was equivalent for both procedures (1.3% vs. 3.4%, p = 0.65). Univariate analysis showed female gender, SILC, and younger age to be predictors for increased pain scores, while SILC was associated with improved cosmesis scores. CONCLUSIONS: In this multicenter randomized controlled trial of SILC versus 4PLC, SILC appears to be safe with a similar biliary complication profile. Pain scores and wound complication rates are higher for SILC; however, cosmesis scores favored SILC. For patients preferring a better cosmetic outcome and willing to accept possible increased postoperative pain, SILC offers a safe alternative to the standard 4PLC. Further follow-up is needed to detail the long-term risk of wound morbidities, including hernia recurrence.

The association of sex with pain scores and perioperative opioid administration following laparoscopic sleeve gastrectomy.

Aim: We investigated whether sex is associated with pain scores and opioid administration after laparoscopic sleeve gastrectomy. Materials & methods: We performed a single-center, retrospective analysis of laparoscopic sleeve gastrectomy patients from December 2016-July 2018. Multivariable linear regressions were performed to investigate the association of sex with pain scores and opioid administration. Results: Baseline pain scores were similar between women and men (n = 266; 78% women). Men reported lower pain scores in all phases of care and received more opioids during their hospitalization (ß = 25.48; 95% CI: 5.77-45.20; p = 0.01), compared with women. Conclusion: Our data suggest that women self-report greater postoperative pain scores, while men received more opioids during their hospitalization. Further studies are needed to understand the reasons for such differences in postoperative pain management.

Men are at higher risk for long-term opioid use compared with women, but it remains unclear whether perioperative management is a sentinel event for such outcomes. Since patients who receive higher amounts of postoperative opioids are more likely to remain on long term narcotics, we investigated whether sex is associated with pain scores and opioid administration after bariatric surgery. We demonstrate that men self-report lower pain scores in the postanesthesia care unit, surgical floor and at discharge, compared with women. We also show that while men and women received comparable doses of opioids in the operating room and postanesthesia care unit, men received more opioids on the surgical floor. Our findings suggest that strategies to reduce opioid administration after bariatric surgery should largely focus on care after the immediate postoperative period.

First Do No Harm: Moving Beyond Universal Preprocedural Testing for COVID-19.

Preprocedural testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was introduced early in the pandemic in an effort to protect health care workers, direct appropriate use of personal protective equipment (PPE), and improve patient outcomes. In light of our appreciation for the efficacy of PPE and the nuances associated with interpretation of polymerase chain reaction testing for SARS-CoV-2, particularly as community transmission decreases, we call for a re-evaluation of universal preprocedural testing. We propose a transition to a patient-centered approach, focusing on testing patients whose outcomes would be improved by a delayed procedure in the event of a positive test and a greater reliance on appropriate PPE rather than preprocedural test results. We recommend that a community infection rate threshold be set at which point preprocedural testing is discontinued, understanding that there is an inflection point at which testing downsides outweigh the benefits.

Evaluation of collagen derived antiangiogenic factors and matrix metalloproteinases in anterior lens epithelial cells of pediatric eyes with persistent fetal vasculature.

Purpose: To measure levels of collagen-derived antiangiogenic factors (arresten, canstatin, tumstatin, endostatin) and matrix metalloproteinases (MMP-2 and MMP-9) in anterior lens epithelial cells (LECs) and anterior capsules of children with cataract and persistent fetal vasculature (PFV) as cases and cataract without PFV as controls. Methods: Anterior capsules harboring LECs were collected from pediatric cataract patients with (n = 13) and without PFV (n = 13) during surgery. Samples were immediately subjected to RNA extraction and cDNA preparation. Quantitative real time PCR was performed to determine the mRNA levels of antiangiogenic factors and matrix metalloproteinases. GAPDH (Glyceraldehyde 3-Phosphate Dehydrogenase) and ß Actin were used as the housekeeping control. The mRNA levels were expressed as a ratio, using the delta-delta method for comparing the relative expression results between controls and cases. The non-parametric Mann-Whitney U test was applied for statistical evaluation. P values < 0.05 were statistically significant. Results: The relative mRNA levels of arresten, canstatin, tumstatin, endostatin, MMP-2 and MMP-9 in cases were 6.20E-03 ± 0.003, 1.49E-01 ± 0.02, 1.70E-01 ± 0.007, 3.20E-03 ± 0.003, 1.11E-03 ± 0.0009 and 3.72E-04 ± 0.0001. The mRNA levels of arresten was 1.6 times lower (P = 0.01) while mRNA levels of MMP-2, tumstatin and canstatin were 4, 2.5, and 2.3 times higher in cases than in controls. No change was observed in mRNA levels of MMP-9 and endostatin (P = 0.82). Conclusion: A significant difference in the levels of arresten, canstatin, tumstatin, and MMP-2 was found in LECs with PFV.

Five-Year Postoperative Outcomes of Bilateral Aphakia and Pseudophakia in Children up to 2 Years of Age: A Randomized Clinical Trial.

PURPOSE: Comparative evaluation of complications and visual outcomes following bilateral congenital cataract surgery in children up to 2 years of age with and without primary intraocular lens (IOL) implantation at 5 years follow-up. DESIGN: Randomized controlled clinical trial. METHODS: Sixty children (120 eyes) up to 2 years of age undergoing bilateral congenital cataract surgery were randomized to Group 1, primary aphakia (n = 30), or Group 2, primary IOL implantation (pseudophakia) (n = 30). A single surgeon performed surgeries with identical surgical technique. All patients were followed up regularly until 5 years postoperatively. At each follow-up, glaucoma, visual axis obscuration (VAO) requiring surgery, and inflammation (cell deposits, posterior synechiae) were assessed. Visual acuity was assessed until 5 years follow-up. The first operated eye was selected for statistical analysis. RESULTS: Median age of the patients at time of surgery was 5.11 months (aphakia group) and 6.01 months (pseudophakia group) (P = .56). Five years postoperatively, incidence of glaucoma was 16% and 13.8% in Groups 1 and 2 (P = .82). Incidence of posterior synechiae was significantly higher in the pseudophakia group (27.6%) compared to the aphakia group (8%) (P = .004). VAO requiring surgery was seen in 8% and 10.3% of eyes in Groups 1 and 2 (P = .76). Mean logMAR visual acuity at 5 years follow-up was 0.59 ± 0.33 and 0.5 ± 0.23 in Groups 1 and 2, respectively (P = .79). However, more eyes in the pseudophakic group started giving documentable vision earlier in their postoperative follow-ups. CONCLUSIONS: Incidence of postoperative complications was comparable between the groups, except for a higher incidence of posterior synechiae in pseudophakic eyes. Visual rehabilitation was faster in the pseudophakic group.

The significance of histologic examination of gastrectomy specimens: a clinicopathologic study of 511 cases.

BACKGROUND: Sleeve gastrectomy (SG) is quickly becoming the preferred procedure for bariatric surgery. According to the American Society for Metabolic and Bariatric Surgery guidelines, routine preoperative upper gastrointestinal endoscopies are not recommended universally for bariatric surgery. Some studies have shown that the histologic examination of SG specimens is insignificant and not a cost-effective practice. However, some speculate SG examination may unveil pertinent findings and prevent further progression of precursor lesions. OBJECTIVES: This study aims to explore the clinically significant or actionable lesions that can be revealed with SG examination. SETTING: Tufts Medical Center, Boston, USA. RESULTS: We analyzed 511 SG specimens obtained during bariatric surgery. Incidental findings were grouped in 2 categories: clinically significant/actionable and minor lesions. The clinically significant lesions accounted for 5.8%. This category included 5 cases of gastrointestinal stromal tumor; one case of MALT lymphoma; 4 cases of autoimmune gastritis with concomitant pancreatic metaplasia or neuroendocrine dysplasia. Intestinal metaplasia without dysplasia was identified in 3 cases; 14 cases of Helicobacter pylori associated active gastritis; 1 case of iron pill induced gastritis and 1 case of gastric glandular siderosis. The minor lesions accounted for 6.3%, showing findings other than chronic gastritis. This category included 19 cases of fundic polyps and 1 case of hyperplastic polyp; one case of leiomyoma; 11 cases of H pylori negative active gastritis. CONCLUSIONS: The majority of histopathology results after SG showed no significant changes. However, a few cases had clinically significant lesions in seemingly healthy patients, altering patient's postoperative management.

Two-Year Outcomes of Vagal Nerve Blocking (vBloc) for the Treatment of Obesity in the ReCharge Trial.

BACKGROUND: The ReCharge Trial demonstrated that a vagal blocking device (vBloc) is a safe and effective treatment for moderate to severe obesity. This report summarizes 24-month outcomes. METHODS: Participants with body mass index (BMI) 40 to 45 kg/m2, or 35 to 40 kg/m2 with at least one comorbid condition were randomized to either vBloc therapy or sham intervention for 12 months. After 12 months, participants randomized to vBloc continued open-label vBloc therapy and are the focus of this report. Weight loss, adverse events, comorbid risk factors, and quality of life (QOL) will be assessed for 5 years. RESULTS: At 24 months, 123 (76 %) vBloc participants remained in the trial. Participants who presented at 24 months (n = 103) had a mean excess weight loss (EWL) of 21 % (8 % total weight loss [TWL]); 58 % of participants had ≥5 % TWL and 34 % had ≥10 % TWL. Among the subset of participants with abnormal preoperative values, significant improvements were observed in mean LDL (-16 mg/dL) and HDL cholesterol (+4 mg/dL), triglycerides (-46 mg/dL), HbA1c (-0.3 %), and systolic (-11 mmHg) and diastolic blood pressures (-10 mmHg). QOL measures were significantly improved. Heartburn/dyspepsia and implant site pain were the most frequently reported adverse events. The primary related serious adverse event rate was 4.3 %. CONCLUSIONS: vBloc therapy continues to result in medically meaningful weight loss with a favorable safety profile through 2 years. TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT01327976.

Postoperative outcomes of intraocular lens implantation in the bag versus posterior optic capture in pediatric cataract surgery.

PURPOSE: To compare complications in children up to 4 years old having cataract surgery with intraocular lens (IOL) implantation using 2 techniques: in-the-bag IOL with anterior vitrectomy or optic capture of IOL with no anterior vitrectomy. SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. DESIGN: Prospective randomized control clinical trial. METHODS: The study included children having cataract surgery with IOL implantation. Patients were randomized to Group 1 (in-the-bag 3-piece hydrophobic acrylic IOL [Acrysof MA60AC] with anterior vitrectomy) or Group 2 (optic capture of the same IOL without anterior vitrectomy). Intraoperative complications were documented. Postoperative visual axis obscuration (VAO), glaucoma, cell deposits on the IOL, and posterior synechiae were compared at 1, 3, 6, and 12 months. RESULTS: The study comprised 61 children (61 eyes). The mean ages were 14.8 months ±11.47 (SD) in Group 1 (n = 30) and 18.2 ± 11.47 months in Group 2 (n = 31). Overall, only 1 eye in Group 1 developed a VAO requiring membranectomy 4 months postoperatively, and 2 eyes in Group 1 developed glaucoma over 12 months (P = .49). Intraocular lens cell deposits and posterior synechiae were comparable between groups. The IOL could not be captured in 5 eyes (16.1%); no complications occurred in these eyes. CONCLUSIONS: Optic capture of 3-piece hydrophobic acrylic IOLs could be achieved in most eyes. The VAO, glaucoma, and inflammation were comparable 12 months postoperatively. Thus, optic capture of an IOL is an alternative surgical technique that can be used to avoid vitrectomy, even in children younger than 4 years.

Preoperative prediction of posterior capsule plaque in eyes with posterior subcapsular cataract.

AIM: To determine whether the plaque on the posterior capsule can be predicted preoperatively, in patients with posterior subcapsular cataract (PSC), undergoing cataract surgery. MATERIALS AND METHODS: A prospective study of 140 consecutive eyes with PSC, who underwent cataract surgery, was conducted. The prediction of preoperative presence or absence of plaque within the PSC was noted on slit lamp examination, in dilated pupils. A single observer made the observations under oblique illumination, where the slit lamp was placed at an angle of 30 degrees to 45 degrees. Evaluation of the plaque through slit lamp examination was standardized in terms of illumination and magnification. The observations were recorded using a video camera (Image archiving system, Carl Zeiss, Jena Germany) attached to a slit lamp (Carl Zeiss, SL 120 Jena, Germany), keeping the illumination at 100%. The prediction of plaque was noted in terms of its presence or absence on the posterior capsule. All the patients received counseling regarding the presence of plaque. Capsule polishing of the posterior capsule in Cap Vac mode, was done in all cases. The posterior capsule was examined for presence or absence of plaque, either on the first postoperative day, or within a week, with maximal mydriasis. The observer's results were tabulated and later analyzed to judge the incidence of predictability of plaque in PSC. RESULTS: The mean age of the patients was 45+/-6.2 years (range 32-61 years); 104 (74.3%) were males. One hundred and eight (77.1%) patients were under 50 years. The presence or absence of plaque was predicted correctly in 124 (88.6%) eyes. The prediction of plaque was incorrect in 16 (11.4%) eyes. CONCLUSION: The prediction of presence or absence of plaque was accurate in 88.6% cases. We believe that counseling patients with posterior capsule plaque before the surgery is the key to avoiding unpleasant surprises.

Effect of Vagal Nerve Blockade on Moderate Obesity with an Obesity-Related Comorbid Condition: the ReCharge Study.

BACKGROUND: Vagal nerve blockade (vBloc) therapy was shown to be a safe and effective treatment for moderate to severe obesity. This report summarizes the safety and efficacy of vBloc therapy in the prespecified subgroup of patients with moderate obesity. METHODS: The ReCharge Trial is a double-blind, randomized controlled clinical trial of participants with body mass index (BMI) of 40-45 or 35-40 kg/m(2) with at least one obesity-related comorbid condition. Participants were randomized 2:1 to implantation with either a vBloc or sham device with weight management counseling. Eighty-four subjects had moderate obesity (BMI 35-40 kg/m(2)) at randomization. RESULTS: Fifty-three participants were randomized to vBloc and 31 to sham. Qualifying obesity-related comorbidities included dyslipidemia (73%), hypertension (58%), sleep apnea (33%), and type 2 diabetes (8%). The vBloc group achieved a percentage excess weight loss (%EWL) of 33% (11% total weight loss (%TWL)) compared to 19% EWL (6% TWL) with sham at 12 months (treatment difference 14 percentage points, 95% CI, 7-22; p < 0.0001). Common adverse events of vBloc through 12 months were heartburn/dyspepsia and implant site pain; the majority of events were reported as mild or moderate. CONCLUSIONS: vBloc therapy resulted in significantly greater weight loss than the sham control among participants with moderate obesity and comorbidities with a well-tolerated safety profile.

Long-term postoperative outcomes after bilateral congenital cataract surgery in eyes with microphthalmos.

PURPOSE: To evaluate the long-term impact of bilateral cataract surgery on postoperative complications, influence of age at surgery on the pattern of axial growth and central corneal thickness (CCT), and visual and orthoptic assessment in microphthalmic eyes. SETTING: Iladevi Cataract and IOL Research Centre, Ahmedabad, India. DESIGN: Prospective longitudinal study. METHODS: This study assessed children with microphthalmos who had bilateral congenital cataract surgery. Microphthalmos was defined as an eye that has an axial length (AL) that was 2 standard deviations smaller than what is normally expected at that age. All eyes were left aphakic. One of the 2 eyes was randomly selected for analysis. Postoperative complications, AL, CCT, and visual acuity were documented. RESULTS: This study included 72 eys of 36 children. The mean age of the patients was 4.8 months ± 6.2 (SD) (range 0.5 to 15 months). Postoperative complications included secondary glaucoma (11/36, 30.6%), visual axis obscuration (4/36, 11.1%), and posterior synechiae (10/36, 27.8%). A significant rate of change was observed in axial growth up to 4 years and in CCT up to 3 years postoperatively. When age at the time of surgery was correlated with the profile of the rate of change in AL and CCT at 1 month and 1, 2, and 4 years, statistically significant differences in AL and CCT at all timepoints were found. Loss of vision after surgery occurred in 2 eyes. CONCLUSION: After early surgical intervention, an acceptable rate of serious postoperative complications and good visual outcomes were obtained in microphthalmic eyes. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Roux-en-Y gastric bypass: hyperamylasemia is associated with small bowel obstruction.

BACKGROUND: Small bowel obstruction after Roux-en-Y gastric bypass (RYGB) can be difficult to diagnose, but usually requires surgical treatment; clinical presentation may be nonspecific. Delay in diagnosis can result in catastrophic outcomes. Patients who present with small bowel obstruction after gastric bypass occasionally have pancreatic enzyme elevation and have been misdiagnosed as having acute pancreatitis. The objective of this study was to determine if there was an association between small bowel obstruction and an elevated amylase or lipase after RYGB. METHODS: Ninety-nine cases of small bowel obstruction treated surgically were prospectively collected and retrospectively analyzed from a database of 4014 RYGB patients. Fifty-eight had a measurement of amylase or lipase at the time of operation. RESULTS: An elevated amylase or lipase was found in 48% of all patients. These elevated rates were higher in an acute obstruction compared to those presenting with chronic symptoms (64% versus 28%; P=.007) and in obstruction involving the biliopancreatic limb compared to those that did not involve that limb (65% versus 21%; P<.001). These elevated rates were most notable in acute biliopancreatic limb obstruction compared to an acute obstruction not in the biliopancreatic limb (94% versus 27%; P<.001). CONCLUSION: In RYGB patients, there is an association between small bowel obstruction and an elevated amylase or lipase. Acute obstruction of the biliopancreatic limb can be difficult to diagnose, and in these patients, the sensitivity of elevated amylase or lipase is very high. RYGB patients with abdominal pain should have their amylase and lipase measured. It is important to recognize that an elevation of these enzymes is not likely a result of acute pancreatitis.

Contrast sensitivity assessment in pediatric cataract surgery: comparison of preoperative and early postoperative outcomes.

PURPOSE: To evaluate the preoperative and early postoperative differences in contrast sensitivity at high and low spatial frequencies after cataract extraction with in-the-bag intraocular lens (IOL) implantation in children presenting with lamellar and posterior subcapsular cataract. SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. DESIGN: Prospective clinical trial. METHODS: In eyes with lamellar or posterior subcapsular cataract having cataract surgery with Acrysof SN60WF IOL implantation, contrast sensitivity testing was performed using the CSV-1000E sine wave grating test face at 3, 6, 12, and 18 cycles per degree under photopic (85.0 candelas [cd]/m(2)) and mesopic (2.7 cd/m(2)) conditions. The main outcome measures were contrast sensitivity under photopic and mesopic conditions preoperatively and 1 and 3 months postoperatively. The corrected distance visual acuity (CDVA) was recorded in logMAR units. The effect of the type of cataract and of age at surgery on contrast sensitivity preoperatively and 1 and 3 months postoperatively was also evaluated. RESULTS: The mean age of 13 patients (22 eyes) was 7.85 years ± 2.6 (SD). There was a statistically significant difference in contrast sensitivity at every timepoint at every spatial frequency under mesopic and photopic conditions. There was also a statistically significant improvement in CDVA from preoperatively to 1 month postoperatively and from 1 month to 3 months postoperatively (both P<.001). CONCLUSION: There was a significant improvement in contrast sensitivity at high and low spatial frequencies, even in children older than 4 years, after cataract surgery for lamellar or posterior subcapsular cataract. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Risk factors for 30-day readmissions and modifying postoperative care after gastric bypass surgery.

BACKGROUND: Although hospital 30-day readmissions policies currently focus on medical conditions, readmission penalties will be expanding to encompass surgical procedures, logically beginning with common and standardized procedures, such as gastric bypass. Therefore, understanding predictors of readmission is essential in lowering readmission rate for these procedures. STUDY DESIGN: This is a retrospective case-control study of patients undergoing laparoscopic gastric bypass at Tufts Medical Center from 2007 to 2012. Variables analyzed included demographics, comorbidities, intraoperative events, postoperative complications, discharge disposition, and readmission diagnoses. Univariate analysis was used to identify factors associated with readmission, which were then subjected to multivariable logistic regression analysis. RESULTS: We reviewed 358 patients undergoing laparoscopic gastric bypass, 119 readmits, and 239 controls. By univariate analysis, public insurance, body mass index >60 kg/m(2), duration of procedure, high American Society of Anesthesiologists (ASA) class, and discharge with visiting nurse services (VNA) were significantly associated with 30-day readmissions. In the regression model, duration of procedure, high ASA class, and discharge with visiting nurse services (VNA) remained significantly associated with readmission when controlling for other factors (odds ratio [OR] 1.523, 95% CI 1.314 to 1.766; OR 2.447, 95% CI 1.305 to 4.487; and OR 0.053 with 95% CI 0.011 to 0.266, respectively). The majority of readmissions occurred within the first week after discharge. Gastrointestinal-related issues were the most common diagnoses on readmission, and included anastomotic leaks, postoperative ileus, and bowel obstruction. The next 2 most common reasons for readmission were wound infection and fluid depletion. CONCLUSIONS: Using readmission risk, we can stratify patients into tiered clinical pathways. Because most readmissions occur within the first postdischarge week and are most commonly associated with dehydration, pain, or wound issues, focusing our postoperative protocols and patient education should further lower the incidence of readmission.

Long-term longitudinal assessment of postoperative outcomes after congenital cataract surgery in children with congenital rubella syndrome.

PURPOSE: To assess the intraoperative and long-term longitudinal postoperative outcomes of cataract surgery in children with congenital rubella syndrome. SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. DESIGN: Prospective observational clinical study. METHODS: Children with congenital rubella syndrome who had cataract surgery were enrolled. All microphthalmic eyes were left aphakic. A 1-piece hydrophobic acrylic intraocular lens was implanted in the capsular bag in eyes without microphthalmos. The postoperative observations included complications and visual assessments up to 5 years. RESULTS: The mean age of the 21 children (37 eyes) was 3.97 months ± 2.1 (SD). Intraocular lens implantation was performed in 12 eyes (32.4%), while 25 eyes (67.6%) were left aphakic. Postoperatively, the median follow-up was 60.79 months. Posterior synechiae were observed in 22 eyes (59.5%) and visual axis opacification in 9 eyes (24.3%). Secondary glaucoma was observed in 16 eyes (43.2%), of which 14 were aphakic and 1 was pseudophakic. Nine eyes required trabeculectomy. Age at surgery and ocular comorbidities were statistically significantly associated with secondary glaucoma (P<.05, χ(2) test and Kendall τB criteria P<.05). The mean corrected distance visual acuity at the final follow-up was 0.72 ± 0.56 logMAR. CONCLUSIONS: The long-term results suggest good visual outcomes can be obtained with congenital cataract associated with congenital rubella syndrome after early surgical intervention. The rate of serious postoperative complications was acceptable.