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.

Prescription drug usage as measure of comorbidity resolution after bariatric surgery: a population-based cohort study.

BACKGROUND: Obesity is a chronic and progressive disease associated with significant morbidity, mortality, and health-care costs. Bariatric surgery is the most effective intervention for sustainable weight loss and resolution of obesity-related comorbidities. Studies examining comorbidity resolution largely rely on individual self-reported outcomes and electronic record reviews. We present a population-based study looking at prescription medication utilization before and after bariatric surgery as a measure of comorbidity resolution. METHODS: All patients enrolled in the Center for Metabolic and Bariatric Surgery who underwent either gastric bypass or sleeve gastrectomy between 2013 and 2019 in Manitoba were included. Demographic information, follow up, and outpatient prescription dispensation data were obtained from the Manitoba Population Research Data Repository housed at the Manitoba Centre for Health Policy for 5 years pre- and post-surgery. RESULTS: A total of 1184 patients were included. Antidepressants and selective serotonin reuptake inhibitors were the most commonly prescribed classes, and along with thyroid medication, utilization remained stable after bariatric surgery. Proton pump inhibitors and opioid class drugs increased at 1 year after surgery then returned to baseline. Glucose and lipid-lowering medications, including statins, biguanides, sulfonylureas, and insulin, were decreased. Antihypertensives, including ACE inhibitors, calcium channel blockers, angiotensin receptors blockers, thiazides, and beta blockers, similarly decreased. CONCLUSION: This is the first Canadian study employing a provincial-wide prescription database to measure long-term comorbidity resolution after bariatric surgery. The use of administrative data eliminates potential biases and inaccuracies in follow up and self-reported outcomes. Consistent with the literature, prescriptions for the treatment of metabolic syndrome all decreased and were sustained at long-term follow up. Further studies are needed to delineate the effects of altered pharmaceutical utilization on patient quality of life and health-care expenditures.

Development of consensus-derived quality indicators for laparoscopic sleeve gastrectomy operative reports.

BACKGROUND: Synoptic operative reporting has been used as a solution to the poor quality of narrative reports. The aim of this study was to develop operative report quality indicators for the laparoscopic sleeve gastrectomy and to generate parameters by which these reports can be evaluated and improved. METHODS: A Delphi protocol was used to determine quality indicators for LSG. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Transferrable consensus items for LSG from previously developed Roux-en-Y gastric bypass operative indictors were put forward for consideration. Participants also initially submitted potential QIs. These were grouped by theme. Items were rated on 5-point Likert scales in subsequent rounds. Scores of 70% or higher were used for inclusion and 30% or less denoted exclusion. Elements scoring 30% to 70% agreement were recirculated by runoff in subsequent rounds to generate the final list of quality indicators. RESULTS: Seven bariatric surgeons, representing all regions preforming LSG in Canada, were invited to participate in the Delphi group. Multidisciplinary invitees included one academic minimally invasive/acute care surgeon, one tertiary abdominal radiologist, and one academic gastroenterologist with bariatric expertise. Two rounds were required to achieve consensus. Both rounds achieved a 100% response (10/10). In round 1, forty items reached consensus. In Round 2, an additional 28 items reached consensus, with three items excluded, bringing the total number of quality indicators to 65. CONCLUSION: This study establishes consensus-derived multidisciplinary quality indicators for LSG operative reports. Application of these findings aims to advance the quality and completeness of operative reporting in LSG in order to improve communication of important surgical details and quality measures to the multidisciplinary team involved in bariatric surgery care.

The incidence of iron deficiency anemia post-Roux-en-Y gastric bypass and sleeve gastrectomy: a systematic review.

SETTING: The physiological and anatomical changes that occur as a consequence of bariatric surgery result in macro- and micro-nutritional deficiencies, especially iron deficiency. The reported incidence of iron deficiency and associated anemia after bariatric surgery varies widely across studies. OBJECTIVES: The aim of this systematic review is to quantify the impact of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on the incidence of iron deficiency. METHODS: Databases including Ovid Medline, Ovid Embase, Helthstar, Scopus, Cochrane (CDSR), LILACS, and ClinicalKey were searched for original articles with additional snowballing search. Search terms included Obesity, nutrient deficiency, iron deficiency, iron deficiency anemia, bariatric surgery, Roux-en-Y gastric bypass, and sleeve gastrectomy. Original articles reporting the incidence of iron deficiency and anemia pre- and post-RYGB and SG from January 2000 to January 2015 with minimum 1-year follow-up were selected. Data extraction from selected studies was based on protocol-defined criteria. RESULTS: There were 1133 articles screened and 20 studies were included in the final analysis. The overall incidence of iron deficiency was 15.2% pre-operatively and 16.6% post-operatively. When analyzed by procedure, the incidence of iron deficiency was 12.9% pre-RYGB versus 24.5% post-RYGB and 36.6% pre-SG versus 12.4% post-SG. The incidence of iron deficiency-related anemia was 16.7% post-RYGB and 1.6% post-SG. Risk factors for iron deficiency were premenopausal females, duration of follow-up, and pre-operative iron deficiency. Prophylactic iron supplementation was reported in 16 studies and 2 studies provided therapeutic iron supplementation only for iron-deficient patients. Iron dosage varied from 7 to 80 mg daily across studies. CONCLUSION: Iron deficiency is frequent in people with obesity and may be exacerbated by bariatric surgery, especially RYGB. Further investigation is warranted to determine appropriate iron supplementation dosages following bariatric surgery. Careful nutritional surveillance is important, especially for premenopausal females and those with pre-existing iron deficiency.

Iron deficiency in bariatric surgery patients: a single-centre experience over 5 years.

Background: As the prevalence of obesity has increased, so too has the demand for bariatric surgery. This study aimed to determine the incidence of postoperative iron deficiency and anemia and the impact of an increased preoperative ferritin target on postoperative outcomes. Methods: Patients undergoing bariatric surgery in Winnipeg from 2010 to 2014 were included in the analysis. Data capture included age, sex and date of surgery and iron, ferritin and hemoglobin levels before surgery and 12 months postoperatively. Before 2014, there was no protocol for preoperative iron supplementation at our centre; in 2014, a more aggressive preoperative iron supplementation program was introduced to target a minimum preoperative ferritin level of 50 mg/L. Data were analyzed using unpaired t tests, paired t tests and χ2 tests. Results: A total of 399 patients were considered; 288 were included in the analysis. The incidence of iron and ferritin deficiency and anemia at 12 months postoperatively was 14.6%, 9.3% and 15.0%, respectively. In patients who underwent surgery before 2014, the 12-month postoperative levels of iron and ferritin were 12.9 mmol/L and 64.0 mg/L, respectively; patients who underwent surgery in 2014 had levels of 18.3 mmol/L and 124.0 mg/L, respectively (all p = 0.001). The 12-month postoperative hemoglobin levels did not significantly differ between the 2 groups. Conclusion: Bariatric surgery performed with more aggressive preoperative iron supplementation is associated with increased iron and ferritin levels at 1 year postoperatively. As this improves overall clinical outcomes by avoiding iron deficiency and anemia, a minimum preoperative ferritin target should be implemented in metabolic and bariatric surgery programs.

Contexte: L'augmentation de la prévalence de l'obésité s'est accompagnée d'un accroissement de la demande de chirurgie bariatrique. La présente étude visait à déterminer l'incidence de la carence en fer et de l'anémie postopératoires ainsi que les conséquences de la hausse du taux cible de ferritine avant l'intervention sur les issues postopératoires. Méthodes: L'analyse a porté sur des patients ayant subi une chirurgie bariatrique à Winnipeg entre 2010 et 2014. Les données recueillies faisaient état de l'âge, du sexe et de la date d'opération des patients, ainsi que de leurs taux de fer, de ferritine et d'hémoglobine avant la chirurgie et 12 mois après celle-ci. Avant 2014, notre centre n'avait pas de protocole de supplémentation préopératoire en fer; en 2014, il a instauré un programme de supplémentation rigoureux visant un taux préopératoire de ferritine d'au moins 50 mg/L. L'analyse des données a été faite au moyen de tests t non appariés, de tests t appariés et de tests χ2. Résultats: Au total, les cas de 399 patients ont été envisagés pour l'analyse, et 288 ont été retenus. L'incidence de la carence en fer, celle de la carence en ferritine et celle de l'anémie 12 mois après la chirurgie étaient de 14,6 %, de 9,3 % et de 15,0 %, respectivement. Chez les patients ayant été opérés avant 2014, les taux de fer et de ferritine à 12 mois étaient de 12,9 mmol/L et de 64,0 mg/L, respectivement, et chez ceux ayant été opérés en 2014, ils étaient de 18,3 mmol/L et de 124,0 mg/L, respectivement (p = 0,001 pour toutes les valeurs). En ce qui concerne le taux d'hémoglobine à 12 mois, aucune différence significative n'a été observée entre les 2 groupes. Conclusion: Les chirurgies bariatriques effectuées après une supplémentation rigoureuse en fer sont associées à des taux accrus de fer et de ferritine 1 an après l'intervention. Sachant que la prévention de la carence en fer et de l'anémie améliore les issues cliniques en général, les programmes de chirurgie métabolique et bariatrique devraient se fixer une cible quant au taux préopératoire minimal de ferritine.

Effect of Roux-en-Y gastric bypass on pharmacologic dependence in obese patients with type 2 diabetes

Background: More than half the diabetes-related health care costs in Canada relate to drug costs. We aimed to determine the effect of Roux-en-Y gastric bypass (RYGB) on the use of insulin and orally administered hypoglycemic medications in patients with diabetes. We also looked to determine overall cost savings with the procedure. Methods: We reviewed the bariatric clinic records of all patients with a confirmed diagnosis of type 2 diabetes mellitus who underwent RYGB between 2010/11 and 2014/15. Percentage estimated weight loss was recorded at 1 year, along with reductions in glycated hemoglobin (HbA1c) level and use of oral hypoglycemic therapy and insulin. We estimated medication costs using Manitoba-specific pricing data. Results: Fifty-two patients with at least 12 months of complete follow-up data were identified. The mean percentage estimated weight loss was 50.2%. The mean HbA1c level decreased from 7.6% to 6.0%, the mean number of orally administered hypoglycemics declined from 1.6 to 0.2, and the number of patients receiving insulin decreased from 18 (35%) to 3 (6%) (all p < 0.001). The rate of resolution of type 2 diabetes was 71%. Estimated mean annual per-patient medication costs decreased from $508.56 to $79.17 (p < 0.001). Potential overall health care savings could total $3769 per patient in the first year, decreasing to $1734 at 10 years. Conclusion: Roux-en-Y gastric bypass resulted in significant improvement in diabetic control, with a reduction in hypoglycemic medication use and associated costs in the early postoperative period. Potentially, large indirect and direct cost savings can be realized in the longer term.

Contexte: Plus de la moitié des coûts des soins de santé liés au diabète au Canada sont générés par les médicaments. Nous avons voulu déterminer l'effet de la dérivation gastrique de Roux-en-Y sur l'utilisation des agents hypoglycémiants oraux et de l'insuline chez les patients diabétiques. Nous avons aussi cherché à déterminer l'ensemble des économies associées à cette intervention. Méthodes: Nous avons passé en revue les dossiers cliniques bariatriques de tous les patients ayant un diagnostic confirmé de diabète de type 2 qui ont subi une dérivation gastrique de Roux-en-Y entre 2010­2011 et 2014­2015. La perte de poids ­ estimée en pourcentage ­ a été notée après un an, ainsi que les réductions des taux d'hémoglobine glyquée (HbA1c) et du recours aux hypoglycémiants oraux et à l'insuline. Nous avons estimé les coûts des médicaments à partir des données de tarification du Manitoba. Résultats: Cinquante-deux patients pour lesquels on disposait d'au moins 12 mois de données de suivi complètes ont été retenus. La perte de poids moyenne estimée en pourcentage était de 50,2 %. Le taux moyen d'HbA1c a diminué de 7,6 % à 6,0 %, le nombre moyen de comprimés d'hypoglycémiants oraux est passé de 1,6 à 0,2, et le nombre de patients sous insuline a diminué de 18 (35 %) à 3 (6 %) (tous p < 0,001). Le taux de résolution du diabète de type 2 était de 71 %. Le coût annuel moyen estimé des médicaments par patient est passé de 508,56 $ à 79,17 $ (p < 0,001). Les économies potentielles globales pour le système de santé pourraient totaliser 3769 $ par patient au cours de la première année, puis passer graduellement à 1734 $ au cours des 10 années suivantes. Conclusion: La dérivation gastrique de Roux-en-Y a permis d'améliorer significativement le contrôle du diabète, ainsi que de réduire le recours aux hypoglycémiants et les coûts associés au début de la période postopératoire. À plus long terme, d'importantes économies sur le plan des coûts indirects et directs pourraient potentiellement être réalisées.

Impact of acute care surgery on timeliness of care and patient outcomes: a systematic review of the literature

Background: Dedicated emergency general surgery (EGS) service models were developed to improve efficiency of care and patient outcomes. The degree to which the EGS model delivers these benefits is debated. We performed a systematic review of the literature to identify whether the EGS service model is associated with greater efficiency and improved outcomes compared to the traditional model. Methods: We searched MEDLINE, Embase, Scopus and Web of Science (Core Collection) databases from their earliest date of coverage through March 2017. Primary outcomes for efficiency of care were surgical response time, time to operation and total length of stay in hospital. The primary outcome for evaluating patient outcomes was total complication rate. Results: The EGS service model generally improved efficiency of care and patient outcomes, but the outcome variables reported in the literature varied. Conclusion: Development of standardized metrics and comprehensive EGS databases would support quality control and performance improvement in EGS systems.

Contexte: Des modèles dédiés de services de chirurgie générale d'urgence (CGU) ont été développés pour améliorer l'efficience des soins et les résultats chez les patients. On ne s'entend toutefois pas sur l'ampleur des bénéfices conférés par le modèle CGU. Nous avons procédé à une revue systématique de la littérature afin de vérifier si le modèle CGU est associé à une plus grande efficience et à de meilleurs résultats comparativement au modèle classique. Méthodes: Nous avons interrogé les bases de données MEDLINE, Embase, Scopus et Web of Science (collection centrale) depuis la plus ancienne couverture du sujet et jusqu'à mars 2017. Les paramètres principaux pour l'efficience des soins étaient le temps de réponse, le délai avant l'intervention et la durée totale du séjour hospitalier. Le paramètre principal pour l'évaluation des résultats chez les patients était le taux de complications total. Résultats: Le modèle de service CGU améliore généralement l'efficience des soins et les résultats chez les patients, mais dans la littérature, les paramètres mesurés varient. Conclusion: Le développement de paramètres standardisés et de bases de données globales sur la CGU appuierait le contrôle de la qualité et l'amélioration du rendement des systèmes CGU.

Canadian general surgery residents' need formal curricula and objective performance assessments in gastrointestinal endoscopy training: a program director census.

INTRODUCTION: Methods of developing and determining General Surgery (GS) residents' competency in gastrointestinal endoscopy in Canada are not currently standardized. This study aimed to assess the status of gastrointestinal endoscopy training in Royal College of Physicians and Surgeons of Canada (RCPSC) GS residency programs. METHODS: A 35-question survey was developed using GS gastrointestinal endoscopy curricula guidelines. All 17 RCPSC GS program directors were contacted to complete the questionnaire via the web-based SurveyMonkey.ca® platform. RESULTS: All 17 program directors completed the survey (100% response rate). Program demographics Sixteen programs reported having dedicated endoscopy rotations with a mean duration of 2.8 months (range 0-4, SD 1.1). Upon completion of dedicated endoscopy rotations, four programs (25%) reported having formal skills assessments and three (18.8%) reported formal knowledge examinations. All programs required endoscopy procedures be logged throughout residency, but only three (21.4%) included quality indicators. Only one program required residents to obtain Fundamentals of Endoscopic Surgery certification. Program outcomes The reported estimated mean number of procedures during residents' endoscopy rotations was 82 (range 10-150, standard deviation 33.6) gastroscopies and 156 (40-350, 76.3) colonoscopies. The mean number of procedures during residents' entire residencies was 150 (20-400, 98.6) gastroscopies and 241 (50-500, 76.3) colonoscopies. The number of months of dedicated endoscopy training significantly correlated with the total estimated number of endoscopic procedures performed (ρ = 0.67, p = 0.02). Eleven program directors (73.3%) believed residents were prepared for independent endoscopy practice, while four disagreed (26.7%). Program directors' perceptions of residents' preparedness were significantly correlated with the number of endoscopic procedures performed by residents (p < 0.01) but not the robustness of the endoscopy curriculum (p = 0.72). CONCLUSION: Endoscopy training in RCPSC GS residency programs is highly variable. Program directors' perceptions of residents' competency appear to be significantly correlated with procedure numbers and few have adopted formal curricula and performance assessments.

Synoptic operative reporting: assessing the completeness, accuracy, reliability, and efficiency of synoptic reporting for Roux-en-Y gastric bypass.

OBJECTIVE: Synoptic reporting (SR) is one solution to improve the quality of operative reports. However, SR has not been investigated in bariatric surgery despite an identified need by bariatric surgeons. SR for RYGB was developed using quality indicators (QIs) established by a national Delphi process. The objective of this study is to assess the completeness, accuracy, reliability, and efficiency of synoptic versus narrative operative reports (NR) in Roux-en-Y gastric bypass (RYGB). METHODS: A NR and SR were completed on 104 consecutive RYGBs. Two evaluators independently compared the reports to QIs. Completeness and accuracy measures were determined. Reliability was calculated using Bland-Altman plots and 95% limits of agreement (LOA). Time to complete SR and NR was also compared. RESULTS: The mean completion rate of SR was 99.8% (±SD 0.98%) compared to 64.0% (±SD 6.15%) for NR (t = 57.9, p < 0.001). All subsections of SR were >99% complete. This was significantly higher than for NR (p < 0.001) except for small bowel division details (p = 0.530). Accuracy was significantly higher for SR than NR (94.2% ± SD 4.31% vs. 53.6% ± SD 9.82%, respectively, p < 0.001). Rater agreement was excellent for both SR (0.11, 95% LOA -0.53 to 0.75) and NR (-0.26, 95% LOA -4.85 to 4.33) (p = 0.242), where 0 denotes perfect agreement. SR completion times were significantly shorter than NR (3:55 min ± SD 1:26 min and 4:50 min ± SD 0:50 min, respectively, p = 0.007). CONCLUSION: The RYGB SR is superior to NR for completeness and accuracy. This platform is also both reliable and efficient. This SR should be incorporated into clinical practice.

Does ultrasongraphy predict intraoperative findings at cholecystectomy? An institutional review.

BACKGROUND: Ultrasonography (US) is the mainstay of biliary tract imaging, but few recent studies have tested its ability to diagnose acute cholecystitis (AC). Our objective was to determine how well a US diagnosis of AC correlates with the intraoperative diagnosis. We hypothesize that US underestimates this diagnosis, potentially leading to unexpected findings in the operating room (OR). METHODS: This retrospective review included all patients admitted to the acute care surgical service of a tertiary hospital in 2011 with suspected biliary pathology who underwent US and subsequent cholecystectomy. We determined the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of US using the intraoperative diagnosis as the gold standard. Further analysis identified which US findings were most predictive of an intraoperative diagnosis of AC. We used a recursive partitioning method with random forests to identify unique combinations of US findings that, together, are most predictive of AC. RESULTS: In total, 254 patients underwent US for biliary symptoms; 152 had AC diagnosed, and 143 (94%) of them underwent emergency surgery (median time to OR 23.03 hr). Ultrasonography predicted intraoperative findings with a sensitivity of 73.2%, specificity of 85.5% and PPV of 93.7%. The NPV (52.0%) was quite low. The US indicators most predictive of AC were a thick wall, a positive sonographic Murphy sign and cholelithiasis. Recursive partitioning demonstrated that a positive sonographic Murphy sign is highly predictive of intraoperative AC. CONCLUSION: Ultrasonography is highly sensitive and specific for diagnosing AC. The poor NPV confirms our hypothesis that US can underestimate AC.

CONTEXTE: L'échographie est la pierre angulaire de l'imagerie des voies biliaires, mais peu d'études récentes ont vérifié sa capacité de diagnostiquer la cholécystite aiguë (CA). Notre objectif était de déterminer dans quelle mesure le diagnostic échographique de la CA est en corrélation avec son diagnostic peropératoire. Selon notre hypothèse, l'échographie sous-estime ce diagnostic, ce qui pourrait entraîner des résultats inattendus au bloc opératoire. MÉTHODES: Cette revue rétrospective a inclus tous les patients admis en 2011 au service chirurgical d'urgence d'un hôpital de soins tertiaires pour une pathologie biliaire présumée et qui ont subi une échographie, suivie d'une cholécystectomie. Nous avons déterminé la sensibilité, la spécificité, la valeur prédictive positive (VPP) et la valeur prédictive négative (VPN) de l'échographie, avec le diagnostic peropératoire comme base de référence. Une analyse plus approfondie a permis d'établir quels paramètres échographiques étaient les plus prédictifs d'un diagnostic peropératoire de CA. Nous avons utilisé la méthode de partitionnement récursif avec forêts aléatoires pour recenser les différents paramètres échographiques qui, ensemble, permettent le mieux de prédire la CA. RÉSULTANTS: En tout, 254 patients ont subi une échographie pour des symptômes biliaires; 152 ont reçu un diagnostic de CA et 143 ont subi une intervention chirurgicale d'urgence (temps médian avant l'arrivée au bloc opératoire 23,03 h). L'échographie a permis de prédire le diagnostic peropératoire avec une sensibilité de 73,2 %, une spécificité de 85,5 % et une VPP de 93,7 %. La VPN (52,0 %) était plutôt faible. Les paramètres échographiques les plus prédictifs de la CA sont une paroi épaisse, un signe de Murphy échographique positif et la cholélithiase. Le partitionnement récursif a démontré qu'un signe de Murphy échographique positif est une solide prédicteur de la CA peropératoire. CONCLUSION: L'échographie est hautement sensible et spécifique pour le diagnostic de la CA. La piètre VPN confirme notre hypothèse selon laquelle l'échographie pourrait sous-estimer la CA.

Pulsed electromagnetic fields dosing impacts postoperative pain in breast reduction patients.

BACKGROUND: Pulsed electromagnetic fields (PEMF) reduce postoperative pain and narcotic requirements in breast augmentation, reduction, and reconstruction patients. PEMF enhances both calmodulin-dependent nitric oxide and/or cyclic guanosine monophosphate signaling and phosphodiesterase activity, which blocks cyclic guanosine monophosphate. The clinical effect of these competing responses on PEMF dosing is not known. METHODS: Two prospective, nonrandomized, active cohorts of breast reduction patients, with 15 min PEMF per 2 h; "Q2 (active)", and 5 min PEMF per 20 min; "5/20 (active)", dosing regimens were added to a previously reported double-blind clinical study wherein 20 min PEMF per 4 h, "Q4 (active)", dosing significantly accelerated postoperative pain reduction compared with Q4 shams. Postoperative visual analog scale pain scores and narcotic use were compared with results from the previous study. RESULTS: Visual analog scale scores at 24 h were 43% and 35% of pain at 1 h in the Q4 (active) and Q2 (active) cohorts, respectively (P < 0.01). Pain at 24 h in the 5/20 (active) cohort was 87% of pain at 1 h, compared with 74% in the Q4 (sham) cohort (P = 0.451). Concomitantly, narcotic usage in the 5/20 (active) and Q4 (sham) cohorts was not different (P = 0.478), and 2-fold higher than the Q4 (active) and Q2 (active) cohorts (P < 0.02). CONCLUSIONS: This prospective study shows Q4/Q2, but not 5/20 PEMF dosing, accelerated postoperative pain reduction compared with historical shams. The 5/20 (active) regimen increases NO 4-fold faster than the Q4 (active) regimen, possibly accelerating phosphodiesterase inhibition of cyclic guanosine monophosphate sufficiently to block the PEMF effect. This study helps define the dosing limits of clinically useful PEMF signals.

Laparoscopic right hemicolectomy with intracorporeal versus extracorporeal anastamosis: a comparison of short-term outcomes.

BACKGROUND: There is wide variation among laparoscopic colon resection techniques, including the approach for mobilization and the extent of intracorporal vessel ligation, bowel division or anastamosis. We compared the short-term outcomes of laparoscopic right hemicolectomy (LRHC) with intracorporeal (IA) versus extracorporeal (EA) anastamosis. METHODS: We retrospectively reviewed all elective laparoscopic right hemicolectomies performed at St. Joseph's Hospital between January 2008 and September 2009 and compared the demographic, pathologic, operative and outcome data. RESULTS: Fifty LRHCs were completed during the study period: 21 IA and 29 EA. The groups were similar in age, sex, body mass index, American Society of Anesthesiologists score, previous laparotomy and preoperative invasive pathology. There was no difference between IA and EA in mean duration of surgery (170 v. 181 min, p = 0.78), estimated blood loss (14 v. 42 mL, p = 0.15), perioperative blood transfusions (5% v. 14%, p = 0.29), in-hospital morbidity (33% v. 41%, p = 0.56), out-of-hospital morbidity (19% v. 31% p = 0.34), emergency department visits (10% v. 17%, p = 0.16) or 30-day readmissions (5% v. 7%, p = 0.75). There was 1 anastamotic leak in each group and no perioperative deaths. Median length of stay was significantly shorter for IA (4 v. 5 d, p = 0.05). There were 6 extraction site hernias with EA and none with IA (p = 0.026). CONCLUSION: Laparoscopic right hemicolectomy with IA has the advantage of a less hernia-prone Pfannenstiel extraction site, faster recovery and shorter stay in hospital EA.

CONTEXTE: Il existe énormément de variations entre les techniques d'exérèse du côlon par laparascopie, y compris en ce qui concerne l'approche adoptée pour la mobilisation et l'étendue de la ligature vasculaire intracorporelle, la séparation du côlon ou l'anastomose. Nous avons comparé les résultats à court terme de l'hémicolectomie droite laparascopique (HDL) avec anastomose intracorporelle (AI) à ceux de l'HDL avec anastomose extracorporelle (AE). MÉTHODES: Nous avons effectué une analyse rétrospective de toutes les hémicolectomies droites laparascopiques non urgentes pratiquées à l'hôpital St. Joseph entre janvier 2008 et septembre 2009, et comparé les données démographiques, pathologiques et opératoires et les données sur les résultats. RÉSULTATS: Cinquante HDL ont été pratiquées au cours de l'étude : 21 avec AI et 29 avec AE. Les groupes de patients étaient comparables pour ce qui était de l'âge, du sexe, de l'indice de masse corporelle, du score de l'American Society of Anesthesiologists, des antécédents de laparatomie et de la pathologie invasive préopératoire. Aucune différence n'a été observée entre l'AI et l'AE pour ce qui est de la durée moyenne de l'intervention chirurgicale (170 c. 181 min, p = 0,78), de la perte de sang estimée (14 c. 42 mL, p = 0,15), des transfusions sanguines péri-opératoires (5 % c. 14 %, p = 0,29), de la morbidité hospitalière (33 % c. à 41 %, p = 0,56), de la morbidité extra-hospitalière (19 % c. 31 %, p = 0,34), des admissions à l'urgence (10 % c. 17 %, p = 0,16) ou des réadmissions à l'hôpital dans les 30 jours (5 % c. 7 %, p = 0,75). On a signalé 1 fuite anastomique dans chaque groupe, mais aucun décès péri-opératoire. La durée médiane de l'hospitalisation était significativement plus courte pour les AI (4 c. 5 j, p = 0,05). Il y a eu 6 hernies au point d'extraction pour les AE, mais aucune pour les AI (p = 0,026). CONCLUSION: L'hémicolectomie droite laparascopique avec AI a l'avantage de réduire le risque d'hernie au point d'extraction après incision de Pfannenstiel, d'accélérer le rétablissement de réduire la durée de l'hospitalisation.

A cost comparison of laparoscopic and open colon surgery in a publicly funded academic institution.

BACKGROUND: The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution. METHODS: Patients undergoing elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann-Whitney U test. Linear regression was used to analyze the relationship between length of stay and total hospital cost. RESULTS: There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open; p = 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open; p = 0.001). There was no difference in complication rates (21.6/22.5 % lap/open; p = 0.900), reoperations (5.8/6.5 % lap/open; p = 0.833) or 30-day readmissions (7.6/12.5 % lap/open; p = 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open; p = 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open; p = 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open; p = 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open; p = 0.000), and this correlated directly with hospital cost. CONCLUSIONS: Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.

Construct validity of individual and summary performance metrics associated with a computer-based laparoscopic simulator.

BACKGROUND: Computer-based surgical simulators capture a multitude of metrics based on different aspects of performance, such as speed, accuracy, and movement efficiency. However, without rigorous assessment, it may be unclear whether all, some, or none of these metrics actually reflect technical skill, which can compromise educational efforts on these simulators. We assessed the construct validity of individual performance metrics on the LapVR simulator (Immersion Medical, San Jose, CA, USA) and used these data to create task-specific summary metrics. METHODS: Medical students with no prior laparoscopic experience (novices, N = 12), junior surgical residents with some laparoscopic experience (intermediates, N = 12), and experienced surgeons (experts, N = 11) all completed three repetitions of four LapVR simulator tasks. The tasks included three basic skills (peg transfer, cutting, clipping) and one procedural skill (adhesiolysis). RESULTS: We selected 36 individual metrics on the four tasks that assessed six different aspects of performance, including speed, motion path length, respect for tissue, accuracy, task-specific errors, and successful task completion. Four of seven individual metrics assessed for peg transfer, six of ten metrics for cutting, four of nine metrics for clipping, and three of ten metrics for adhesiolysis discriminated between experience levels. Time and motion path length were significant on all four tasks. We used the validated individual metrics to create summary equations for each task, which successfully distinguished between the different experience levels. CONCLUSION: Educators should maintain some skepticism when reviewing the plethora of metrics captured by computer-based simulators, as some but not all are valid. We showed the construct validity of a limited number of individual metrics and developed summary metrics for the LapVR. The summary metrics provide a succinct way of assessing skill with a single metric for each task, but require further validation.

Propranolol promotes accelerated and dysregulated adipogenesis in hemangioma stem cells.

BACKGROUND: Infantile hemangiomas (IHs) are the most common tumor of infancy, yet there are no Food and Drug Administration-approved therapeutics to date. Recently, the nonselective ß-adrenergic-blocker propranolol has been shown to be a safe and effective means of treating IHs, although its mechanism has yet to be elucidated. We have previously demonstrated that propranolol induces early and incomplete adipogenesis in stem cells derived from hemangiomas. We hypothesize that propranolol promotes dysregulated adipogenesis via the improper regulation of adipogenic genes. METHODS: Hemangioma stem cells (HemSCs) isolated from resected IH specimens were treated with adipogenic medium for 1 or 4 days in either propranolol or vehicle. Cell death was measured by the incorporation of annexin V and propidium iodide by flow cytometry. Adipogenesis was assessed by visualizing lipid droplet formation by Oil Red O staining. Proadipogenic genes C/EBPα, C/EBPß, C/EBPδ, PPARδ, PPARγ, RXRα, and RXRγ were analyzed by quantitative reverse transcription and polymerase chain reaction. RESULTS: Hemangioma stem cells treated with propranolol increased lipid droplet formation compared to vehicle-treated cells indicating increased adipogenesis. Cell death as measured by FACS analysis indicated that the propranolol-treated cells died due to necrosis and not apoptosis. During adipogenesis, transcript levels of PPARδ, PPARγ, C/EBPß, and C/EBPδ were significantly increased (P<0.01) in propranolol-treated cells relative to control cells. In contrast, RXRα and RXRγ levels were significantly decreased (P<0.05), and C/EBPα, a gene required for terminal adipocyte differentiation, was strongly suppressed by propranolol when compared to vehicle-treated cells (P<0.01). CONCLUSIONS: In HemSCs, propranolol accelerated dysregulated adipogenic differentiation characterized by improper adipogenic gene expression. Consistent with accelerated adipogenesis, propranolol significantly increased the expression of the proadipogenic genes, PPARγ, C/EBPß, and C/EBPγ compared to control. However, propranolol treatment also led to improper induction of PPARδ and suppression of C/EBPα, RXRα, and RXRγ. Taken together these data indicate that propranolol promoted dysregulated adipogenesis and inhibited the HemSCs from becoming functional adipocytes, ultimately resulting in cell death. Understanding this mechanism behind propranolol's effectiveness will be a vital factor in producing more effective therapies in the future.

The impact of operative time on complications after plastic surgery: a multivariate regression analysis of 1753 cases.

BACKGROUND: Little evidence within plastic surgery literature supports the precept that longer operative times lead to greater morbidity. OBJECTIVE: The authors investigate surgery duration as a determinant of morbidity, with the goal of defining a clinically relevant time for increased risk. METHODS: A retrospective chart review was conducted of patients who underwent a broad range of complex plastic surgical procedures (n = 1801 procedures) at UT Southwestern Medical Center in Dallas, Texas, from January 1, 2008 to January 31, 2012. Adjusting for possible confounders, multivariate logistic regression assessed surgery duration as an independent predictor of morbidity. To define a cutoff for increased risk, incidence of complications was compared among quintiles of surgery duration. Stratification by type of surgery controlled for procedural complexity. RESULTS: A total of 1753 cases were included in multivariate analyses with an overall complication rate of 27.8%. Most operations were combined (75.8%), averaging 4.9 concurrent procedures. Each hour increase in surgery duration was associated with a 21% rise in odds of morbidity (P < .0001). Compared with the first quintile of operative time (<2.0 hours), there was no change in complications until after 3.1 hours of surgery (odds ratio, 1.6; P = .017), with progressively greater odds increases of 3.1 times after 4.5 hours (P < .0001) and 4.7 times after 6.8 hours (P < .0001). When stratified by type of surgery, longer operations continued to be associated with greater morbidity. CONCLUSIONS: Surgery duration is an independent predictor of complications, with a significantly increased risk above 3 hours. Although procedural complexity undoubtedly affects morbidity, operative time should factor into surgical decision making.

Experiences and Outcomes of Indigenous Patients Undergoing Bariatric Surgery: a Mixed-Method Scoping Review.

Obesity and type 2 diabetes (T2D) are growing global health concerns. Evidence suggests that Indigenous peoples are at higher lifetime risk of obesity and its associated conditions. Obesity increases the risk of T2D, cardiovascular disease, and all-cause mortality. Bariatric surgery is the most sustained and effective intervention for treating obesity-associated medical problems. This review aims to explore the experiences and outcomes of Indigenous peoples undergoing bariatric surgery in Canada, the USA, Australia, and New Zealand (CANZUS). Analysis of quantitative data revealed that Indigenous patients had fewer bariatric procedures, poorer clinic attendance, similar weight loss outcomes and slightly higher post-operative complication rates. Qualitative data analysis revealed that Indigenous patients living with obesity have a desire to improve their health and quality of life.

Treatment of hyperhidrosis with botulinum toxin.

Botulinum toxin type A is a safe and effective method for treating focal hyperhidrosis, providing longer-lasting results than topical treatments without the necessity of invasive surgical procedures. Although more useful for axillary hyperhidrosis, botulinum toxin injections can also be effective in treating palmar and plantar disease. The effects of botulinum toxin last for six to nine months on average, and treatment is associated with a high satisfaction rate among patients. In this article, the authors discuss their preferred methods for treating axillary, palmar, and plantar hyperhidrosis. This article serves as guide for pretreatment evaluation, injection techniques, and posttreatment care.

Impact of a Preoperative Exercise Program on General Fitness in Patients Awaiting Bariatric Surgery: A Pilot Randomized Trial.

Background Evidence supports the association between exercise and outcomes following bariatric surgery. However, there is a lack of knowledge regarding the short-term benefits of preoperative exercise. Objectives The objective of this pilot study was to evaluate the feasibility and functional benefits of a 12-week preoperative exercise program in patients awaiting bariatric surgery. The primary aim was the six-minute walk test (6MWT). The secondary aim of this study included anthropometric measures, strength, and quality of life. Methods A total of 54 patients were enrolled in this pilot randomized controlled study. Of them, 29 patients received standard multidisciplinary preoperative care, while 25 patients participated in a 12-week supervised exercise program in addition to standard preoperative care consisting of strength and aerobic exercises three times per week in a fitness facility. The primary outcome was improvement in 6MWT. Secondary outcomes included other functional outcomes, quality of life, and anthropometric measures. Results Average attendance for the intervention group was 27.2 (75.6%) of 36 sessions. There was a mean improvement of 27 ± 10 meters in the intervention group compared with a reduction of 5 ± 10 meters in the control group (p = 0.003). Patients in the intervention group had significant improvement in all self-reported quality-of-life domains, particularly in the variables related to symptoms, hygiene, and emotions. Conclusions A 12-week preoperative exercise intervention was feasible and showed association with a statistically significant improvement in 6MWT and quality-of-life measures in patients awaiting bariatric surgery. The results of this study will inform sample size calculations and recruitment planning for a future study that will assess the longer-term benefits of a pre-surgical fitness intervention.