Bariatric surgery in managing diabetes mellitus.

PURPOSE OF REVIEW: Obesity is a worldwide epidemic, having profound effects on Western populations. Bariatric surgery has long been employed to treat obesity and its related comorbidities. Over time, researchers have amassed significant data to support bariatric surgery in the pursuit of treating diabetes mellitus. This review serves to introduce the most recent findings and their relation to the various bariatric surgical options as bariatric surgery will continue to cement itself in the treatment paradigm of diabetes mellitus. RECENT FINDINGS: Numerous studies performed in the past 10 years have demonstrated the improvement or cessation of diabetes with bariatric surgical intervention. In comparing the vertical sleeve gastrectomy and Roux-en-Y gastric bypass, data demonstrate a more beneficial response of diabetes to the Roux-en-Y gastric bypass, and an even further exaggerated response with the biliopancreatic diversion/duodenal switch. The benefit has long been established, but what causes the improvement in diabetes mellitus after bariatric surgery? Recent data suggest a decrease in circulating bile salts as well as changes to inflammatory markers and circulating cytokines. Furthermore, tailoring of existing surgical procedures has led to the development of the SIPS procedure, and its benefit is demonstrated in bypassing a large portion of intestine while eliminating an enteroenterostomy, helping to reduce short gut syndrome and resultant diarrhea. SUMMARY: The surgical climate within the bariatric field is changing and will continue to do so in the future. As the understanding of the causes or mechanisms in which bariatric surgery improves metabolic disorders becomes more evident, the process of individualizing care for specific patients will become more prevalent.

Operative Management of Complications Following Intestinal Vaginoplasty: A Case Series and Systematic Review.

OBJECTIVE: To describe the authors' experience with surgical management of complications following intestinal vaginoplasty and review the literature on incidence of complications following gender-affirming intestinal vaginoplasty. METHODS: Retrospective chart review identified patients presenting with complications following prior intestinal vaginoplasty requiring operative management. Charts were analyzed for medical history, preoperative exam and imaging, intraoperative technique, and long-term outcomes. Systematic literature review was performed to identify primary research on complications following gender-affirming intestinal vaginoplasty. RESULTS: Four patients presented to the senior authors' clinic requiring operative intervention for complications following intestinal vaginoplasty, all of whom underwent surgical revision. Complications included vaginal stenosis (2 patients, 50%), vaginal false passage (1 patient, 25%), and diversion colitis (1 patient, 25%). Postoperatively all patients were able to dilate successfully to a depth of at least 15 cm. Systematic review identified 10 studies meeting inclusion criteria. There were 215 complications reported across 654 vaginoplasties (33% overall complication rate). Average return to operating room rate was 18%. The most common complications were stenosis (11%), mucorrhea (7%), vaginal prolapse (6%), and malodor (5%). Six intestinal vaginoplasty segments developed vascular compromise leading to flap loss. There were 2 reported mortalities. CONCLUSION: Intestinal vaginoplasty is associated with a range of complications including vaginal stenosis, mucorrhea, and vaginal prolapse. Intra-abdominal complications, including diversion colitis, anastomotic bowel leak, and intra-abdominal abscess can occur many years after surgery, be life-threatening and require prompt diagnosis and management.

Hematoma following gender-affirming mastectomy: A systematic review of the evidence.

BACKGROUND: Hematomas are reported to be the most common immediate complication in patients undergoing gender-affirming mastectomy, with rates substantially higher than those associated with other types of breast surgery. This study sought to examine the breadth of current literature and provide evidence-based explanations regarding the development of hematomas in chest masculinizing surgery and technical considerations for reducing their incidence. METHODS: A systematic review was conducted to identify all articles related to gender-affirming mastectomy published through September 2021. Literature search yielded 2,661 articles for screening, of which 20 met inclusion criteria. Themes from the selected articles were compiled to generate consensus statements qualified by associated level of evidence (LOE). RESULTS: The rate of hematoma following gender-affirming mastectomy is reported in the literature ranging from 0% to 31.2%. The use of more limited, nipple-sparing incisions is associated with a higher hematoma rate than mastectomy with free nipple grafting (Level III). There is no conclusive evidence indicating any relationship between the use of masculinizing hormones and the incidence of hematoma (Level IV). Factors such as body mass index (Level III) and breast size (Level III) were not found to influence hematoma risk, though nicotine use (Level IV) was significantly associated with the incidence of hematoma. CONCLUSIONS: Hematoma is a known complication following gender-affirming mastectomy. The use of limited incision approaches has the strongest association with an increased risk of hematoma. There is no evidence indicating an association between hormone use (i.e., testosterone) and hematoma incidence. Future studies are needed to better define factors, interventions, and protocols to reduce the rate of hematoma. LEVEL OF EVIDENCE: III.

Gender-affirming Phalloplasty: A Postoperative Protocol for Success.

Increased access to care and insurance coverage has led to an increase in gender-affirming surgeries performed in the United States. Gender-affirming phalloplasty has a variety of donor sites and surgical techniques including both pedicled and free flaps. Although surgical techniques and patient outcomes are well-described, no reports in the literature specifically discuss postoperative management, which plays a crucial role in the success of these operations. Here, we present a postoperative protocol based on our institution's experience with gender-affirming phalloplasty with the hope it will serve as a standardized, reproducible reference for centers looking to offer these procedures. Methods: Patients undergoing gender-affirming phalloplasty at our institution followed a standardized protocol from the preoperative stage through phases of postoperative recovery. Medication, laboratory, physical and occupational therapy, flap monitoring, and dressing change guidelines were extracted and compiled into a single resource detailing the postoperative protocol in full. Results: Our institution's standardized postoperative protocol for gender-affirming phalloplasty is detailed, focusing on flap monitoring, mobilization and activity, medications, and postoperative dressing care. One hundred thirty first-stage phalloplasty procedures were performed between May 2017 and December 2021, with two patients (1.5%) experiencing partial necrosis and one incidence (0.8%) of total flap loss. Conclusions: For optimal and safe surgical outcomes, the surgical and extended care teams need to understand flap monitoring as well as specific postoperative protocols. A systematic approach focusing on flap monitoring, mobilization and activity, medications, and postoperative dressing care decreases errors, accelerates recovery, shortens length of stay, and instills confidence in the patient.

Gender-affirming Mastectomy: Comparison of Periareolar and Double Incision Patterns.

Background: Gender-affirming mastectomy has become one of the most frequently performed procedures for transgender and nonbinary patients. Although there are a variety of potential surgical approaches available, the impact of technique on outcomes remains unclear. Here we present our experience performing periareolar and double incision mastectomies, with a focus on comparing patient demographics, preoperative risk factors, and surgical outcomes and complication rates between techniques. Methods: Retrospective review identified patients undergoing gender-affirming mastectomy by the senior author between 2017 and 2020. Patients were stratified according to surgical technique, with demographics and postoperative outcomes compared between groups. Results: In total, 490 patients underwent gender-affirming mastectomy during the study period. An estimated 96 patients underwent periareolar mastectomy, whereas 390 underwent double incision mastectomy. Demographics were similar between groups, and there were no differences in rates of hematoma (3.1% versus 5.6%, respectively; P = 0.90), seroma (33.3% versus 36.4%; P = 0.52), or revision procedures (14.6% versus 15.8% P = 0.84) based on technique. Conclusions: Our results demonstrate no difference in the rates of postoperative complications or revision procedures based on surgical technique. These results also suggest that with an experienced surgeon and proper patient selection, both techniques of gender-affirming mastectomy can be performed safely and with comparable outcomes.