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.

Relation of body mass index to long-term survival and cardiac remodelling for patients undergoing mitral valve replacement surgery.

BACKGROUND AND AIMS: Studies have demonstrated that obesity is paradoxically associated with reduced mortality following cardiac surgery. However, these studies have treated various types of cardiac surgery as a single entity. With mitral valve (MV) surgeries being the fastest-growing cardiac surgical interventions in North America, the purpose of this study was to identify the impact of body mass index (BMI) on long-term survival and cardiac remodelling of patients undergoing MV replacement (MVR). METHODS AND RESULTS: In this retrospective, single-center study, 1071 adult patients who underwent an MVR between 2004 and 2018 were stratified into five BMI groups (<20, 20-24.9, 25-29.9, 30-34.9, >35). Cox proportional hazard regression models were used to determine the association between BMI and all-cause mortality. Patients who were underweight had significantly higher all-cause mortality rates at the longest follow-up (median 8.2 years) than patients with normal weight (p = 0.01). Patients who were in the obese group had significantly higher readmission rates due to myocardial infarction (MI) at the longest follow-up (p = 0.017). Subgroup analysis revealed a significant increase in long-term all-cause mortality for female patients who were underweight. Significant changes in left atrial size, mitral valve peak and mean gradients were seen in all BMI groups. CONCLUSIONS: For patients undergoing mitral valve replacement, BMI is unrelated to operative outcomes except for patients who are underweight.

The role of routine groin ultrasonography in the management of inguinal hernia.

BACKGROUND: Groin ultrasonography (US) has been used as an adjunct to inguinal hernia diagnosis, but there is limited evidence as to whether its use affects surgical decision-making. The primary aim of this study was to examine whether groin US affects surgical management of inguinal hernia; the secondary goal was to estimate the frequency of groin US ordered before surgical consultation. METHODS: We performed a retrospective chart review of 400 consecutive patients aged older than 18 years referred to 1 of 4 general surgeons in Calgary, Alberta, for inguinal hernia between January 2014 and January 2015. Bilateral groin examinations were entered as separate entries into the database. Outcomes assessed included the frequency of groin US examinations performed within 1 year before the general surgery consultation, presence of inguinal hernia on clinical examination (CE), presence of inguinal hernia on groin US, and whether the hernia proceeded to herniorrhaphy. RESULTS: A total of 476 groins in the 400 patients (354 [88.5%] male; mean age 53.5 yr [standard deviation 15.2 yr]) were evaluated for a hernia during the study period. Groin US was performed before general surgery consultation in 336 cases (70.6%). Overall, 364 (76.5%) of the hernias were clinically palpable; of the 364, 220 (60.4%) had preconsultation US, even in the presence of a positive CE finding. Of the 112 groins that did not have a clinically palpable hernia, 103 (92.0%) underwent preconsultation US. Of the 476 groins, 315 (66.2%) underwent inguinal hernia repair: 310 (85.2%) of the 364 with clinically palpable hernias and 5 (4.8%) of the 103 with clinically negative findings but positive groin US findings. Surgical decision-making based on CE findings occurred in 390 cases (81.9%) overall, whereas surgery based on groin US findings alone occurred in 5 of 336 cases (1.5%). CONCLUSION: Routine groin US was frequently performed before general surgery consultation, whether a hernia was detectable on clinical examination or not. Positive groin US results alone infrequently affected whether the patient proceeded to surgery. Clinical examination findings played a larger role in surgical decision-making than groin US results. Eliminating the practice of routine groin US may provide considerable health care cost savings.

The effects of body mass index on long-term outcomes and cardiac remodeling following mitral valve repair surgery.

BACKGROUND: Previous literature has demonstrated equivalent or improved survival post mitral valve (MV) surgery amongst patients with obesity when compared to their normal-weight counterparts. This relationship is poorly understood and the impact of body mass index (BMI) on cardiac remodeling has not been established. METHODS: In this retrospective, single-center study, we sought to identify the impact that BMI may have on long-term outcomes and cardiac remodeling post-MV repair. Outcomes were compared between patients of varying BMI undergoing MV repair between 2004 and 2018. The primary outcome was mortality and secondary outcomes included stroke, myocardial infarction, reoperation of the MV, rehospitalization, and cardiac remodeling. RESULTS: A total of 32 underweight, 249 normal weight, 249 overweight, 121 obese, and 50 morbidly obese patients were included in this study. Underweight patients had increased mortality at longest follow-up. Patients with morbid obesity were found to have higher rates of readmission for heart failure. Only underweight patients did not demonstrate a significant reduction in LVEF. Patients with normal weight and overweight had a significant reduction in left atrial size, and patients with obesity had a significant reduction in MV area. CONCLUSIONS: An obesity paradox has been identified in cardiac surgery. While patients with obesity have higher rates of comorbidities preoperatively, their rates of mortality are equivalent or even superior to those with lower BMI. The results of our study confirm this finding with patients of high BMI undergoing MV repair demonstrating equivalent rates of morbidity to their normal BMI counterparts. While the obesity paradox has been relatively consistent in the literature, the understanding of its cause and long-term impacts are not well understood. Further focused investigation is necessary to elucidate the cause of this relationship.

The effects of body mass index on outcomes for patients undergoing surgical aortic valve replacement.

BACKGROUND: Most of the studies of obesity and postoperative outcome have looked predominantly at coronary artery bypass grafting with fewer focused on valvular disease. The purpose of this study was to compare the outcomes of patients undergoing aortic valve replacement stratified by body mass index (BMI, kg/m^2). METHODS: The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry captured 4780 aortic valve replacements in Alberta, Canada from January 2004 to December 2018. All recipients were stratified by BMI into five groups (BMI: < 20, 20-24.9, 25-29.9, 30-34.9, and > = 35). Log-rank test and Cox regression were used to examine the crude and adjusted survival differences. RESULTS: Intra-operative clamp time and pump time were similar among the five groups. Significant statistical differences between groups existed for the incidence of isolated AVR, AVR and CABG, hemorrhage, septic infection, and deep sternal infection (p < 0.05). While there was no significant statistical difference in the mortality rate across the BMI groups, the underweight AVR patients (BMI < 20) were associated with increased hazard ratio (1.519; 95% confidence interval: 1.028-2.245) with regards to all-cause mortality at the longest follow-up compared with normal weight patients. CONCLUSION: Overweight and obese patients should be considered as readily for AVR as normal BMI patients.

Does body mass index affect the rate of adverse outcomes in total hip and knee arthroplasty? A retrospective review of a total joint replacement database

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are reliable surgical options to treat pain and disability resulting from degenerative conditions around the hip and knee. Obesity is a modifiable risk factor that contributes to significant morbidity. The purpose of this study was to retrospectively compare outcomes in primary hip and knee arthroplasty for patients with increased body mass index (BMI) and those with normal BMI, using data from the registry of the Alberta Bone and Joint Health Institute (ABJHI). Methods: We retrospectively reviewed the data compiled in the ABJHI registry between March 2010 and July 2016. We reviewed outcomes with respect to length of stay, discharge destination, 30-day readmission, postoperative infection, postoperative transfusion requirements, postoperative adverse events and in-hospital postoperative mechanical complications. Results: A total of 10 902 patients (6076 women, 4826 men) who underwent THA and 16 485 patients (10 057 women, 6428 men) who underwent TKA were included in the study. For both THA and TKA, patients with increased BMI had an increased number of in-hospital medical events, had an increased rate of deep infection, were less likely to be discharged home (p < 0.001) and had decreased transfusion requirements (p < 0.001) than patients whose weight was in the normal range. Increased BMI increased the rate of 30-day readmission and length of stay in the THA cohort but not in the TKA cohort. Increased BMI had no effect on acute postoperative dislocation or periprosthetic fractures. Patients with a BMI of 30 kg/m2 or greater required a THA 1.7 years earlier than patients of normal weight, patients whose BMI was 35 kg/m2 or greater required a THA 3.4 years earlier, and patients whose BMI was 40 kg/m2 or greater required a THA 5.8 years earlier. In the TKA cohort, patients with a BMI of 30 kg/m2 or greater required a TKA 2.7 years earlier than patients whose weight was in the normal range, patients with a BMI of 35 kg/m2 or greater required a TKA 4.6 years earlier, and patients whose BMI was 40 kg/m2 or greater required a TKA 7.6 years earlier. Conclusion: Our study quantifies the effects of obesity in primary hip and knee arthroplasty. It provides a greater understanding of the risks in the obese population when contemplating joint arthroplasty.

Contexte: La prothèse totale de la hanche (PTH) et la prothèse totale du genou (PTG) sont des options chirurgicales fiables pour traiter la douleur et l'invalidité résultant de maladies dégénératives de la hanche et du genou. L'obésité est un facteur de risque modifiable qui contribue significativement à la morbidité. Le but de cette étude était de comparer de manière rétrospective le résultat des interventions primaires pour prothèses de la hanche et du genou selon que les patients avaient un indice de masse corporelle (IMC) normal ou élevé à partir des données du registre de l'Alberta Bone and Joint Health Institute (ABJHI). Méthodes: Nous avons analysé de manière rétrospective les données compilées par le registre de l'ABJHI entre mars 2010 et juillet 2016. Nous avons passé en revue les paramètres suivants : durée du séjour hospitalier, destination post-congé, réadmissions dans les 30 jours, infections postopératoires, besoins transfusionnels postopératoires, complications postopératoires et complications mécaniques postopératoires perhospitalières. Résultats: En tout, 10 902 patients (6076 femmes, 4826 hommes) ayant subi une PTH et 16 485 patients (10 057 femmes, 6428 hommes) ayant subi une PTG ont été inclus dans l'étude. Tant pour la PTH que pour la PTG, les patients ayant un IMC élevé ont présenté un plus grand nombre de complications médicales en cours d'hospitalisation; ils ont aussi présenté un nombre plus élevé d'infections profondes, étaient moins susceptibles de pouvoir retourner chez eux au moment de leur congé (p < 0,001) et ont eu moins besoin de transfusions (p < 0,001) comparativement aux patients dont le poids se situait dans l'éventail des valeurs normales. L'IMC élevé a été en corrélation avec une augmentation du taux de réadmission à 30 jours et de la durée du séjour dans la cohorte soumise à une PTH, mais non dans la cohorte soumise à une PTG. L'IMC élevé n'a exercé aucun effet sur la dislocation postopératoire aiguë ou les fractures périprothétiques. Les patients ayant un IMC de 30 kg/m2 ou plus ont eu besoin d'une PTH 1,7 an plus tôt que les patients de poids normal, les patients ayant un IMC de 35 kg/m2 ou plus ont eu besoin d'une PTH 3,4 ans plus tôt, et les patients ayant un IMC de 40 kg/m2 ou plus ont eu besoin d'une PTH 5,8 ans plus tôt. Dans la cohorte soumise à la PTG, les patients ayant un IMC de 30 kg/m2 ou plus ont eu besoin d'une PTG 2,7 ans plus tôt que les patients de poids normal, les patients ayant un IMC de 35 kg/m2 ou plus ont eu besoin d'une PTG 4,6 ans plus tôt, et les patients ayant un IMC de 40 kg/m2 ou plus ont eu besoin d'une PTG 7,6 ans plus tôt. Conclusion: Notre étude quantifie les effets de l'obésité sur le recours aux interventions primaires pour prothèse de la hanche et du genou. Elle permet de mieux comprendre les risques auxquels est exposée la population obèse lorsqu'une intervention pour prothèse articulaire est envisagée.

Idiopathic intracranial hypertension and bariatric surgery: a systematic review

Background: Idiopathic intracranial hypertension (IIH) is a rare condition typically affecting women with obesity who are of child-bearing age. Patients commonly present with headaches, visual disturbances, pulsatile tinnitus and papilledema. The association between IIH and obesity has been well established in the literature, suggesting that weight loss may contribute to improving IIH. For patients with severe obesity for whom conservative management is not successful, bariatric surgery is an effective modality for weight loss. We aimed to systematically review the literature to determine the efficacy of bariatric surgery in the treatment of IIH Methods: We conducted a comprehensive search of MEDLINE, Embase, Scopus, the Cochrane Library and Web of Science (limited to studies in humans published in English between January 1946 and July 2015). Results: Twelve primary studies (n = 39 patients) were included in the systematic review. All patients had a preoperative diagnosis of IIH. Preoperative body mass index (BMI) was 47.4 ± 3.6 kg/m2 ; BMI improved to 33.7 ± 2.1 kg/m2 and 33.9 ± 11.6 kg/m2 at 6 and 12 months postoperatively, respectively. Lumbar puncture opening pressures decreased from 34.4 ± 6.9 cmH2O to 14.0 ± 3.6 cmH2O after surgery. Common symptoms of IIH improved after bariatric surgery: headaches (100% preoperatively v. 10% postoperatively), visual complaints (62% v. 44%), tinnitus (56% v. 3%) and papilledema (62% v. 8%). Conclusion: Bariatric surgery appears to lead to considerable improvement in IIH. Idiopathic intracranial hypertension is not a well-publicized comorbidity of obesity, but its presence may be considered as an indication for bariatric surgery.

Contexte: L'hypertension intracrânienne (HTIC) idiopathique est une affection rare qui touche surtout les femmes atteintes d'obésité en âge de procréer. Les symptômes courants sont des maux de tête, des troubles de la vue, des acouphènes pulsatiles et un oedème papillaire. Le lien entre l'HTIC idiopathique et l'obésité est bien établi dans la littérature, ce qui suggère que la perte de poids pourrait améliorer le tableau clinique de l'HTIC. Pour les patients atteints d'obésité sévère pour lesquels le traitement conservateur ne fonctionne pas, la chirurgie bariatrique est un moyen efficace de perdre du poids. Cette revue systématique de la littérature vise à déterminer l'efficacité de la chirurgie bariatrique dans le traitement de l'HTIC idiopathique. Méthodes: Nous avons interrogé MEDLINE, Embase, Scopus, la Bibliothèque Cochrane et Web of Science (limites : études portant sur les humains publiées en anglais entre janvier 1946 et juillet 2015). Résultats: Douze études primaires (n = 39 patients) ont été incluses dans la revue systématique. Tous les patients avaient un diagnostic préopératoire d'HTIC idiopathique. L'indice de masse corporelle (IMC) préopératoire était de 47,4 ± 3,6 kg/m2 ; l'IMC est passé à 33,7 ± 2,1 kg/m2 6 mois après l'opération, puis à 33,9 ± 11,6 kg/m2 12 mois après l'opération. Les pressions d'ouverture des ponctions lombaires sont passées de 34,4 ± 6,9 cmH2O à 14,0 ± 3,6 cmH2O après l'opération. Les symptômes courants de l'HTIC idiopathique se sont améliorés après la chirurgie bariatrique : maux de tête (100% avant opération c. 10% après), troubles de la vue (62% c. 44%), acouphènes pulsatiles (56% c. 3%) et œdème papillaire (62% c. 8%). Conclusion: La chirurgie bariatrique semble améliorer considérablement les symptômes d'HTIC idiopathique. Cette affection n'est pas une comorbidité bien connue de l'obésité, mais sa présence peut être une indication pour la chirurgie bariatrique comme traitement.

Predicting venous thromboembolism following laparoscopic bariatric surgery: development of the BariClot tool using the MBSAQIP database.

BACKGROUND: Bariatric surgery is an effective treatment for severe obesity; however, postoperative venous thromboembolism (VTE) remains a leading cause of morbidity and mortality. The objective of this study is to develop a tool to stratify individuals undergoing laparoscopic bariatric surgery according to their 30-day VTE risk. METHODS: This is a retrospective cohort study of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. This registry collects data specific for metabolic or bariatric surgery with 30-day outcomes from 791 centers. Individuals undergoing primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were included. Characteristics associated with 30-day VTE were identified using univariate and multivariable analyses. A predictive model, BariClot, was derived from a randomly-generated derivation cohort using a forward selection algorithm. BariClot's robustness was tested against a validation cohort of subjects not included in the derivation cohort. The calibration and discrimination of two previously published VTE risk tools were assessed in the MBSAQIP population and compared to BariClot. RESULTS: A total of 274,221 patients underwent LRYGB or LSG. Overall, 1106 (0.4%) patients developed VTE, 452 (0.2%) developed pulmonary embolism, and 43 (0.02%) died due to VTE. VTE was the most commonly identified cause of 30-day mortality. A prediction model to assess for risk of VTE, BariClot, was derived and validated. BariClot consists of history of VTE, operative time, race, and functional status. It stratifies individuals into very high (> 2%), high (1-2%), medium (0.3-1%), and low risk groups (< 0.3%). This model accurately predicted events in the validation cohort and outperformed previously published scoring systems. CONCLUSIONS: BariClot is a predictive tool that stratifies individuals undergoing bariatric surgery based on 30-day VTE risk. Stratifying low- and high-risk populations for VTE allows for informed clinical decision-making and potentially enables further research on customized prophylactic measures for low- and high-risk populations.

Sleeve gastrectomy and hypertension: a systematic review of long-term outcomes.

INTRODUCTION: Bariatric surgery has been shown to be a safe and durable intervention for patients struggling with obesity and metabolic syndrome, including hypertension. Buchwald et al. reported hypertension resolution rates in 67.1% and improvement in 78.5% following aggregate bariatric surgery. The laparoscopic sleeve gastrectomy (LSG) is becoming increasingly utilized as a primary bariatric surgery, but lacks long-term outcome data. There are a growing number of studies reporting outcome data beyond 5 years. OBJECTIVE: This study aims to systematically evaluate the efficacy of laparoscopic sleeve gastrectomy on hypertension amongst obese patients. MATERIALS AND METHODS: A comprehensive literature search was conducted through Medline, Embase, Scopus, Web of Science, Dare, Cochrane library, and HTA database. The search terms used were broad: sleeve gastrectomy AND hypertension OR blood pressure. Adult patients undergoing LSG with follow-up hypertension outcome results of at least 5 years were included. Revisional surgeries were excluded. Two independent reviewers were used. RESULTS: Fourteen studies were included in this systematic review, which included 3550 subjects in total. Mean age was 41.1 ± 10.7 years. Mean pre-operative BMI and weight were 47.7 ± 8.83 kg/m2 and 272.8 ± 48.4 lb, respectively. Pre-operative prevalence of hypertension was 36.5% (range 6.7-91%) which dropped to 14.79% (range 0-33.3%) at approximately 5-year follow-up. Hypertension resolved in 62.17% (range 0-100%) of patients and improved in 35.7% (range 13.3-76.9%) at a mean of 5.35 years of follow-up. CONCLUSION: From this systematic review, LSG is an effective intervention for bariatric patients with hypertension. In addition to the observed reduction in the incidence of hypertension, it is likely that LSG may lead to additional health system benefits such as cost savings due to reductions in antihypertensive medications. Further prospective studies should include estimates of cost savings associated with reductions in chronic antihypertensive medication usage.

Diagnostic accuracy of transabdominal ultrasonography for gallbladder polyps: systematic review.

BACKGROUND: Previous research has shown variable but generally poor accuracy of transabdominal ultrasonography in the diagnosis of gallbladder polyps. We performed a systematic review of the literature with the aim of helping surgeons interpret and apply these findings in the preoperative assessment and counselling of their patients. METHODS: We searched PubMed, MEDLINE and the Cochrane database using the keywords "gallbladder," "polyp," "ultrasound," "pathology" and "diagnosis" for English-language articles published after 1990 with the full-text article available through our institutional subscriptions. Polyps were defined as immobile features that on transabdominal ultrasonography appear to arise from the mucosa and that lack an acoustic shadow, and pseudopolyps were defined as features such as inflammation, hyperplasia, cholesterolosis and adenomyomatosis that convey no risk of malignant transformation. RESULTS: The search returned 1816 articles, which were narrowed down to 14 primary sources involving 15 497 (range 23-13 703) patients who had preoperative transabdominal ultrasonography, underwent cholecystectomy and had postoperative pathology results available. Among the 1259 patients in whom a gallbladder polyp was diagnosed on ultrasonography, 188 polyps were confirmed as true polyps on pathologic examination, and 81 of these were found to be malignant. Of the 14 238 patients for whom a polyp was not seen on ultrasonography, 38 had a true polyp on pathologic examination, none of which were malignant. For true gallbladder polyps, transabdominal ultrasonography had a sensitivity of 83.1%, specificity of 96.3%, positive predictive value of 14.9% (7.0% for malignant polyps) and negative predictive value of 99.7%. CONCLUSION: Transabdominal ultrasonography has a high false-positive rate (85.1%) for the diagnosis of gallbladder polyps. Further study of alternative imaging modalities and reevaluation of existing management guidelines are warranted.

CONTEXTE: Des recherches antérieures ont montré la précision variable, mais généralement médiocre, de l'échographie transabdominale pour le diagnostic des polypes de la vésicule biliaire. Nous avons procédé à une revue systématique de la littérature scientifique afin d'aider les chirurgiens à interpréter et à appliquer ces résultats lors de l'évaluation préopératoire, et à conseiller leurs patients. MÉTHODES: Nous avons interrogé les réseaux PubMed, MEDLINE et la base de données Cochrane à partir des mots clés « gallbladder ¼, « polyp ¼, « ultrasound ¼, « pathology ¼ et « diagnosis ¼ (vésicule biliaire, polype, échographie, pathologie et diagnostic) pour recenser les articles en langue anglaise publiés après 1990, pour lesquels le texte intégral était accessible par abonnement institutionnel. À l'échographie, les polypes étaient définis comme des structures fixes semblant émaner de la muqueuse et dépourvues d'ombre acoustique, et les pseudopolypes étaient définis par des caractéristiques telles que l'inflammation, l'hyperplasie, la cholestérolose et l'adénomyomatose ne comportant pas de risque de transformation maligne. RÉSULTATS: La recherche a généré 1816 articles qui ont été ramenés à 14 sources principales regroupant 15 497 (éventail, 23-13 703) patients ayant subi une échographie transabdominale préopératoire et une cholécystectomie, et pour lesquels on disposait des résultats de l'examen anatomopathologique postopératoire. Sur les 1259 patients chez qui des polypes intravésiculaires ont été diagnostiqués à l'échographie, 188 polypes ont été jugés vrais à l'examen anatomopathologique, et 81 d'entre eux se sont révélés malins. Parmi les 14 238 patients chez lesquels aucun polype n'avait été détecté à l'échographie, 38 étaient porteurs d'un vrai polype à l'examen anatomopathologique et aucun ne s'est révélé malin. En ce qui concerne les vrais polypes intravésiculaires, l'échographie transabdominale a une sensibilité de 83,1 %, une spécificité de 96,3 %, une valeur prédictive positive de 14,9 % (7,0 % dans le cas des polypes malins) et une valeur prédictive négative de 99,7 %. CONCLUSION: L'échographie transabdominale présente un taux de résultats faux positifs élevé (85,1 %) pour le diagnostic des polypes de la vésicule biliaire. Il faudra approfondir la recherche sur d'autres techniques d'imagerie et réévaluer les lignes directrices actuelles de prise en charge.

LINX® magnetic esophageal sphincter augmentation versus Nissen fundoplication for gastroesophageal reflux disease: a systematic review and meta-analysis.

BACKGROUND: The LINX® magnetic sphincter augmentation system (MSA) is a surgical technique with short-term evidence demonstrating efficacy in the treatment of medically refractory or chronic gastroesophageal reflux disease (GERD). Currently, the Nissen fundoplication is the gold-standard surgical treatment for GERD. We are the first to systematically review the literature and perform a meta-analysis comparing MSA to the Nissen fundoplication. METHODS: A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science and the Cochrane Library) using search terms "Gastroesophageal reflux or heartburn" and "LINX or endoluminal or magnetic" and "fundoplication or Nissen" was completed. All randomized controlled trials, non-randomized comparison study and case series with greater than 5 patients were included. Five hundred and forty-seven titles were identified through primary search, and 197 titles or abstracts were screened after removing duplicates. Meta-analysis was performed on postoperative quality of life outcomes, procedural efficacy and patient procedural satisfaction. RESULTS: Three primary studies identified a total of 688 patients, of whom 273 and 415 underwent Nissen fundoplication and MSA, respectively. MSA was statistically superior to LNF in preserving patient's ability to belch (95.2 vs 65.9%, p < 0.00001) and ability to emesis (93.5 vs 49.5%, p < 0.0001). There was no statistically significant difference between MSA and LNF in gas/bloating (26.7 vs 53.4%, p = 0.06), postoperative dysphagia (33.9 vs 47.1%, p = 0.43) and proton pump inhibitor (PPI) elimination (81.4 vs 81.5%, p = 0.68). CONCLUSION: Magnetic sphincter augmentation appears to be an effective treatment for GERD with short-term outcomes comparable to the more technically challenging and time-consuming Nissen fundoplication. Long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation.

Quality of Follow-up: Systematic Review of the Research in Bariatric Surgery.

OBJECTIVE: We aim to systematically review the bariatric surgery literature with regards to adequacy of patient follow-up, meeting the McMaster criteria of ≥80% follow-up. BACKGROUND: Loss to follow-up is a major concern and can potentially bias the outcome and interpretation of a study. The quality of follow-up in bariatric surgery is quite variable with recent systematic reviews criticizing the field for its lack of overall follow-up. METHODS: A complete search of PubMed was performed. Literature was restricted to a range of 5 years (2007-2012), English language, and publications listed in PubMed. The McMaster Evidence-based Criteria for High Quality Studies was used to assess the follow-up data adequacy and a logistic meta-regression was performed to identify factors associated with high quality follow-up studies. RESULTS: Ninety-nine published manuscripts were included. For follow-up at study end, only 40/99 (40.4%) of papers had adequate patient follow-up, 42/99 (42.4%) failed to meet the McMaster criteria and 17/99 (17.2%) failed to report any follow-up results. On average, 31% were lost to follow-up at the study's end. Only shorter study duration, and if the study was performed in the US, were associated with studies meeting the McMaster criteria. CONCLUSIONS: Only 40% of studies in the bariatric surgery literature meet criteria for adequate follow-up. On average, studies have 30% of patients lost to follow-up at the stated end-point. Identified study characteristics associated with high quality follow-up included shorter study duration and studies performed in the US.

Comparative effectiveness and safety of gastric bypass, sleeve gastrectomy and adjustable gastric banding in a population-based bariatric program: prospective cohort study.

BACKGROUND: Bariatric surgery in Canada is primarily delivered within publicly funded specialty clinics. Previous studies have demonstrated that bariatric surgery is superior to intensive medical management for reduction of weight and obesity-related comorbidities. Our objective was to compare the effectiveness and safety of laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (LSG) and adjustable gastric banding (LAGB) in a publicly funded, population-based bariatric treatment program. METHODS: We followed consecutive bariatric surgery patients for 2 years. The primary outcome was weight change (in kilograms). Between-group changes were analyzed using multivariable regression. Last-observation-carried-forward imputation was used for missing data. RESULTS: We included 150 consecutive patients (51 RYGB; 51 LSG; 48 LAGB) in our study. At baseline, mean age was 43.5 ± 9.5 years, 87.3% of patients were women, and preoperative body mass index (BMI) was 46.2 ± 7.4. Absolute and relative (% of baseline) weight loss at 2 years were 36.6 ± 19.5 kg (26.1 ± 12.2%) for RYGB, 21.4 ± 16.0 kg (16.4 ± 11.6%) for LSG and 7.0 ± 9.7 kg (5.8 ± 7.9%) for LAGB (p < 0.001). Change in BMI was greater for the RYGB (-13.0 ± 6.6) than both the LSG (-7.6 ± 5.7) and the LAGB (-2.6 ± 3.5) groups (p < 0.001). The reduction in diabetes, hypertension and dyslipidemia was greater after RYGB than after LAGB (all p < 0.05). There were no deaths. The anastomotic and staple leakage rate was 1.3%. CONCLUSION: In a publicly funded, population-based bariatric surgery program, RYGB and LSG demonstrated greater weight loss than the LAGB procedure. Bypass resulted in the greatest reduction in obesity-related comorbidities. All procedures were safe.

BACKGROUND: Au Canada, la chirurgie bariatrique est effectuée principalement dans des cliniques spécialisées financées par le secteur public. Des études ont démontré que les interventions de cette nature sont supérieures à la prise en charge médicale intensive pour la perte de poids et la réduction des affections comorbides liées à l'obésité. L'objectif de notre étude était de comparer l'efficacité et l'innocuité de la dérivation gastrique Roux-en-Y par laparoscopie (DGRY), de la gastrectomie longitudinale (GL) et de la gastroplastie par anneau gastrique modulable (GAGM) dans le cadre d'un programme de traitement bariatrique basé sur la population financé par les deniers publics. METHODS: Nous avons suivi pendant 2 ans des patients ayant subi une chirurgie bariatrique. Le résultat primaire à l'étude était la variation pondérale (en kilogrammes). Nous avons analysé la variation intergroupe au moyen d'une régression multivariable et utilisé la méthode d'imputation des données manquantes par report de la dernière observation. RESULTS: Nous avons retenu 150 patients consécutifs (51 DGRY; 51 GL; 48 GAGM). Au début de l'étude, l'âge moyen était de 43,5 ± 9,5 ans, 87,3 % des patients étaient des femmes, et leur indice de masse corporelle (IMC) avant l'opération était de 46,2 ± 7,4. Après 2 ans, la perte de poids moyenne (pourcentage du poids de départ) était de 36,6 ± 19,5 kg (26,1 ± 12,2 %) pour la DGRY, de 21,4 ± 16,0 kg (16,4 ± 11,6 %) pour la GL, et de 7,0 ± 9,7 kg (5,8 ± 7,9 %) pour la GAGM (p < 0,001). La variation de l'IMC était plus grande pour le groupe DGRY (13,0 ± 6,6) que pour les 2 autres groupes (7,6 ± 5,7 pour la GL et 2,6 ± 3,5 pour la GAGM; p < 0,001). L'incidence sur le diabète, l'hypertension et la dyslipidémie était également plus grande après la DGRY qu'après la GAGM (p < 0,05 pour tous). Il n'y a eu aucun décès. Le taux de fuites anastomotiques et liées aux sutures était de 1,3 %. CONCLUSION: Dans le cadre d'un programme de chirurgie bariatrique basé sur une population et financé par le secteur public, la DGRY et la GL ont entraîné une plus grande perte de poids que la GAGM. La dérivation a donné lieu à la plus forte réduction des affections comorbides liées à l'obésité. Toutes les interventions se sont avérées sécuritaires.

Endoscopic versus open component separation: systematic review and meta-analysis.

BACKGROUND: The component separation technique (CST) was developed to improve the integrity of abdominal wall reconstruction for large, complex hernias. Open CST necessitates large subcutaneous skin flaps and, therefore, is associated with significant ischemic wound complications. The minimally invasive or endoscopic component separation technique (MICST) has been suggested in preliminary studies to reduce wound complication rates post-operatively. In this study, we systematically reviewed the literature comparing open versus endoscopic component separation and performed a meta-analysis of controlled studies. METHODS: A comprehensive search of electronic databases was completed. All English, randomized controlled trials, non-randomized comparison study, and case series were included. All comparison studies included in the meta-analysis were assessed independently by two reviewers for methodological quality using the Cochrane Risk of Bias tools. RESULTS: 63 primary studies (3,055 patients) were identified; 7 controlled studies and 56 case series. The total wound complication rate was lower for MICST (20.6 %) compared to Open CST (34.6 %). MICST compared to open CST was shown to have lower rates of superficial infections (3.5 vs 8.9 %), skin dehiscence (5.3 vs 8.2 %), necrosis (2.1 vs 6.8 %), hematoma/seroma formation (4.6 vs 7.4 %), fistula tract formation (0.4 vs 1.0 %), fascial dehiscence (0.0 vs 0.4 %), and mortality (0.4 vs 0.6 %.) The open component CST did have lower rates of intra-abdominal abscess formation (3.8 vs 4.6 %) and recurrence rates (11.1 vs 15.1 %). The meta-analysis included 7 non-randomized controlled studies (387 patients). A similar suggestive overall trend was found favoring MICST, although most types of wound complications did not show to significance. MICST was associated with a significantly decreased rate of fascial dehiscence and was shown to be significantly shorter procedure. CONCLUSION: This systematic review and meta-analysis comparing MICST to open CST suggests MICST is associated with decreased overall post-operative wound complication rates. Further prospective studies are needed to verify these findings.

The effect of bariatric surgery on gastroesophageal reflux disease.

Obesity is an epidemic that is known to play a role in the development of gastroesophageal reflux disease (GERD). Studies have shown that increasing body mass index plays a role in the incompetence of the gastroesophageal junction and that weight loss and lifestyle modifications reduce the symptoms of GERD. As a method of producing effective and sustainable weight loss, bariatric surgery plays a major role in the treatment of obesity. We reviewed the literature on the effects of different types of bariatric surgery on the symptomatic relief of GERD and its complications. Roux-en- Y gastric bypass was considered an effective method to alleviate symptoms of GERD, whereas laparoscopic sleeve gastrectomy appeared to increase the incidence of the disease. Adjustable gastric banding was seen to initially improve the symptoms of GERD; however, a subset of patients experienced a new onset of GERD symptoms during long-term follow-up. The literature suggests that different surgeries have different impacts on the symptomatology of GERD and that careful assessment may be needed before performing bariatric surgery in patients with GERD.

L'obésité atteint des proportions épidémiques et on sait qu'elle joue un rôle dans l'apparition du phénomène de reflux gastro-oesophagien (RGO). Des études ont montré que l'augmentation de l'indice de masse corporelle contribue à l'incompétence de la jonction entre l'oesophage et l'estomac et que la perte de poids et des modifications de l'hygiène de vie réduisent les symptômes de RGO. Comme mé - thode pour obtenir une perte de poids efficace et durable, la chirurgie bariatrique occupe une place importante dans le traitement de l'obésité. Nous avons passé en revue la littérature traitant des effets de différents types de chirurgie bariatrique sur le soulagement des symptômes du RGO et ses complications. La dérivation gastrique Roux-en-Y a été considérée comme une méthode efficace pour le soulagement des symptômes de RGO, tandis que la gastrectomie verticale par laparoscopie a semblé faire augmenter l'incidence de la maladie. Quant au cerclage gastrique ajustable, il a semblé améliorer initialement le RGO; toutefois chez une catégorie de patients, le RGO s'est manifesté de nouveau lors du suivi à long terme. Selon la littérature, chaque type d'intervention exerce un impact différent sur la symptomatologie du RGO et une évaluation soigneuse s'impose avant de procéder à une chirurgie bariatrique chez les patients souffrant de RGO.

Prioritization and willingness to pay for bariatric surgery: the patient perspective.

BACKGROUND: Access to publicly funded bariatric surgery is limited, potential candidates face lengthy waits, and no universally accepted prioritization criteria exist. We examined patients' perspectives regarding prioritization for surgery. METHODS: We surveyed consecutively recruited patients awaiting bariatric surgery about 9 hypothetical scenarios describing patients waiting for surgery. Respondents were asked to rank the priority of these hypothetical patients on the wait list relative to their own. Scenarios examined variations in age, clinical severity, functional impairment, social dependence and socioeconomic status. Willingness to pay for faster access was assessed using a 5-point ordinal scale and analyzed using multivariable logistic regression. RESULTS: The 99 respondents had mean age of 44.7 ± 9.9 years, 76% were women, and the mean body mass index was 47.3 ± SD 7.6. The mean wait for surgery was 34.4 ± 9.4 months. Respondents assigned similar priority to hypothetical patients with characteristics identical to theirs (p = 0.22) and higher priority (greater urgency) to those exhibiting greater clinical severity (p < 0.001) and functional impairment (p = 0.003). Lower priority was assigned to patients at the extremes of age (p = 0.006), on social assistance (p < 0.001) and of high socioeconomic status (p < 0.001). Most (85%) respondents disagreed with payment to expedite access, although participants earning more than $80 000/year were less likely to disagree. CONCLUSION: Most patients waiting for bariatric surgery consider greater clinical severity and functional impairments related to obesity to be important prioritization indicators and disagreed with paying for faster access. These findings may help inform future efforts to develop acceptable prioritization strategies for publicly funded bariatric surgery.

CONTEXTE: Les régimes publics donnent un accès limité à la chirurgie bariatrique; les candidats potentiels font face à des attentes prolongées et il n'existe pas de critères de priorisation universellement acceptés. Nous avons analysé le point de vue des patients relativement à la priorisation des candidats à la chirurgie. MÉTHODES: Nous avons recruté consécutivement des patients en attente de chirurgie bariatrique et nous les avons interrogés au sujet de 9 scénarios hypothétiques décrivant des patients en attente de chirurgie. Nous avons demandé aux répondants de classer ces patients hypothétiques par ordre de priorité sur la liste d'attente par rapport à la priorité de leur propre cas. Les scénarios présentaient des variations d'âge, de gravité de l'état clinique, d'atteintes fonctionnelles, de dépendance sociale et de statut socioéconomique. Nous avons déterminé au moyen d'une échelle ordinale en 5 points si les patients étaient disposés à payer pour accéder plus rapidement au traitement et nous avons analysé les réponses par régression logistique multivariée. RÉSULTATS: Les 99 répondants avaient en moyenne 44,7 ± 9,9 ans, 76 % étaient des femmes dont l'indice de masse corporelle moyen était de 47,3 ± 7,6. Le temps d'attente moyen pour la chirurgie était de 34,4 ± 9,4 mois. Les répondants ont assigné une priorité similaire aux patients hypothétiques dont les caractéristiques étaient identiques aux leurs (p = 0,22) et une priorité plus élevée (urgence supérieure) à ceux qui présentaient un état clinique plus grave (p < 0,001) et une détérioration fonctionnelle plus prononcée (p = 0,003). Une priorité moins grande a été assignée aux patients qui se trouvaient aux 2 extrémités de l'éventail des âges (p = 0,006), aux bénéficiaires de l'aide sociale (p < 0,001) et aux personnes de statut socioéconomique élevé (p < 0,001). La plupart des répondants (85 %) se sont exprimés contre le paiement pour accélérer l'accès, même si les participants qui gagnaient plus de 80 000 $ par année étaient moins enclins à s'y opposer. CONCLUSION: La plupart des patients en attente d'une chirurgie bariatrique considèrent que la gravité de l'état clinique et les atteintes fonctionnelles associées à l'obésité sont d'importants indicateurs de priorisation et s'opposent à payer pour un accès plus rapide à l'intervention. Ces observations pourraient guider une éventuelle mise au point de stratégies de priorisation pour la chirurgie bariatrique financée par les régimes publics.

Postresuscitation cyclosporine treatment attenuates myocardial and cardiac mitochondrial injury in newborn piglets with asphyxia-reoxygenation.

OBJECTIVES: Cardiovascular dysfunction occurs in the majority of asphyxiated neonates and has been suggested to be a major cause of neonatal morbidity and mortality. We previously demonstrated that cyclosporine A treatment during resuscitation can significantly improve cardiovascular performance in asphyxiated newborn piglets. However, the mechanisms through which cyclosporine elicits its protective effect in neonates have not yet been fully characterized. We hypothesized that cyclosporine A treatment would attenuate myocardial and cardiac mitochondrial injury during the resuscitation of asphyxiated newborn piglets. DESIGN: After acute instrumentation, piglets received normocapnic alveolar hypoxia (10% to 15% oxygen) for 2 hours followed by reoxygenation with 100% oxygen (0.5 hr) and then 21% oxygen (3.5 hr). At 4 hours of reoxygenation, plasma troponin level, left ventricle myocardial levels of lipid hydroperoxides, cytochrome-c, and mitochondrial aconitase activity were determined. SETTING: Neonatal asphyxia and reoxygenation. SUBJECTS: Twenty-four newborn (1-4 days old) piglets. INTERVENTIONS: Piglets were randomized to receive an IV bolus of cyclosporine A (10 mg/kg) or normal saline (placebo, control) at 5 minutes of reoxygenation (n=8/group). Sham-operated piglets (n=8) underwent no asphyxia-reoxygenation. MEASUREMENTS AND MAIN RESULTS: Asphyxiated piglets treated with cyclosporine had lower plasma troponin and myocardial lipid hydroperoxides levels (vs. controls, both p<0.05, analysis of variance). Cyclosporine treatment also improved mitochondrial aconitase activity and attenuated the rise in cytosol cytochrome-c level (vs. controls, all p<0.05). The improved mitochondrial function significantly correlated with cardiac output (p<0.05, Spearman rank-correlation test). CONCLUSIONS: We demonstrate that the postresuscitation administration of cyclosporine attenuates myocardial and cardiac mitochondrial injury in asphyxiated newborn piglets following resuscitation.

Pharmacokinetic characterization of intravenous cyclosporine treatment for cardioprotection during resuscitation of asphyxiated newborn piglets.

OBJECTIVES: Cyclosporine treatment, as a single intravenous bolus, during resuscitation has been shown to attenuate myocardial injury in asphyxiated newborn piglets. However, the pharmacokinetics of cyclosporine treatment for cardioprotection in newborns has not been studied. We aimed to assess the pharmacokinetics of a single intravenous cyclosporine treatment during resuscitation of asphyxiated newborn piglets and compare these parameters with healthy newborn piglets. DESIGN: Newborn piglets were acutely instrumented and normocapnic alveolar hypoxia was induced for 2 hours followed by 4 hours of reoxygenation. Piglets were block-randomized to receive a single intravenous bolus of cyclosporine (2.5-25 mg/kg) (n = 8 per group). Eight piglets underwent no hypoxia-reoxygenation and received 10 mg/kg cyclosporine at the corresponding time point. Plasma cyclosporine and troponin concentrations during reoxygenation period were determined by high-pressure liquid chromatography and enzyme-linked immunosorbent assay, respectively. Noncompartmental methods were used to calculate the pharmacokinetic parameters. Cyclosporine concentrations and pharmacokinetic parameters were analyzed by one-way analysis of variance. SETTING: University animal laboratory. SUBJECTS: Piglets (1-4 days old, weighing 1.4-2.5 kg). INTERVENTIONS: Intravenous cyclosporine (2.5, 10, or 25 mg/kg) given during resuscitation. MEASUREMENTS AND MAIN RESULTS: In the hypoxic-reoxygenated piglets, the plasma AUC(0-4 hrs) and C(max) of cyclosporine at reoxygenation were in the following rank order: 25 > 10 > 2.5 mg/kg treatment (p < 0.001 between groups, analysis of variance). Plasma AUC(0-4 hrs) and C(max) in piglets treated with cyclosporine at 25 mg/kg was associated with increased plasma troponin levels, a marker of myocardial injury, relative to piglets treated with 2.5 and 10 mg/kg. Asphyxiated newborn piglets had higher clearance and lower AUC(0-∞), but similar AUC(0-4 hrs), steady-state volume of distribution, and mean residence time compared with those of healthy newborn piglets. CONCLUSIONS: This is the first study to demonstrate the pharmacokinetics of intravenous cyclosporine treatment during resuscitation of asphyxiated newborn piglets, which did not appear to different from that of healthy piglets.

Endoscopic Submucosal Dissection Versus Surgery or Endoscopic Mucosal Resection for Metachronous Early Gastric Cancer: a Meta-analysis.

BACKGROUND: Resection options for early gastric cancer (EGC) include endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and surgery. In patients with metachronous EGC following previous resection, the optimal resection technique is not well elucidated. We conducted a systematic review and meta-analysis of studies comparing ESD to EMR, or ESD to surgery, in patients with metachronous EGC. METHODS: We conducted an electronic search of studies reporting on outcomes and AEs following ESD versus either EMR or surgery for patients with metachronous EGC. Pooled odds ratios (OR) of included studies were obtained using DerSimonian and Laird random effects models. Funnel plots were produced and visually inspected for evidence of publication bias. The quality of the evidence was assessed using GRADE. RESULTS: A total of 9367 abstracts were screened and 10 observational studies were included. The odds of complete resection were higher amongst patients undergoing ESD compared to EMR (OR 5.88, 95% confidence intervals, CI, 1.79-19.35), whereas the odds of complete resection were no different between ESD and surgery (OR 0.57, 95% CI 0.04-8.24). There were no differences in the odds of local recurrence with ESD versus surgery (OR 5.01, 95% CI 0.86-29.13). Post-procedural bleeding did not differ significantly between ESD and EMR (OR 0.70, 95% CI 0.16-3.00). There was no evidence of publication bias. DISCUSSION: For metachronous EGC, ESD or surgery is preferred over EMR depending on local expertise and patient preferences, largely due to a higher risk of incomplete resection with EMR. REVIEW REGISTRATION: PROSPERO CRD42021270445.

Cyclosporine treatment improves cardiac function and systemic hemodynamics during resuscitation in a newborn piglet model of asphyxia: a dose-response study.

OBJECTIVES: Asphyxiated neonates often have myocardial depression, which is a significant cause of morbidity and mortality. Cardioprotective effects of cyclosporine have been observed in adult patients and animals with myocardial infarction. However, the cardioprotective effect of cyclosporine in neonates has not yet been studied. We hypothesize that cyclosporine will improve cardiac function and reduce myocardial injury in asphyxiated newborn piglets. DESIGN: Thirty-six piglets (1-4 days old, weighing 1.4-2.5 kg) were acutely instrumented for continuous monitoring of cardiac output and systemic arterial pressure. After stabilization, normocapnic alveolar hypoxia (10% to 15% oxygen) was instituted for 2 hrs followed by reoxygenation with 100% oxygen for 0.5 hrs and then 21% for 3.5 hrs. A nonasphyxiated, sham-operated group was included (n = 4) to control for effects of the surgical model. Plasma troponin and myocardial lactate concentrations were determined as well as morphologic examinations. SETTING: Neonatal asphyxia and reoxygenation. SUBJECTS: Newborn (1-4 days old) piglets. INTERVENTIONS: Piglets were block-randomized to receive intravenous boluses of cyclosporine A (2.5, 10, or 25 mg/kg) or normal saline (control) at 5 mins of reoxygenation (n = 8/group). MEASUREMENTS AND MAIN RESULTS: Cardiac index, heart rate, systemic oxygenation, plasma troponin, and left ventricular lactate were measured. Hypoxic piglets had cardiogenic shock (cardiac output 40% to 48% of baseline), hypotension (mean arterial pressure 27-31 mm Hg), and acidosis (pH 7.04). Cyclosporine treatment caused bell-shaped improvements in cardiac output, stroke volume, and systemic oxygen delivery (p < .05 vs. controls). Plasma troponin and left ventricle lactate were higher in controls than that of 2.5 and 10 mg/kg cyclosporine-treated groups (p < .05). Although histologic features of myocardial injury were not different among groups, severe damage was observed in mitochondria of control piglets but attenuated in that of cyclosporine (10 mg/kg) treatment. CONCLUSIONS: Postresuscitation administration of cyclosporine causes preservation of cardiac function and attenuates myocardial injury in newborn piglets after asphyxia-reoxygenation.