Association of bariatric surgery with indicated and unintended outcomes: An umbrella review and meta-analysis for risk-benefit assessment.

Bariatric surgery can cause numerous functional changes to recipients, some of which are unintended. However, a systematic evaluation of wide-angled health benefits and risks following bariatric surgery has not been conducted. We systematically evaluated published systematic reviews of randomized controlled trials and observational studies reporting the association between bariatric surgery and health outcomes. We performed subgroup analyses by surgery type and sensitivity analysis, excluding gastric band. Thirty systematic reviews and 82 meta-analyzed health outcomes were included in this review. A total of 66 (80%) health outcomes were significantly associated with bariatric surgery, of which 10 were adverse outcomes, including suicide, fracture, gastroesophageal reflux after sleeve gastrectomy, and neonatal morbidities. The other 56 outcomes were health benefits including new-onset diabetes mellitus (DM) (odds ratio [OR] = 0.39; 95% confidence interval [CI] = 0.19-0.79), hypertension (OR = 0.36; 95% CI = 0.33-0.40), dyslipidemia (OR = 0.33; 95% CI = 0.14-0.81), cancers (OR = 0.65; 95% CI = 0.53-0.80), cardiovascular diseases (CVDs), and women's health. Surgery is associated with reductions in all-cause mortality and death due to cancer, DM, and CVD. Bariatric surgery has both beneficial and harmful effects on a broader than expected array of patients' health outcomes. An expansion of the indication for bariatric surgery could be discussed to include a broader population with metabolic vulnerabilities.

Delphi survey of intercontinental experts to identify areas of consensus on the use of indocyanine green angiography for tissue perfusion assessment during plastic and reconstructive surgery.

BACKGROUND: In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery. METHODS: A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement. RESULTS: Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments. CONCLUSION: ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.

Shifting surgical archetypes of ICG fluorescent-angiography for bowel perfusion assessment in cardiogenic shock under ECMO support.

Extracorporeal membrane oxygenation (ECMO) has been adopted to support patients with acute severe cardiac or pulmonary failure that is potentially reversible and unresponsive to conventional management. Mesenteric ischemia (MI) can present as a life-threatening complication in patients receiving veno-arterial echocardiogram (ECHO) support. Due to the nature and acuity of these conditions, determining adequate perfusion upon surgical intervention is challenging for the operating surgeon, especially in cardiogenic shock (CS) patients on ECMO support persenting low arterial pulsatility. Indocyanine green fluorescent angiography (ICG-FA) has proven to be useful for real-time assessment of vascular perfusion, which may help determine the extent of bowel ischemia in patients receiving ECMO support. The case report here-in presented, breaks the paradigm of performing non-cardiac surgical procedures on ECMO support via a pioneering visual aid technique. LEARNING OBJECTIVE: ICG-FA is a promising visual intraoperatory technique providing real-time feedback for the adequate identification and assessment of target tissue/organs. The high morbidity and mortality rates associated to MI and CS-particularly when concomitantly present-hinders salvage surgical therapy. The use of ECMO provides hemodynamic stability This case report highlights the importance of adequate surgical intervention under extracorporeal life support in the presence of both CS and MI. To the authors' knowledge, this is the first report of application of ICG-FA to evaluate mesenteric perfusion in a patient receiving ECMO support.

Obesity in America.

BACKGROUND: The prevalence of obesity in America continues to grow significantly. Awareness and understanding of the disease of obesity and treatment options for it appear to be lacking among the general US population. OBJECTIVE: This study aimed to identify misperceptions in diagnosis and treatment of obesity, struggles Americans face in obtaining treatment, consequences of obesity, and perceived barriers to weight loss. SETTING: University hospital, United States. METHODS: A survey of 1509 adults was completed in September 2016 using AmeriSpeak, a probability-based panel designed to be representative of the US household population. The survey included oversamples of blacks and Hispanics. The study analyzed quantitative data from structured interviews and presents descriptive statistics related to public attitudes toward obesity. RESULTS: Of Americans, 81% consider obesity to be the most serious health problem facing the nation, tying cancer as the top issue and landing ahead of diabetes (72%), heart disease (72%), mental illness (65%), and HIV infection and AIDS (46%). Nearly all Americans (94%) agree that obesity itself, even when no other diseases are present, increases the risk for early death. Most Americans overestimate the effectiveness of some obesity treatments, such as diet and exercise alone. Many overweight and obese Americans do not consult a doctor at all about their issues of excess weight. CONCLUSIONS: There is increased awareness about the serious consequences of obesity, but there is still a lack of understanding about the reasons and best treatment modalities for the disease.

Constructing a competency-based bariatric surgery fellowship training curriculum.

BACKGROUND: Bariatric fellowship training after general surgery has historically been time based and competence was determined at completion based on a minimum number of cases during the fellowship. Graduate medical education is moving toward competency-based medical education where learners are evaluated during the course of their training and competence assessment occurs throughout. OBJECTIVES: The Executive Council of the American Society of Metabolic and Bariatric Surgery (ASMBS) at the direction of the American Board of Surgery wanted to transition the bariatric surgery fellowship curriculum from its traditional format to a competency-based curriculum using competency-based medical education principles. METHODS: The ASMBS Education and Training Committee established a task force of 9 members to create a new curriculum and all of the necessary evaluation tools to support the curriculum, and initiate a pilot program. RESULTS: A competency-based curriculum consisting of 6 modules with cognitive and technical milestones, and the innovative evaluation tools needed to evaluate the learners, was created. A pilot program consisting of 10 programs and 19 fellows has been undertaken for the 2016-2017 academic year. CONCLUSION: The Education Committee of the ASMBS is leading the charge in curriculum development for competency-based medical education for bariatric fellowship.

Does implementing a general surgery residency program and resident involvement affect patient outcomes and increase care-associated charges?

BACKGROUND: Variable results regarding general surgery residency program (GSRP) impact on patient outcomes and charges are reported. The aim of this study was to determine any significant differences in patient outcomes and cost with a new GSRP. METHODS: We analyzed all laparoscopic appendectomies (lap-ap), cholecystectomies (lap-chole), and inguinal hernia repairs (IHR) performed before and after implementing a GRSP. RESULTS: Operative time significantly increased for lap-ap (p < 0.0001), lap-chole (p < 0.0001) and IHR (p = 0.03). Time to close the incision significantly increased for lap-ap (p < 0.0001), lap-chole (p = 0.006) and IHR (p = 0.03). Length of stay only increased for lap-ap (p = 0.04). Complication rates did not increase for any procedure. However, charges significantly increased for lap-ap (p < 0.0001), lap-chole (p < 0.0001), and IHR (p = 0.03). CONCLUSIONS: Although a newly implemented GSRP caused increases in overall operative times, times to close incisions, and charges, it did not negatively impact patient outcomes.

Routine use of fluorescent incisionless cholangiography as a new imaging modality during laparoscopic cholecystectomy.

BACKGROUND: Intraoperative incisionless fluorescent cholangiography (IOIFC) has been described to identify extrahepatic biliary anatomy. Potential advantages of the routine use of intraoperative incisionless fluorescent cholangiography were evaluated in a consecutive series of cases. METHODS: A total of 45 patients undergoing laparoscopic cholecystectomy between January and July 2013 were consented and included in this study. We analyzed a prospectively collected database for feasibility, cost, time, usefulness, teaching tool, safety, learning curve, X-ray exposure, complexity, and real-time surgery of IOIFC. A single dose of 0.05 mg/kg of Indocyanine green was administered prior to surgery. During the procedure, a laparoscopic fluorescence system was used. RESULTS: IOIFC could be performed in all 45 patients, whereas intraoperative cholangiography could be performed in 42 (93 %). Individual median cost of performing IOFC was cheaper than IOC (13.97 ± 4.3 vs 778.43 ± 0.4 USD) per patient, p = 0.0001). IOFC was faster than IOC (0.71 ± 0.26 vs 7.15 ± 3.76 minutes, p < 0.0001). The cystic duct was identified by IOFC in 44 out of 45 patients (97.77 %). CONCLUSION: IOIFC appears to be a feasible, low-cost, expeditious, useful, and effective imaging modality when performing LC. It is safe, easy to perform and interpret, and does not require a learning curve or X-ray. It can be used for real time surgery to delineate the extrahepatic biliary structures.

Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy.

BACKGROUND: Despite the standardization of laparoscopic cholecystectomy (LC), the rate of bile duct injury (BDI) has risen from 0.2 to 0.5%. Routine use of intraoperative cholangiography (IOC) has not been widely accepted because of its cost and a lack of evidence concerning its use in preventing BDI. Fluorescent cholangiography (FC), which has recently been advocated as an alternative to IOC, is a novel intraoperative procedure involving infrared visualization of the biliary structures. This study evaluated costs and effectiveness of routinely implemented FC and IOC during LC. MATERIALS AND METHODS: Between February and June 2013, the authors prospectively collected the data of all patients undergoing laparoscopic cholecystectomy. We retrospectively reviewed and compared the use of FC and IOC. Procedure time, procedure cost, and effectiveness of the two methods were analyzed and compared. The surgeons involved in the cases completed a survey on the usefulness of each method. RESULTS: A total of 43 patients (21 males and 22 females) were analyzed during the study period. Mean age was 49.53 ± 14.35 years and mean body mass index was 28.35 ± 8 kg/m(2). Overall mean operative time was 64.95 ± 17.43 min. FC was faster than IOC (0.71 ± 0.26 vs. 7.15 ± 3.76 min; p < 0.0001). FC was successfully performed in 43 of 43 cases (100%) and IOC in 40 of 43 cases (93.02%). FC was less expensive than IOC (US$14.10 ± 4.31 vs. US$778.43 ± 0.40; p < 0.0001). According to the survey, all surgeons found routine use of FC useful. CONCLUSION: In this study, FC was effective in delineating important anatomic structures. It required less time and expense than IOC, and was perceived by the surgeons to be easier to perform, and at least as useful as IOC. Further prospective studies are warranted to evaluate the effectiveness of FC in decreasing BDI.

Laparoscopic sleeve gastrectomy--volume and pressure assessment.

BACKGROUND: Aiming to clarify the mechanism of weight loss after the restrictive bariatric procedure of sleeve gastrectomy (LSG), the volumes and pressures of the stomach, of the removed part, and of the remaining sleeve were measured in 20 morbidly obese patients. METHODS: The technique used consisted of occlusion of the pylorus with a laparoscopic clamp and of the gastroesophageal junction with a special orogastric tube connected to a manometer. Instillation of methylene-blue-colored saline via the tube was continued until the intraluminal pressure increased sharply, or the inflated stomach reached 2,000 cc. After recording of measurements, LSG was performed. RESULTS: Mean volume of the entire stomach was 1,553 cc (600-2,000 cc) and that of the sleeve 129 cc (90-220 cc), i.e., 10% (4-17%) and that of the removed stomach was 795 cc (400-1,500 cc). The mean basal intragastric pressure of the whole stomach after insufflations of the abdominal cavity with CO(2) to 15 mmHg was 19 mmHg (11-26 mmHg); after occlusion and filling with saline it was 34 mmHg (21-45 mmHg). In the sleeved stomach, mean basal pressure was similar 18 mmHg (6-28 mmHg); when filled with saline, pressure rose to 43 mmHg (32-58 mmHg). The removed stomach had a mean pressure of 26 mmHg (12-47 mmHg). There were no postoperative complications and no mortality. CONCLUSIONS: The notably higher pressure in the sleeve, reflecting its markedly lesser distensibility compared to that of the whole stomach and of the removed fundus, indicates that this may be an important element in the mechanism of weight loss.