GERD after Bariatric Surgery: A Review of the Underlying Causes and Recommendations for Management.

PURPOSE OF REVIEW: GERD after bariatric surgery is an ongoing concern for bariatric surgeons and their patients. This paper reviews the association of persistent or de novo GERD after multiple types of bariatric surgery, and focuses on the work up and management of GERD after SG. RECENT FINDINGS: Two recent large, multicenter randomized clinical trials have shown stronger associations between SG and GERD compared to RYGB. A large group of internationally recognized bariatric surgeons collaborated on 72 consensus statements to help guide the bariatric community on the subject of redo surgeries after SG, including as it pertains to GERD. We present an algorithm that consolidates the best-practices recommendations of the work-up and management of GERD after sleeve gastrectomy, and mention areas of persistent controversy where future research is warranted.

Insulin-like growth factor binding protein 2 null mice (Igfbp2-/-) are protected against trabecular bone loss after vertical sleeve gastrectomy.

BACKGROUND: Bariatric surgery has been shown to result in weight loss, improved hemoglobin A1C, and decreased mortality but can also lead to bone loss and increased fracture rates. Serum IGFBP-2 is elevated in patients after bariatric surgery and although it may lead to improved blood glucose, may also drive bone resorption, and inhibit IGF-I action. This study tested the hypothesis that Igfbp2-/- mice were acutely protected from bone loss after vertical sleeve gastrectomy (VSG). METHODS: Thirty-four mice, 17 Igfbp2-/- and 17 + / + underwent a hand-sewn VSG or sham surgery, at 16 weeks of age. Mice were harvested at 20 weeks of age. DXA was measured for body composition, areal bone mineral density (aBMD), areal bone mineral content (aBMC), femoral bone mineral density (fBMD), and femoral bone mineral content (fBMC) at 15, 18, and 20 weeks of age. Micro-computed tomography and serum ELISA assays were measured and analyzed at 20 weeks of age. RESULTS: Both Igfbp2-/- and + / + mice lost significant weight (P = 0.0251, P = 0.0003, respectively) and total fat mass (P = 0.0082, P = 0.0004, respectively) at 4 weeks after VSG. Igfbp2+/+ mice lost significant aBMD, fBMD, fBMC, trabecular BMD, trabecular BV/TV and cortical tissue mineral density (P = 0.0150, P = 0.0313, P = 0.0190, P = 0.0072, and 0.0320 respectively). The Igfbp2-/- mice did not show significant bone loss in these parameters nor in trabecular BV/TV. Both Igfbp2-/- and + / + mice had less cortical bone area (P = 0.0181, P = < .00001), cortical area over total area (P = 0.0085, P = 0.0007), and cortical thickness (P = 0.0050, P = < 0.0001), respectively. Igfbp2+/+ mice demonstrated significantly lower polar, minimum, and maximum moments of inertia (P = 0.0031, P = 0.0239, and P = 0.0037, respectively). Igfbp2+/+ had significantly higher levels of IGFBP-2 at 2 weeks postoperatively after VSG (P = 0.035), and elevated levels of CTx and P1NP (P = 0.0127, P = 0.0058, respectively). CONCLUSIONS: Igfbp2-/- mice were protected against trabecular bone loss and had attenuated cortical bone loss 4 weeks after VSG.

Study Strategies for General Surgery Residents Preparing for the American Board of Surgery In-Training Examination: What to Keep, Discard, and Adopt.

OBJECTIVE: Undergraduate and graduate education research has stratified study strategies from low-utility to high-utility with respect to durable learning. The purpose of this study was to determine the prevalence of these evidence-based learning strategies among surgery residents in preparation for the American Board of Surgery In-Training Examination (ABSITE). DESIGN: A 23-item survey was administered during individual interviews. It assessed whether they had a study plan, and the average length and frequency of their independent study, both during the year and the month prior to the ABSITE. Data were also collected on their primary resources and study strategies. Residents rated their usage of those strategies based on a 5-point Likert scale. SETTING: Maine Medical Center, an academic tertiary care center located in Portland, ME. PARTICIPANTS: All residents in the Department of Surgery. RESULTS: Residents (n= 23) intensified their preparation for the ABSITE in the month prior to the exam compared to the remainder of the year, adopting study plans (87% vs 61%, p = 0.53) and increasing the time spent studying (median, 420 vs 120 minutes per week, p < 0.001). Primary resources used were textbooks (65%), ABSITE review books (26%) and online question banks (9%). All residents (100%) often or always used testing, but fewer residents often or always used spacing (24%), both considered high-utility strategies. Most residents (60%) often or always used highlighting, considered a low-utility strategy. There were no relationships between study strategies and ABSITE scores. CONCLUSIONS: All residents use self-testing as a study strategy. Most underuse spacing and overuse highlighting. Further research is needed to establish the relationship between these study strategies and ABSITE scores.

Don't Shoot the Messenger: Surgical Programs Can Do More to Keep Applicants Informed.

OBJECTIVE: The interview process for applying to general surgery residency is burdened by a high volume of applicants, resulting in unprofessional behavior by both applicants and programs. Sharing more information regarding interview scheduling with applicants may limit fourth year medical student educational disruptions, minimized late cancellations to interview, and improve overall satisfaction with the process. Thus, we set out to determine what information is currently available to applicants. DESIGN: We used publicly accessible sources to determine what information was shared by US general surgery residency programs with applicants. Specifically, we looked at the deadline for applications, United States Medical Licensing Examination Step 1 and 2 score cutoffs, number of interview dates available, specific interview dates, a stated policy to not offering more interviews than slots, dates when applicants can expect to be notified of interview offers, notification of decision to decline, and International Medical Graduate and visa policies. SETTING: This study took place at Maine Medical Center in Portland, Maine, an academic medical center with a general surgery residency program. PARTICIPANTS: Not applicable. RESULTS: Three hundred seventeen programs were examined. Seventy-six percent of programs specified an application deadline, 65% of programs specified a Step 1 cut-off score, 50% of programs specified a Step 2 cut-off score, 61% of programs stated a visa policy, and 50% of programs stated an International Medical Graduate policy. Twenty-five percent of programs disclosed the number of interview dates, 23% disclosed what those interview dates were. About 3.4% of programs gave interview release dates, 2.8% of programs notify applicants of decline to interview, and 0.63% of programs explicitly describe a policy of offering only as many interviews as slots available. Thirty-two percent of programs provided conflicting information. CONCLUSIONS: The information available to applicants from public access sources regarding interview scheduling is minimal, unstandardized, and unreliable. Notably lacking were policies that only offer as many interviews as slots available, dates when applicants can expect to be notified of interview offers, and notification of declines. Providing such information to applicants in a standardized way may improve satisfaction with the interview scheduling process.

Photovoice and Clubfoot: Using a Participatory Research Method to Study Caregiver Adherence to the Ponseti Method in Perú.

The Ponseti Method of casting and bracing is the gold-standard treatment for congenital clubfoot in young children. Despite its many advantages, outcomes depend heavily on caregiver adherence to the treatment protocol. Our study explored the experience caregivers had with the Ponseti method using a photography-based participatory research method known as Photovoice. Five adult caregivers were recruited from families pursuing clubfoot treatment at the Children's Hospital in Lima, Perú, during June, 2013. Each was provided a digital camera and training and agreed to photograph their experiences caring for a child undergoing Ponseti Method clubfoot treatment. Participants held four to five weekly one-on-one meetings with the researcher to discuss their photos. They also attended a group meeting at the end of the study to view and discuss photos of other participants. Using photos collected at this meeting, participants identified themes that summarized their experiences with treatment and discussed ways to improve delivery of care in order to support caregiver adherence to treatment. These results were presented to clinicians in Lima who use the Ponseti Method. The Photovoice method allowed researchers and participants to study the experience caregivers have with the Ponseti Method, and results can be used to inform the design of patient-based care models.