Pathological Roles for Endothelial Colony-Forming Cells in Neonatal and Adult Lung Disease.

Endothelial colony-forming cells (ECFCs) are vascular resident and circulating endothelial cell subtypes with potent angiogenic capacity, a hierarchy of single-cell clonogenic potentials, and the ability to participate in de novo blood vessel formation and endothelial repair. Existing literature regarding ECFCs in neonatal and adult pulmonary diseases is confounded by the study of ambiguously defined "endothelial progenitor cells," which are often not true ECFCs. This review contrasts adult and fetal ECFCs, discusses the effect of prematurity on ECFCs, and examines their different pathological roles in neonatal and adult pulmonary diseases, such as bronchopulmonary dysplasia, congenital diaphragmatic hernia, pulmonary artery hypertension, pulmonary fibrosis, and chronic obstructive pulmonary disease. Therapeutic potential is also discussed in light of available preclinical data.

Resting state functional connectivity in SLE patients and association with cognitive impairment and blood-brain barrier permeability.

OBJECTIVE: Extensive blood-brain barrier (BBB) leakage has been linked to cognitive impairment in SLE. This study aimed to examine the associations of brain functional connectivity (FC) with cognitive impairment and BBB dysfunction among patients with SLE. METHODS: Cognitive function was assessed by neuropsychological testing (n = 77). Resting-state FC (rsFC) between brain regions, measured by functional MRI (n = 78), assessed coordinated neural activation in 131 regions across five canonical brain networks. BBB permeability was measured by dynamic contrast-enhanced MRI (n = 61). Differences in rsFC were compared between SLE patients with cognitive impairment (SLE-CI) and those with normal cognition (SLE-NC), between SLE patients with and without extensive BBB leakage, and with healthy controls. RESULTS: A whole-brain rsFC comparison found significant differences in intra-network and inter-network FC in SLE-CI vs SLE-NC patients. The affected connections showed a reduced negative rsFC in SLE-CI compared with SLE-NC and healthy controls. Similarly, a reduced number of brain-wide connections was found in SLE-CI patients compared with SLE-NC (P = 0.030) and healthy controls (P = 0.006). Specific brain regions had a lower total number of brain-wide connections in association with extensive BBB leakage (P = 0.011). Causal mediation analysis revealed that 64% of the association between BBB leakage and cognitive impairment in SLE patients was mediated by alterations in FC. CONCLUSION: SLE patients with cognitive impairment had abnormalities in brain rsFC which accounted for most of the association between extensive BBB leakage and cognitive impairment.

Short-term outcomes of thoracoscopic versus open lobectomy for congenital lung malformations.

PURPOSE: Thoracoscopic and open approaches for the management of congenital lung malformations (CLM) has been debated. The aim of this study is to compare 30-day outcomes for non-emergent lobectomies in children. METHODS: The National Surgical Quality Improvement Program-Pediatric database was queried for patients undergoing CLM resection from 2013 to 2020. Outcomes were compared by operative technique in an intention-to-treat model and then propensity matched. RESULTS: 2157 patients met inclusion criteria and underwent non-emergent pulmonary lobectomy for CLM. The intended operative approach was thoracoscopic in 57.7% of patients. Patients in the open group compared to the thoracoscopic were more likely to be born premature, have chronic lung disease, require preoperative oxygen support, and be ventilator dependent. After propensity matching, there was no statistically significant difference in 30-day mortality, unplanned readmission, and other complications between the thoracoscopic and open groups. Thoracoscopic approach was associated with a shorter length of stay. The proportion of cases approached via thoracoscopy increased over time from 48.8% in 2013 to 69.9% in 2020. CONCLUSIONS: This large multicenter retrospective matched analysis demonstrates thoracoscopic lobectomy in children has similar favorable 30-day outcomes and shorter length of stay for the non-emergent management of CLM, compared to open thoracotomy. LEVEL OF EVIDENCE: Level III.

Role of Traditional Chinese Herbal Medicines in Functional Gastrointestinal and Motility Disorders.

PURPOSE OF REVIEW: Traditional Chinese medicine (TCM) has been in use for thousands of years in Asian countries and is rapidly gaining popularity in the Western world. Among different forms of TCM, the traditional Chinese herbal therapy and acupuncture are the most popular modalities. Here, we review the fundamentals of TCMs for clinicians practicing in the West and will also detail the evidence-based utility of Chinese herbal medicine in the management of functional gastrointestinal disorders (FGIDs). RECENT FINDINGS: In the recent decades, the popularity and usage of traditional Chinese herbal medicine in FGIDs is increasing in the West. TCMs are commonly utilized by many patients with FGIDs as the conventional therapies do have limitations such as cost, inadequate symptom control and adverse effects. The unfamiliarity of TCM philosophy among clinicians in the West, and shortage of traditional Chinese herbalists remain. The philosophy of TCM is complex and entirely different from the Western medical concepts and is difficult to understand for a clinician trained in the West. Further traditional Chinese herbal therapies are often viewed skeptically by the clinicians in the West for various reasons such as lack of scientific rigor, inconsistencies in the constituents of herbal products, and also concerns due to adverse herb effects. Future clinical trials in FGIDs should focus on herb product quality, herb-drug interactions, and standardized criteria for diagnosis and management outcomes.

Acute kidney injury in necrotizing enterocolitis predicts mortality.

BACKGROUND: Morbidity and mortality with necrotizing enterocolitis (NEC) remains a significant challenge. Acute kidney injury (AKI) has been shown to worsen survival in critically ill neonates. To our knowledge, this study is the first to evaluate the prevalence of AKI and its impact on outcomes in neonatal NEC. METHODS: We carried out a single-center retrospective chart review of all neonates treated for NEC between 2003 and 2015 (N = 181). AKI is defined as a rise in serum creatinine (SCr) from a previous trough according to neonatal modified KDIGO criteria (stage 1 = SCr rise 0.3 mg/dL or SCr 150 < 200%, stage 2 = SCr rise 200 < 300%, stage 3 = SCr rise ≥300%, SCr 2.5 mg/dL or dialysis). Primary outcome was in-hospital mortality and secondary outcomes were hospital length of stay (LOS) and need for and type of surgery. RESULTS: Acute kidney injury occurred in 98 neonates (54%), with 39 stage 1 (22%), 31 stage 2 (18%), and 28 stage 3 (16%), including 5 requiring dialysis. Non-AKI and AKI groups were not statistically different in age, weight, Bell's NEC criteria, and medication exposure (vasopressors, vancomycin, gentamicin, or diuretic). Neonates with AKI had higher mortality (44% vs 25.6%, p = 0.008) and a higher chance of death (HR 2.4, CI 1.2-4.8, p = 0.009), but the effect on LOS on survivors did not reach statistical significance (79 days, interquartile range [IQR] 30-104 vs 54 days, IQR 30-92, p = 0.09). Overall, 48 (27.9%) patients required surgical intervention. CONCLUSIONS: This study shows that AKI not only occurs in over half of patients with NEC, but that it is also associated with more than a two-fold higher mortality, highlighting the importance of early recognition and potentially early intervention for AKI.

Uncomplicated Acute Diverticulitis: Identifying Risk Factors for Severe Outcomes.

BACKGROUND: The management of uncomplicated (Modified Hinchey Classification Ia) acute diverticulitis (AD) has become increasingly conservative, with a focus on symptomatic relief and supportive management. Clear criteria for patient selection are required to implement this safely. This retrospective study aimed to identify risk factors for severe clinical course in patients with uncomplicated AD. MATERIALS AND METHODS: Patients admitted to General Surgery at two New Zealand tertiary centres over a period of 18 months were included. Univariate and multivariate analyses were carried out in order to identify factors associated with a more severe clinical course. This was defined by three endpoints: need for procedural intervention, admission >7 days and 30-day readmission; these were analysed separately and as a combined outcome. RESULTS: Uncomplicated AD was identified in 319 patients. Fifteen patients (5%) required procedural intervention; this was associated with SIRS (OR 3.92). Twenty-two (6.9%) patients were admitted for >7 days; this was associated with patient-reported pain score >8/10 (OR 5.67). Thirty-one patients (9.8%) required readmission within 30 days; this was associated with pain score >8/10 (OR 6.08) and first episode of AD (OR 2.47). Overall, 49 patients had a severe clinical course, and associated factors were regular steroid/immunomodulator use (OR 4.34), pain score >8/10 (OR 5.9) and higher temperature (OR 1.51) and CRP ≥200 (OR 4.1). CONCLUSION: SIRS, high pain score and CRP, first episode and regular steroid/immunomodulator use were identified as predictors of worse outcome in uncomplicated AD. These findings have the potential to inform prospective treatment decisions in this patient group.

Steroid use for refractory hypotension in congenital diaphragmatic hernia.

PURPOSE: Guidelines for diagnosis and treatment of adrenal insufficiency (AI) in newborns with congenital diaphragmatic hernia (CDH) are poorly defined. METHODS: From 2002 to 2016, 155 infants were treated for CDH at our institution. Patients with shock refractory to vasopressors (clinically diagnosed AI) were treated with hydrocortisone (HC). When available, random cortisol levels <10 µg/dL were considered low. Outcomes were compared between groups. RESULTS: Hydrocortisone was used to treat AI in 34% (53/155) of patients. That subset of patients was demonstrably sicker, and mortality was expectedly higher for those treated with HC (37.7 vs. 17.6%, p = 0.0098). Of the subset of patients with random cortisol levels measured before initiation of HC, 67.7% (21/31) had low cortisol levels. No significant differences were seen in survival between the high and low groups, but mortality trended higher in patients with high cortisol levels that received HC. After multivariate analysis, duration of HC stress dose administration was associated with increased risk of mortality (OR 1.11, 95% CI 1.02-1.2, p = 0.021), and total duration of HC treatment was associated with increased risk of sepsis (OR 1.04, 95% CI 1.005-1.075, p = 0.026). CONCLUSION: AI is prevalent amongst patients with CDH, but prolonged treatment with HC may increase risk of mortality and sepsis.

Effect of Diversion Ileostomy on the Occurrence and Consequences of Chemotherapy-Induced Diarrhea.

BACKGROUND: The benefits of adjuvant chemotherapy in the treatment of colorectal cancer are well established. Chemotherapy-induced diarrhea is a common adverse effect of these regimens. The occurrence of chemotherapy-induced diarrhea not only directly affects patient health but may also compromise treatment efficacy because of consequent dosing alterations or discontinuation. OBJECTIVE: This study aimed to investigate the effect of diverting loop ileostomy during chemotherapy on the occurrence and consequences of chemotherapy-induced diarrhea. DESIGN: This was a retrospective evaluation of a prospective surgical database. SETTINGS: This was a single-institution retrospective study. PATIENTS: All patients receiving curative adjuvant chemotherapy after anterior resection for colorectal cancer at Auckland Hospital from 2002 to 2013 were retrospectively evaluated. MAIN OUTCOME MEASURES: Patient-, perioperative-, and chemotherapy-related variables were collected. Chemotherapy-induced diarrhea occurrence was graded according to National Cancer Institute Common Terminology Criteria for Adverse Events. Logistic regression analysis was performed to identify independent predictors for chemotherapy-induced diarrhea occurrence, treatment modifications, and hospital admission. RESULTS: A total of 109 identified patients received 691 chemotherapy cycles; 84% of patients with a diverting ileostomy experienced chemotherapy-induced diarrhea compared with 47% in those who were not defunctioned (p < 0.01). On logistic regression analysis, the presence of a diverting ileostomy during chemotherapy was an independent predictor of chemotherapy-induced diarrhea grade 3 or higher (OR, 13.6 (95% CI: 1.2-150.9); p = 0.02), the need for a dosing reduction (OR, 4.0 (95% CI: 1.3-12.4); p = 0.02), and the need for any modification in the chemotherapy regimen (OR, 3.4 (95% CI: 1.2-9.6); p = 0.02). LIMITATIONS: This study is limited by its retrospective design, potentially limiting the accuracy of chemotherapy-induced diarrhea grade reporting. CONCLUSIONS: The presence of an ileostomy during adjuvant chemotherapy is a predictor of severe chemotherapy-induced diarrhea and the need for modifications in the chemotherapy regimen. This may have important consequences for long-term survival. Prospective investigation is needed to further assess the impact of diverting ileostomy on the delivery of chemotherapy and oncologic outcomes.

Cost analysis of early versus delayed loop ileostomy closure: a case-matched study.

BACKGROUND/AIMS: The optimal timing for the closure of loop ileostomies remains controversial. The aim of the current study was to investigate whether early ileostomy closure (EC) (<2 weeks post-formation) results in significant healthcare savings as against late closure (LC). METHODS: Patients with available cost data that underwent EC between January 2008 and December 2012 were compared against matched patients undergoing LC during the same period. Direct hospital costs for the two groups were compared. RESULTS: There were 42 EC patients and 61 LC patients. EC patients had significantly less ileostomy-related complications (p < 0.001) and hospital readmissions (p < 0.001). Operative time (p < 0.001) and operative cost (p = 0.002) were also both significantly less in the EC group. Community nursing costs favoured the LC group (p = 0.047). The EC group had an increased post-closure wound infection rate (p = 0.02). The mean total direct cost per patient was NZD 13,724 (SD NZD 3,736) for EC and NZD 16,728 (SD NZD 8,028) for LC. Representing an average costs saving of NZD 3,004 per patient favouring EC (p = 0.012). CONCLUSION: Although EC increases the post-closure wound infection rate, EC reduces ileostomy complications, hospital readmissions and operative costs resulting in significant healthcare savings. In order to improve patient outcomes and make EC even more cost effective, efforts should be taken to reduce wound infections.

A rare cause of acute pancreatitis: Percutaneous mechanical rheolytic thrombectomy of deep venous thrombosis.

INTRODUCTION: Percutaneous mechanical rheolytic thrombectomy is an effective treatment option for deep vein thrombosis as well as arterial and graft thromboses. Acute pancreatitis, a rare complication of this technique, is described in this case report. CASE REPORT: A 40-year-old man underwent AngioJet mechanical rheolytic thrombectomy for iliocaval deep vein thrombosis. He subsequently developed acute pancreatitis. This case report outlines the clinical presentation of acute pancreatitis after rheolytic thrombectomy and also discusses the possible pathogenesis and etiological factors.

Surgical techniques used for the treatment of atrial fibrillation.

The use of surgical lesion sets for the treatment of atrial fibrillation has been increasing, particularly in patients with complicated anatomical substrates and those undergoing concomitant surgery. Preferences in terms of lesion set, surgical approach and ablation technology vary by center. This review discusses both the surgical techniques and the outcomes for the most commonly performed procedures in the context of recent consensus guidelines. The Cox-Maze IV, pulmonary vein isolation, extended left atrial lesion sets, the hybrid approach and ganglionated plexus ablation are each reviewed in an attempt to provide insight into current clinical practice and patient selection.

White matter microstructure predicts measures of clinical symptoms in chronic back pain patients.

Chronic back pain (CBP) has extensive clinical and social implications for its sufferers and is a major source of disability. Chronic pain has previously been shown to have central neural factors underpinning it, including the loss of white matter (WM), however traditional methods of analyzing WM microstructure have produced mixed and unclear results. To better understand these factors, we assessed the WM microstructure of 50 patients and 40 healthy controls (HC) using diffusion-weighted imaging. The data were analyzed using fixel-based analysis (FBA), a higher-order diffusion modelling technique applied to CBP for the first time here. Subjects also answered questionnaires relating to pain, disability, catastrophizing, and mood disorders, to establish the relationship between fixelwise metrics and clinical symptoms. FBA determined that, compared to HC, CBP patients had: 1) lower fibre density (FD) in several tracts, specifically the right anterior and bilateral superior thalamic radiations, right spinothalamic tract, right middle cerebellar peduncle, and the body and splenium of corpus callosum; 2) higher FD in the genu of corpus callosum; and 3) lower FDC - a combined fibre density and cross-section measure - in the bilateral spinothalamic tracts and right anterior thalamic radiation. Exploratory correlations showed strong negative relationships between fixelwise metrics and clinical questionnaire scores, especially pain catastrophizing. These results have important implications for the intake and processing of sensory data in CBP that warrant further investigation.

Single-cell transcriptomic profiling of microvascular endothelial cell heterogeneity in congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) is a neonatal anomaly that includes pulmonary hypoplasia and hypertension. We hypothesized that microvascular endothelial cell (EC) heterogeneity is different in CDH lungs and related to lung underdevelopment and remodeling. To test this, we evaluated rat fetuses at E21.5 in a nitrofen model of CDH to compare lung transcriptomes among healthy controls (2HC), nitrofen-exposed controls (NC) and nitrofen-exposed subjects with CDH. Single-cell RNA sequencing with unbiased clustering revealed 3 distinct microvascular EC clusters: a general population (mvEC), a proliferative population and a population high in hemoglobin. Only the CDH mvEC cluster had a distinct inflammatory transcriptomic signature as compared to the 2HC and NC endothelial cells, e.g. greater activation and adhesion of inflammatory cells and production of reactive oxygen species. Furthermore, CDH mvECs had downregulated Ca4, Apln and Ednrb gene expression. Those genes are markers for ECs important to lung development, gas exchange and alveolar repair (mvCa4+). mvCa4+ ECs were reduced in CDH (2HC [22.6%], NC [13.1%] and CDH [5.3%], p < 0.0001). Overall, these findings identify transcriptionally distinct microvascular endothelial cell clusters in CDH, including the distinctly inflammatory mvEC cluster and the depleted group of mvCa4+ ECs, which together may contribute to pathogenesis.

Use of Image Guidance During Pediatric Venovenous Extracorporeal Membrane Oxygenation Cannulation: A Survey of the American Pediatric Surgical Association.

This study evaluated practices for image guidance during placement of bicaval dual-lumen (BCDL) venovenous extracorporeal membrane oxygenation (VV-ECMO) cannulas in pediatric and adolescent patients and elucidates reasoning behind surgeon practices. A survey covering VV-ECMO practice and opinions was distributed by the American Pediatric Surgical Association (APSA) to all attending members. A total of 110 pediatric surgeons responded (11.3%). During initial BCDL cannula placement, 67.7% of surgeons reported using bimodal imaging with either fluoroscopy (38.4%) or x-ray (29.3%) plus echocardiography. Although 37.4% of surgeons used serial x-rays during cannula placement, only 5.9% believed it was best practice to do so ( P < 0.0001). Rather, 60.4% believed that fluoroscopy was the standard. Among surgeons not using fluoroscopy, 27.6% (13.3% of respondents) reported fluoroscopy added unnecessary complexity or that they preferred another modality. More frequently, reasons for not using fluoroscopy are related to resource limitations. Echocardiography use to confirm cannula position was considered best practice by 92.1% of surgeons, with 86.9% utilization. Therefore, most pediatric surgeons use multimodal imaging during cannulation and consider it best practice. Fluoroscopy is preferred, but its use is frequently limited by hospital resources. Echocardiography is widely available and used. These data represent increased consensus among surgeons and present opportunities for modernization of hospital resources and standards.

Discontinuation of the OriGen® Dual-Lumen Right Atrial Cannula Decreased Venovenous ECMO Usage in Neonates and Older Children: A Survey of the American Pediatric Surgical Association.

INTRODUCTION: Dual-lumen cannulas for venovenous (VV)-ECMO are widely used in pediatric patients. The popular OriGen® dual-lumen right atrial cannula was discontinued in 2019 without a comparable replacement. METHODS: A survey covering VV-ECMO practice and opinions was distributed to attending members of the American Pediatric Surgical Association. RESULTS: 137 pediatric surgeons responded (14%). Prior to discontinuation of the OriGen®, 82.5% offered VV-ECMO to neonates, and 79.6% cannulated with the OriGen®. Following its discontinuation, those that offered only venoarterial (VA)-ECMO to neonates increased to 37.6% from 17.5% (p = 0.0002). An additional 33.8% changed their practice to sometimes use VA-ECMO when VV-ECMO was indicated. Reasons for not incorporating dual-lumen bi-caval cannulation into practice included risk of cardiac injury (51.7%), inexperience with bi-caval cannulation in neonates (36.8%), difficulty with placement (31.0%), and recirculation and/or positioning problems (27.6%). For the pediatric/adolescent population, 95.5% of surgeons offered VV-ECMO prior to OriGen® discontinuation. Few switched to exclusive VA-ECMO (1.9%) when the OriGen® was discontinued, but 17.8% of surgeons began to incorporate selective use of VA-ECMO. CONCLUSION: Discontinuation of the OriGen® cannula drove pediatric surgeons to alter their cannulation practices, dramatically increasing VA-ECMO use for neonatal and pediatric respiratory failure. These data may suggest a need for targeted education accompanying major technological shifts. LEVEL OF EVIDENCE: Level IV.

Are pediatric surgery fellowship websites ready for the changing paradigms in the virtual interview era?

Purpose: With the COVID-19 pandemic, in-person fellowship interviews were curtailed, leading candidates to seek information from other resources. Our main purposes were (1) to determine what information recent participants in the match needed to evaluate programs and (2) to assess which of these were available online. Methods: A focus group of ten recent graduates/applicants identified information that was important in choosing a fellowship program. In August 2020 and December 2021, websites belonging to the American Pediatric Surgical Association (APSA) and individual programs were assessed. Results: Recent applicants identified 55 pieces of information considered important to their decision making. Of 57 pediatric surgery fellowships, 98% were listed on APSA's website. Program descriptions on APSA's website listed on average 60% of program information desired by applicants. All listed fellowship director, accreditation status, faculty list, and current fellow(s). Other descriptors frequently noted were alumni (95%), graduate's board performance (83%), ECMO exposure (77%), and curriculum (70%). Information desired but less frequently available were fellow case logs (63%), trauma center designation (53%), burn center designation (40%), research opportunities (30%), candidate interview assistance (25%), and supplemental fellowships (12%). There were 7% of program descriptions that were not updated for at least a year. Conclusions: APSA and individual program websites were complimentary. Websites often lacked data that applicants sought to inform their rank list. To best adapt to the evolving virtual interview paradigm, we suggest reporting key information on a central APSA website with more nuanced information available via links to program specific websites. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-023-00104-w.

The Current Pediatric Surgery Job Market: A Perspective of Recent Fellowship Graduates.

PURPOSE: This study describes the job market from the perspective of recent pediatric surgery graduates. METHODS: An anonymous survey was circulated to the 137 pediatric surgeons who graduated from fellowships 2019-2021. RESULTS: The survey response rate was 49%. The majority of respondents were women (52%), Caucasian (72%), and had a median student debt burden of $225,000. Considering job opportunities, respondents strongly emphasized camaraderie (93%), mentorship (93%), case mix (85%), geography (67%), faculty reputation (62%), spousal employment (57%), compensation (51%), and call frequency (45%). 30% were satisfied with the employment opportunities available, and 21% felt strongly prepared to negotiate for their first job. All respondents were able to secure a job. Most jobs were university-based (70%) or hospital employed (18%) positions where surgeons covered median of two hospitals. 49% wanted protected research time, and 12% of respondents were able to secure substantial, protected research time. The median compensation for university-based jobs was $12,583 below the median AAMC benchmark for assistant professors for the corresponding year of graduation. CONCLUSION: These data highlight the ongoing need for assessment of the pediatric surgery workforce and for professional societies and training programs to further assist graduating fellows in preparing to negotiate their first job. TYPE OF STUDY: Survey LEVEL OF EVIDENCE: Level V.

Can't we all just get along? A primer on student incivility in nursing education.

Student incivility is a growing problem in the academic nursing community. The purpose of this study was to identify factors associated with the increasing prevalence of incivility among nursing students. Various databases (Allied and Complimentary Medicine, Cumulative Index to Nursing and Allied Health Literature, and Ovid MEDLINE) were queried using the key words incivility, student incivility, nursing education, student-faculty relations, student aggression, and student violence. Both research- and non-research-based articles were selected for review. Also included among the references retrieved were articles pertaining to unethical conduct and disruptive behavior. Virtually all of the articles characterized incivility as the product of a symbiotic relationship between students and faculty. Fundamentally, incivility was found to be a multifaceted problem whose resolution is predicated on gaining a heightened understanding of the economic, sociological, and psychological underpinnings of disruptive behavior.

Duodenal Switch Combined with Systematic Post-operative Supplementation and Regular Patient Follow-up Results in Good Nutritional Outcomes.

INTRODUCTION: The duodenal switch is the most effective bariatric surgical procedure. Due to technical demands of the surgery and concerns regarding high rates of post-operative nutritional sequelae, many surgeons remain hesitant to adopt this technique. METHODS: Sixty-five patients undergoing duodenal switch surgery at our hospital between 2008 and 2015 were followed up for 5 years. All patients were provided with a thorough post-operative nutritional supplementation regimen. Nutritional deficiencies as evidenced by blood testing, excess body weight loss, and remission rates from type 2 diabetes, hypertension, and dyslipidaemia were studied. RESULTS: The average excess body weight loss 5 years post-operatively was 62% ± 23.03%. Remission rates for type 2 diabetes, hypertension, and dyslipidaemia were 96%, 77% and 84% respectively. Patients achieved good nutritional outcomes. After 5 years, deficiencies in fat-soluble vitamins A and D occurred in 3.3% and 1.6% of patients respectively. The rate of ferritin deficiency at the 5-year post-operative mark was 19.4%. No predictors of nutritional deficiency were identified on univariate analysis. CONCLUSION: Patients undergoing a duodenal switch achieve good long-term excess body weight loss and high obesity-related co-morbidity remission rates. The rates of post-operative nutritional deficiencies in patients who are subjected to a thorough post-operative nutritional supplementation regimen are lower than what was historically expected.

Failed fundoplication with delayed gastric emptying: efficacy of subtotal gastrectomy.

BACKGROUND: The management of patients with gastroparesis and recurrent reflux after previous fundoplication is challenging. The aim of this study was to evaluate the safety and efficacy of subtotal gastrectomy with Roux-en-Y reconstruction as a remedial procedure in this select patient population. METHOD: Retrospective analysis of a prospectively populated database identified all patients that underwent subtotal gastrectomy with Roux-en-Y reconstruction (SGRNY) due to reflux symptoms and delayed gastric emptying (DGE). Demographic, intra-operative and post-operative data including pre and post-operative modified reflux aspiration scintigraphy studies were evaluated. Standardized questionnaires were used to assess symptomatic outcomes. RESULTS: From 2018 SGRNY has been selectively performed in 13 patients. Preoperative workup confirmed DGE and severe symptomatic reflux in all patients. The median number of previous fundoplication and or hiatal hernia operations was two (range 1-3). The mean hospital length of stay was 10 ± 6 days. Post-operative morbidity was experienced in three patients (23%). Seven patients (64%) had significant improvement or complete resolution of reflux on post-operative scintigraphy. Symptom improvement was reported in 92% of patients. CONCLUSION: In a select patient cohort with post-fundoplication reflux and DGE symptoms, SGRNY is a moderately safe and effective salvage option.