Body Contouring Surgery and the Maintenance of Weight-Loss Following Roux-En-Y Gastric Bypass: A Retrospective Study.

BACKGROUND: Bariatric surgery leads to significant weight loss with reduced morbidity and mortality. However, excess skin as a consequence of weight loss represents a major problem, impacting upon patient's functionality with potential negative effects on weight loss. OBJECTIVES: We evaluated the effect of body-contouring surgery on weight-loss maintenance following bariatric surgery. METHODS: We undertook a retrospective analysis of patients undergoing Roux-en-Y gastric bypass (RYGB) +/- body-contouring surgery (BC). The control group (n = 61) received RYGB, the test group (n = 30) received RYGB+BC 12 to 18 months after bariatric surgery. Each RYGB+BC patient was matched to two control patients for age, sex, glycaemic status, and weight on day of surgery. Per cent weight loss (%WL) was calculated at 3, 6, 12, 24, 36, 48, and 60 months post-RYGB for both groups. RESULTS: The %WL was similar at 3, 6, and 12 months post-RYGB. At 24 months, %WL was 35.6% in the RYGB+BC group and 30.0% in the RYGB group (P < 0.05). At 36 months, the RYGB+BC group maintained their weight loss (%WL 33.0%), in contrast, the RYGB gained weight (%WL = 27.3%, P < 0.05). This trend continued (RYGB+BC vs RYGB) at 48 months (%WL 30.8% vs 27.0%) and at 60 months (%WL 32.2% vs 22.7%, P < 0.05). CONCLUSIONS: Our results suggest patients who undergo body contouring after bariatric surgery are able to lose significantly more weight and maintain weight loss at five years of follow up compared to those undergoing bariatric surgery alone.

A Meta-analysis of Clinical, Patient-Reported Outcomes and Cost of DIEP versus Implant-based Breast Reconstruction.

INTRODUCTION: Comparative data on clinical outcomes and cost of deep inferior epigastric perforator (DIEP) and implant-based reconstruction (IBR) are limited. We conducted a Preferred Reporting Items for Systematic Review and Meta-analysis-compliant systematic review and meta-analysis to compare clinical, patient-reported outcomes (PROs) and cost. METHODS: The protocol was published a priori on PROSPERO (CRD42017072557). EMBASE, MEDLINE, Google Scholar, Cochrane Controlled Register of Trials, Science Citation Index, and ClinicalTrials.gov were searched from January 1994 to August 2018. Two independent reviewers evaluated the articles for inclusion. Study quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation, and risk of bias (RoB) was assessed using Cochrane's RoB in Nonrandomized Studies of Interventions tool. RESULTS: Out of 6,381 articles screened, 16 were included [unilateral 782 DIEPs, 376 implants; mean age 49 years, follow-up (months): DIEP 29.9; IBR 35.5]. Mean flap loss and fat necrosis rates were 3.97% (SD 4.90) and 9.67% (SD 17.0), respectively. There was no difference in mean length of stay {standard mean difference 0.63 [confidence interval (CI) -9.17 to 10.43]; P =0.90}. The number of reoperations for complications was significantly lower in DIEP versus IBR [SMD -0.29 (CI -0.48 to -0.09); P < 0.01]. There were no randomized controlled trials. Study quality was low with high RoB. One study reported $11,941/Quality-adjusted Life Year incremental cost-effectiveness ratio for DIEP, with higher breast Quality-adjusted Life Year (DIEP 19.5; IBR 17.7) using Breast Questionnaire; 3 studies evaluated cost, favoring DIEP. Two comparative studies evaluating PROs favored DIEP. CONCLUSIONS: DIEP reconstruction maybe more cost-effective and yield superior PROs. However, poor-quality, bias-ridden studies limit the findings. Adequate reporting of core outcome measures is required to minimize reporting bias and facilitate evidence synthesis. Prospective, multicenter, cohort studies using robust patient-reported outcome measures (PROMs) tools, evaluating cost-effectiveness and contributing to national/international registries, will facilitate national-level policy and shared decision-making.

Demonstration of the Effectiveness of Augmented Reality Telesurgery in Complex Hand Reconstruction in Gaza.

Augmented reality (AR) is defined as "a technology that superimposes a computer-generated image on a user's view of the real world, thus providing a composite view."1 This case report describes how emerging AR telesurgery technologies may be used to facilitate international surgeon-surgeon collaboration and training. Here, we illustrate how a remote surgeon in Beirut, Lebanon, was able to offer assistance to a surgeon in Gaza, Palestine, during a complex hand reconstruction case following a bomb-blast injury in an 18-year-old male. We discuss the implications of AR technology on the future of global surgery and how it may be used to reduce structural inequities in access to safe surgical care.