Predictors and outcomes of same day discharge after minimally invasive hysterectomy in gynecologic oncology within the National Surgical Quality Improvement Program database.

OBJECTIVE: To assess trends over time of same day discharge after minimally invasive hysterectomy in oncology, identify perioperative factors influencing same day discharge, and evaluate 30 day postoperative morbidity. METHODS: A retrospective cohort of elective minimally invasive hysterectomies performed for gynecologic oncologic indications between January 2013 and December 2021 was identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Clinical and surgical characteristics, length of stay, and 30 day postoperative complications were captured. Clinical and surgical factors affecting same day discharge rate and impact of same day discharge on postoperative outcomes were evaluated using χ2 tests and logistic regression. RESULTS: Patients undergoing minimally invasive hysterectomy (n=32 823) had a same day discharge rate of 34.5% over the 9 year period, increasing from 15.5% in 2013 to 55.1% in 2021. The rate of patients discharged on postoperative day 1 decreased from 76.4% to 41.4% over this period. On multivariable analysis, same day discharge decreased with: age 70-79 years (odds ratio (OR) 0.80) and ≥80 years (OR 0.42); body mass index 40-49.9 kg/m2 (OR 0.89) and ≥50 kg/m2 (OR 0.67); patient comorbidities, including hypertension (OR 0.85), chronic steroid use (OR 0.74), bleeding disorder (OR 0.54), anemia (OR 0.89), and hypoalbuminemia (OR 0.76); and surgical time >90th percentile (OR 0.40) (all p<0.05). Lymphadenectomy did not impact the same day discharge rate (unadjusted OR 1.03, p=0.22). Same day discharge had no effect on 30 day postoperative composite morbidity (OR 0.91, p=0.20), and was associated with fewer readmissions (OR 0.75, p=0.005). Age 70-79 years (OR 1.07, p=0.435) and age ≥80 years (OR 1.11, p=0.504) did not increase postoperative morbidity. However, body mass index categories 40-49.9 kg/m2 (OR 1.28, 95% CI 1.08 to 1.51) and ≥50 kg/m2 (OR 1.60, 95% CI 1.27 to 2.01) were associated with greater 30 day composite morbidity. CONCLUSION: In this study, same day discharge following minimally invasive hysterectomy for oncologic indications was safe, and rates are rising among all age and body mass index categories. Quality improvement initiatives are needed at oncology centers to promote early discharge after minimally invasive gynecologic oncology surgery.

Virtual fundamentals of laparoscopic surgery (FLS) boot-camp using telesimulation: an educational solution during the COVID-19 pandemic.

BACKGROUND: The Fundamentals of Laparoscopic Surgery (FLS) is an internationally recognized educational and certification program designed to teach the knowledge and skills required for basic laparoscopic surgery. Previously, our institution has organized an FLS boot-camp to teach PGY1 residents the FLS manual skills. During the COVID-19 pandemic, in-person sessions were not possible. The purpose of this study was to utilize telesimulation as an education solution for teaching FLS technical skills to PGY1 residents during the COVID-19 pandemic. METHODS: A virtual FLS program was established. A complete, easily portable FLS kit was distributed to participants and instructors to set up an FLS box and connect remotely using telesimulation. The program was delivered by three senior residents using the Zoom™ platform. Participants were split into groups of 3-4 individuals, each receiving three 1-h sessions. Sessions were structured with initial demonstration of tasks followed by individual coaching of participants in 'break-out' rooms. The official FLS exam was administered in-person on the 4th week. Pre- and post-course surveys were administered to participants gauging self-reported proficiency with FLS tasks and overall course feedback. Anonymized FLS exam results were collected. RESULTS: A total of 14 residents participated, and 11 responded to the survey. Participants reported that their overall FLS skills proficiency significantly improved on a 5-point likert scale from 1.5 ± 0.5 pre-course to 4.0 ± 0.5 post-course (mean ± SD). Participants unanimously stated that having the FLS box at home was valuable and enabled them to practice more. On the FLS exam, 13 of 14 participants passed the manual skills component. CONCLUSIONS: We developed a telesimulation hands-on FLS course as an alternative to in-person training. The course was practical and effective and was preferred to traditional methods by participants. With ever-expanding technological solutions, virtual telesimulation education is an attractive and underutilized tool, not only in the setting of COVID-19, but also more broadly across current educational programs.

Adverse postoperative outcomes associated with perioperative blood transfusion in gynecologic oncology surgery.

OBJECTIVE: To examine the incidence of perioperative blood transfusion and association with 30 day postoperative outcomes in gynecologic cancer surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all gynecologic oncology cases from 2013 to 2019. Clinical and surgical characteristics and 30 day postoperative complications were retrieved. The primary outcome was 30 day composite morbidity, based on the occurrence of one or more of the 18 adverse events. Secondary outcomes were 30 day mortality, length of stay in hospital, and composite surgical site infection, defined as superficial, deep, or organ space surgical site infection. The χ2 test and logistic regression analyses were performed to compare the outcomes of patients with and without perioperative blood transfusion. RESULTS: There were 62 531 surgical gynecologic oncology cases with an overall transfusion incidence of 9.4%. The transfusion incidence was significantly higher at 22.4% with laparotomy compared with 1.7% with minimally invasive surgery (p<0.0001). On multivariable analysis for laparotomy patients, blood transfusion was predictive of composite morbidity (adjusted odds ratio (OR) 1.65, 95% confidence interval (CI) 1.48 to 1.85) and length of stay in hospital ≥5 days (adjusted OR 9.02, 95% CI 8.21 to 9.92). In advanced ovarian cancer patients (n=3890), the incidence of perioperative blood transfusion was 40.8%. On multivariable analysis, perioperative blood transfusion was the most predictive factor for composite morbidity (adjusted OR 1.67, 95% CI 1.35 to 2.07) and length of stay in hospital ≥7 days (adjusted OR 9.75, 95% CI 7.79 to 12.21). CONCLUSION: Perioperative blood transfusion is associated with increased composite morbidity and prolonged length of stay in hospital. Preoperative patient optimization and institutional practices should be reviewed to improve the use of blood bank resources and adherence to restrictive blood transfusion protocols.

Weight loss outcomes for patients undergoing conversion to Roux-en-Y-gastric bypass after sleeve gastrectomy.

BACKGROUND: Despite excellent reported outcomes after laparoscopic sleeve gastrectomy (LSG), a percentage of patients go on to have a secondary bariatric surgery to manage side-effects or address weight regain after LSG. Reported weight loss outcomes for patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) after previous LSG are variable. We sought to determine the weight-loss outcomes of patients undergoing LRYGB after LSG in the largest bariatric surgical network in Canada and to determine whether outcomes differ according to indications for conversion. METHODS: The Bariatric Registry is a multi-center database with prospectively collected standardized data on patients undergoing bariatric surgery at ten Bariatric Centers of Excellence within the Ontario Bariatric Network in Ontario, Canada. A retrospective analysis was performed of patients who underwent LRYGB after previous LSG between 2012 and 2019. Weight loss outcomes were compared between patients who underwent LRYGB for insufficient weight loss/weight regain and those who underwent conversion to LRYGB for other reasons. RESULTS: Excluding patients with multiple revisions and those without follow-up data, 48 patients were included in the analysis: 33 patients (69%) underwent conversion to LRGYB for insufficient weight loss/weight regain (Group 1) and 15 patients (31%) underwent conversion for other reasons (Group 2). Mean body mass index (BMI) measured pre-LSG, pre-LRYGB, and at mid-term follow-up after LRYGB was 61, 48, and 43 kg/m2 in Group 1 and 51, 39, and 34 kg/m2 in Group 2, respectively. ΔBMI and %total weight loss (TWL) at mid-term follow-up were not significantly different between the groups. CONCLUSIONS: Conversion to LRYGB after previous LSG resulted in an additional loss of 4 kg/m2 in BMI points at mid-term follow-up. Patients lost a similar number of BMI points and cumulative %TWL was similar regardless of reason for conversion. This can help inform surgical decision-making in the setting of weight regain after LSG.

A regional approach to reduce postoperative opioid prescribing in Ontario, Canada.

BACKGROUND: Opioid-related morbidity and mortality continue to rise in the province of Ontario. We implemented a provincial campaign to reduce the number of opioid pills prescribed at discharge after surgery in the Ontario Surgical Quality Improvement Network (ON-SQIN). METHODS: Activities related to the provincial campaign were implemented between April 2019 and March 2020 and between October 2020 and March 2021. Self-reported data from participating hospitals were used to determine changes in postoperative opioid prescribing patterns across participating hospitals. RESULTS: A total of 33 and 26 hospitals participated in the provincial campaign in the first and second year, respectively. During the first year of the campaign, the median morphine equivalent (MEQ) from opioid prescriptions decreased significantly in a number of surgical specialties, including General Surgery (from 105 [75-130] to 75 [55-107], P < 0.001) (median, interquartile range) and Orthopedic Surgery (from 450 [239-600] to 334 [167-435], P < 0.001). The median number of opioid pills prescribed at discharge per surgery also decreased significantly, from 25 (15-53) to 15 (11-38) for 1 mg hydromorphone (P < 0.001) and 25 (20-51) to 20 (15-30) for oxycodone (P < 0.001). The decrease in opioid prescriptions continued in the second year of the campaign. CONCLUSIONS: Our approach resulted in a significant reduction in the number of postoperative opioids prescribed across a number of surgical specialties. Our findings indicate that evidence-based strategies derived from a regional collaborative network can be leveraged to promote and sustain quality improvement activities.

Cost of postoperative complications after general surgery at a major Canadian academic centre.

BACKGROUND: In a fiscally constrained health care environment, the need to reduce unnecessary spending is paramount. Postoperative complications contribute to hospital costs and utilization of health care resources. OBJECTIVE: The purpose of this observational study was to identify the cost associated with complications of common general surgery procedures performed at a major academic hospital in Toronto, Ontario. METHODS: The institutional National Surgical Quality Improvement Program database was used to identify complications in patients who underwent general surgical procedures at our institution from April 2015 to February 2018. A mix of elective and emergent cases was included: bariatric surgery, laparoscopic appendectomy, laparoscopic cholecystectomy, thyroidectomy, right hemicolectomy and ventral incisional hernia repair. The total cost for each visit was calculated by adding all the aggregate costs of inpatient care. Median total costs and the breakdown of cost components were compared in cases with and without complications. RESULTS: A total of 2713 patients were included. Nearly 6% of patients experienced at least one complication, with an incidence ranging from 1.1% after bariatric surgery to 23.8% after right hemicolectomy. The most common type of complication varied by procedure. Median total costs were significantly higher in cases with complications, with a net increase ranging from $2989 CAD (35% increase) after bariatric surgery to $10 459 CAD (161% increase) after ventral incisional hernia repair. CONCLUSION: Postoperative complications after both elective and emergent general surgery procedures add substantially to hospital costs. Quality improvement initiatives targeted at decreasing postoperative complications could significantly reduce costs in addition to improving patient outcomes.

Low incidence of venous thromboembolism after gynecologic oncology surgery: Who is at greatest risk?

OBJECTIVE: To determine the 30-day incidence of venous thromboembolism (VTE) after gynecologic oncologic surgery and identify perioperative factors associated with postoperative VTE. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify all gynecologic oncology cases from 2013 to 2019. Clinical and surgical characteristics, VTE events and 30-day postoperative complications were retrieved. Chi-square analysis and logistic regression models were performed to compare characteristics and postoperative outcomes of patients with and without VTE. RESULTS: A total of 63,198 gynecologic oncology patients were included. The incidence of 30-day postoperative VTE was 1.2% (n = 781). On multivariable analysis, postoperative VTE was significantly associated with ascites (odds ratio (OR) 1.8), disseminated cancer (OR 1.7), pre-operative albumin <30 g/L (OR 1.9), laparotomy (OR 2.8), operative time > 180 min (OR 2.0), and increased surgical complexity (OR 2.2) (all p < 0.001). The incidence of VTE was higher after laparotomy compared to minimally invasive surgery (MIS) (2.3% v. 0.6%, p < 0.001). When stratified by type of gynecologic malignancy undergoing laparotomy, incidence of VTE was higher in patients with ovarian (2.4%) and uterine (2.4%) malignancies, compared to cervical cancer (1.1%) (p < 0.001). The 30-day incidence of VTE was 1.7% in 2013 compared to 0.9% in 2019 (laparotomy: 2.6% in 2013 to 1.6% in 2019 and MIS: 0.8% in 2013 to 0.4% in 2019). CONCLUSION: Postoperative VTE is a potentially preventable complication of gynecologic oncology surgery. Our findings indicate that laparotomy, ascites, disseminated cancer, longer operative time, and low pre-operative albumin are risk factors for VTE.

Operative management of recalcitrant marginal ulcers following laparoscopic Roux-en-Y gastric bypass for morbid obesity: a systematic review.

One of the short- and long-term complications following Roux-en-Y gastric bypass (RYGB) for morbid obesity is the development of marginal ulcers (MUs). Although chronic and recalcitrant/recurrent marginal ulcers (rMUs) are common, there is no consensus on their optimal management. The objective of this study was to perform a systematic review of the elective operative management of rMUs. A systematic search of the literature was conducted. Relevant databases were searched up to May 16, 2020. Articles were included if they met the following inclusion criteria: (1) bariatric patients were included as the study population, (2) laparoscopic RYGB was performed as the index operation, (3) study patients developed rMUs, and (4) MUs required elective operative (surgical, endoscopic) interventions. Quality of articles was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The search identified 3470 citations; of these, 16 observational studies were included. Elective management of rMUs consisted of endoscopic (oversewing ± stents) and surgical interventions (gastrojejunostomy revision, vagotomy, conversion to sleeve gastrectomy, subtotal/total gastrectomy, reversal to normal anatomy). Quality of the studies as assessed by the GRADE system was low to very low. Recalcitrant/recurrent MUs are challenging complications both for bariatric patients and for their treating surgeons. There are no established algorithms for the management of rMUs, and the currently available evidence in the literature is limited both in quantity and in quality. Future multicentre, multisurgeon, randomized, controlled trials are needed to address this issue.

Committed to Better Outcomes: Reducing Infection after Surgery Across the Ontario Surgical Quality Improvement Network.

BACKGROUND: In 2015, the Ontario Surgical Quality Improvement Network was established to create a community of practice for Ontario hospitals to improve surgical quality. A provincial campaign to decrease postsurgical infections was launched in 2017. STUDY DESIGN: Thirty hospitals implemented activities related to the campaign from April 2018 to March 2019. The community of practice was used to disseminate suggested change ideas in each area. Self-reported data from participating hospitals and collaborative-wide aggregate risk-adjusted data from the American College of Surgeons NSQIP were reviewed to determine the impact of the campaign on the rates of postoperative surgical site infections (SSIs), urinary tract infections (UTIs), and pneumonia. RESULTS: A total of 24, 8, and 2 hospitals selected SSIs, UTIs, and pneumonia, respectively, as their targets for improvement. Three hospitals selected both SSIs and UTIs, 1 hospital selected SSIs and pneumonia, and 1 hospital selected all 3 indicators as targets. Self-reported data demonstrated that the rates of SSIs and UTIs decreased significantly post campaign from 4.87% to 3.99% (p < 0.0001) and from 3.65% to 1.25% (p = 0.007), respectively. Pneumonia rates also decreased from 1.27% to 1.05%. Overall rates of SSIs, UTIs, and pneumonia across all Ontario Surgical Quality Improvement Network hospitals were reduced from 3.4%, 1.29%, and 0.88% to 3.37%, 1.14%, and 0.84%, respectively. CONCLUSIONS: The 1-year campaign resulted in a clinically significant reduction in the rates of SSIs and UTIs, as well as a trend for decrease in pneumonia incidence among participating hospitals. Using a flexible approach with priority setting and leveraging the community of practice for dissemination of change ideas is an effective way of sustaining quality improvement activities.

Efficiency of Lithium Cations in Hydrolysis Reactions of Esters in Aqueous Tetrahydrofuran.

Lithium cations were observed to accelerate the hydrolysis of esters with hydroxides (KOH, NaOH, LiOH) in a water/tetrahydrofuran (THF) two-phase system. Yields in the hydrolysis of substituted benzoates and aliphatic esters using the various hydroxides were compared, and the effects of the addition of lithium salt were examined. Moreover, it was presumed that a certain amount of LiOH was dissolved in THF by the coordination of THF with lithium cation and hydrolyzed esters even in the THF layer, as in the reaction by a phase-transfer catalyst.

The Effect of Tissue Adhesive on Surgical Site Infection Following Elective Bariatric Surgery: a Retrospective Cohort Study.

PURPOSE: The reported incidence of surgical site infection (SSI) following bariatric surgery ranges from 1.4 to 30%. The use of skin staples and tissue adhesive was shown to be superior to sutures in reducing SSI in a variety of surgical disciplines; however, this area is under-investigated in elective bariatric surgery. The aim of this study was to examine the effect of tissue adhesive for skin closure on SSI in patients undergoing bariatric surgery. METHODS: A retrospective analysis was performed to determine the incidence of SSI in patients who underwent elective laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Tissue adhesive was selectively used for skin closure during the study period. Patient characteristics, operative data, and 30-day postoperative outcomes were collected from patient charts and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. RESULTS: A total of 1,579 patients were included in the study. Tissue adhesive was used in 31.2% of all operations (n = 494). The rate of incisional SSI in our study was 2.2% (n = 35). The use of tissue adhesive was more common in patients who developed incisional SSI compared with those without incisional SSI (54.3 vs. 30.8%, p = 0.003). On multivariate analysis, the use of tissue adhesive remained an independent predictor for the development of incisional SSI (OR 2.77, p = 0.007). CONCLUSION: The use of tissue adhesive was an independent predictor for incisional SSI following elective bariatric surgery. This is the first study to report the effects of tissue adhesive in this patient population.

Impact of a Mobile App to Support Home Recovery of Patients Undergoing Bariatric Surgery.

BACKGROUND: Perioperative patient education and engagement are critical components of care in patients undergoing bariatric surgery, given the short length of stay and the requirements to adhere to various instructions. The use of patient engagement mobile technology may promote adherence to perioperative protocols and improve care by potentially identifying complications earlier and reducing associated health care costs. MATERIALS AND METHODS: We introduced a mobile app that provides bariatric patients with access to educational materials and the ability to report on their symptoms. Using the data from the app and linking the data to patient outcomes collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we examined the effects of the app on readmission, length of stay, visits to the emergency department (ED), and patient satisfaction. RESULTS: A total of 505 patients were enrolled in the app between July 2017 and March 2019. Among them, 396 patients who met the inclusion criteria for the study were compared with 458 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who were not enrolled in the app for the same study period. While the use of the app was not associated with the rates of prolonged length of stay, ED visits, and readmission, patients who completed a survey at 30 d after discharge reported that the app helped them avoid phone calls to the hospital (48.5%) and ED visits (13.0%). Furthermore, 94.8% of these patients reported that they would recommend the app to other patients undergoing the same surgery. CONCLUSIONS: Additional features, such as the ability for patients to directly communicate with the health care providers within the app, may be effective in decreasing unnecessary health care utilization.

A bundled approach to care: reducing the incidence of postoperative pneumonia in patients undergoing hepatectomy and Whipple procedures.

Postoperative occurrence of pneumonia can increase lengths of stay, risk of morbidity and death and health care costs. At Toronto General Hospital, we identified a high incidence of postoperative pneumonia in patients undergoing hepatectomy and Whipple procedures in 2016. To reduce the incidence of postoperative pneumonia, we implemented an evidence-based bundle approach in 2017. The bundle included the following components: oral care, incentive spirometry, coughing and deep breathing, physical activity, elevation of the head of the bed, and patient and family education. In addition to the bundle components, we provided staff education and created patient education and monitoring tools to ensure competency and compliance with the bundle components. Data collected as part of the National Surgical Quality Improvement Program were reviewed to monitor progress. In this article, we discuss our approach, aimed to reduce the incidence of postoperative pneumonia and associated health care costs in the general surgery population.

Marginal ulceration following Roux-en-Y gastric bypass: risk factors for ulcer development, recurrence and need for revisional surgery.

BACKGROUND: Marginal ulcer formation is a known complication following RYGB. While most respond to medical therapy, many patients have recurrent or chronic MU. Although non-steroidal anti-inflammatory drug (NSAID) use, smoking and Helicobacter pylori infection are known risk factors of MU, little is known about what increases the likelihood of developing recalcitrant ulcers. The objective of this study is to identify risk factors for marginal ulcer (MU) formation, including recalcitrant ulcers requiring surgical revision, and to define the incidence and outcomes of revisional surgery. METHODS: All patients who underwent RYGB between 2011 and 2017 at a high-volume academic center were included. Patients with a postoperative diagnosis of MU were identified from the institution's bariatric database. Patient characteristics, operative data and surgical outcomes were analyzed using data collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and the Ontario Bariatric Registry. RESULTS: A total of 2830 RYGB were performed during the study period. The incidence of MU was 6.9% with 1% of patients requiring revisional surgery for a recalcitrant ulcer. Patients with a history of smoking (HR 5.03), immunosuppression (HR 4.60) and preoperative NSAID use (HR 3.11) were significantly more likely to develop a MU requiring surgical revision. Patients undergoing revision reported resolution of their symptoms in only 36% of cases with 57% developing a recurrent ulcer. CONCLUSION: Patients with a history of smoking and use of immunosuppressive medication were at significantly higher risk of developing MU that failed medical therapy. Additional evidence is needed to inform perioperative management of bariatric patients.

Engineering functional microvessels in synthetic polyurethane random-pore scaffolds by harnessing perfusion flow.

Recently reported biomaterial-based approaches toward prevascularizing tissue constructs rely on biologically or structurally complex scaffolds that are complicated to manufacture and sterilize, and challenging to customize for clinical applications. In the current work, a prevascularization method for soft tissue engineering that uses a non-patterned and non-biological scaffold is proposed. Human fibroblasts and HUVECs were seeded on an ionomeric polyurethane-based hydrogel and cultured for 14 days under medium perfusion. A flow rate of 0.05 mL/min resulted in a greater lumen density in the constructs relative to 0.005 and 0.5 mL/min, indicating the critical importance of flow magnitude in establishing microvessels. Constructs generated at 0.05 mL/min perfusion flow were implanted in a mouse subcutaneous model and intravital imaging was used to characterize host blood perfusion through the construct after 2 weeks. Engineered microvessels were functional (i.e. perfused with host blood and non-leaky) and neovascularization of the construct by host vessels was enhanced relative to non-prevascularized constructs. We report on the first strategy toward engineering functional microvessels in a tissue construct using non-bioactive, non-patterned synthetic polyurethane materials.

Impact of preoperative opioid use on health outcomes after bariatric surgery.

BACKGROUND: Opioid consumption in North America has risen to alarming levels and represents a potentially modifiable risk factor in perioperative management. Chronic pain and obesity are commonly associated and bariatric surgery remains the most effective intervention for weight loss in morbidly obese patients. OBJECTIVES: To understand how preoperative opioid use impacts surgical outcomes in patients undergoing bariatric surgery. SETTING: The Ontario Bariatric Registry. METHODS: Data collected in the Ontario Bariatric Registry between 2010 and 2018 were used for this retrospective study. Preoperative opioid use was retrospectively retrieved from the medication review during preoperative assessment. Primary outcomes were complications and readmissions at 30 and 90 days of surgery. Secondary outcomes included hospital length of stay and complication types at 30 and 90 days. Analyses were risk-adjusted for procedure type and patient-specific risk factors, such as age, sex, race, body mass index, and co-morbid conditions. RESULTS: Overall, 5357 patients were included in the study. Among those, 12% (n = 643) used opioids preoperatively. Risk-adjusted analyses demonstrated that opioid users, compared with opioid-naïve patients, had a longer length of stay (odds ratio: 2.50, 95% confidence interval: 1.05-6.00, P < .05) and higher rates of complications at 30 days (odds ratio: 1.40, 95% confidence interval: 1.02-2.18, P < .05). Subgroup analyses revealed that within preoperative opioid users, patients who underwent Roux-en-Y gastric bypass had poorer outcomes than those who underwent sleeve gastrectomy. CONCLUSION: Opioid use is common before bariatric surgery and is independently associated with prolonged length of stay and complication rates at 30 days. Preoperative opioid use represents a potentially modifiable risk factor and a unique target to improving the quality of surgical care.

Preoperative Helicobacter pylori Screening and Treatment in Patients Undergoing Laparoscopic Sleeve Gastrectomy.

BACKGROUND: The role of preoperative screening and treatment of Helicobacter pylori (HP) in asymptomatic patients undergoing laparoscopic sleeve gastrectomy (LSG) remains unclear. This study aims to define the preoperative prevalence and management of HP and their effect on postoperative outcomes at our institution. MATERIALS AND METHODS: We reviewed the medical records and surgical specimens of all LSG performed at an academic centre in Toronto, ON between 2010 and 2017. RESULTS: Review of our institutional database identified 222 patients that underwent LSG, of which 200 had preoperative HP screening: 18% tested positive and 15% were treated. Seven surgical specimens were HP-positive (3.2%). No association was found between preoperative HP status, treatment or HP-positive specimen and postoperative complications at 1 year. CONCLUSION: Although preoperative screening and treatment likely reduce the prevalence of HP in LSG specimens, our findings suggest that they may be of limited clinical value in LSG as they have little influence on surgical morbidity.

Unexpected histopathological findings after sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) represents one of the most commonly performed bariatric procedures and, in contrast to the Roux-en-Y gastric bypass, produces a specimen for pathologic examination. This study aims to describe unexpected histopathological findings in order to better define preoperative management of patients undergoing LSG. METHODS: All LSG cases performed at an academic center in Toronto, Ontario between 2010 and 2017 were reviewed. All specimens underwent histopathological assessment, while those with findings suspicious for neoplasia or the presence of Helicobacter pylori underwent additional immunohistochemical stainings. Baseline patient characteristics and surgical outcomes were obtained from our internal database. RESULTS: A total of 222 patients underwent LSG during the study period and had their specimens examined histologically. Among them, 22.5% underwent preoperative endoscopy. The most common histopathological diagnosis was no abnormal findings (50.9%) followed by gastritis (25.7%). Abnormal findings warranting a change in postoperative management or follow-up were discovered in 8.6% of specimens and included H. pylori infection, intestinal metaplasia, malignancy, and atrophic gastritis. Only 4.7% of all patients had not undergone preoperative endoscopy and had truly unexpected findings. No significant association was found between abnormal findings and age, sex, or baseline body mass index (BMI). CONCLUSIONS: Although a majority of patients had a gastric specimen within normal limits, 8.6% had findings requiring a change in postoperative management. This rate dropped to 4.7% when patients whose diagnoses were known preoperatively were excluded. Our findings suggest that further research is needed to better define the role of preoperative endoscopy to potentially reduce the number of unexpected findings following LSG.

Physical activity and its association with psychosocial health following bariatric surgery.

Physical activity (PA) helps sustain weight loss and may also provide psychological benefits in patients undergoing bariatric surgery. Using a set of questionnaires, we demonstrated that bariatric patients with increased level of PA at 1-year follow-up had better psychosocial outcomes including depressive symptoms and mental health-related quality of life compared with those who had reduced or unchanged level of PA. Our findings indicate the benefit of incorporating PA in the postoperative care for bariatric patients. Novelty Postoperative behavioural change in terms of physical activity improves psychosocial health in patients undergoing bariatric surgery.

Nanosurfaces modulate the mechanism of peri-implant endosseous healing by regulating neovascular morphogenesis.

Nanosurfaces have improved clinical osseointegration by increasing bone/implant contact. Neovascularization is considered an essential prerequisite to osteogenesis, but no previous reports to our knowledge have examined the effect of surface topography on the spatio-temporal pattern of neovascularization during peri-implant healing. We have developed a cranial window model to study peri-implant healing intravitally over clinically relevant time scales as a function of implant topography. Quantitative intravital confocal imaging reveals that changing the topography (but not chemical composition) of an implant profoundly affects the pattern of peri-implant neovascularization. New vessels develop proximal to the implant and the vascular network matures sooner in the presence of an implant nanosurface. Accelerated angiogenesis can lead to earlier osseointegration through the delivery of osteogenic precursors to, and direct formation of bone on, the implant surface. This study highlights a critical aspect of peri-implant healing, but also informs the biological rationale for the surface design of putative endosseous implant materials.