Effect of routine jejunostomy tube insertion in esophagectomy: A systematic review and meta-analysis.

BACKGROUND: Routine feeding jejunostomy tube post esophagectomy is being revaluated because of its associated postoperative complications. We performed a systematic review and meta-analysis to evaluate the effect of routine feeding jejunostomy tube insertion on mortality and postesophagectomy outcomes. METHODS: Electronic databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) were queried through December 2020. Included studies compared esophagectomy with and without postoperative feeding jejunostomy. The primary outcome was 30-day mortality. Secondary outcomes included readmission rate, length of stay, postoperative complications (sepsis, pneumonia, chyle leakage, and anastomotic leakage), and duration of surgery. Random effects pairwise meta-analysis was used to compare groups, and the risk of bias was assessed using the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. RESULTS: The meta-analyses of 12 studies (2 randomized controlled trials, 10 observational) that enrolled 36,284 participants showed lower 30-day all-cause mortality in the jejunostomy tube group (risk ratio [RR] = 1.53 [95% CI, 1.37-1.70], P < .01; I2 = 0%, P = .80). Duration of surgery favored the no jejunostomy group (mean difference = -37.18; 95% CI, -59.48 to -14.87; P < .01). However, the 2 groups were not different in incidence of anastomotic leakage (RR = 0.88; 95% CI, 0.61-1.28; P = .50), length of stay (mean difference = -0.22; 95% CI, -1.34-0.89; P = .69), readmission (RR = 0.97; 95% CI, 0.92-1.02; P = .20), chyle leakage (RR = 1.05; 95% CI, 0.34-3.27; P = .94), sepsis (RR = 1.20; 95% CI, 0.96-1.50; P = .11), pneumonia (RR = 0.88; 95% CI, 0.75-1.03; P = .11). CONCLUSIONS: Feeding jejunostomy tube after esophagectomy might lead to lower 30-day all-cause mortality with no difference in common postesophagectomy complications. A routine insertion of a jejunostomy tube should be considered at the time of surgery for esophageal cancer resection.

Benefits of dexmedetomidine on postoperative analgesia after bariatric surgery.

INTRODUCTION: Anesthetic management of morbidly obese patients is challenging, particularly in those undergoing bariatric surgery. Dexmedetomidine is a α2-adrenergic receptor agonist that is increasingly used in the perioperative setting for its beneficial properties including sedation, anxiolysis, analgesia with opioid-sparing effects, and minimal impact on respiration. The objective of this study was to evaluate the effect of dexmedetomidine on postoperative analgesia and recovery-related outcomes among patients undergoing bariatric surgery. EVIDENCE ACQUISITION: We conducted a systematic review and meta-analysis of MEDLINE, EMBASE, and CENTRAL databases from conception to September 2021 for randomized controlled trials (RCTs) using dexmedetomidine in bariatric patients on postoperative outcomes. Outcomes were pooled using random effects model and presented as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI). EVIDENCE SYNTHESIS: In total, 20 RCTs with 665 patients in the dexmedetomidine group and 671 patients in the control groups were included. Among RCTs, the dexmedetomidine group had significantly lower opioid usage at 24-hours postoperatively (MD: -5.14, 95% CI: -10.18 to -0.10; moderate certainty), reduced pain scores on a 10-point scale at PACU arrival (MD: -1.69, 95% CI: -2.79 to -0.59; moderate certainty) and six hours postoperatively (MD: -1.82, 95% CI: -3.00 to -0.64; low certainty), and fewer instances of nausea (RR: 0.59, 95% CI: 0.45 to 0.75; moderate certainty) and vomiting (RR: 0.25, 95% CI: 0.15 to 0.43; moderate certainty), compared to control groups. CONCLUSIONS: Dexmedetomidine is an efficacious anesthesia adjunct in patients undergoing bariatric surgery. These benefits of dexmedetomidine may be considered in the multi-modal analgesic management and enhanced recovery pathways in this high-risk population.

Improvement of kidney function in patients with chronic kidney disease and severe obesity after bariatric surgery: A systematic review and meta-analysis.

The general management for chronic kidney disease (CKD) includes treating reversible causes, including obesity, which may be both a driver and comorbidity for CKD. Bariatric surgery has been shown to reduce the likelihood of CKD progression and improve kidney function in observational studies. We performed a systematic review and meta-analysis of patients with at least stage 3 CKD and obesity receiving bariatric surgery. We searched Embase, MEDLINE, CENTRAL and identified eligible studies reporting on kidney function outcomes in included patients before and after bariatric surgery with comparison to a medical intervention control if available. Risk of bias was assessed with the Newcastle-Ottawa Risk of Bias score. Nineteen studies were included for synthesis. Bariatric surgery showed improved eGFR with a mean difference (MD) of 11.64 (95%CI: 5.84 to 17.45, I2  = 66%) ml/min/1.73m2 and reduced SCr with MD of -0.24 (95%CI -0.21 to -0.39, I2  = 0%) mg/dl after bariatric surgery. There was no significant difference in the relative risk (RR) of having CKD stage 3 after bariatric surgery, with a RR of -1.13 (95%CI: -0.83 to -2.07, I2  = 13%), but there was reduced likelihood of having uACR >30 mg/g or above with a RR of -3.03 (95%CI: -1.44 to -6.40, I2  = 91%). Bariatric surgery may be associated with improved kidney function with the reduction of BMI and may be a safe treatment option for patients with CKD. Future studies with more robust reporting are required to determine the feasibility of bariatric surgery for the treatment of CKD.

Obesity, Cancer, and Risk Reduction with Bariatric Surgery.

The prevalence of noncommunicable diseases has increased dramatically in North America and throughout the world and is expected to continue increasing in coming years. Obesity has been linked to several types of cancers and is associated with increased morbidity and mortality following cancer diagnosis. Bariatric surgery has emerged as the prominent model to evaluate the effects of intentional weight loss on cancer incidence and outcomes. Current literature, comprising prospective cohort investigations, indicates site-specific reductions in cancer risk with select bariatric procedures. Future research is required to establish evidence-based indications for bariatric surgery in the context of cancer prevention.

Bridging interventions before bariatric surgery in patients with BMI ≥ 50 kg/m2: a systematic review and meta-analysis.

BACKGROUND: Bariatric surgery on patients with body mass index (BMI) ≥ 50 kg/m2, historically known as superobesity, is technically challenging and carries a higher risk of complications. Bridging interventions have been introduced for weight loss before bariatric surgery in this population. This systematic review and meta-analysis aims to assess the efficacy and safety of bridging interventions before bariatric surgery in patients with BMI ≥ 50 kg/m2. METHODS: MEDLINE, EMBASE, Web of Science, and Scopus were searched from database inception to September 2018. Studies were eligible for inclusion if they conducted any bridging intervention for weight loss in patients with BMI greater than 50 kg/m2 prior to bariatric surgery. Primary outcome was the change in BMI before and after bridging intervention. Secondary outcomes included comorbidity status after bridging interventions and resulting complications. Pooled mean differences (MD) were calculated using random effects meta-analysis. RESULTS: 13 studies including 550 patients met inclusion criteria (mean baseline BMI of 61.26 kg/m2). Bridging interventions included first-step laparoscopic sleeve gastrectomy (LSG), intragastric balloon (IGB), and liquid low-calorie diet program (LLCD). There was a reduction of BMI by 12.8 kg/m2 after a bridging intervention (MD 12.8, 95% CI 9.49-16.1, P < 0.0001). Specifically, LSG demonstrated a BMI reduction of 15.2 kg/m2 (95% CI 12.9-17.5, P < 0.0001) and preoperative LLCD by 9.8 kg/m2 (95% CI 9.82-15.4, P = 0.0006). IGB did not demonstrate significant weight loss prior to bariatric surgery. There was remission or improvement of type 2 diabetes, hypertension, and sleep apnea in 62.8%, 74.6%, and 74.6% of patients, respectively. CONCLUSIONS: First-step LSG and LLCD are both safe and appropriate bridging interventions which can allow for effective weight loss prior to bariatric surgery in patients with BMI greater than 50 kg/m2.