Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study.

BACKGROUND: Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. METHODS: A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved. RESULTS: A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. CONCLUSION: This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Presence of SARS-CoV-2 in abdominal tissues and biologic fluids during abdominal surgery: a systematic review.

BACKGROUND: Viral transmission to healthcare providers during surgical procedures was a major concern at the outset of the COVID-19 pandemic. The presence of the severe acute respiratory disease syndrome coronavirus (SARS-CoV-2), the virus responsible for COVID-19, in the abdominal cavity as well as in other abdominal tissues which surgeons are exposed has been investigated in several studies. The aim of the present systematic review was to analyze if the virus can be identify in the abdominal cavity. METHODS: We performed a systematic review to identify relevant studies regarding the presence of SARS-CoV-2 in abdominal tissues or fluids. Number of patients included as well as patient's characteristics, type of procedures, samples and number of positive samples were analyzed. RESULTS: A total of 36 studies were included (18 case series and 18 case reports). There were 357 samples for detection of SARS-CoV-2, obtained from 295 individuals. A total of 21 samples tested positive for SARS-CoV-2 (5.9%). Positive samples were more frequently encountered in patients with severe COVID-19 (37.5% vs 3.8%, p < 0.001). No health-care provider related infections were reported. CONCLUSION: Although a rare occurrence, SARS-CoV-2 can be found in the abdominal tissues and fluids. It seems that the presence of the virus in the abdominal tissues or fluids is more likely in patients with severe disease. Protective measures should be employed in the operating room to protect the staff when operating patients with COVID-19.

Comparison of Outcomes Between Banded and Non-banded Sleeve Gastrectomy: a Systematic Review and Meta-analysis.

BACKGROUND: Sleeve gastrectomy (SG) is the most common bariatric procedure performed worldwide. It accounts for more than 50% of primary bariatric surgeries performed each year. Recent long-term data has shown an alarming trend of weight recidivism. Some authors have proposed the concurrent use of a non-adjustable gastric band to decrease long-term sleeve failure. OBJECTIVE: To compare the outcomes (weight loss) and safety (rate of complication and presence of upper GI symptoms) between SG and BSG. METHODS: A systematic search with no language or time restrictions was performed to identify relevant observational studies and randomized controlled trials (RCT) evaluating people with morbid obesity undergoing SG or SGB for weight loss. An inverse-of-the-variance meta-analysis was performed by random effects model. Heterogeneity was assessed using Cochrane X2 and I2 analysis. RESULTS: A total of 7 observational studies and 3 RCT were included in the final analysis. There were 911 participants pooled from observational studies and 194 from RCT. BSG showed a significant higher excess of weight loss (% EWL). The difference among groups was clinically relevant after the third year where the weighted mean difference (SMD) was 16.8 (CI 95% 12.45, 21.15, p < 0.0001), while at 5 years, a SMD of 25.59 (16.31, 34.87, p < 0.0001) was noticed. No differences related to overall complications were noticed. Upper GI symptoms were up to three times more frequent in the BSG group (OR 3.26. CI 95% 1.96, 5.42, p < 0.0001). CONCLUSIONS: According to the results, BSG is superior to SG in weight loss at 5 years but is associated with a higher incidence of upper GI symptoms. However, these conclusions are based mainly on data obtained from observational studies. Further RCT are needed to evaluate the effect and safety of BSG.

Roux-en-Y Gastric Bypass in Patients with Super Obesity: Primary Response Criteria and Their Relationship with Comorbidities Remission.

BACKGROUND: The prevalence of super obesity has increased considerably in recent years, representing up to the 0.5% of the population. Even though bariatric surgery induces significant weight loss in these patients, it has been reported that up to 50% of the patients with super obesity will fail according to the current primary response criteria. OBJECTIVE: To evaluate and compare different primary response criteria and their impact regarding comorbidities remission. PATIENTS AND METHODS: A total of 104 patients with super obesity who underwent Roux-en-Y gastric bypass (RYGB) were identified in our institution from March 2004 to February 2019. An evaluation of the primary response at a 2-year follow-up was made using different criteria. A multivariate analysis was made to evaluate related variables to comorbidities remission. RESULTS: Two years later, the rate of patients who achieved an EWL > 50%, %EWL > 70%, and BMI < 35 kg/m2 were 84.5%, 52.1%, and 62%, respectively. Regarding the comorbidities, 85%, 84.8%, and 81.1% of the patients improved or remitted T2D, HBP, and hyperlipidemia, respectively. An EWL > 50% 2 years later was related to complete remission of hyperlipidemia (p = 0.047), whereas weight regain above 10% is a risk factor for failure of complete remission of HBP in 3 years. CONCLUSIONS: More than 75% of patients with super obesity yield an EWL > 50% 2 years later. In terms of hyperlipidemia, it is desirable to achieve an EWL of at least 50%. Whereas for T2D and HBP, a minimum of 25% TWL yields 72% and 60.5% of complete remission.

LAW Trial - The Impact of Local Anesthetics Infiltration in Surgical Wound for Gastrointestinal Procedures (LAW): A Double-Blind, Randomized Controlled Trial.

INTRODUCTION AND AIMS: Prior studies have suggested that infiltration of local anesthetics reduce the rate of surgical site infections (SSIs). Opioid usage has become an epidemic. Some analgesic modalities, such as epidural analgesia and transversus abdominis plane block are associated with shorter length of stay and lower opioid use. The aim of our study was to assess the relationship between local infiltration of bupivacaine with rates of SSI and pain control. MATERIALS AND METHODS: We conducted a prospective, double-blinded randomized controlled trial in patients who underwent open major gastrointestinal procedures from July 2016 to June 2017. Patients were divided into two groups based on administration of 0.5% bupivacaine (n = 30) (group 1) or placebo (n = 30) (control group). Outcomes evaluated were SSI, postoperative opioid requirements and pain scores. RESULTS: Patients in the bupivacaine group required a lower dose of epidural analgesia during the first 24 h (5.3 mcg/kg/h vs. 6.4 mcg/kg/h; p = 0.05). Opioid requirement was shorter in the bupivacaine group (3.5 ± 2.3 days vs. 5.7 ± 2.9 days; p = 0.01). No difference was found between groups in terms of SSI rates (0% vs. 6.7%, p = 0.49). CONCLUSIONS: There is no clear association between bupivacaine infiltration and reduction of SSI rate according to our study. Wound bupivacaine infiltration is associated with a lower dose of epidural infusion and opioid requirements.

Reaching LDL-C Targets in Patients with Moderate, High, and Very High Risk for Cardiovascular Disease After Bariatric Surgery According to Different Guidelines.

BACKGROUND: Cardiovascular disease (CVD) is highly prevalent in obese patients and is the leading cause of death. High levels of plasma low-density lipoprotein cholesterol (LDL-C) are associated with higher coronary artery disease (CAD) risk. The aim of the study was to assess the impact of the Roux-en-Y gastric bypass on the achievement of the currently proposed cardiovascular prevention goals after 1 year. PATIENTS AND METHODS: We performed a retrospective analysis from a prospectively built database of patients who underwent a primary Roux-en-Y gastric bypass (RYGB) from 2004 to 2018. Patients with intermediate, high, or very high risk for CVD according to the 2018 AHA/ACC or the 2019 ESC/EAS guidelines were selected. An analysis of clinical and biochemical variables in 1 year was performed. Logistic multivariate regressions were made to assess the impact of preoperative and weight loss parameters in the achievement of LDL-C goals. RESULTS: From 1039 patients, 70 met the selection criteria and were included in the analysis of the 2018 AHA/ACC guidelines, and 75 in the 2019 ESC/EAS guidelines. Mean decrease in LDL-C levels was 21.1 ± 40.2 mg/dL 1 year after surgery, and 29/34 patients were off medications. The percentage of patients achieving LDL-C goals according to the 2018 AHA/ACC guidelines was 27.1%, whereas according to the 2019 ESC/EAS guidelines, the percentages was 9.3%. The %TWL was associated with achieving LDL-C goals according to the 2018 AHA/ACC at 1 year. CONCLUSIONS: RYGB induces a significant weight loss and an improvement in LDL-C levels 1 year after surgery. The number of patients that reached the goals varies according to the guidelines used and ranged from 9.3 to 27.1%.

Thrombocytosis and Hyponatremia as Predictors of Complicated Acute Appendicitis: Predictors of Appendicitis.

BACKGROUND: Multiple serologic markers have been studied to predict complicated acute appendicitis (CAA) (C-reactive protein and procalcitonin); these increase health care costs and are not always available in medical centers in Mexico. There is a need for low-cost serologic markers to predict CAA and guide the preoperative management of patients. Our objective was to analyze the predictive value of hyponatremia and thrombocytosis for complicated acute appendicitis. METHODS: We analyzed 274 patients with AA surgically treated and divided them into two groups: the CAA group and the uncomplicated AA group. We compared the serum values of sodium and platelet blood counts on presentation in the emergency room between the two groups and the proportion of patients with hyponatremia and/or thrombocytosis. Receiver operating characteristic analysis was performed for the two biochemical markers. Sensitivity, specificity, and positive and negative predictive values were calculated for complicated appendicitis in the presence of hyponatremia and thrombocytosis. RESULTS: We found 87 patients with CAA and 187 with uncomplicated acute appendicitis. Patients with CAA presented with lower serum sodium values and higher platelet counts than uncomplicated patients. Hyponatremia was found in 54.8% of complicated patients and 29.2% in the uncomplicated group. Thrombocytosis was present in 11.6% of the complicated group and 3.2% in uncomplicated patients. We found a specificity and positive predictive value of 100% for complicated appendicitis in patients with hyponatremia and thrombocytosis. CONCLUSIONS: In patients with abdominal pain and suspected acute appendicitis, the presence of hyponatremia and thrombocytosis is a strong predictive tool for the complicated disease. This is the first study to analyze the association between thrombocytosis and complicated appendicitis.

Roux-en-Y Gastric Bypass in Patients >60 Years of Age: Morbidity and Short-Term Outcomes.

BACKGROUND: Obesity is a common disease in the elderly population, and bariatric surgery is the most effective intervention to achieve significant and sustainable weight loss. Many bariatric programs have established an arbitrary cutoff at the age of 60 to 65 years. The aim of this study was to evaluate the safety and short-term outcomes of Roux-en-Y gastric bypass (RYGB) in patients older than 60 years. PATIENTS AND METHODS: We conducted a retrospective cohort study of patients who underwent RYGB from 2004 to 2019 in a single center. Logistic and linear multivariate regressions were made to compare complications and short-term outcomes between patients aged > 60 years and < 60 years. The statistical significance was set at p ≤ 0.05. RESULTS: From 849 patients who underwent a primary RYGB, 57 were > 60 years of age. Overall, early and late complications were similar in both groups, except for unexpected intensive care unit (ICU) admission which was more frequent in the > 60 years group. Excess body weight loss (%EWL) and percentage total weight loss (%TWL) at 1 year in patients > 60 years old were 76.6 ± 21.8% and 30.73 ± 6.8%, respectively. Figures for the same parameters in the control group were 81.7 ± 19.9% (p = 0.09) and 34.3 ± 7.2 (p = 0.001), respectively. CONCLUSIONS: In our experience, an age > 60 is not related to higher rates of overall early and late complications after RYGB. Comorbidity remission rates are similar to those in younger patients. Elderly patients had lower total weight loss at 1 year, but the %EWL was similar in both groups.

Improvement of the 10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Risk Following Bariatric Surgery.

BACKGROUND: Several studies have shown improvement in cardiometabolic risk factors, as well as in the related mortality following bariatric surgery. However, few studies have assessed changes in the estimated cardiovascular risk. OBJECTIVE: The aim of the present study was to investigate the effect of bariatric surgery on the estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk. PATIENTS AND METHODS: We performed a retrospective analysis from a prospectively maintained database of patients who underwent a primary bariatric procedure from 2004 to 2018. The 10-year ASCVD risk was estimated before and after 1 year of surgery using the ASCVD Risk Estimator Plus of the American College of Cardiology. Changes in the ASCVD risk were evaluated. RESULTS: There were 58 (51.3%) women and 55 (48.7%) men with a mean age of 49.9 years. Before surgery, 64 patients had arterial hypertension, 57 T2DM, and 49 were smokers. Baseline mean estimated 10-year ASCVD risk was 8.50 ± 7.92%. Fifty-one (45.1%), 10 (8.8%), 41 (36.3%), and 11 (9.7%) patients were classified as low, borderline, intermediate, and high risk, respectively. One year after surgery, 92.9% of the patients showed a reduction of the estimated 10-year ASCVD risk. Mean values were significantly lower (5.31 ± 5.95%) when compared to basal ones (p < 0.0001). According to the risk classification, 71 (62.8%), 13 (11.5%), 26 (23%), and 3 (2.7%) were cataloged as low, borderline, intermediate, and high risk, respectively. CONCLUSIONS: Surgically induced weight loss leads to a significant improvement in the estimated 10-year ASCVD risk, 1 year after surgery.

Mid-Term and Long-Term Impact of Permanent Hypoparathyroidism After Total Thyroidectomy.

BACKGROUND: Permanent hypoparathyroidism (PH) is the most frequent long-term complication after total thyroidectomy. PH is related to many short-term and long-term complications, including clinical manifestations of hypocalcemia, hypercalcemia due to overtreatment, hyperphosphatemia, gastrointestinal, neuropsychiatric symptoms, decrease in renal function and infectious complications. The aim of this study was to identify the most frequent effects of PH and its associated risk factors. METHODS: We performed a retrospective analysis of a single institutional series of patients who developed PH after total thyroidectomy between 2000 and 2016. PH was defined as hypoparathormonemia (≤12 pg/mL) or the need for calcium/vitamin D supplementation to achieve normal calcium levels for more than 12 months. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. RESULTS: Thirty-nine patients fulfilled the criteria for PH. Mean ± SD age was 46.26 ± 13.4 years; 6 (15.4%) were males and 33 (84.6%) females. Mean follow-up was 6.13 ± 3.25 years. Mean calcium carbonate supplementation doses per day were 18.95 ± 17.5 g and 21.4 ± 19.3 g at 1 year and last follow-up, respectively. Hypocalcemic crisis was the most common complication (66.7%), followed by neuropsychiatric (38.5%) and gastrointestinal symptoms (33.3%). Ten patients showed a decrease in renal function (eGFR drop ≥25%) and 4 developed chronic kidney disease. The amount of calcium supplementation was the most relevant related risk factor. CONCLUSIONS: PH is associated with multiple complications, including renal function impairment, gastrointestinal, neuropsychiatric and infectious complications. Lower calcium supplementation doses are related to lower complications rates.

Transoral Endoscopic Thyroidectomy by Vestibular Approach-Initial Experience and Comparative Analysis in the First Reported Mexican Cohort.

Introduction: Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) is a relatively new technique for the surgical treatment of thyroid diseases. We present the initial experience of a reference hospital of Mexico with TOETVA. Materials and Methods: This is a comparative retrospective study of cases (TOETVA) and controls (open thyroidectomy) treated by the endocrine surgeons between July 2017 and April 2019. Cases were patients of any gender, older than 18 years of age, with malignant thyroid nodules <2 cm or undetermined <5 cm without extrathyroidal extension and no lymph node or distant metastasis. Demographic, operative, and postoperative data were obtained and analyzed. Results: Twenty patients were surgically treated by TOETVA during the study period. Controls were paired based on type of surgery and dominant thyroid nodule. Ninety percent of the patients had a definitive diagnosis of malignancy. No statistically significant differences were found in age, BMI, length of stay, thyroid lobes size, and complication rates. Operative time was longer in TOETVA (216.7 ± 62.5 vs. 153.9 ± 49.25 minutes; t test P < .0001) and intraoperative blood loss was lesser for the TOETVA group (38.25 ± 38.9 vs. 101.8 ± 126.6 mL; t test P < .04). Conclusions: TOETVA is a feasible and relatively safe surgical technique for patients with benign and malignant thyroid diseases. Complication rates seem to be comparable with conventional open technique with lesser intraoperative bleeding; nevertheless, it requires longer operative times.

Surgery in Patients with Super Obesity: Medium-Term Follow-Up Outcomes at a High-Volume Center.

OBJECTIVE: There is a need to determine which bariatric operations are the most effective for patients with super obesity and super-super obesity. METHODS: A retrospective cohort study was performed on patients with super obesity and super-super obesity at Mohak Bariatrics and Robotics Surgery Center in Indore, India. RESULTS: Five hundred fourteen patients with super obesity and super-super obesity had surgery at our center from January 2010 through December 2013. The baseline characteristics were different in different operations. The initial average age, weight, and BMI were 44.4 (SD 11.9) years, 145.4 (SD 24.2) kg, and 55.48 (SD 5.32) kg/m2 , respectively. Sleeve gastrectomy (SG) (227 [44.2%]) was the most common procedure, followed by one-anastomosis gastric bypass (OAGB) (124 [24.1%]), Roux-en-Y gastric bypass (RYGB) (102 [19.8%]), banded sleeve gastrectomy (BSG) (33 [6.4%]), and banded Roux-en-Y gastric bypass (BRYGB) (28 [5.4%]). After 3 years, the percentages of excess body weight loss (%EBWL) for SG, OAGB, RYGB, BSG, and BRYGB were 62.38%, 78.59%, 69.55%, 85.11%, and 75.77% (P < 0.0001), respectively. Failure to achieve BMI < 35 kg/m2 was more frequent in the group who underwent SG (67.9%), followed by RYGB (29.16%), BRYGB (22.2%), OAGB (9.87%), and none in the BSG group. CONCLUSIONS: BSG, OAGB, and BRYGB have very good to excellent midterm outcomes for patients with super obesity and super-super obesity, whereas RYGB and SG have average outcomes at 3 years. There is a need for multicenter, long-term, and prospective studies to be performed to confirm these findings.

Correction to: Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands.

In the original version of the article, the last three column headings in Table 3 were mislabeled. The original article has been corrected. Following is the corrected table.

Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands.

BACKGROUND: Total thyroidectomy is the most common surgical procedure for the treatment of thyroid diseases. Postoperative hypocalcemia/hypoparathyroidism is the most frequent complication after total thyroidectomy. The aim of this study was to evaluate the rate of postoperative hypocalcemia and permanent hypoparathyroidism after total thyroidectomy in order to identify potential risk factors and to evaluate the impact of parathyroid autotransplantation. PATIENTS AND METHODS: We performed a retrospective analysis of 1018 patients who underwent total thyroidectomy at our institution between 2000 and 2016. Medical records were reviewed to analyze patient features, clinical presentation, management and postoperative complications. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. Statistical significance was set at p ≤ 0.05. RESULTS: Mean ± SD age was 46.79 ± 15.9 years; 112 (11.7%) were males and 844 (88.3%) females. A total of 642 (67.2%) patients underwent surgery for malignant disease. The rate of postoperative hypocalcemia, transient, protracted and permanent hypoparathyroidism was 32.8%, 14.43%, 18.4% and 3.9%, respectively. Permanent hypoparathyroidism was significantly associated with the number of parathyroid glands remaining in situ (4 glands: 2.5%, 3 glands: 3.8%, 1-2 glands: 13.3%; p ˂ 0.0001) [OR for 1-2 glands in situ = 5.32, CI 95% 2.61-10.82]. Other risk factors related to permanent hypoparathyroidism were obesity (OR 3.56, CI 95% 1.79-7.07), concomitant level VI lymph node dissection (OR 3.04, CI 95% 1.46-6.37) and incidental parathyroidectomy without autotransplantation (OR 3.6, CI 95% 1.85-7.02). CONCLUSIONS: Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia (30.4%) and permanent postoperative hypoparathyroidism (2.79%).