Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures.

OBJECTIVE: To define "best possible" outcomes for secondary bariatric surgery (BS). BACKGROUND: Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. METHODS: Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years. RESULTS: The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ±â€Š10 years, 8.4 ±â€Š5.3 years after primary BS, with a BMI 35.2 ±â€Š7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. CONCLUSION: Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Vessel heterogeneity of TIMI frame count and its relation to P-wave dispersion in patients with coronary slow flow.

BACKGROUND: The vessel heterogeneity of thrombolysis in myocardial infarction (TIMI) frame count (TFC) in patients with coronary slow flow (CSF) remains to be further evaluated, and the correlation between TFC heterogeneity and P-wave dispersion (PWD) has not been elucidated. We aim to investigate the vessel heterogeneity of TFC in coronary arteries, and its relation to PWD in patients with CSF and otherwise normal coronary arteries. METHODS: We studied 72 patients with angiographically documented CSF and 66 age- and gender-matched control subjects. The coefficient of variation (CV) and mean TFC of the three vessels were calculated. P-wave duration and PWD were measured on the standard electrocardiograms (ECGs). RESULTS: The mean TFC and CV were both significantly higher in CSF patients than in controls (P<0.001 for both comparisons). The maximum P-wave duration (Pmax) and PWD were found to be significantly higher in CSF patients than in controls (P<0.001 for both comparisons). In patients with CSF, both Pmax and PWD were mildly correlated to mean TFC (r=0.318, P=0.009; and r=0.307, P=0.010), and were more significantly correlated to CV (r=0.506, P<0.001; and r=0.579, P<0.001). CONCLUSIONS: These data demonstrate that variability of TFC in three coronary arteries is increased in CSF patients, and that the vessel heterogeneity in coronary flow might be intimately associated with PWD.

Primary mucosa-associated lymphoid tissue lymphoma of the esophagus masquerading as a benign tumor.

We report a case of primary esophageal low-grade B-cell lymphoma of MALT type in a 50-year-old Saudi male patient who presented to our hospital with a history of dysphagia and heartburn for more than 2 years. Endoscopy showed a large esophageal mass with an intact mucosa located in the distal esophagus, 28 cm-35 cm from the incisor teeth. Endoscopic ultrasonography (EUS) showed a large well demarcated sub-epithelial lesion 4 cm in width and 10 cm in length arising from the muscularis mucosa with mixed echogenicity consistent with benign leiomyoma. Subsequently, the patient underwent surgical resection of the tumor; the histopathology confirmed the diagnosis of esophageal lymphoma. The tumor was considered to be completely resected and therefore additional treatment was not administered. The patient was doing well on follow up after treatment. Clinically and radiologically he did not reveal any signs of recurrence. Surgical resection is beneficial as a primary treatment option in incipient primary low grade MALT esophageal lymphomas.

Folic acid awareness among female college students: neural tube defects prevention.

OBJECTIVE: To investigate the level of awareness among female college students on the importance of preconception folic acid supplementation in preventing neural tube defects (NTDs). We have also studied their response after educating them. METHODS: This is a questionnaire-based study. Five hundreds questionnaires were distributed to the female students of the 3 colleges, namely, Humanities, Sciences, and Health in Jeddah, Kingdom of Saudi Arabia in April 2008. The questions included an enquiry on their knowledge regarding the importance of folic acid preconception, and if they will implement what they learned after listening to lectures, delivered by the 4th year medical students, who were trained and supervised by the faculty members of the King Abdul-Aziz University. RESULTS: Two hundred and seventeen questionnaires were filled, and returned (43.4%). Mean age +/- SD was 20.96 +/- 2.25 years. Almost 88% were not aware of the importance of folic acid in preventing NTDs. After listening to the lecture, 82.9% thought that they will surely use folic acid preconception, and 98.6% will relay the important message about the importance of folic acid to others. CONCLUSION: There is a need to increase the awareness of the importance of folic acid among females' childbearing age. Medical students' involvement in educating college students was an effective way to increase their awareness. Similar educating programs are required, in order to reduce the high incidence of NTDs.