Factors Influencing Referral for Bariatric Surgery by Primary Care Physicians in Northern Israel.

PURPOSE: Obesity is a chronic metabolic disease with global distribution among adults and children which affects daily functioning and ultimately quality of life. Primary care physicians (PCPs) provide an important role for the treatment of severe obesity. Better understanding of obesity and its treatment options may increase patients' referral rates to the various treatment modalities, including metabolic/bariatric surgery (MBS). MATERIALS AND METHODS: A quantitative cross-sectional study used a self-reported questionnaire among PCPs of Clalit Health Services (CHS) in Northern Israel. The quantitative questionnaire examined the PCP's knowledge, opinions, attitude, and approaches to managing severe obesity. RESULTS: A total of 246 PCPs from Northern Israel filled the questionnaire (42.9%), the majority were Muslim Arabs (54.5%), who gained their medical degree outside of Israel (73.8%) and practicing for over 10 years (58.8%). 64.3% of PCPs had a high workload (over 100 appointments per week), 77.1% did not know the definition of severe obesity, and 69.17% did not attend educational meetings regarding obesity during the previous year. The referral rate for MBS was 50.4% ± 23.3. Two prognostic factors that had a statistically significant effect on the referral rate for bariatric surgery were the total appointments per week, and the number of practice years. Both had a negative association. CONCLUSION: The knowledge and referral rates for bariatric surgery are higher among PCPs with lower workload and relatively fewer practice years. Workshops and annual training courses may fortify knowledge and awareness for the treatment of obesity, which in turn could increase the referral rate for MBS.

Early safety outcomes of laparoscopic one anastomosis gastric bypass in patients with class III, IV, and V obesity.

BACKGROUND: The extremely obese patient deserves special consideration: significant comorbidities, technical difficulties, and increased postoperative morbidity and mortality are all expected in this patient population. The study compared early postoperative complications (≤30-day) following one-anastomosis gastric bypass (OAGB) morbidity in patients with morbid obesity class IV obesity, body mass index (BMI) ≥50-59.9 kg/m2, and class V obesity, BMI ≥60 patients. METHODS: We retrospectively reviewed perioperative OAGB outcomes in three BMI groups. Operative time, length of stay (LOS), and overall early postoperative complication rates were studied. Patient-reported complications were ranked by Clavien-Dindo Classification (CDC). RESULTS: Between January 2017-December 2021, consecutive patients with obesity class III (n = 2950), IV (n = 256), and V (n = 23) underwent OAGB. BMI groups were comparable in sex, age, and associated comorbidities. Mean operative time was significantly longer in the higher BMI groups: class III (66.5 ± 25.6 min), IV (70.5 ± 28.7 min), and V (80.0 ± 34.7 min), respectively (p = 0.018); no difference in LOS. In respective BMI classes, ≤30-day complication rates were 3.2%, 3.5%, and 4.3% (p = 0.926). The respective number of patients with CDC grades of one to two were 45 (1.5%), 6 (2.3%), and 1 (4.3%), p = 0.500; and in grade ≥3a, 25 (0.8%), 1 (0.4%), 0 (0.0%), p = 0.669. There was 0.06% mortality (n = 2 in 3229), both in BMI class III. CONCLUSIONS: OAGB is a safe BS procedure in patients with class III, IV, and V obesity in the perioperative term with comparable ≤30-day morbidity in the three BMI groups.

Early outcomes of one-anastomosis gastric bypass in the elderly population at high-volume bariatric centers.

The increasing rate of obesity and life expectancy will lead to increasing numbers of bariatric procedures in the elderly. We aim to report the early (≤ 30 days) adverse events of One-Anastomosis Gastric Bypass (OAGB) in this patient population. Assuta Bariatric Centers in Israel. Retrospective review of perioperative OAGB outcomes between elderly group (≥ 65 years) and non-elderly group (18-64 years) at high-volume bariatric centers between January 2017-December 2021. Operative time, length of stay (LOS), and overall ≤ 30 days complication rates, as ranked by the Clavien-Dindo Classification (CDC) were compared. There were 6618 patients (non-elderly group) and 104 (elderly group) who underwent OAGB. Gender and preoperative BMI were comparable between the two age groups. The elderly group had significantly higher rate of ischemic heart disease and chronic renal failure. The number of patients with LOS ≥ 3 days was significantly higher in the elderly group [19.4% (n = 20) vs. 6.6% (n = 331), respectively; p < 0.001]. The total early adverse events were higher in the elderly group with no statistical significance [7.7% (n = 8) vs. 3.8% (n = 250), respectively; p = 0.062]. The rate of minor and major adverse events and reoperation rate was comparable between the two groups. The rate of readmissions was significantly higher in the elderly group 5.8% (n = 6) vs. 1.9% (n = 124), respectively p = 0.015. There was 0.06% mortality (n = 2) in the non-elderly group. OAGB is a relatively safe metabolic and bariatric surgery for elderly obese patients with early (≤ 30 days) morbidity rates similar to the non-elderly population.

One Anastomosis Gastric Bypass in 6722 Patients: Early Outcomes from a Private Hospital Registry.

BACKGROUND: One-anastomosis gastric bypass (OAGB) is an emerging metabolic bariatric surgery (MBS) type used in both primary OAGB (pOAGB) and revisional OAGB (rOAGB). We studied ≤30-day outcomes of pOAGB and rOAGB and identified predictors of early complications. METHODS: Electronic medical records of all OAGBs performed between January 2017 and December 2021 at a high-volume bariatric clinic in Israel comprising four hospital centers were scanned retrospectively using specialized data software (MDClone software, version 6.1). Data gathered were patients' characteristics, surgical procedure, and ≤30-day complications with Clavien-Dindo Classification (CDC). Multivariate logistic regression analyses were used to identify factors related to early complications of pOAGB and rOAGB. RESULTS: A total of 6722 patients underwent a pOAGB (n = 5088, 75.7%) or rOAGB (n = 1634, 24.3%) procedure at our institution. Preoperative mean age and body mass index (BMI) were 40.6 ± 11.5 years and 41.2 ± 4.6 kg/m2, respectively. Early complications occurred in 258 (3.8%) patients (176 pOAGB and 82 rOAGB) and included mainly bleeding (n = 133, 2.0%), leaks (n = 31, 0.5%), and obstruction/strictures (n = 19, 0.3%). CDC complications for grades 1-2 and grades 3a--5 were 1.5% and 1.6%, respectively. The overall mortality rate was 0.03% (n = 2). Age, operative time ≥3 h, and any additional concomitant procedure were independent predictors of early complications following pOAGB, while a diagnosis of diabetes mellitus and operative time ≥3 h were independent predictors of early complications following rOAGB. CONCLUSIONS: OAGB was found to be a safe primary and revisional MBS procedure in the ≤30-postoperative day term. The most common complications were gastrointestinal bleeding, leaks, and obstruction/stricture.

Is acute appendicitis more severe in foreign workers of northern Israel? A retrospective cohort study.

BACKGROUND: Acute appendicitis (AA) is one of the most common surgical emergencies worldwide. It's classified into simple or complicated disease. Due to the high prevalence of the disease, AA has been studied as a marker to assess the quality of care afforded to minority groups. The purpose of this study was to compare AA outcomes in foreign workers (FW) to the general population in northern Israel. METHODS: This is a retrospective cohort study. We identified all patients aged 18-50 who were admitted to our institution between January 1st, 2013 and October 31st, 2018, with the diagnosis of acute appendicitis. The study group included all FW and the control group included citizens of Israel. Study patients were matched based on age, sex, and co-morbidities. We compared time to presentation, admission parameters and disease outcomes. Our study outcomes were disease severity and length of hospital stay. RESULTS: We identified 20 FW and 97 matched local patients. FW presented with significantly higher heart rate, temperature, and white blood cell count (WBC). Duration of symptoms was comparable between the two groups. The rates of complicated disease were significantly higher among FW (45 vs 17.5%, p < 0.0001). Length of hospitalization was significantly longer in the FW group (4.8 vs. 3.9 days, p = 0.01). The odds ratio of FWs for having a complicated disease was OR = 3.85 [95% CI: 1.38, 10.72], p = 0.01. Multivariate analysis identified FW and duration of symptoms as significantly contributing to a complicated disease outcome. CONCLUSIONS: Although duration of symptoms was comparable to the local population, FW in northern Israel are at increased risk for a complicated disease which resulted in longer hospital stay. Further studies may enlighten the reason for this disparity.

High rates of recurrence of gallstone associated episodes following acute cholecystitis during long term follow-up: a retrospective comparative study of patients who did not receive surgery.

INTRODUCTION: Patients who are admitted with acute cholecystitis (AC) and do not undergo urgent cholecystectomy, are usually referred for interval cholecystectomy. Many do not have surgery for various reasons, and some of those do not suffer from any recurrent symptoms. The primary objective of this study was to assess the rate and nature of recurrent gallstone-related events in this population over a long period, and its association with demographic and clinical parameters. A secondary objective was to assess the reasons for not undergoing surgery. METHODS: This is a retrospective cohort study, where the study group were adult patients admitted with AC. Patients that have suffered recurrent episodes were compared with those who did not. A control group of patients that had undergone cholecystectomy following an admission with AC was used for comparison. Demographic and clinical parameters were recorded for all patients, and the association with a recurrent episode was analyzed using univariate analysis. RESULTS: The study population was 197 patients. The group of patients who did not undergo surgery were significantly older (68.7 vs 54.2) and sicker (ASA > 3 50% vs 19%). The rate of recurrent episodes in the study group was 38.5%, and it was not found to be associated with the studied parameters. There was a trend towards higher gallstone disease specific mortality in the study group (5.5% vs 1.45% p = 0.062). CONCLUSIONS: This is a study of long-term follow-up of patients following an episode of AC we showed that the rate of recurrent episodes is quite high and involves severe inflammatory diseases, such as obstructive jaundice and pancreatitis.

What patient factors influence bariatric surgery outcomes? A multiple regression analysis of Ontario Bariatric Registry data.

BACKGROUND: As bariatric surgery evolves and gains popularity, statistical analysis of its outcomes could improve the process of decision-making and risk assessment. This study aimed to evaluate the influence of age and other factors on bariatric surgery outcomes in order to improve patient selection and outcomes. METHODS: We analyzed data from the Ontario Bariatric Registry to evaluate the influence of age and 10 other factors on early (< 90 d) and 1-year surgical outcomes among patients aged 18 years or older who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between January 2010 and May 2013. Early outcomes included composite adverse events and readmission. The 1-year outcomes included percent excess body weight loss (%EBWL), and remission of diabetes mellitus and hypertension. We performed multiple regression analysis to identify independent variables that influenced these outcomes. RESULTS: We identified 3166 patients (2655 women [83.9%] and 511 men [16.1%], mean age 44.8 yr, mean body mass index [BMI] 48.4) who underwent LRYGB (2839 [89.7%]) or LSG (327 [10.3%]) over the study period and completed their 1-year follow-up. Preoperative American Society of Anesthesiologists (ASA) score and history of angina were independent variables that influenced the composite adverse event outcome. Obstructive sleep apnea was the only factor that influenced early readmission. The independent factors that influenced %EBWL were age, type of surgery, BMI and baseline glycosylated hemoglobin (HbA1c) level: age was found to influence hypertension remission, and HbA1c level and obstructive sleep apnea were found to influence diabetes remission. CONCLUSION: Complications after bariatric surgery can be predicted by preoperative ASA score and history of angina; patient age was not related to an increase in postoperative complications. These factors could help both surgeon and patient make appropriate surgical decisions.

Early Outcomes and Mid-Term Safety of One Anastomosis Gastric Bypass Are Comparable with Roux-en-Y Gastric Bypass: a Single Center Experience.

BACKGROUND: The use of one anastomosis gastric bypass (OAGB) has increased in recent years. However, the efficacy and safety outcomes of this procedure remain under debate. Here, we compare our early outcome and mid-term safety of OAGB with primary Roux-en-Y gastric bypass (RYGB). METHODS: This was a retrospective study using computerized electronic medical records data of patients who underwent RYGB or OAGB as a primary procedure from February 2012 to February 2019 in our bariatric center. Data collected included demographics, weight-outcomes, adverse events, hospital readmission, reoperation rates, and mortality following both procedures. RESULTS: A total of 314 patients were included (132 RYGB and 182 OAGB). Operative time and costs were significantly lower for OAGB (80 vs. 125 min, p<0.01 and 2018.8 vs. 2912.3 USD, p < 0.01, respectively), but length of hospital stay was longer (4.06 ± 0.67 days vs. 3.58 ± 0.79, p < 0.0001). At 12 months post-surgery, the percentage of excess body mass index loss was comparable between the two groups, but the change in body mass index (BMI) was significantly higher in the OAGB group. Early (< 30 days) and late (> 30 days) surgical adverse events were also similar between the two groups. CONCLUSION: Comparable short- and mid-term outcomes and adverse events are found for primary OAGB and RYGB. OAGB is not inferior to RYGB as a primary bariatric procedure for the treatment of obesity.

The Bacteriology of Acute Cholecystitis: Comparison of Bile Cultures and Clinical Outcomes in Diabetic and Non-Diabetic Patients.

BACKGROUND: Acute cholecystitis is one of the most common acute surgical diseases. Diabetic patients have been shown to have an increased risk for gallbladder disease, but the correlation between the severity of gallstone disease and diabetes is still debated. The aim of this study is to examine the possible difference in the disease process between patients with diabetes mellitus (DM) and those without. PATIENTS AND METHODS: A retrospective study was conducted of all patients who underwent percutaneous cholecystostomy between 2005 and 2015 at Emek Medical Center, Afula, Israel. Demographic and medical history including data on bile and blood culture results, antimicrobial susceptibility, and clinical outcomes were retrieved from patient files. RESULTS: The cohort included 272 patients. Mean age was 68 years old, 50.74% were male and 43.75% had diabetes mellitus. Bile cultures were obtained from 252 (92.64%) patients and were positive in 134 (53.2%) patients. In 11 patients (4%) two pathogens were isolated. Blood cultures obtained from 231 patients and were positive in 35 (15.2%). Escherichia coli was the most common isolate, and was seen in 22.3% of positive bile cultures and 40% of blood cultures. Although diabetic patients had significantly more positive bile cultures, the severity of the disease, according to the Tokyo guidelines, was not higher. CONCLUSIONS: Acute cholecystitis was neither more severe nor had significant difference in bacteriological properties when comparing diabetic patients to non-diabetic ones.

Primary small cell type of non-Hodgkin lymphoma of the colon: a case report.

INTRODUCTION: Primary lymphoma of the colon is exceedingly rare and comprises 0.2-1% of all colon tumors. The most common subtype of lymphoma in the colon is non-Hodgkin lymphoma. Symptoms are often nonspecific, and treatment varies between chemotherapy alone and a combination of surgery and chemotherapy. CASE PRESENTATION: We describe a case of a Ashkenazi Jew patient who presented in the typical way that carcinoma of the colon might present but turned out to have a very rare type of tumor in both its histology and its location. CONCLUSION: There was apparent discordance between the relative bulkiness and gross appearance of the tumor with the unrevealing result of the biopsies, demanding a high level of suspicion as to the actual presence and possible type of such a tumor in the future.

The use of Ursolit for gallstone prophylaxis following bariatric surgery: a randomized-controlled trial.

BACKGROUND: Although bariatric surgery (BS) predisposes patients to development of gallstone formation, a preventive strategy is still in debate. AIM: To compare the incidence of gallstone formation between patients treated with ursodeoxycholic acid (UDCA) vs. placebo for a duration of 6 months following BS. METHODS: This multicenter randomized, double-blind controlled trial entails treatment with UDCA vs. an identical-looking placebo. The primary outcome was gallstone formation, as measured by abdominal ultrasound. RESULTS: The data of 209 subjects were enrolled in the study, and 92 subjects completed the study and were analyzed (n = 46 for each study group). The high dropout rate was mainly due to difficulties in adding more medications and swallowing the pill. Among the subjects who completed the study, 77.2% were women, and their mean age and pre-surgery BMI were 42.2 ± 10.2 years and 44.4 ± 6.1 kg/m2, respectively. Gallstone formation was recorded in 45.7% (n = 21) vs. 23.9% (n = 11) of subjects among placebo vs. UDCA groups, respectively, p = 0.029. Subgroup-analysis, according to surgery type, found that the results were significant only for SG subjects (p = 0.041), although the same trend was observed for OAGB/RYGB. Excess Weight Loss percent (%EWL) at 6 months post-surgery was 66.0 ± 17.1% vs. 71.8 ± 19.5% for the placebo and UDCA groups, respectively; p = 0.136. A trend towards a reduction in prescribed comorbidity medications was noted within-groups during the follow-up period, as compared to baseline, with no between-group differences (p ≥ 0.246). Moreover, no between-group differences were found for blood test results (p ≥ 0.063 for all). CONCLUSION: Administration of UDCA significantly decreased gallstone formation at 6 months at following BS. CLINICALTRIALS. GOV NUMBER: NCT02319629.

Trends in Bariatric Surgery: a 5-Year Analysis of the Israel National Bariatric Surgery Registry.

BACKGROUND: The worldwide prevalence of obesity nearly tripled between 1975 and 2016. There are limited data quantifying national trends. The aim of this study is to evaluate and summarize current trends in bariatric surgery in Israel. METHODS: Data for all bariatric surgeries (BS) performed between January 2014 and December 2018 was collected from the Israel National Bariatric Surgery Registry (INBSR) and analyzed. RESULTS: During the study period, 42,296 BS were included in the INBSR. Females accounted for 68% and the mean age and body mass index were 41.6 ± 12.6 years and 42.0 ± 5.4 kg/m2, respectively. Most of the patients were Jewish, but there was a significant rise in number of Arabs undergoing BS during the study period. There was a gradual decline in the annual numbers of BS, except for a small rise in 2015. There was a significant rise in the rate of One Anastomosis-Mini Gastric Bypass (OAGB-MGB), from 0.1% in 2014 to 46.1% in 2018, making it the most prevalent BS in that year. Laparoscopic sleeve gastrectomy (SG) surgeries decreased steadily, from 80% in 2014 to 37% in 2018. The annual rate of Roux-en-Y gastric bypass (RYGB) remained essentially constant at 10%. The annual rates of gastric banding decreased sharply and the annual rates of duodenal switch, single anastomosis duodenal switch and biliopancreatic diversion were negligible. Bariatric surgery was distributed evenly between private (50.4%) and public (49.6%) hospitals. CONCLUSIONS: The numbers of BS are decreasing in Israel. There is a gradual but noticeable shift from SG to OAGB-MGB.

[DIAGNOSIS, TREATMENT AND PREVENTION OF GASTROINTESTINAL DISEASES PRE AND POST BARIATRIC SURGERY PROCEDURES].

INTRODUCTION: In the last decade, the number of bariatric surgery procedures increased dramatically in Israel similar to what has occurred worldwide. Bariatric surgery procedures have a proven efficacy in the treatment of morbid obesity. However, post-operative complications that involve the gastrointestinal tract may occur. Beyond the importance of early diagnosis and treatment, it is crucial to understand that we may decrease and prevent some of the complications by selecting the bariatric procedure according to the patient's medical background. This review addresses diagnosis, treatment and prevention of gastrointestinal diseases pre- and post-bariatric surgery procedures. Recommended pre-operative diagnostic procedures are listed including the eradication of helicobacter pylori and the protective effect of proton pump inhibitors. We reviewed the effect of specific bariatric procedures on gastroesophageal reflux disease and on intestinal motility. Prevention and treatment of nutritional deficits and metabolic complications are also discussed. Finally, this document was written by a panel of experts representing the attitudes of the Israeli Societies for Metabolic and Bariatric Surgery (ISMBS), Pharmaceutical (PSI), Study of Obesity and the Israeli Gastroenterology and Liver Diseases Association, all endorsed by the Institute for Quality in Medicine of the Israeli Medical Association (IMA).

The lost stone - Laparoscopic exploration of abscess cavity and retrieval of lost gallstone post cholecystectomy: A case series and review of the literature.

BACKGROUND: Laparoscopic cholecystectomy (LC) is considered the gold standard operation for symptomatic gallstones. Gallbladder perforation occurs in 6-40% of operations. It can lead to spillage of gallstones into the abdominal cavity with possible consequences of long-term complications. We report two cases where a unique use of laparoscopic technique was used to explore abscess cavity and retrieve lost gallstones without penetrating the peritoneal cavity. CASE PRESENTATION: We report two cases of peri-hepatic abscess treated with laparoscopic cavity exploration, using 5 mm and 10 mm ports, to retrieve lost gallstones. It was done without entering the peritoneal cavity. DISCUSSION: Today, minimally invasive technique is used in a variety of surgical cases. We report a novel technique, using laparoscopic skills, to drain abscesses caused by lost gallstones post LC without entering the peritoneal cavity. The use of minimally invasive surgery techniques in order to explore abscess cavities not only help us to extract the cause of the abscess but also prevents another surgery in the abdominal cavity. CONCLUSION: Laparoscopic exploration of an abscess cavity is a feasible and safe technique treating long-term complications of gallbladder perforation post LC.

Bariatric Surgery in the Elderly Is Associated with Similar Surgical Risks and Significant Long-Term Health Benefits.

PURPOSE: Older age (> 60) has been considered a relative contraindication for bariatric surgery due to increased complication risk. This study examined the risks and benefits of bariatric surgery for patients older than 60 years in Canadian population. METHODS: This was a retrospective cohort study of the Ontario Bariatric Registry: a database recording peri-operative and post-operative outcomes of publicly funded bariatric surgeries across the province. Patients who completed 1 year follow-up, who underwent laparoscopic gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between January 2010 and May 2013, were divided into older (> 60) and younger (> 60) cohorts, and outcomes were compared. RESULTS: Between January 2010 and May 2013, 3166 registry patients underwent LRYGB or LSG and completed 1-year follow-up. Of these, 204 (6.5%) were older than 60 years, with 175 (85.8%) undergoing LRYGB and 29 (14.2%) LSG. Demographics were similar, except for a higher number of males in the older group (59 (28.9%) versus 452 (15.3%) (p < 0.001)). No significant difference in complication rate was noted (15% for younger cohort versus 13.8% (p = 0.889)). The average percentage of excess weight loss was significantly higher in the younger population (60.72% versus 56.25% (p < 0.05)) overall, however not significantly in the LSG group. Reduction in medication use post-surgery for management of co-morbidities was significantly higher in the older patients (- 0.91 versus - 2.03 (p < 0.001)). CONCLUSION: The older cohort who underwent LRYGB or LSG was at no greater risk for intra-operative and post-operative complications and showed greater reduction in medication use post-surgery when compared to the younger cohort.

Two weeks delayed bleeding in blunt liver injury: case report and review of the literature.

Most cases of blunt hepatic trauma are treated nowadays non-operatively. This type of conservative treatment has resulted in increased complication rate. Delayed complications occur in cases that didn't require surgical intervention during the first 24 hours. The most common late complication is hemorrhage. We report a case of two weeks delayed hemorrhage after blunt hepatic trauma in an adult. We describe the diagnostic procedures, the surgical treatment and review the relevant literature.