Unintended consequences for patients denied bariatric surgery: a 12-year follow-up.

BACKGROUND: Many patients who seek weight loss surgery are denied an operation because of insurance barriers, psychological concerns, and poor medical fitness for surgery. OBJECTIVE: The aim of this cohort study was to study the causes and outcomes of selected patients denied metabolic and bariatric surgery (MBS). SETTING: Academic, accredited bariatric program. METHODS: From January to December 2007, a multidisciplinary, accredited MBS program denied 107 patients surgery. Twelve years later a retrospective chart review and phone survey was conducted. Qualitative and quantitative analysis was performed using Χ2 and t test, respectively. RESULTS: Forty patients either declined participation or were lost to follow-up. Of 64 remaining patients, 13 patients were noted to have been ineligible for surgery by National Institutes of Health criteria. Three additional patients were excluded from the study. Of the remaining 51 denied patients, 24 patients (47%) ultimately underwent MBS at a later date. These patients had less severe hypertension (P < .05), hyperlipidemia (P < .05), diabetes (P < .05), and pain (P < .05) in comparison to those who never underwent MBS. All 24 patients were alive at 12-year follow-up compared with the 27 patients who did not undergo MBS, of which 12 (44%) were deceased at 12-year follow-up (P < .05). Of note, 10 of the remaining 15 living patients who did not undergo MBS are eligible today based on National Institutes of Health consensus criteria. CONCLUSION: This study found that most patients who were initially turned away from MBS ultimately satisfied qualification criteria. Those who are denied MBS represent a vulnerable group of patients who may never seek MBS again despite eventually qualifying. These patients may benefit from continued follow-up and counseling to achieve weight loss.

Preoperative Versus Extended Postoperative Antimicrobial Prophylaxis of Surgical Site Infection During Spinal Surgery: A Comprehensive Systematic Review and Meta-Analysis.

INTRODUCTION: Surgical site infection (SSI) following spinal surgery is a major source of postoperative morbidity. Although studies have demonstrated perioperative antimicrobial prophylaxis (AMP) to be beneficial in the prevention of SSI among spinal surgery patients, consensus is lacking over whether preoperative or extended postoperative AMP is most efficacious. To date, no meta-analysis has investigated the comparative efficacy of these two temporally variable AMP protocols in spinal surgery. We undertook a systemic review and meta-analysis to determine whether extended postoperative AMP is associated with a difference in the rate of SSI occurrence among adult patients undergoing spinal surgery. METHODS: Embase and MEDLINE databases were systematically searched for clinical trials and cohort studies directly comparing SSI rates among adult spinal surgery patients receiving either preoperative or extended postoperative AMP. Quality of evidence of the overall study population was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group approach. Random effects meta-analyses were performed utilizing both pooled and stratified data based on instrumentation use. RESULTS: Five studies met inclusion criteria. No individual study demonstrated a significant difference in the rate of SSI occurrence between preoperative and extended postoperative AMP protocols. The GRADE quality of evidence was low. Among the overall cohort of 2824 patients, 96% underwent lumbar spinal surgery. Pooled SSI rates were 1.38% (26/1887) for patients receiving extended postoperative AMP and 1.28% (12/937) for patients only receiving preoperative AMP. The risk of SSI development among patients receiving extended postoperative AMP was not significantly different from the risk of SSI development among patients only receiving preoperative AMP [RR (risk ratio), 1.11; 95% CI (confidence interval) 0.53-2.36; p = 0.78]. The difference in risk of SSI development when comparing extended postoperative AMP to preoperative AMP was also not significant for both instrumented (RR, 0.92; 95% CI 0.15-5.75; p = 0.93) and non-instrumented spinal surgery (RR, 1.25; 95% CI 0.49-3.17; p = 0.65). There was no evidence of heterogeneity of treatment effects for all meta-analyses. CONCLUSION: Preoperative AMP appears to provide equivalent protection against SSI development when compared to extended postoperative AMP. Prudent antibiotic use is also known to decrease hospital length of stay, healthcare expenditure, and risk of complications. However, until higher-quality evidence becomes available regarding AMP in spinal surgery, surgeons should continue to exercise discretion and clinical judgment when weighing the effects of patient comorbidities and complications before determining the optimal duration of perioperative AMP.

The history of metabolic and bariatric surgery: Development of standards for patient safety and efficacy.

Weight loss surgery, also referred to as bariatric surgery, has been in existence since the 1950's. Over the decades, it has been demonstrated to successfully achieve meaningful and sustainable weight loss in a large number of patients who undergo these procedures. Additionally, the benefits observed across a number of metabolic disorders such as type 2 diabetes mellitus and hyperlipidemia, are often to a degree, independent of the weight loss, thus the term "metabolic bariatric surgery (MBS)" has become a better descriptor. Throughout its long history, MBS has evolved from an era of high morbidity and mortality to one of laudable safety despite the high-risk nature of the patients undergoing these major gastrointestinal procedures. This article will describe the historic evolution of MBS and concentrate on those events that were instrumental in reducing the morbidity of these operations.

Occurrence of colorectal adenomas in younger adults: an epidemiologic necropsy study.

BACKGROUND & AIMS: The colorectal adenoma is the precursor lesion in virtually all colorectal cancers. Occurrence of colorectal adenomas has been studied in older adults but analysis in younger adults is lacking. METHODS: The prevalence by age, sex, race, and location, and the number of colorectal adenomas detected was investigated using epidemiologic necropsy in 3558 persons ages 20 to 89 autopsied from 1985 to 2004 at the Johns Hopkins Hospital. Results were standardized to the general population. Younger adults 20 to 49 years old were compared with older adults 50 to 89 years old. RESULTS: The prevalence of colorectal adenomas in younger adults increased from 1.72% to 3.59% from the third to the fifth decade of life and then sharply increased after age 50. In younger adults, adenomas were more prevalent in men than in women (risk ratio, 1.09; 95% confidence interval, 1.07-1.11) and in whites than in blacks (risk ratio, 1.28; 95% confidence interval, 1.26-1.31). Overall, both younger and older adults had predominately left-sided adenomas, but blacks in both age groups had more right-sided adenomas. Occurrence of 2 or more adenomas in younger adults and 5 or more in older adults was greater than 2 SDs from the mean. CONCLUSIONS: Colorectal adenomas infrequently occur in younger adults and are more prevalent in the left colon. Irrespective of age, blacks have more right-sided adenomas, suggesting the need for screening the entire colorectum. Two or more adenomas in younger adults and 5 or more in older adults represents polyp burden outside the normal expectation.