A Different Kind of Craving: Incidence and Treatment of Pica After Laparoscopic Roux-en-Y Gastric Bypass.

BACKGROUND: Iron deficiency can occur in patients after Roux-en-y gastric bypass due to altered absorption. Pica, the compulsive craving and intake of non-nutritive substances, is a rare and poorly understood presentation of iron deficiency. To our knowledge, the rate of pica after RYGB has never been reported. METHODS: The medical records of patients who underwent laparoscopic RYGB from 2001 to 2011 were reviewed. Patients with pica or other abnormal cravings were identified. RESULTS: Pica was identified in 16/959 (1.7%) patients who underwent RYGB during the study period. The most common presenting sign was pagophagia. All patients with pica were female and had multiple risk factors for iron deficiency with 13/16 being premenopausal and 7/16 non-compliant with oral iron supplementation. Pica symptoms presented at a mean of 3.9 ± 1.9 years after RYGB. Iron deficiency was identified in all 16 patients, with a median ferritin level of 5.0 ng/mL (range 2-27). All 16 patients received intravenous iron and pica symptoms resolved. CONCLUSIONS: Pica is a rare phenomenon associated with iron deficiency and can occur despite oral iron supplementation. In our experience, intravenous iron can relieve symptoms. Patients considering bariatric surgery should be counseled on pica. Patients with unusual cravings should be evaluated for iron deficiency.

Impact of laparoscopic Roux-en-Y Gastric bypass versus sleeve gastrectomy on postoperative lipid values.

BACKGROUND: Metabolic surgery has been shown to significantly improve many obesity-related co-morbidities, including dyslipidemia. The literature has produced mixed results comparing postoperative lipid values after laparoscopic Roux-en-Y gastric bypass (LRYGB) compared to laparoscopic sleeve gastrectomy (LSG); with some indicating significantly greater reductions in total cholesterol and low-density lipoprotein (LDL) in LRYGB versus LSG, and others reporting no significant differences. OBJECTIVES: To evaluate the postoperative lipid values after LRYGB versus LSG at a community hospital. SETTING: Integrated multispecialty health system with a community teaching hospital. METHODS: A retrospective review of our prospective database was completed to identify patients who underwent either LRYGB or LSG at our institution from 2001 through 2013. Lipid values available at 6-18 months postoperative were evaluated. Statistical analysis included χ2 and Wilcoxon rank-sum tests. A P value<.05 was considered significant. RESULTS: There were 1326 and 121 patients who underwent LRYGB and LSG during the study period, respectively. Of these patients, 644 LRYGB and 67 LSG patients had pre- and postoperative lipid values available and included in the final analysis. Postoperative mean total cholesterol and LDL values were significantly lower in LYRGB versus LSG patients. Postoperatively, 10% and 30% of LRYGB and LSG patients had a total cholesterol values≥200 mg/dL (P<.001); 4% and 24% had LDL values≥130 mg/dL (P<.001); and 8% and 9% had triglyceride levels>130 mg/dL (P = .68), respectively. HDL values were within the recommended range in 52% and 57% of LRYGB and LSG patients, respectively (P = .64). CONCLUSION: Patients who underwent LRYGB had a greater postoperative reduction in total cholesterol, LDL, and triglycerides. LRYGB may be the more appropriate bariatric procedure for patients with significant preoperative hypercholesterolemia.

Long-term outcomes of an integrated transfusion reduction initiative in patients undergoing resection for colorectal cancer.

BACKGROUND: Perioperative blood transfusion in patients with colorectal cancer has been associated with increased cost, morbidity, mortality, and decreased survival. Five years ago, a transfusion reduction initiative (TRI) was implemented. We sought to evaluate the 5-year effectiveness and patient outcomes before and after the TRI. METHODS: Patients who underwent colorectal resection for adenocarcinomas before (January 2006 to October 2009) and after the TRI (November 2009 to December 2013) were reviewed. RESULTS: A total of 484 patients were included; 267 and 217 patients were in the pre- and post-TRI groups, respectively. Decreased overall transfusion rates were sustained throughout the entire post-TRI era (17% vs 28%, P = .006). Three-year colorectal cancer disease-free survival rates were similar in the pre- and post-TRI eras at 85.3% (95% confidence interval [CI]: 79.9 to 89.3) and 81.6% (95% CI: 71.9 to 88.2), respectively. Three-year disease-free survival rate was lower in those receiving BTs vs those without BTs at 78.4% (95% CI: 65.7 to 86.8) vs 85.3% (95% CI: 80.4 to 89.1), respectively. CONCLUSIONS: A TRI remains a safe, effective way to reduce blood utilization in colorectal cancer surgery.

Determining whether excision of all fibroepithelial lesions of the breast is needed to exclude phyllodes tumor: upgrade rate of fibroepithelial lesions of the breast to phyllodes tumor.

Fibroepithelial lesions (FELs) are a common histologic finding on core needle biopsy (CNB) of the breast. Fibroepithelial lesions include fibroadenoma and phyllodes tumor, which can be difficult to distinguish with an initial CNB. An institutional experience was reviewed from February 12, 2001, to January 4, 2007, to determine the safety of selective rather than routine excision of FELs and to determine the factors associated with upgrading diagnosis of FELs to phyllodes tumors without definitive phyllodes tumor diagnosis by CNB. Of 313 patients, 261 (83%) with FELs diagnosed by CNB received observation with long-term follow-up (mean, 8 years). Of the observed patients, 3 (1%) were diagnosed with phyllodes tumor on follow-up. Eighteen of 52 patients (35%) who received excision had an upgrade of diagnosis to phyllodes tumor. Sensitivity and specificity of the pathologist's comment of concern for phyllodes tumor on a CNB demonstrating FELs without definitive phyllodes tumor diagnosis were 82% and 93%, respectively. Our policy of selective excision of FELs without definitive phyllodes tumor diagnosis resulted in safe avoidance of many surgical procedures.

"Same as it ever was"--only different: a successful ACGME innovative project to equip PGY I residents to take at-home call.

OBJECTIVE: Establish a competency-based system for advancement of postgraduate year (PGY) I residents to take at-home call, with indirect and direct supervision available. DESIGN: Application of an innovative project approved by the ACGME to equip PGY I residents to take at-home call was successful. Formal education of PGY I residents with a variety of modalities included the successful completion of the Fundamentals of Surgery Curriculum and a structured 12-week curriculum, which focused on medical knowledge, patient care, systems-based practice, and skills lab scenarios. Residents were responsible for inpatient care during the day with direct supervision. Patient care logs (PCLs) were maintained by the resident for patient encounters. The PGY I residents were evaluated with faculty and senior resident review of the PCLs, a written examination, nurse mock pages, and oral proficiency examinations. The decision to permit the resident to take at-home call was determined by the Clinical Competency Committee (CCC). SETTING: Independent academic medical center with 3 categorical surgical residents per year. PARTICIPANTS: Categorical PGY I surgery residents from 2013 to 2014. RESULTS: Residents completed the structured program and successfully passed the oral and written examinations. The CCC determined that the residents were able to take at-home call starting in October of the PGY I year. The number and type of patients were monitored with specified limitations and ongoing maintenance and review of PCLs. A formal backup system, with senior resident and faculty availability by phone or physical presence, was used. CONCLUSION: We present an Accreditation Council for Graduate Medical Education-approved innovative project, which appears to have been successful in implementing at-home call for PGY I residents. This enables the progressive development of PGY I residents and assists our CCC in the development of competency-based milestones for advancement. The effect of this project is significant for those residency programs where incorporation of at-home call is possible.

Running sutures anchored with square knots are unreliable.

BACKGROUND: A previous study showed that running polypropylene sutures anchored with square knots retain only 75% of their strength compared with half hitches. The aim of this study was to investigate whether anchor knot geometry similarly affects the tensile strength of other types of sutures used in continuous closures. METHODS: Monofilament and multifilament sutures (all 3-0) were anchored with either square knots or half hitches to 1 tensionometer post, and the running ends were secured to the other. The force required to break the running suture and the site of suture failure were recorded. RESULTS: The running sutures anchored with square knots retained only 50% to 84% of the strength of the identical sutures secured with half hitches (P < .001). CONCLUSIONS: A running suture anchored with half hitches is stronger and safer in comparison with the same suture anchored with square knots. This study provokes a fundamental reconsideration of the use of square knots to anchor running sutures.