Assessment of guidelines for bariatric and metabolic surgery: a systematic review and evaluation using appraisal of guidelines for research and evaluation II (AGREE II).

BACKGROUND: In recent years, multiple guidelines on bariatric and metabolic surgery were published, however, their quality remains unknown, leaving providers with uncertainty when using them to make perioperative decisions. This study aims to evaluate the quality of existing guidelines for perioperative bariatric surgery care. METHODS: A comprehensive search of MEDLINE and EMBASE were conducted from January 2010 to October 2022 for bariatric clinical practice guidelines. Guideline evaluation was carried out using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. RESULTS: The initial search yielded 1483 citations, of which, 26 were included in final analysis. The overall median domain scores for guidelines were: (1) scope and purpose: 87.5% (IQR: 57-94%), (2) stakeholder involvement: 49% (IQR: 40-64%), (3) rigor of development: 42.5% (IQR: 22-68%), (4) clarity of presentation: 85% (IQR: 81-90%), (5) applicability: 6% (IQR: 3-16%), (6) editorial independence: 50% (IQR: 48-67%), (7) overall impressions: 48% (IQR: 33-67%). Only six guidelines achieved an overall score >70%. CONCLUSIONS: Bariatric surgery guidelines effectively outlined their aim and presented recommendations. However, many did not adequately seek patient input, state search criteria, use evidence rating tools, and consider resource implications. Future guidelines should reference the AGREE II framework in study design.

Third time's a charm: band to sleeve to bypass.

BACKGROUND: Adjustable gastric bands (AGB) are frequently converted to sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) due to weight recurrence or band complications. Such conversions carry a higher-risk than primary procedures. Some patients undergo two conversions-from AGB to SG, and subsequently from SG to RYGB. This presents a unique situation with limited literature on indications and complication rates associated with these double conversions. METHODS: We examined the 2020-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use File to evaluate conversions from AGB to SG and then to RYGB. Patient and operative characteristics, along with outcomes, were evaluated. Descriptive statistics were applied. RESULTS: We identified 276 patients who underwent a conversion from AGB to SG and then to RYGB. The primary reason for the second conversion (SG to RYGB) was gastroesophageal reflux disease (GERD) at 55.1%, followed by inadequate weight loss or weight regain (IWL/WR) at 36.9%. The remaining reasons included dysphagia, nausea, vomiting, or others. Patients converted for IWL/WR demonstrated a higher baseline body mass index and prevalence of sleep apnea compared to other cohorts (both p < 0.001). Meanwhile, patients in the "other reasons" group had the highest rate of open surgical approaches (9.1%) and concurrent lysis of adhesions (p = 0.001 and p = 0.022), with correspondingly higher rates of anastomotic leak, reoperations, serious complications, and mortality. CONCLUSIONS: Patients undergoing double conversions (AGB to SG to RYGB) do so primarily for GERD or IWL/WR. Further research is required to better define the optimal primary operation for each patient, aiming to reduce the necessity for multiple conversions.

Revisional bariatric surgery for gastroesophageal reflux disease: characterizing patient and procedural factors and 30-day outcomes for a retrospective cohort of 4412 patients.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes. METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity. RESULTS: 4412 patients required revisional surgery for GERD, encompassing 24% of all conversion procedures. In most cases, patients underwent sleeve gastrectomy (SG) as their original surgery (n = 3535, 80.1%). The revisional surgery for most patients was a Roux-en-Y gastric bypass (RYGB) (n = 3722, 84.4%). Major complications occurred in 527 patients (11.9%) and 10 patients (0.23%) died within 30 days of revisional surgery. Major complications included anastomotic leak in 31 patients (0.70%) and gastrointestinal bleeding in 38 patients (0.86%). Multivariable analyses revealed that operative length, pre-operative antacid use, and RYGB were predictors of major complications. CONCLUSION: GERD is the second most common indication for revisional surgery in patients who have undergone bariatric surgery. Patients who underwent SG as their initial procedure were the primary group who required revisional surgery for GERD; most underwent revision via RYGB. Further inquiry is needed to tailor operative approaches and pre-operative optimization for revisional surgery patients.

Machine learning prediction of major adverse cardiac events after elective bariatric surgery.

BACKGROUND: Machine learning (ML) is an emerging technology with the potential to predict and improve clinical outcomes including adverse events, based on complex pattern recognition. Major adverse cardiac events (MACE) after bariatric surgery have an incidence of 0.1% but carry significant morbidity and mortality. Prior studies have investigated these events using traditional statistical methods, however, studies reporting ML for MACE prediction in bariatric surgery remain limited. As such, the objective of this study was to evaluate and compare MACE prediction models in bariatric surgery using traditional statistical methods and ML. METHODS: Cross-sectional study of the MBSAQIP database, from 2015 to 2019. A binary-outcome MACE prediction model was generated using three different modeling methods: (1) main-effects-only logistic regression, (2) neural network with a single hidden layer, and (3) XGBoost model with a max depth of 3. The same set of predictor variables and random split of the total data (50/50) were used to train and validate each model. Overall performance was compared based on the area under the receiver operating curve (AUC). RESULTS: A total of 755,506 patients were included, of which 0.1% experienced MACE. Of the total sample, 79.6% were female, 47.8% had hypertension, 26.2% had diabetes, 23.7% had hyperlipidemia, 8.4% used tobacco within 1 year, 1.9% had previous percutaneous cardiac intervention, 1.2% had a history of myocardial infarction, 1.1% had previous cardiac surgery, and 0.6% had renal insufficiency. The AUC for the three different MACE prediction models was: 0.790 for logistic regression, 0.798 for neural network and 0.787 for XGBoost. While the AUC implies similar discriminant function, the risk prediction histogram for the neural network shifted in a smoother fashion. CONCLUSION: The ML models developed achieved good discriminant function in predicting MACE. ML can help clinicians with patient selection and identify individuals who may be at elevated risk for MACE after bariatric surgery.

The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on revisional bariatrics.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program designated bariatric surgery as a clinical pathway. Among the tiers of the Masters Program, revisional bariatric surgery is the highest tier of "mastery" within the pathway. This article presents the top 10 seminal studies representing the current landscape of revisional bariatrics. METHODS: The literature was systematically searched and seminal articles designated by consensus agreement of the SAGES Metabolic and Bariatric Surgery committee using multiple criteria, including impact on the field, citation frequency, and expert opinion. Articles were reviewed by committee members and presented in summarized fashion. RESULTS: The top 10 papers are presented in grouped thematic categories covering the early evolution of revisional bariatrics, changing criteria for reoperative bariatric surgery, divergence of revision versus conversion bariatric surgery, and recent technologic innovations in revisional bariatric surgery. Each summary is presented with expert appraisal and commentary. CONCLUSION: These seminal papers represent a snapshot of the dynamic field of revisional bariatric surgery and emphasize the need to not only remain current with contemporary trends but also keep a patient-oriented perspective on patient and intervention selection for optimal success.

Long-term outcomes following Dor, Toupet, and Nissen fundoplication: a network meta-analysis of randomized controlled trials.

BACKGROUND: In the surgical management of GERD, the traditional procedure is laparoscopic total (Nissen) fundoplication. However, partial fundoplication has been advocated as providing similar reflux control while potentially minimizing dysphagia. The comparative outcomes of different approaches to fundoplication are a topic of ongoing debate and long-term outcomes remain uncertain. This study aims to compare long-term gastroesophageal reflux disease (GERD) related outcomes following different fundoplication procedures. METHODS: MEDLINE, EMBASE, PubMed, and CENTRAL databases were searched up to November 2022 to identify randomized controlled trials (RCTs) comparing different types of fundoplications reporting long-term (> 5 years) outcomes. The primary outcome was incidence of dysphagia. Secondary outcomes included incidence of heartburn/reflux, regurgitation, inability to belch, abdominal bloating, reoperation, and patient satisfaction. DataParty, which uses Python 3.8.10 was used to perform the network meta-analysis. We evaluated the overall certainty of evidence with the GRADE framework. RESULTS: 13 RCTs were included, with 2063 patients across Nissen (360°), Dor (anterior 180°-200°), and Toupet (posterior 270°) fundoplications. Network estimates demonstrated that Toupet had lower incidence of dysphagia compared to Nissen (OR 0.285; 95% CrI 0.06-0.958). There were no differences in dysphagia between Toupet and Dor (OR 0.473, 95% CrI 0.072-2.835) or between Dor and Nissen (OR 1.689, 95% CrI 0.403-7.699). The three fundoplication types were comparable in all other outcomes. CONCLUSIONS: All three approaches of fundoplication share similar long-term outcomes, with the Toupet fundoplication likely providing the best long-term durability with lowest odds of developing postoperative dysphagia.

Optimizing management for early-stage esophageal adenocarcinoma: longitudinal results from a multidisciplinary program.

BACKGROUND: The management of early-stage esophageal cancer is nuanced. A multidisciplinary approach may optimize management through selection of candidates for surgical or endoscopic therapies. The objective of this research was to examine long-term outcomes of patients with early-stage esophageal cancer who undergo treatment with endoscopic resection or surgery. METHODS: Data on patient demographics, co-morbidities, pathology results, OS and RFS were obtained for both the endoscopic resection group and esophagectomy group. Univariate analysis of OS and RFS were conducted using the Kaplan-Meier method with calculation of the log-rank test. Multivariate cox-proportional hazards models were created for OS and RFS using a hypothesis-driven approach. A multivariate logistic regression model was created to identify predictors of esophagectomy among patients undergoing initial endoscopic resection. RESULTS: A total of 111 patients were included. The median OS for the surgery group was 67.0 months compared to 74.0 months in the endoscopic resection group (log-rank p = 0.93). The median RFS for the surgery group was 109.4 months compared to 63.3 months in the endoscopic resection group (log-rank p = 0.0127). On multivariable analysis, patients undergoing endoscopic resection had significantly worse RFS (HR 2.55, 95% CI 1.09-6.00; p = 0.032), but equivalent OS (HR 1.03, 95% CI 0.46-2.32; p = 0.941), compared to patients undergoing esophagectomy. High-grade disease (OR 5.43, 95% CI 1.13-26.10; p = 0.035) and submucosal involvement (OR 7.75, 95% CI 1.90-31.40; p = 0.004) were identified as significant predictors of proceeding to esophagectomy. CONCLUSIONS: Through a multidisciplinary approach, patients with early-stage esophageal cancer achieve excellent RFS and OS. Submucosal involvement and high-grade disease place patients at increased risk for local disease recurrence; these patients may undergo endoscopic resection safely if treated with a multidisciplinary approach incorporating endoscopic surveillance and surgical consultation. Further risk-stratification models may enable better patient selection and optimization of long-term outcomes.

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.

Primary single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) versus sleeve gastrectomy to SADI conversions: a comparison study of prevalence and safety.

BACKGROUND: Conversion from sleeve gastrectomy (SG) to single anastomosis duodeno-ileal bypass (SADI) is becoming increasingly common, but data regarding safety is of these conversions is scarce. As such, the objective of this study was to compare the 30-day rate of serious complications and mortality of primary SADI (p-SADI-S) with SG to SADI (SG-SADI) conversions. METHODS: This retrospective cohort study analyzed the MBSAQIP database. Patients undergoing p-SADI-S and SG-SADI were included. Data collection was limited to 2020 and 2021. A multivariable logistic regression analysis was performed between groups to determine if SG-SADI was an independent predictor of 30-day serious complications or mortality. RESULTS: A total of 783 patients were included in this study, 488 (62.3%) underwent p-SADI-S and 295 (37.6%) underwent SG-SADI. The mean body mass index (BMI) at the time of surgery was lower in the SG-SADI cohort (45.1 vs 51.4 kg/m2, p < 0.001). Indications for revision in the SG-SADI cohort included weight recurrence (50.8%), inadequate weight loss (41.0%), other (3.0%), GERD (2.7%), and persistent comorbidities (2.5%). SG-SADI had longer operative times (156.7 vs 142.1 min, p < 0.001) and was not associated with a higher rate of serious complications (5.7 vs 6.9%, p = 0.508) compared to p-SADI-S. p-SADI-S was associated with a higher rate of pneumonia (1.2 vs 0.0%, p < 0.001), and SG-SADI was not correlated with higher rates of reoperation (3.0 vs 3.2%, p = 0.861), readmission (5.4 vs 5.5%, p = 0.948) and death (0.0 vs 0.2%, p = 0.437). On multivariable analysis, SG-SADI was not independently predictive of serious complications (OR 0.81, 95% CI 0.43 to 1.52, p = 0.514) when adjusting for age, sex, BMI, comorbidities, and operative time. CONCLUSIONS: The prevalence of SG-SADI is high, representing 37.6% of SADI-S procedures. Conversion from sleeve to SADI, is safe, and as opposed to other studies of revisional bariatric surgery, has similar 30-day complication rates to primary SADI-S.

Gastric ischemic conditioning prior to esophagectomy reduces anastomotic leaks and strictures: a systematic review and meta-analysis.

BACKGROUND: Gastric ischemic conditioning (GIC) is a strategy to promote neovascularization of the gastric conduit to reduce the risk of anastomotic complications following esophagectomy. Despite a number of studies and reviews published on the concept of ischemic conditioning, there remains no clear consensus regarding its utility. We performed an updated systematic review and meta-analysis to determine the impact of GIC, particularly on anastomotic leaks, conduit ischemia, and strictures. METHODS: A systematic search of MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library was performed on February 5th, 2020 by a university librarian after selection of key search terms with the research team. Inclusion criteria included human participants undergoing esophagectomy with gastric conduit reconstruction, age ≥ 18, N ≥ 5, and GIC performed prior to esophagectomy. Our primary outcome of interest was anastomotic leaks. Our secondary outcome was gastric conduit ischemia, anastomotic strictures, and overall survival. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel fixed-effects model. RESULTS: A total of 1712 preliminary studies were identified and 23 studies included for final review. GIC was performed in 1178 (53.5%) patients. Meta-analysis revealed reduced odds of anastomotic leaks (OR 0.67; 95% CI 0.46-0.97; I2 = 5%; p = 0.03) and anastomotic strictures (OR 0.48; 95% CI 0.29-0.80; I2 = 65%; p = 0.005). Meta-analysis revealed no difference in odds of conduit ischemia (OR 0.40; 95% CI 0.13-1.23; I2 = 0%; p = 0.11) and no difference in odds of overall survival (OR 0.54; 95% CI 0.29-1.02; I2 = 22%; p = 0.06). CONCLUSION: GIC is associated with reduced odds of anastomotic leaks and anastomotic strictures and may decrease morbidity in patients undergoing esophagectomy. Further prospective randomized trials are needed to better identify the optimal patient population, timing, and techniques used to best achieve GIC.

Management of choledocholithiasis after Roux-en-Y gastric bypass: a systematic review and pooled proportion meta-analysis.

BACKGROUND: Several therapeutic modalities have been proposed for the management of choledocholithiasis (CDL) following Roux-en-Y gastric bypass (RYGB), yet debate exists regarding the optimal management. The purpose of our study was to review the current literature to compare the efficacy of various techniques in the management of CDL post-RYGB. METHODS: A comprehensive search of multiple databases was conducted. Studies reporting on the management of CDL in patients post-RYGB and including at least 5 patients were eligible for inclusion. The primary outcome was successful stone clearance. Secondary outcomes included procedure duration, length of hospital stay, and adverse events. RESULTS: Of 3259 identified studies, 53 studies involving 857 patients were included in the final analysis. The mean age was 54.4 years (SD 7.05), 78.8% were female (SD 13.6%), and the average BMI was 30.8 kg/m2 (SD 6.85). Procedures described included laparoscopy-assisted ERCP (LAERCP), balloon-assisted enteroscopy (BAE), ultrasound-directed transgastric ERCP (EDGE), laparoscopic common bile duct exploration (LCBDE), EUS-guided intra-hepatic puncture with antegrade clearance (EGHAC), percutaneous trans-hepatic biliary drainage (PTHBD), and rendezvous guidewire-associated (RGA) ERCP. High rates of successful stone clearance were observed with LAERCP (1.00; 95% CI 0.99-1.00; p = 0.47), EDGE (0.97; 95% CI 0.9-1.00; p = 0.54), IGS ERCP (1.00; 95% CI 0.87-1.00), PTHBD (1.0; 95% CI 0.96-1.00), and LCBDE (0.99; 95% CI 0.93-1.00, p < 0.001). Lower rates of stone clearance were observed with BAE (61.5%; 95%CI 44.3-76.3, p = 0.188) and EGHAC (74.0%; 95% CI 42.9-91.5, p = 0.124). Relative to EDGE, LAERCP had a longer procedure duration (133.1 vs. 67.4 min) but lower complication rates (12.8% vs. 24.3%). CONCLUSION: LAERCP and EDGE had high rates of success in the management of CDL post-RYGB. LAERCP had fewer complications but was associated with longer procedure times. BAE had lower success rates than both LAERCP and EDGE.

Characterization of Near-Infrared Imaging and Indocyanine-Green Use Amongst General Surgeons: A Survey of 263 General Surgeons.

BACKGROUND: Near-infrared fluorescence imaging (NIRFI) is an increasingly utilized imaging modality, however its use amongst general surgeons and its barriers to adoption have not yet been characterized. METHODS: This survey was sent to Canadian Association of General Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons members. Survey development occurred through consensus of NIRFI experienced surgeons. RESULTS: Survey completion rate for those opening the email was 16.0% (n = 263). Most respondents had used NIRFI (n = 161, 61.2%). Training, higher volumes, and bariatric, thoracic, or foregut subspecialty were associated with use (P < .001).Common reasons for NIRFI included anastomotic assessment (n = 117, 72.7%), cholangiography (n = 106, 65.8%), macroscopic angiography (n = 66, 41.0%), and bowel viability assessment (n = 101, 62.7%). Technical knowledge, training and poor evidence were cited as common barriers to NIRFI adoption. CONCLUSIONS: NIRFI use is common with high case volume, bariatric, foregut, and thoracic surgery practices associated with adoption. Barriers to use appear to be lack of awareness, low confidence in current evidence, and inadequate training. High quality randomized studies evaluating NIRFI are needed to improve confidence in current evidence; if deemed beneficial, training will be imperative for NIRFI adoption.

Sodium phosphate is superior to polyethylene glycol in constipated patients undergoing colonoscopy: a systematic review and meta-analysis.

BACKGROUND: Constipation is an important and highly prevalent predictor of inadequate bowel preparation during colonoscopy. In North America, between 2 and 28% of the general population suffer from constipation. Despite the high prevalence of constipation, to our knowledge, no meta-analysis on the optimal bowel preparation for constipated patients has been performed. We aimed to systematically review the literature to determine the ideal bowel preparation regiment for patients with chronic constipation. METHODS: A comprehensive search of electronic databases (MEDLINE, EMBASE, SCOPUS, and Web of Science) was performed. We included studies that assessed the quality of bowel preparation in constipated patients receiving different agents prior to colonoscopy. The primary outcome was colon cleanliness. Secondary outcomes included tolerability of the bowel preparation and serious adverse events. RESULTS: Preliminary database search yielded 1581 articles after duplicates were removed. After screening of the titles and abstracts using the exclusion criteria, 358 full-text articles were retained. Full-text articles were reviewed and eight studies meeting the inclusion criteria were included for qualitative synthesis. Three randomized controlled trials identified a total of 1636 constipated patients, of whom 225 were eligible for meta-analysis. Of those, 107 (47.6%) received NaP and 118 (52.4%) received PEG. Patients receiving NaP before colonoscopy had a higher chance of a successful bowel preparation than patients receiving PEG (OR 1.87, CI 1.06 to 3.32, P = 0.003). In the studies comparing PEG to NaP, two found that NaP resulted in greater tolerability of the bowel preparation and one study found that PEG resulted in superior tolerability. CONCLUSIONS: In chronically constipated patients undergoing colonoscopy, the use of NaP may result in superior colonic cleanliness when compared to PEG, however, quality of evidence was low. Further high-quality studies are required to delineate the optimal bowel preparation in patients with constipation.

Surgical management of hiatal hernia vs medical therapy to treat bleeding Cameron lesions: a systematic review and meta-analysis.

INTRODUCTION: Cameron lesions (CL) are an under-recognized cause of gastrointestinal bleeding. Diagnosis is often impaired by technical difficulty, and once diagnosed, management remains unclear. Typically, patients are medically managed with proton pump inhibitors (PPI). Small studies have demonstrated improved therapeutic success with surgical management, hypothesizing that reversing mechanical gastric trauma and ischemia allows CL healing. This systematic review and meta-analysis aim to compare therapeutic success of surgical versus medical management of Cameron lesions (CL). METHODS AND PROCEDURES: A comprehensive search and systematic review selected manuscripts using the following inclusion criteria: (1) Endoscopically diagnosed CL (2) Treated surgically (3) Follow-up for resolution of anemia or CL (4) n ≥ 5 (5) Excluding non-English, animal, and studies with patients < 18 years old Meta-analysis was performed to compare resolution of CLs with medical and surgical therapy. RESULTS: Systematic search retrieved 1664 studies, of these, 14 were included (randomized controlled trial = 1; prospective = 2; retrospective = 11). Patients had a mean age of 61.2 years (range 24-91) and were more often female (59.3%). Follow-up was between 3 and 120 months, and 82.9% of patients had hernias > 5 cm. Surgical management was associated with therapeutic success (OR 5.20, 1.83-14.77, I2 = 42%, p < 0.001) with 92% having resolution, compared to 67.2% for those treated with PPI. Surgical complications occurred in 42/109 (38.5%) of patients (48.1% for Open Hill Repair, 15.4% for laparoscopic fundoplication). 40.0% of patients underwent a laparoscopic Nissen or Collis fundoplication, 21.7% underwent open modified Hill repair, and 38.3% had unspecified operations. Hemoglobin improved from 8.85 g/dL pre-operatively to 13.60 g/dL post-operatively. In six studies, surgical patients previously failed medical management. CONCLUSIONS: This is the first systematic review comparing surgical and medical treatment of CL. Surgical management significantly improved therapeutic success. Our study supports therapeutic benefit of surgery in these patients.

Higher Edmonton Obesity Staging System scores are independently associated with postoperative complications and mortality following bariatric surgery: an analysis of the MBSAQIP.

INTRODUCTION: Bariatric surgery is an evidence-based approach for sustained weight loss in patients with severe obesity. The most common procedures in North America are the laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). The Edmonton Obesity Staging System (EOSS) is a tool that assigns patients a score of 0 to 4 according to their obesity-related comorbidities and functional status. Previous research demonstrates that increasing EOSS score is associated with overall non-operative mortality risk. OBJECTIVE: We sought to assess the association of the EOSS with major 30-day postoperative complications following LSG or LRYGB. METHODS: Primary LSG or LRYGB patients were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Patients were assigned EOSS scores according to their comorbidities and functional limitations extracted from the database. Multivariable logistic regression analysis was conducted to evaluate the relationship between EOSS score, age, sex, BMI, type of procedure, or operative time with 30-day major complications. RESULTS: From 2015 to 2017, 430,238 patients (79.4% female) who underwent primary LSG or LRYGB were identified. The relative frequencies of patients by EOSS score were: 0 and 1 (23.9%), 2 (62.8%), 3 (10.5%), and 4 (2.9%). Mean preoperative BMI was 45.4 (SD 7.9) kg/m2 and mean age was 44.6 (SD 12.0) years. The overall 30-day major complication rate was 3.5%. EOSS 2, 3, and 4 were significantly associated with major complications. The strongest associations with major complications were EOSS 4 (OR 2.30; 95% CI 2.11-2.51, p < 0.001) and LRYGB versus LSG (OR 2.03; 95% CI 1.97-2.11, p < 0.001). EOSS 3 and 4 were most strongly associated with death. CONCLUSION: Higher EOSS scores are independently associated with 30-day major postoperative complications and mortality. The EOSS provides utility in staging patients and identifying those at greater risk of postoperative complications.

Intraoperative fluorescence imaging with indocyanine green in hepatic resection for malignancy: a systematic review and meta-analysis of diagnostic test accuracy studies.

BACKGROUND: Fluorescence imaging during hepatic resection has the potential to identify additional malignant tumors, increasing the chance for complete tumor resection. Indocyanine green (ICG) is an FDA approved, fluorescent dye used in a variety of surgical procedures. The objective of this study was to define the sensitivity of intraoperative ICG fluorescent imaging in the detection of hepatic malignancy in adult patients during hepatic resection, which was accomplished by performing a systematic review and meta-analysis. METHODS: The databases Medline, EMBASE, Scopus and Web of Science were assessed in September 2018. Article inclusion criteria was (1) Liver resection for malignancy (2) ICG injected pre or intraoperatively (3) Use of infrared electronic endoscopy or near-infrared fluorescence imaging intraoperatively (4) Patient age ≥ 18 years (5) N > 5 patients (6) Human and English studies only. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) guidelines were used for quality assessment. Data synthesis was completed using Meta-Disc and MedCalc software. A DerSimonian-Laird random effects model was used for the meta-analysis. RESULTS: 21 studies and 841 patients were included in our systematic review. Seven studies and 319 patients were included in the meta-analysis. The pooled sensitivity of intraoperative ICG fluorescence was 0.75 (0.71-0.79). Sensitivity for superficial tumors ranged from 0.96 to 1.00. Heterogeneity (I2) was calculated at 65.1%. ICG-related fluorescence imaging detected new malignant tumors not detected by conventional means in 42 of 362 patients across 13 studies. CONCLUSION: The sensitivity of intraoperative ICG-related imaging for superficial tumors is high; however, overall sensitivity is low, at 0.75, suggesting that it would have to be used in combination with current identification methods such as intraoperative ultrasound. Our study also found that intraoperative ICG fluorescence imaging was able to detect additional malignant hepatic tumors in 11.6% of patients.

Predicting surgical site infections following laparoscopic bariatric surgery: development of the BariWound tool using the MBSAQIP database.

BACKGROUND: Although bariatric surgery is a safe procedure for severe obesity, incisional surgical site infections (SSI) remain a significant cause of morbidity. Bariatric surgery patients are at high risk due to obesity and diabetes. The objective of this study was to develop a predictive tool for incisional SSI within 30 days of bariatric surgery. METHODS: Data were retrieved from the 2015 and 2016 MBSAQIP databases. This study included patients who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG). The primary outcome of interest was incisional SSI occurring within 30 days. Surgeries performed in 2015 were used in a derivation cohort and the predictive tool was validated against the 2016 cohort. A forward selection algorithm was used to build a logistic regression model predicting probability of SSI. RESULTS: A total of 274,187 patients were included with 71.7% being LSG and 28.3% LRYGB. 0.7% of patients had a SSI in which 71.0% had an incisional SSI, and 29.9% had an organ/space SSI. Of patients who had an incisional SSI, 88.7% were superficial, 10.9% were deep, and 0.4% were both. A prediction model to assess for risk of incisional SSI, BariWound, was derived and validated. BariWound consists of procedure type, chronic steroid or immunosuppressant use, gastroesophageal reflux disease, obstructive sleep apnea, sex, type 2 diabetes, hypertension, operative time, and body mass index. It stratifies individuals into very high (> 10%), high (5-10%), medium (1-5%), and low risk (< 1%) groups. This model accurately predicted events in the validation cohort with an area under the receiver operating characteristic curve of 0.73. CONCLUSIONS: BariWound accurately predicted the risk of 30-day incisional SSI in individuals undergoing bariatric surgery. Stratifying low- and high-risk groups allows for customized SSI prophylactic measures for patients in various risk categories and potentially enables future research targeted at high-risk patients.

Higher Edmonton Obesity Staging System scores are associated with complications following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The Edmonton Obesity Staging System (EOSS) is a staging system describing comorbidities and functional limitations associated with obesity, thus facilitating the prioritization of patients for bariatric surgery. Our objective was to elucidate any associations of EOSS scores with major complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: A retrospective chart review examined patients who received primary LRYGB from 2009 to 2015 at a single center. Collected data included patient comorbidities, preoperative EOSS stage, body mass index (BMI), age, percent excess weight loss, and 1-year major complications. Major complications were defined by a Clavien-Dindo classification ≥ IIIa. RESULTS: 378 patients (81.7% female) receiving primary LRYGB were reviewed with the following EOSS stages: 0 (3.7%), 1 (10.8%), 2 (78.6%), 3 (6.9%), and 4 (0.0%). The mean preoperative BMI was 45.9 (SD 6.3) kg/m2. The overall major complication rate was 9.3%. Major complication rates for EOSS stages 0, 1, 2, and 3 were 7.1%, 4.9%, 8.8%, and 23.1%, respectively. Follow-up rates at 12 months were 76.6% with a mean overall follow-up of 10.9 (2.1) months. Multivariable analysis showed that patients undergoing LRYGB with an EOSS of 3 were more likely to experience major complications (OR 2.94; CI 1.04 to 8.35, p = 0.043). CONCLUSION: Our findings suggest that undergoing LRYGB with EOSS stage 3 has increased odds of major complications. As such, the EOSS demonstrates utility in identifying bariatric surgery candidates at risk of major postoperative morbidity. Further studies are required to assess the applicability of the EOSS for patients undergoing other forms of bariatric surgery.

Canadian consensus statement: enhanced recovery after surgery in bariatric surgery.

BACKGROUND: In Canada, bariatric surgery continues to remain the most effective treatment for severe obesity and its comorbidities. As the number of bariatric surgeries continues to grow, the need for consensus guidelines for optimal perioperative care is imperative. In colorectal surgery, enhanced recovery after surgery (ERAS) protocols were created for this purpose. The objective of this review is to develop evidence-based ERAS guidelines for bariatric surgery. METHODS: A literature search of the MEDLINE database was performed using ERAS-specific search terms. Recently published articles with a focus on randomized controlled trials, systematic reviews, and meta-analyses were included. Quality of evidence and recommendations were evaluated using the GRADE assessment system. RESULTS: Canadian bariatric surgeons from six provinces and ten bariatric centers performed a review of the evidence surrounding ERAS in bariatric surgery and created consensus guidelines for 14 essential ERAS elements. Our main recommendations were (1) to encourage participation in a presurgical weight loss program; (2) to abstain from tobacco and excessive alcohol; (3) low-calorie liquid diet for at least 2 weeks prior to surgery; (4) to avoid preanesthetic anxiolytics and long-acting opioids; (5) unfractionated or low-molecular-weight heparin prior to surgery; (6) antibiotic prophylaxis with cefazolin ± metronidazole; (7) reduced opioids during surgery; (8) surgeon preference regarding intraoperative leak testing; (9) nasogastric intubation needed only for Veress access; (10) to avoid abdominal drains and urinary catheters; (11) to prevent ileus by discontinuing intravenous fluids early; (12) postoperative analgesia with acetaminophen, short-term NSAIDS, and minimal opioids; (13) to resume full fluid diet on first postoperative day; (14) early telephone follow-up with full clinic follow-up at 3-4 weeks. CONCLUSIONS: The purpose of addressing these ERAS elements is to develop guidelines that can be implemented and practiced clinically. ERAS is an excellent model that improves surgical efficiency and acts as a common perioperative pathway. In the interim, this multimodal bariatric perioperative guideline serves as a common consensus point for Canadian bariatric surgeons.

Factors that predict 30-day readmission after bariatric surgery: experience of a publicly funded Canadian centre.

Background: Hospital readmissions after bariatric surgery can significantly increase health care costs. Rates of readmission after bariatric surgery have ranged from 0.6% to 11.3%, but the rate of complications and the factors that predict readmission have not been well characterized in Canada. The objective of this study was to characterize readmission rates and the factors that predict 30-day readmission in a Canadian centre. Methods: A retrospective study was performed on all patients who underwent bariatric surgery between 2010 and 2015 in a single Canadian centre. Procedures included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB). Prospectively collected data were extracted from an administrative database. Multivariable logistic regression analysis was performed to determine which factors predict 30-day readmission. Results: A total of 1468 patients had bariatric surgery (51.0% LRYGB, 40.5% LSG, 8.6% LAGB) during the 6-year study period, with an overall 30-day readmission rate of 7.5%. LRYGB was associated with a higher readmission rate (11.4%) than LSG (3.7%) or LAGB (1.6%). Common reasons for readmission were infection (24.8%), pain (17.4%) and nausea or vomiting (10.1%). Multivariable analysis identified 3 factors that independently predicted readmission: length of stay greater than 4 days (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.03-4.63, p = 0.042), LRYGB (OR 5.21, 95% CI 1.19-22.73, p = 0.028) and acute renal failure (OR 14.10, 95% CI 1.07-186.29, p = 0.045). Conclusion: Readmissions after bariatric surgery were most commonly caused by potentially preventable factors, such as pain, nausea or vomiting. Strategies to identify and address factors associated with readmission may reduce readmissions and health care costs after bariatric surgery in a publicly funded health care system.

Contexte: Les réadmissions hospitalières après la chirurgie bariatrique peuvent accroître significativement le coût des soins de santé. Les taux de ces réadmissions ont varié de 0,6 % à 11,3 %, mais le taux de complications et les facteurs de prédiction des réadmissions n'ont pas été bien caractérisés au Canada. L'objectif de cette étude est de caractériser les taux de réadmissions et les facteurs qui permettent de prédire une réadmission à 30 jours dans un centre canadien. Méthodes: Nous avons étudié rétrospectivement tous les cas de chirurgie bariatrique effectués entre 2010 et 2015 dans un établissement canadien. Les interventions incluaient la dérivation gastrique Roux-en-Y laparoscopique (DGRYL), la gastrectomie en manchon laparoscopique (GML) et la gastroplastie laparoscopique avec anneau ajustable (GLAA). Les données recueillies de manière prospective ont été extraites d'une base de données administrative. Nous avons procédé à une analyse de régression logistique multivariée pour déterminer quels facteurs permettaient de prédire la réadmission à 30 jours. Résultats: En tout, 1468 patients ont subi une chirurgie bariatrique (51,0 % DGRYL, 40,5 % GML et 8,6 % GLAA) durant les 6 années de l'étude, avec un taux global de réadmission à 30 jours de 7,5 %. La DGRYL a été associée un taux de réadmission plus élevé (11,4 %) que la GML (3,7 %) ou la GLAA (1,6 %). Les raisons de réadmission les plus fréquentes ont été infection (24,8 %), douleur (17,4 %) et nausées ou vomissements (10,1 %). L'analyse multivariée a permis de dégager 3 facteurs indépendants de réadmission, soit séjour de plus de 4 jours (rapport des cotes [RR] 2,18, intervalle de confiance [IC] de 95 % 1,03­4,63, p = 0,042), DGRYL (RC 5,21, IC de 95 % 1,19­22,73, p = 0,028) et insuffisance rénale aiguë (RC 14,10, IC de 95 % 1,07­186,29, p = 0,045). Conclusion: Les réadmissions après la chirurgie bariatrique ont le plus souvent été dues à des facteurs évitables, tels que douleur, nausées et vomissements. Des stratégies visant à identifier et à corriger les facteurs de réadmission pourraient réduire ces dernières et le coût des soins de santé après la chirurgie bariatrique dans un système de santé public.