Search

Introduction: Obesity is a risk factor for non-alcoholic steatohepatitis (NASH) and hepatocellular carcinoma (HCC). Bariatric surgery can provide durable weight-loss, but little is known about the later development of NASH and HCC after surgery., Methods: Bariatric surgery (n = 3,410) and obese controls (n = 46,873) from an institutional data repository were propensity score matched 1:1 by demographics, comorbidities, BMI, and socioeconomic factors. Comparisons were made through paired univariate analysis and conditional logistic regression., Results: Total of 4,112 patients were well matched with no significant baseline differences except initial BMI (49.0 vs 48.2, p = 0.04). Bariatric group demonstrated fewer new-onset NASH (6 0.0% vs 10.3%, p < 0.0001) and HCC (0.05% vs 0.34%, p = 0.03) over a median follow-up of 7.1 years. After risk-adjustment, bariatric surgery was independently associated with reduced development of NASH (OR 0.52, p < 0.0001)., Conclusions: Bariatric surgery is associated with reduced incidence of NASH and HCC in this large propensity matched cohort. This further supports the use of bariatric surgery for morbidly obese patients to ameliorate NASH cirrhosis and development of HCC., (Copyright © 2019. Published by Elsevier Inc.)

Background: Total abdominal colectomy (TAC) is the standard surgical treatment of Clostridium difficile infection (CDI). An alternative therapy, loop ileostomy and colonic lavage (IL), was described in 2011, but the results have never been validated., Methods: Patients treated surgically for CDI between April 2011 and June 2015 were included. Bivariable analysis was used to compare 30-day mortality, 1-year mortality, CDI recurrence, colon preservation and ileostomy reversal., Results: Ten IL patients and thirteen TAC patients were identified. 30-day mortality (30% vs 23%, p = 1.0) and 1-year mortality (40% vs 46%, p = 1.0) were similar. Four IL and three TAC patients (57% vs 30%, p = 0.35) experienced recurrent CDI. All six surviving IL patients had successful colon preservation; five underwent ileostomy reversal compared to three in the TAC group (83% vs 43%, p = 0.27)., Conclusions: Although IL allowed colon preservation and return of intestinal continuity in most patients, IL did not decrease mortality or recurrent CDI when compared to TAC., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The purpose of this study is to evaluate the long-term survival following gastric bypass using propensity-matched controls., Methods: We identified all patients who either received a gastric bypass (GBP) or met criteria to receive a GBP between January 1, 2002 and December 31, 2003. Propensity matching was performed. Long-term, all-cause mortality data were collected and evaluated using Kaplan-Meier curves., Results: Four hundred thirty GBP cases and 5,323 controls were identified from the enrollment period. Ultimately, 802 cases and controls (1:1 matching, 93.2% match rate) were identified using propensity matching. Median follow-up was similar between groups. Overall mortality was lower for the GBP group (odds ratio .48, 95% confidence interval .29 to .78). GBP demonstrated significantly increased survival when compared with controls (P = .002). Similar patterns were noted among diabetics., Conclusion: We have demonstrated that gastric bypass provides a clear long-term survival advantage compared with nonsurgical propensity-matched controls., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: With the advent of clinical fellowships in general surgery, there has been a continual debate over the effect on general surgical resident training. Will a fellowship interfere with a chief resident's experience or case volume? The aim of this study was to test the hypothesis that the presence of an advanced laparoscopic fellow in a tertiary care hospital and residency has had no deleterious effect on chief resident laparoscopic case volume., Methods: The operative case logs of graduating residents and fellows from 2001 to 2011 were reviewed, focusing on laparoscopic basic and complex cases and comparing between those 2 groups and comparing residents' case numbers with the national average published by the Accreditation Council for Graduate Medical Education., Results: Residents graduating from 2001 to 2011 (4-6 chief residents per year) performed an average of 989 ± 76.2 laparoscopic cases per graduating chief class, with each chief averaging 207.7 ± 10.7. The average number of laparoscopic basic cases per graduating chief year was 555.3 ± 42.1, with each chief averaging 116.2 ± 4.9. The average number of laparoscopic complex cases per graduating chief year was 434.4 ± 39.2, with each chief averaging 91.5 ± 7.2. Over the same period of time (1 or 2 fellows per year), fellows performed an average of 336 ± 23.3 cases per year. When comparing residents' total average cases with the national data, the residents performed a similar number of cases (209.9 ± 11.9 vs 195.0 ± 19.5, P = .53). When comparing years when there were 2 clinical fellows vs years with 1 fellow, there was no change in the total number of laparoscopic cases per chief (224.2 vs 195.6, P = .26) and no change in the number of complex laparoscopic cases (97.1 vs 88.7, P = .63). There was a significant difference for basic laparoscopic cases, with a slight decrease when there were 2 fellows (127.8 vs 106.9, P = .04)., Conclusions: A laparoscopic fellowship has not had an adverse impact on the complex or basic laparoscopic case experience of surgical residents. In a busy academic practice, laparoscopic fellowships and general surgical residency can coexist., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The stomach can either be divided or undivided in performing Roux-en-Y gastric bypass (RGB) for morbid obesity. We evaluated whether surgical technique is the sole contributing factor to the formation of gastrogastric fistula (GGF)., Methods: A retrospective analysis of 1,036 consecutive patients was evaluated. RGB was performed as open undivided, open divided, and laparoscopic (divided). Incidence of GGF was identified for each technique and its relationship to surgical experience was assessed., Results: Overall incidence of GGF was 1.3%. All fistulae occurred in patients who received undivided open RGB. There was a significant difference between the undivided open group and the divided open+laparoscopic groups (2.1% vs 0%, P<.01). Incidence of GGF decreased over time with increasing open undivided RGB volume., Conclusions: GGF was only identified in undivided RGB. The occurrence decreased with increasing surgical experience. Together, overall surgical technique in addition to gastric division must play a role in fistula formation., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: Revisional bariatric surgery may be necessary due to inadequate weight loss or postoperative complications of the primary operation. We sought to identify the reasons for revision, characteristics of the surgery, and outcomes. We hypothesize that revisional surgery, although technically challenging, can produce desirable outcomes., Methods: Patients undergoing bariatric surgery at our institution between 1998 and 2007 were reviewed from a prospective database. Patients who had revisional surgery were compared to those who had primary surgery., Results: We have identified 46 of 1,038 patients who underwent revisional surgery. Twenty of 46 had a primary Roux-en-Y gastric bypass. The most common indication for revisions is inadequate weight loss secondary to gastrogastric fistula (15/20). Leaks occurred more frequently following revisional surgeries (11% vs 1.2%), but intensive care unit (ICU) utilization was less (11% vs 4.4%) and mortality was lower (0% vs .3%) with bariatric revision surgery., Conclusions: Although we saw a 9-fold increase in leaks, a 2-5 fold increase in ICU utilization, and 1.5-fold increase in length of stay, our mortality rate was zero. In experienced hands, bariatric revision surgery can be performed to produce desirable outcomes.

Background: Many patients undergoing bariatric surgery have severe comorbidities, including obstructive sleep apnea (OSA). We suspected that sleep apnea was underdiagnosed in our study population., Methods: A retrospective chart review of our bariatric database was conducted comparing OSA evaluation based on clinical parameters (Era 1) with mandatory OSA evaluation for all patients (Era 2)., Results: In both Era groups approximately 19% of patients presented to our program with an established diagnosis of OSA. In Era 1 this increased to 56% based on clinical parameters and in Era 2 this increased to 91% with mandatory polysomnography testing of all patients., Conclusions: OSA is grossly underdiagnosed in patients with morbid obesity presenting for bariatric surgery. Clinical evaluation continues to miss a substantial percentage of patients with OSA. Mandatory testing of all patients for OSA with polysomnography before bariatric surgery is recommended.

Background: The use of ultrasound cholangiography during cholecystectomy has been well described. This study was undertaken to assess the use of the umbilical port exclusively for ultrasound and to assess its employment on the use of fluoroscopy resources. In addition, we also looked at the increased use of ultrasound from 2000 to 2004., Methods: The use of imaging techniques during all cholecystectomies was analyzed from January 2000 to July 2001 for one surgeon and compared with that surgeon's present use from January 2004 to June 2004. Patient demographics, intraoperative finding, and postoperative results were reviewed., Results: During the first study period, ultrasound was used in 29% of 189 laparoscopic cholecystectomies. During 2004, ultrasound was used in 77% of 66 laparoscopic cholecystectomies. Throughout both periods, fluoroscopy was only used during 6 laparoscopic common bile duct explorations (2.4% of all cases). There were no false-positive or -negative ultrasounds, and there were no bile duct injuries., Conclusions: As experience with ultrasound cholangiography increases, there is little indication for fluoroscopic cholangiography except for rare questions concerning anatomy and during therapeutic maneuvers for common bile duct stones.