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ImportanceExcess adiposity confers higher risk of breast cancer for women. For women who have lost substantial weight, it is unclear whether previous obesity confers residual increased baseline risk of breast cancer compared with peers without obesity.ObjectivesTo determine whether there is a residual risk of breast cancer due to prior obesity among patients who undergo bariatric surgery.Design, Setting, and ParticipantsRetrospective matched cohort study of 69 260 women with index date between January 1, 2010, and December 31, 2016. Patients were followed up for 5 years after bariatric surgery or index date. Population-based clinical and administrative data from multiple databases in Ontario, Canada, were used to match a cohort of women who underwent bariatric surgery for obesity (baseline body mass index [BMI] ≥35 with comorbid conditions or BMI ≥40) to women without a history of bariatric surgery according to age and breast cancer screening history. Nonsurgical controls were divided into 4 BMI categories (ExposuresWeight loss via bariatric surgery.Main Outcomes and MeasuresResidual hazard of breast cancer after washout periods of 1, 2, and 5 years. Comparisons were made between the surgical and nonsurgical cohorts overall and within each of the BMI subgroups.ResultsIn total, 69 260 women were included in the analysis, with 13 852 women in each of the 5 study cohorts. The mean (SD) age was 45.1 (10.9) years. In the postsurgical cohort vs the overall nonsurgical cohort (n = 55 408), there was an increased hazard for incident breast cancer in the nonsurgical group after washout periods of 1 year (hazard ratio [HR], 1.40 [95% CI, 1.18-1.67]), 2 years (HR, 1.31 [95% CI, 1.12-1.53]), and 5 years (HR, 1.38 [95% CI, 1.21-1.58]). When the postsurgical cohort was compared with the nonsurgical cohort with BMI less than 25, the hazard of incident breast cancer was not significantly different regardless of the washout period, whereas there was a reduced hazard for incident breast cancer among postsurgical patients compared with nonsurgical patients in all high BMI categories (BMI ≥25).Conclusions and RelevanceFindings suggest that bariatric surgery was associated with a reduced risk of developing breast cancer for women with prior obesity equivalent to that of a woman with a BMI less than 25 and a lower risk when compared with all groups with BMI greater than or equal to 25.

Background With a growing bariatric population, a better understanding of the patient and health provider-related factors associated with later reoperations could help providers enhance follow-up and develop reliable benchmarking targets. Objectives To investigate the patient and provider-related risk factors associated with abdominal reoperations in bariatric patients. Setting This is a cohort study using data from a large clinical registry of Ontario bariatric patients between 2010 and 2016. Methods A multilevel mixed effect logistic regression model using hospital and surgeon identifiers as random effects was performed to adjust for clustering of patients. The primary outcome was any abdominal operation performed within 2 years of primary bariatric surgery. Results Among a cohort of 10,946 bariatric patients (86.6% receiving gastric bypass surgery), 15.8% underwent an abdominal operation within 2 years and about a third of these were urgent. The multilevel analysis demonstrated that 98% of patient variation among reoperations was a result of patient characteristics rather than disparities between surgeons or center experience. Type of procedure was not a significant factor after adjustment for surgeon and hospital level experience (OR [odds ratio] .85, 95% CI [confidence interval] .70-1.03). Concurrent abdominal wall (OR 2.40, 95% CI 1.26-4.59), hiatal hernia repairs (OR 1.29, 95% CI 1.02-1.62), and previously higher health care users (OR 1.30, 95% CI 1.15-1.46) were most significantly associated with reoperations. Conclusion Reoperations are significantly more common among certain bariatric patients, especially those undergoing concurrent hernia procedures. Reoperations were not associated with provider-related factors and may not be a suitable target for health provider benchmarking.

Background: Traditionally, reversal of neuromuscular blocking agents following the completion of surgery was achieved with cholinesterase inhibitors. Recently, sugammadex has been increasingly relied upon. Sugammadex is a γ-cyclodextrin molecule that rapidly reverses steroidal neuromuscular blocking drugs. Its use following colorectal surgery has become more common, and while the rapidity of reversal is undoubtedly improved, whether sugammadex impacts clinical postoperative outcomes is unknown. This systematic review and meta-analysis aims to compare postoperative outcomes in patients receiving sugammadex to those receiving a control during colorectal surgery. Methods: Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared sugammadex with a control (e.g., neostigmine, pyridostigmine, placebo) in patients undergoing colorectal surgery in terms of total hospital length of stay and frequency of postoperative adverse respiratory events. Pairwise meta-analyses using inverse variance random effects was performed. Results: From 269 citations, five studies with 535 patients receiving sugammadex (45.8% female; mean age: 64.4) and 569 patients receiving a control (45.0% female; mean age: 64.3) were included. There was no significant difference in length of stay between the two groups (MD -0.01, 95% CI -0.27 to 0.25, P = 0.95). The risk of adverse respiratory events postoperatively was similar between the two groups (RR 1.33, 95% CI 0.81-2.19, P = 0.25). Conclusion: There are no current data to suggest an improvement in postoperative outcomes with the use of sugammadex in patients undergoing colorectal surgery. This study is limited by the number of included studies. Further prospective studies comparing sugammadex and a control in colorectal surgery is required.

Objective To evaluate the efficacy of prophylactic mesh placement during end colostomy formation at reducing rates of parastomal hernia using the most recently available data. Background Systematic reviews and meta-analyses of randomized controlled trials (RCTs) have uniformly concluded that the use of prophylactic surgical mesh when fashioning an end colostomy reduces the risk of parastomal hernia. However, recent RCTs have failed to corroborate these findings. This study was designed to provide an updated systematic review and meta-analysis evaluating the efficacy of prophylactic mesh placement during end colostomy formation. Methods A search of Medline, EMBASE, and CENTRAL was performed. Articles were included if they were RCTs that compared the use of prophylactic mesh to no prophylactic mesh during construction of an end colostomy following colorectal resection for benign or malignant disease. The primary outcome was parastomal hernia rate. A pairwise meta-analysis was performed using inverse variance random effects. Results From 1,089 citations, 12 RCTs with 581 patients having prophylactic mesh placement and 671 patients not having prophylactic mesh placement met inclusion criteria. Incidence of parastomal hernia was significantly reduced in patients receiving prophylactic mesh (OR 0.60, 95% CI 0.46 to 0.80, p = 0.0003, I2 = 74%). Results were no longer significantly different when only studies conducted in the last 5 years were analyzed (p = 0.10). There was no significant difference in postoperative morbidity, postoperative mortality, colostomy-specific morbidity, or length of stay between groups. Conclusions There remains a significant reduction in the risk of parastomal hernia with the use of prophylactic mesh at the time of end colostomy formation, despite recent evidence suggesting no difference. Further contemporary trials with the application of modern surgical technology are required.

Background Obesity is a major risk factor for breast cancer. This study examines whether bariatric surgery affects breast cancer incidence in women with obesity compared to BMI-matched controls. Methods EMBASE, MEDLINE, Web of Science, and CINAHL were searched. Primary studies on female breast cancer incidence after bariatric surgery were eligible. Results 11 studies were included (n = 1,106,939). The rate of cancer diagnosis was lower in the surgical group (0.54%) compared to control (0.84%; risk ratio (RR) 0.50, 95%CI 0.37–0.67, I2 = 88%). The results were robust to sensitivity analyses for patient age and study size. Bariatric surgery was associated with increased risk of stage I cancer (RR 1.23, 95%CI 1.06–1.44) and reduced risk of stage III or IV cancer (RR 0.50, 95%CI 0.28–0.88). Hormone receptor characteristics were not affected. Conclusions Bariatric surgery is associated with reduced incidence and earlier stage at diagnosis of breast cancer in women with obesity compared to BMI-matched controls.

In rectal cancer surgery, larger mesorectal fat area has been shown to correlate with increased intraoperative difficulty. Prior studies were mostly in Asian populations with average body mass indices (BMIs) less than 25 kg/m2. This study aimed to define the relationship between radiological variables on pelvic magnetic resonance imaging (MRI) and intraoperative difficulty in a North American population. This is a single-center retrospective cohort study analyzing all patients who underwent low anterior resection (LAR) or transanal total mesorectal excision (TaTME) for stage I–III rectal adenocarcinoma from January 2015 until December 2019. Eleven pelvic magnetic resonance imaging measures were defined a priori according to previous literature and measured in each of the included patients. Operative time in minutes and intraoperative blood loss in milliliters were utilized as the primary indicators of intraoperative difficulty. Eighty-three patients (39.8% female, mean age: 62.4 ± 11.6 years) met inclusion criteria. The mean BMI of included patients was 29.4 ± 6.2 kg/m2. Mean operative times were 227.2 ± 65.1 min and 340.6 ± 78.7 min for LARs and TaTMEs, respectively. On multivariable analysis including patient, tumor, and MRI factors, increasing posterior mesorectal thickness was significantly associated with increased operative time (p = 0.04). Every 1 cm increase in posterior mesorectal thickness correlated with a 26 min and 6 s increase in operative time. None of the MRI measurements correlated strongly with BMI. As the number of obese rectal cancer patients continues to expand, strategies aimed at optimizing their surgical management are paramount. While increasing BMI is an important preoperative risk factor, the present study identifies posterior mesorectal thickness on MRI as a reliable and easily measurable parameter to help predict operative difficulty. Ultimately, this may in turn serve as an indicator of which patients would benefit most from pre-operative resources aimed at optimizing operative conditions and postoperative recovery.

Background The COVID-19 pandemic has disrupted surgical practice worldwide. There is widespread concern for surgeon and provider safety, and the implications of hospital lockdown on patient care during epidemics. Methods Medline, EMBASE, CENTRAL, and PubMed were systematically searched from database inception to July 1, 2020 and ongoing monthly surveillance will be conducted. We included studies that assessed postoperative patient outcomes or protection measures for surgical personnel during epidemics. Results We included 61 studies relevant to the COVID-19 pandemic and past epidemics. Lockdown measures were noted globally including cancellation of elective surgeries and outpatient clinics. The pooled postoperative complication rate during epidemics was 21.0% among 2095 surgeries. 31 studies followed the health of surgical workers with the majority noting no adverse outcomes with proper safety measures. Conclusions This review highlights postoperative patient outcomes during worldwide epidemics including the COVID-19 pandemic and identifies specific safety measures to minimize infection of healthcare workers., Highlights • Cancellation of elective surgery was the most reported surgical lockdown measure. • The pooled postoperative complication rate during epidemics was 21.0%. • Modified hospital protocols to limit infection was the most noted safety measure. • The pooled percentage of healthcare workers infected during epidemics was 6.2%.

Randomized controlled trials (RCTs) have demonstrated that bariatric surgery improves glycemic control among people with diabetes. However, evidence from RCTs may not be generalizable to real-world clinical care with unselected patients in routine clinical practice.To examine long-term glycemic control and glucose-lowering drug regimens following bariatric surgery for people with type 2 diabetes (T2D) in unselected patients in routine clinical practice.Population-based cohort study using linked routinely collected real-world data from Ontario, Canada.Individuals with T2D who were assessed for bariatric surgery at any referral center in the province between February 2010 and November 2016 were identified and divided into those who received surgery within 2 years of the initial assessment and those who did not.There were 3674 people who had bariatric surgery and 1335 who did not. By 2 years, people who had undergone surgery had a significantly lower HbA1C (6.3 ± 1.2 % versus 7.8 ± 1.8 %, P.0001), and this difference persisted at 3, 4, 5, and 6 years. Even by 6 years, half of those who had undergone surgery remained on no glucose-lowering drugs, and they were nearly 6 times less likely to be on insulin than those who had not undergone surgery.In real-world clinical care, bariatric surgery was associated with large and sustained improvements in glycemic control.

The Senhance Surgical System allows for infrared eye tracking, haptic feedback, and an adjustable upright seat allowing for improved ergonomics. This systematic review was designed with the aim of reviewing the current literature pertaining to the use of the Senhance Surgical System in colorectal surgery. Medline, EMBASE, and CENTRAL were searched. Articles were eligible for inclusion if they evaluated adults undergoing colorectal surgery with the Senhance Surgical System. The primary outcome was intraoperative efficacy; as defined by operative time, estimated blood loss (EBL), and conversion. A DerSimonian and Laird inverse variance random-effects meta-analysis was used to generate overall effect size estimates and narrative review was provided for each outcome. Six observational studies with 223 patients (mean age: 63.7, 41.2% female, mean BMI: 24.4 kg/m

Over the last decade, use of laparoscopy for the treatment of colon cancer has been variable despite evidence of benefit, possibly reflecting surgeon expertise rather than other factors.The purpose of this study was to examine the spatial variation in the use of laparoscopy for colon cancer surgery and to determine what factors may influence use.This was a population-based retrospective analysis from April 2008 to March 2015.All Canadian provinces (excluding Quebec) were included.The study included all patients ≥18 years of age undergoing elective colectomy for colon cancer.The primary outcome was laparoscopy use rates. Predictors of use included patient and disease characteristics, year of surgery, rurality, hospital and surgeon volumes, and distance from a colorectal fellowship training center.A total of 34,725 patients were identified, and 42% underwent laparoscopic surgery. Significant spatial variations in laparoscopy use were identified, with 95% of high-use clusters located ≤100 km and 98% of low-use clusters located100 km from a colorectal fellowship center. There were no high-use clusters located around large academic centers without colorectal fellowships. At the individual level, patients living within 25 km and 26 to 100 km of a fellowship center were 2.6 and 1.6 times more likely to undergo laparoscopic surgery compared with those100 km away (95% CI, 2.47-2.79, p0.00; 95% CI, 1.53-1.71, p0.001). Surgeon and hospital volumes were associated with increased rates of laparoscopy use (p0.001).Data were obtained from an administrative database, and despite 85% to 95% published validity, they remain subject to misclassification, response, and measurement bias.Significant spatial variations in the use of laparoscopy for colon cancer surgery exist. After adjusting for patient and system factors, proximity to a colorectal fellowship training center remained a strong predictor of laparoscopy use. There remain regional variations in colon cancer treatment, with discrepancies in the surgical care offered to Canadian patients based solely on location. See Video Abstract at http://links.lww.com/DCR/B595.ANTECEDENTES:Durante la última década, la utilización de la laparoscopia para el tratamiento del cáncer de colon ha sido variable a pesar de la evidencia de beneficio; posiblemente reflejando la experiencia del cirujano, más que otros factores.OBJETIVO:Examinar la variación espacial en el uso de la laparoscopia para la cirugía del cáncer de colon y determinar qué factores pueden influir en la utilización.DISEÑO:Análisis retrospectivo poblacional de abril de 2008 a marzo de 2015.ENTORNO CLÍNICO:Todas las provincias canadienses (excepto Quebec).PACIENTES:Todos los pacientes18 años sometidos a colectomía electiva por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fueron las tasas de utilización de laparoscopia. Los predictores de uso incluyeron las características del paciente y la enfermedad, el año de la cirugía, la ruralidad, los volúmenes de hospitales y cirujanos, y la distancia a un centro de formación de residentes colorectales.RESULTADOS:Se identificaron 34.725 pacientes, 42% fueron sometidos a cirugía laparoscópica. Se identificaron variaciones espaciales significativas en el uso de laparoscopia, con el 95% de los conglomerados de alto uso ubicados a100 km y el 98% de los conglomerados de bajo uso ubicados a100 km, desde un centro de residencia colorectal. No había grupos de alto uso ubicados alrededor de grandes centros académicos sin residentes colorrectales. A nivel individual, los pacientes que vivían dentro de los 25 km y 26-100 km de un centro de residentes tenían 2,6 y 1,6 veces más probabilidades de someterse a una cirugía laparoscópica, respectivamente, en comparación con aquellos a100 km de distancia (95% CI 2,47-2,79, p0,00; IC del 95% 1,53-1,71, p0,001). Los volúmenes de cirujanos y hospitales se asociaron con mayores tasas de utilización de laparoscopia (p0,001).LIMITACIONES:Los datos se obtuvieron de una base de datos administrativa y, a pesar de una validez publicada del 85-95%, siguen sujetos a errores de clasificación, respuesta y sesgo de medición.CONCLUSIONES:Existen variaciones espaciales significativas en el uso de la laparoscopia para la cirugía del cáncer de colon. Después de ajustar por factores del paciente y del sistema, la proximidad a un centro de formación de residentes colorectales siguió siendo un fuerte predictor del uso de laparoscopia. Sigue habiendo variaciones regionales en el tratamiento del cáncer de colon, con discrepancias en la atención quirúrgica ofrecida a los pacientes canadienses basadas únicamente en la ubicación. Consulte Video Resumen en http://links.lww.com/DCR/B595.

The number of Canadian Residency Matching Service (CaRMS) applicants ranking surgical specialties as their first choice has declined over the past 20 years; concurrently, there has been a reduction in the number of hours spent teaching undergraduate medical education (UGME) anatomy, particularly with cadaveric dissection. The aim of this study was to determine the factors that most influence selection of a surgical specialty, with specific focus on the impact of UGME anatomy training.A 36-item cross-sectional survey was designed by experts in medical education and distributed to all current surgical residents in Canada in October 2018. Responses were recorded on a 5-point Likert scale or by means of list ranking. We analyzed univariable outcomes with a t test for continuous outcomes and the χ2 test for dichotomous outcomes.Of 1493 surgical residents, 228 responded to the survey (response rate 15.3%). Respondents reported experiences on core rotations and elective rotations, and access to a mentor as the most important factors in deciding to pursue a surgical residency. Anatomy training with or without cadaveric dissection was moderately influential in respondents' first-choice CaRMS discipline (mean Likert scale score 2.97 [standard deviation (SD) 1.34] and 2.87 [SD 1.26], respectively). General surgery residents' CaRMS applications were more likely to have been influenced by UGME anatomy training than the applications by residents in other surgical specialties (p0.001). The impact of UGME anatomy training did not vary between postgraduate years or between male and female residents.Canadian surgical residents' decision to apply to a surgical specialty did not seem to be strongly influenced by their UGME anatomy training, with or without cadaveric dissection, but, rather, by factors such as clinical experience and surgical mentorship. Further evaluation of groups that were more positively affected by their UGME anatomy training is warranted.Le nombre de candidats inscrits au Service de jumelage canadien des résidents (SJCR) qui classent les spécialités chirurgicales parmi leurs premiers choix a diminué ces 20 dernières années. Simultanément, dans les programmes d’études médicales prédoctorales, on a noté une baisse du nombre d’heures consacrées à l’enseignement de l’anatomie, particulièrement à la dissection de cadavres. Le but de cette étude était d’identifier les principaux facteurs qui influent sur le choix d’une spécialité chirurgicale, en portant une attention particulière à l’impact de la formation prédoctorale en anatomie.Des experts en formation médicale ont préparé un sondage de 36 questions qui a été distribué à tous les résidents en chirurgie au Canada en date d’octobre 2018. Les réponses ont été reportées sur une échelle de Likert en 5 points ou sous forme de liste de classement. Nous avons analysé les résultats univariés au moyen d’un test t pour les résultats continus et d’un test du χ2 pour les variables dichotomiques.Sur 1493 résidents en chirurgie, 228 ont répondu au sondage (taux de réponse, 15,3 %). Parmi les plus importants facteurs pour décider de poursuivre leur résidence, les répondants ont mentionné leurs expériences de stages obligatoires et électifs et l’accès à un mentor. La formation en anatomie, avec ou sans dissection de cadavres, a eu une influence modérée sur le premier choix d’une discipline du SJCR (score moyen à l’échelle de Likert 2,97 [écart-type (É.-T.) 1,34] et 2,87 [É.-T. 1,26], respectivement). Les demandes d’admission des résidents en chirurgie générale étaient plus susceptibles de dépendre de la formation prédoctorale en anatomie que les demandes d’admission dans d’autres spécialités chirurgicales (p0.001). L’impact de la formation prédoctorale en anatomie n’a pas varié en fonction de l’année de résidence ni selon le sexe des résidents.La décision des résidents de chirurgie canadiens de s’inscrire dans une spécialité chirurgicale n’a pas semblé fortement influencée par la formation prédoctorale en anatomie, avec ou sans dissection de cadavres, mais plutôt par des facteurs tels que l’expérience clinique et le mentorat en chirurgie. Il faudrait étudier plus en profondeur les groupes pour qui la formation prédoctorale en anatomie a été positive.

The prevalence of noncommunicable diseases has increased dramatically in North America and throughout the world and is expected to continue increasing in coming years. Obesity has been linked to several types of cancers and is associated with increased morbidity and mortality following cancer diagnosis. Bariatric surgery has emerged as the prominent model to evaluate the effects of intentional weight loss on cancer incidence and outcomes. Current literature, comprising prospective cohort investigations, indicates site-specific reductions in cancer risk with select bariatric procedures. Future research is required to establish evidence-based indications for bariatric surgery in the context of cancer prevention.

The incidence of colorectal cancer in North America is rising among patients younger than 50 years. Available data are conflicting regarding presentation and outcomes in this population. This review aimed to synthesize literature regarding young patients with colorectal cancer with respect to patient demographics, disease extent and survival, compared with patients older than 50 years.We searched Medline, Embase, the Cochrane Central Register of Controlled Trials and PubMed for articles published between 1990 and the time of search. Articles comparing North American patients with colorectal cancer younger and older than 50 years were eligible for inclusion. We used a random-effects model to pool odds ratios.Eight retrospective studies were eligible for inclusion (n = 790 959). Mean age was 42.6 years (standard deviation [SD] 5.07) in the younger group, and 69.1 years (SD 9.25) in the older group. Young patients were more likely to present with regional (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.16-1.40) and distant disease (OR 1.47, 95%CI 1.30-1.67). Considering patients at all stages of disease, differences in 5-year overall survival (OR 1.54, 95%CI 0.96-2.47) and cancer-specific survival (OR 1.01, 95%CI 0.91-1.13) were not statistically significant between groups. However, when controlling for disease extent, 5-year cancer-specific survival was significantly higher among young patients with local (OR 1.69, 95%CI 1.43-1.99), regional (OR 1.37, 95%CI 1.16-1.63) and distant disease (OR 1.79, 95%CI 1.45-2.21).North American patients presenting with colorectal cancer before the age of 50 years are more likely to have advanced disease. Although overall and cancer-specific survival is not significantly different between these groups, younger patients have improved survival when controlling for cancer stage.L’incidence du cancer colorectal en Amérique du Nord est en hausse chez les patients de moins de 50 ans. Les données disponibles quant à la présentation et aux issues de la maladie dans cette population sont contradictoires. La présente revue systématique vise à synthétiser les données de la littérature sur les jeunes patients atteints d’un cancer colorectal, entre autres les caractéristiques démographiques des patients, le stade de la maladie et le taux de survie, et à les comparer aux données des patients de plus de 50 ans.Nous avons interrogé les bases de données Medline, Embase, PubMed et le Cochrane Central Register of Controlled Trials pour repérer les articles publiés entre 1990 et le moment de la recherche. Les études comparants les patients nord-américains atteints d’un cancer colorectal de moins de 50 ans et ceux de plus de 50 ans ont été incluses. Nous avons utilisé un modèle à effets aléatoires pour regrouper les rapports de cotes.Huit études rétrospectives ont été retenues (n = 790 959). L’âge moyen était de 42,6 ans (écart type [É. T.] 5,07) pour le groupe des moins de 50 ans, et de 69,1 ans (É.-T. 9,25) pour l’autre groupe. Les jeunes patients étaient plus susceptibles de présenter un cancer régional (rapport de cotes [RC] 1,27; intervalle de confiance [IC] à 95 % 1,16–1,40) ou un cancer à distance (RC 1,47; IC à 95 % 1,30–1,67). Si on ne tenait pas compte du stade de la maladie, la différence entre le taux de survie globale à 5 ans (RC 1,54; IC à 95 % 0,96–2,47) et le taux de survie au cancer à 5 ans (RC 1,01; IC à 95 % 0,91–1,13) n’était pas statistiquement significative. Toutefois, si on tenait compte de l’étendue de la maladie, le taux de survie lié au cancer à 5 ans était significativement plus élevé chez les jeunes patients ayant un cancer localisé (RC 1,69; IC à 95 % 1,43–1,99), régional (RC 1,37; IC à 95 % 1,16–1,63) ou à distance (RC 1,79; IC à 95 % 1,45–2,21).Les patients nord-américains de moins de 50 ans présentant un cancer colorectal sont plus susceptibles d’être à un stade avancé de la maladie. Bien que le taux de survie globale et le taux de survie au cancer ne diffèrent pas de manière significative entre les 2 groupes, les jeunes patients présentaient un meilleur taux de survie lorsqu’on tenait compte du stade de la maladie.

Bariatric surgery in older patients is safe and effective. Current guidelines do not endorse age limits for surgery; however, older patients may encounter difficulties with access given perceived risks. This study compares the adjusted probability of failing to receive bariatric surgery between older (≥ 60 years) and younger (

Very low energy diets serve as an intensive approach to weight loss in a short period of time. Although the preoperative use of very low energy diets to optimize patients with obesity before bariatric surgery is well established, the evidence for very low energy diets before other types of surgery remains unclear. The aim of this review was to determine the impact of preoperative very low energy diets on perioperative outcomes in nonbariatric surgery.Medline, EMBASE, CENTRAL, and PubMed were systematically searched from inception through to July 2021. Articles were included if they evaluated very low energy diets use before any type of nonbariatric surgery. The primary outcome was postoperative morbidity. Secondary outcomes included compliance, safety, and preoperative weight loss. A pairwise meta-analyses using inverse variance random effects was performed.From 792 citations, 13 studies with 395 patients (mean age: 56.5 years, 55.8% female) receiving very low energy diets preoperatively in preparation for nonbariatric surgery were included. Mean duration of preoperative very low energy diets was 6.6 weeks (range, 0.42-17 weeks). Target daily caloric intake ranged from 450 kcal to 1,400 kcal. Compliance with very low energy diets ranged from 94% to 100%. The mean preoperative weight loss ranged from 3.2 kg to 19.2 kg. There were no significant differences in postoperative morbidity (odds ratio, 1.10; 95% confidence interval, 0.64-1.91; P = .72), operative time (standard mean difference -0.35; 95% confidence interval, 1.13-0.43, P = .38), or postoperative length of stay (standard mean difference 0.40, 95% confidence interval -0.11-0.91, P = .12) with very low energy diets.Although the currently available evidence is heterogenous, preoperative very low energy diets are safe, well tolerated, and effectively induce preoperative weight loss in patients undergoing nonbariatric surgery for both benign and malignant disease. Further prospective studies are warranted.

Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization.A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization.Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%,Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.Les protocoles de récupération optimisée après une chirurgie (ou ERAS, pour enhanced recovery after surgery) utilisent des pratiques périopératoires fondées sur des données probantes pour réduire la morbidité, abréger la durée des séjours hospitaliers et améliorer la satisfaction des patients. Les protocoles ERAS sont considérés comme une norme thérapeutique; toutefois, leur utilisation reste faible et on note une importante variation dans leur application. Le but de cette étude était de caractériser dans les faits les variations des pratiques en chirurgie colorectale et d’identifier les prédicteurs de l’utilisation des protocoles ERAS.Un sondage a été effectué auprès des chirurgiens généraux de la base de données du Collège des médecins et chirurgiens de l’Ontario. On a recueilli des données sur les caractéristiques démographiques de base, l’utilisation des protocoles ERAS et les prédicteurs de leur déploiement. Neuf pratiques ERAS ont été analysées. L’analyse multivariée a permis de déterminer les effets des covariables démographiques, hospitalières et celles des chirurgiens sur le recours aux protocoles ERAS.Nous avons invité 797 chirurgiens généraux à participer au sondage, et 235 d’entre eux représentant 84 hôpitaux ontariens y ont répondu (taux de réponse 30 %). Les chirurgiens des établissements universitaires et des grands hôpitaux communautaires ont représenté respectivement 30 % et 47 % des répondants. En tout, 20 % des répondants ont déclaré appliquer les 9 pratiques ERAS de manière constante. L’alimentation précoce au Jour 0 postopératoire, la restriction des liquides intraveineux et les directives concernant les cathéters et les sondes étaient significativement mieux observées chez les répondants qui adhéraient aux protocoles ERAS que chez ceux qui n’y adhéraient pas (74 % c. 54 %,On continue d’observer une importante variation des pratiques en chirurgie colorectale. Les principes ERAS individuels sont généralement suivis, mais ils ne sont pas formellement intégrés aux protocoles hospitaliers.

While cannabis is the most commonly used non-prescription drug in the USA and has established effects on weight, its implication for bariatric surgery has not been formally evaluated. We aimed to review the current literature on perioperative cannabis use in patients undergoing bariatric surgery. Our systematic search of MEDLINE and Embase until March 2020 returned 169 citations. Screening and abstraction of results were performed in duplicate, and qualitative synthesis of the data was performed. Primary outcomes were cannabis use characteristics, weight loss outcomes, and 30-day postoperative morbidity. Study quality was assessed through the MINORS risk-of-bias tool. Six observational studies with a total of 1167 patients (78.6% female, median follow-up 12 months [3–38.4 months]) were included. A total of 9.9% of patients (n = 116/1167) used cannabis in the perioperative period. Compared with non-users, 1-year weight loss was significantly higher in a study evaluating 8 preoperative cannabis users (n = 8/239, p = 0.002); however, there were no differences in single-study data on 90-day total weight loss (n = 434, p = 0.89) nor 2-year excess BMI loss (n = 146, p = 0.631). There was no difference in 30-day minor (RR 0.91, 95%CI 0.49–1.71, p = 0.77) or major morbidity (RR 0.75, 95%CI 0.31–1.79; p = 0.50). There are only uncontrolled studies to date on cannabis use in bariatric surgery. While these have reported conflicting effects on weight loss and no effect on morbidity to date, validation in randomized trials is required to facilitate evidence-based recommendations.

Morbid obesity is considered a relative contraindication for liver transplantation (LTX) because of increased risk of complications. The aim of this study was to investigate the role of bariatric surgery before, during, and after LTX. A systematic review of MEDLINE, EMBASE, CENTRAL, and PubMed databases was performed for studies investigating bariatric surgery in patients before, during, or after LTX. Random-effects meta-analysis of proportions was used to calculate pooled effect estimates. One hundred eighty-seven patients underwent bariatric surgery before LTX (8 studies). After surgery, 82% (95% confidence interval, 62%-97%) of patients were successfully listed for LTX and 70% (95% confidence interval, 40%-93%) successfully received LTX. The 30-day mortality rate was 0%. The graft survival rate after 1 year was 70% (95% confidence interval, 30%-99%). Thirty-day minor and major complications rate was 4% and 1%, respectively. Thirty-two patients underwent bariatric surgery during LTX (2 studies). The 30-day mortality rate after surgery was 0% and 1-year graft survival was 100%. Sixty-four patients underwent bariatric surgery after LTX (9 studies). The 30-day mortality was 0%, but 5 deaths occurred beyond 30 days (7.8%). Bariatric surgery may be safe and feasible as a bridge to LTX for patients who would otherwise be ineligible and post-LTX patients for weight loss.

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered gastrointestinal anatomy is challenging. Double-balloon enteroscopy (DBE) has been shown to be safe and efficacious for ERCP in these patients but attempts to synthesize existing data are limited. The purpose of this study was to conduct a systematic review and meta-analysis to evaluate the safety and efficacy of DBE-ERCP in surgically altered anatomy. We searched MEDLINE, EMBASE, and CENTRAL databases through March 2020 for studies that conducted DBE-ERCP in patients with surgically altered gastrointestinal anatomy. Primary outcomes were enteroscopic, diagnostic, and procedural success rates of DBE-ERCP. Secondary outcomes were adverse events after DBE-ERCP. Random effects meta-analysis of proportions was performed when appropriate. The Newcastle–Ottawa scale was used to evaluate risk of bias. Heterogeneity was assessed using the inconsistency (I2) statistic. 24 studies involving 1523 patients were included. The pooled enteroscopic, diagnostic, and procedural success rates of DBE-ERCP were 90% (95% confidence interval (CI), 84–94%), 94% (95% CI 88–98%), and 93% (95% CI 88–97%). Adverse events were reported in 4% (95% CI 3–6%) of cases. Subgroup analysis of short-scope DBE-ERCP (

Total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) is commonly performed for patients with refractory ulcerative colitis (UC). Pouchitis occurs in 20–50% of these patients. Fecal calprotectin is a biomarker that correlates well with the pouchitis disease activity index. However, its role in the diagnosis and management of acute pouchitis has not been thoroughly defined. The aim of this study is to review previously established cut-off values and contextualize the clinical utility of fecal calprotectin. Search of Medline, EMBASE, CENTRAL, and PubMed was performed. Articles were eligible if they measured fecal calprotectin in the setting of pouchitis in patients who underwent TPC with IPAA for UC. Risk of bias of the included studies was evaluated with the QUADAS-2. From 117 relevant citations, seven studies with 256 patients (44.8% female, 39.88 years) met inclusion criteria. The pooled prevalence of pouchitis was 42%. The derived fecal calprotectin cut-off values ranged from 56 to 494 μg/g. The corresponding sensitivities and specificities ranged from 57 to 100% and 38 to 92%, respectively. The area under the curve was reported in three studies and ranged from 0.832 to 0.840. Fecal calprotectin may be a reliable diagnostic tool for acute pouchitis in patients following TPC with IPAA for UC. The high sensitivity of fecal calprotectin for detection of pouchitis makes it a valuable test for ruling out pouchitis. When used in conjunction with other biomarkers, the high specificity offers value in ruling in pouchitis. However, given the complexity of this disease process, relying solely on biomarkers for diagnosis is currently unreasonable.

Despite the widespread implementation of the acute care surgery (ACS) model, limited access to operating room time represents a barrier to the optimal delivery of emergency general surgery (EGS) care. The objective of this study was to describe the effect of operative timing on outcomes in EGS in a network of teaching hospitals.We conducted a retrospective review of EGS operations performed at 3 teaching hospitals in a single academic network. Time of operation was categorized as daytime (8 am to 5 pm), after hours (5 pm to 11 pm) or overnight (11 pm to 8 am). Time to operation was calculated as the interval from admission to operative start time and categorized as less than 24 hours, 24-72 hours and greater than 72 hours.After we excluded nonindex cases, trauma cases and cases occurring more than 5 days after admission, 1505 EGS cases were included. We found that 39.0% of operations were performed in the daytime, 46.3% after hours and 14.8% overnight. In terms of time to operation, 52.3% of operations were performed within 24 hours of admission, 33.4% in 24-72 hours and 14.3% in more than 72 hours. The overall complication rate was 20.6% (310 patients) and the overall mortality rate was 3.8% (57 patients). After multivariable analysis, time to operation more than 72 hours after admission was independently associated with increased odds of morbidity (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.09-2.47), while overnight operating was associated with increased odds of death (OR 3.15, 95% CI 1.29-7.70).Increasing time from admission to operation and overnight operating were associated with greater morbidity and mortality, respectively, for EGS patients. Strategies to provide timely access to the operating room should be considered to optimize care in an ACS model.Même si le modèle de chirurgie en soins actifs (CSA) est largement répandu, l’accès limité aux blocs opératoires représente un obstacle à la chirurgie générale chez les patients des services d’urgence (CGSU). L’objectif de cette étude était de décrire l’effet du moment de l’intervention sur l’issue des CGSU dans un réseau d’hôpitaux universitaires.Nous avons procédé à une revue des CGSU effectuées dans 3 hôpitaux d’enseignement d’un réseau universitaire. Le moment opératoire était catégorisé selon que les interventions étaient effectuées le jour (8 h 00 à 17 h 00), le soir (17 h 00 à 23 h 00) ou la nuit (23 h 00 à 8 h 00). Le délai opératoire représentait l’intervalle entre l’admission et le début de l’intervention et était réparti selon les catégories suivantes : moins de 24 heures, de 24 à 72 heures et plus de 72 heures.Après exclusion des cas non index, des cas de traumatologie et des cas survenus plus de 5 jours après l’admission, 1505 CGSU ont été incluses. Nous avons constaté que 39,0 % des interventions avaient été effectuées le jour, 46,3 % le soir et 14,8 % la nuit. Pour ce qui est du délai opératoire, 52,3 % des interventions ont été effectuées dans les 24 heures suivant l’admission, 33,4 % dans les 24 à 72 heures et 14,3 % plus de 72 heures après l’admission. Le taux global de complications a été de 20,6 % (310 patients) et le taux de mortalité global a été de 3,8 % (57 patients). Après analyse multivariée, le délai opératoire de plus de 72 heures suivant l’admission a été associé de manière indépendante à un risque accru de morbidité (rapport ces cotes [RC] 1,64, intervalle de confiance [IC]) de 95 % 1,09 à 2,47), tandis que les interventions effectuées la nuit ont été associées à un risque de décès plus élevé (RC 3,15, IC de 95 % 1,29 à 7,70).L’augmentation du délai entre l’admission et l’intervention et les interventions de nuit ont été associées à une morbidité et une mortalité plus élevées, respectivement, chez les patients soumis à des CGSU. Des stratégies visant à offrir un accès rapide aux blocs opératoires sont à envisager pour optimiser le modèle de CSA.

The purpose of this study was to conduct a systematic review of the existing literature to determine the effect of bariatric surgery on various pharmacokinetic parameters of oral antibiotic absorption as well as overall patient outcomes. MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to February 2020. Outcomes of interest included change in pharmacokinetic parameters of oral antibiotics administered to patients following bariatric surgery, using variables such as maximum plasma concentration (Cmax), time to reach maximum plasma concentration (Tmax), area under the concentration-time curve (AUC), clearance, and volume of distribution. MINORS and Cochrane risk of bias tools were used to assess quality of evidence. Ten studies with 100 patients assessing 8 oral antibiotics were included. The majority (77%) of patients underwent Roux-en-Y gastric bypass (RYGB), with fewer undergoing ventral banded gastroplasty (VBG) (14%), jejunoileostomy (6%), and jejunoileal bypass (3%). Antibiotic classes investigated included beta-lactams (5 studies), fluoroquinolones (2 studies), macrolides (2 studies), and oxazolidinones (1 study). Heterogeneity between studies precluded meaningful pooling or meta-analysis of data. Overall risk of bias was fair. Patients given oral beta-lactams and macrolides warrant close monitoring due to unpredictable absorption post-bariatric surgery, whereas oral fluoroquinolones and linezolid may not be affected. Several studies also showed decreased absorption following RYGB, as well as lower serum exposure in patients with obesity compared to non-obese controls. Clinicians should monitor patients on a case-by-case basis for signs of antibiotic failure or toxicity and reassess dosing accordingly.

Enhanced recovery after surgery (ERAS) protocols have been effective in improving postoperative recovery after major abdominal surgeries including colorectal cancer surgery, however its impact after gastric cancer surgery is unclear. A systematic review and meta-analysis was conducted to evaluate the effect of ERAS after gastric cancer surgery. Medline, EMBASE, CENTRAL, and PubMed was searched from database inception to December 2018. Randomized controlled trials (RCTs) comparing ERAS versus standard care in gastric cancer surgery were included. Outcomes included the postoperative length of stay (LOS), hospital costs, time to first flatus, defecation, oral intake, and ambulation after surgery, and complications. Pooled estimates were calculated using random-effects meta-analysis. The GRADE approach assessed overall quality of evidence. 18 RCTs involving 1782 patients were included. ERAS significantly reduced the LOS (Mean Difference (MD) -1.78 days, 95%CI -2.17 to -1.40, P 0.0001), reduced hospital costs (MD -650 U S. dollars, 95%CI -840 to -460, P 0.0001), and reduced time to first flatus, defecation, ambulation, and oral intake. ERAS had significantly lower rates of pulmonary infections (Risk Ratio (RR) 0.48, 95%CI 0.28 to 0.82, P = 0.007), but not surgical site infections, anastomotic leaks, and postoperative complications. However, ERAS significantly increased readmissions (RR 2.43, 95%CI 1.09 to 5.43, P = 0.03). The quality of evidence was low to moderate for all outcomes. Implementation of an ERAS protocol may reduce LOS, costs, and time to return of function after gastric cancer surgery compared to conventional recovery. However, ERAS may increase the number of postoperative readmissions, albeit with no impact on the rate of postoperative complications.

We hypothesized that patients living in rural neighborhoods experience delayed access to surgical services manifesting in increased appendiceal perforation rates in cases of appendicitis. This population-based cohort study included adult patients with acute appendicitis in Canada (excluding Quebec) between April 2008 and March 2015. The main outcome of interest was rate of perforation. Predictors of interest included socioeconomic, geographic, and individual predictors of perforation. Spatial analysis was used to analyze spatial clustering of perforation. We identified 143,195 patients throughout the course of the study. The average perforation rate across our study was 35.9% (n = 51,456). Cluster analysis identified 286 (24%) neighborhoods with perforation rates greater than the average. Rural neighborhoods had a 1.89 times higher odds of being in a high perforation cluster (95% CI 1.08–3.08, p = 0.024). Compared to neighborhoods > 75 km from the admitting hospital, closer neighborhoods were less likely to be in a high perforation cluster (0–35 km OR 0.64, 95% CI 0.38–0.98, p = 0.049; 36–75 km OR 0.60, 95% CI 0.37–0.92, p = 0.019). Patients admitted to small community hospitals had a 0.51 times lower odds of perforation than those admitted to academic centers (95% CI 0.47–0.54, p

Obesity is associated with increased breast cancer risk in women. Bariatric surgery induces substantial weight loss. However, the effects of such weight loss on subsequent breast cancer risk in women with obesity are poorly understood. To examine breast cancer incidence and related outcomes in women with obesity undergoing bariatric surgery.This was a population-based matched cohort study of breast surgery outcomes utilizing linked clinical databases in Ontario, Canada. Women with obesity who underwent bariatric surgery were 1:1 matched using a propensity score to non-surgical controls for age and breast cancer screening history. The main outcomes were incidence of breast cancer after lag periods of 1, 2, and 5 years. Additional outcomes included tumor hormone receptor status, cancer stage, and treatments undertaken. Time-varying Cox proportional hazard models accounting for screening during follow-up were used to model cancer incidence.A total of 12,724 women per group were included, average age 45.09. After a 1-year lag, breast cancer incidence occurred in 1.09% and 0.79% of the control and surgery groups, respectively (adjusted hazard ratio, 0.81 [95%CI 0.69-0.95]; p = 0.01). This association was maintained after lag periods of 2 and 5 years. Women in the surgical cohort diagnosed with breast cancer were more likely to have low-grade tumors and less likely to have high-grade tumors (overall p 0.01). No association was found for tumor hormone receptor status, although the surgical group was more likely to have her2neu-negative tumors (p = 0.01).Bariatric surgery was associated with a lower incidence of breast cancer and lower tumor grade in women with obesity. Further evaluation of outcomes, including mortality, is required.

Key Points Question Do the 4-year health care expenditures associated with Roux-en-Y gastric bypass (RYGB) differ from those associated with sleeve gastrectomy? Findings In this population-based, matched cohort study of 1624 patients receiving either RYGB or sleeve gastrectomy in Ontario, Canada, there was no statistically significant difference in mean health care expenditures between RYGB and sleeve gastrectomy 4 years after the procedures ($33 682 vs $33 948, respectively). Meaning These results may help to inform patients, surgeons, and policy makers on the relative values of RYGB and sleeve gastrectomy., Importance Data on the long-term health care expenditures associated with bariatric surgery consisting of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are lacking. Objective To compare 4-year health care expenditures after RYGB vs sleeve gastrectomy, identify factors independently associated with 4-year health care expenditures, and compare the procedures in terms of subsequent hospitalizations, bariatric procedures, and all-cause mortality. Design, Setting, and Participants In this propensity score–matched cohort study, all residents of Ontario, Canada, who underwent publicly funded surgery with RYGB (n = 6301) or sleeve gastrectomy (n = 926) from March 1, 2010, to March 31, 2015, and consented to participate in the Ontario Bariatric Registry were eligible for the study. Follow-up was completed on March 31, 2019, and data were analyzed from May 5, 2020, to May 20, 2021. Interventions RYGB and sleeve gastrectomy. Main Outcomes and Measures Publicly funded health care expenditures, subsequent hospitalizations, bariatric procedures, and mortality during the 4 years after RYGB or sleeve gastrectomy. Results The 1:1 matched study cohorts consisted of 1624 patients (812 per cohort) with a mean (SD) age of 48.0 (10.6) years, and 1242 women (76.5%). The mean body mass index (calculated as weight in kilograms divided by height in square meters) was 51.9 (8.3) for the RYGB cohort and 51.9 (8.9) for the sleeve gastrectomy cohort. The 4-year cumulative costs were not statistically significantly different between RYGB and sleeve gastrectomy (mean [SD], $33 682 [$31 169] vs $33 948 [$32 633], respectively; P = .86). Having a history of coronary artery disease was associated with a 35% increase in overall health care expenditures; chronic kidney disease, a 54% increase; and mental health admissions, a 67% increase. There were no statistically significant differences in all-cause mortality between RYGB and sleeve gastrectomy (1.5% vs 2.2%, respectively; P = .26) or the total number of hospitalizations (754 vs 669, respectively; P = .11) during the 4-year follow-up period. However, nonelective hospitalizations occurred more frequently with RYGB vs sleeve gastrectomy (472 vs 339, respectively; P = .002). Roux-en-Y gastric bypass was associated with relatively fewer subsequent bariatric procedures during the 4-year follow-up period (9 vs 40, respectively; P, This propensity score–matched cohort study compares the 4-year health care expenditures of matched cohorts of patients undergoing Roux-en-Y gastric bypass vs sleeve gastrectomy and, secondarily, assesses factors independently associated with expenditures and compares them between procedures.

The general management for chronic kidney disease (CKD) includes treating reversible causes, including obesity, which may be both a driver and comorbidity for CKD. Bariatric surgery has been shown to reduce the likelihood of CKD progression and improve kidney function in observational studies. We performed a systematic review and meta-analysis of patients with at least stage 3 CKD and obesity receiving bariatric surgery. We searched Embase, MEDLINE, CENTRAL and identified eligible studies reporting on kidney function outcomes in included patients before and after bariatric surgery with comparison to a medical intervention control if available. Risk of bias was assessed with the Newcastle-Ottawa Risk of Bias score. Nineteen studies were included for synthesis. Bariatric surgery showed improved eGFR with a mean difference (MD) of 11.64 (95%CI: 5.84 to 17.45, I2 = 66%) mL/min/1.73m2 and reduced SCr with MD of -0.24 (95%CI -0.21 to -0.39, I2 = 0%) mg/dL after bariatric surgery. There was no significant difference in the relative risk (RR) of having CKD stage 3 after bariatric surgery, with a RR of -1.13 (95%CI: -0.83 to -2.07, I2 = 13%), but there was reduced likelihood of having uACR >30 mg/g or above with a RR of -3.03 (95%CI: -1.44 to -6.40, I2 = 91%). Bariatric surgery may be associated with improved kidney function with the reduction of BMI and may be a safe treatment option for patients with CKD. Future studies with more robust reporting are required to determine the feasibility of bariatric surgery for the treatment of CKD. This article is protected by copyright. All rights reserved.

OBJECTIVE The aim of this study was to compare weight loss, obesity-related comorbidities, and biochemical outcomes of LSG versus LRYGB through a meta-analysis of randomized controlled trials (RCTs). SUMMARY OF BACKGROUND DATA LSG and LRYGB are the 2 most commonly performed bariatric surgeries for the treatment of obesity. The comparative outcomes of the 2 surgeries is a topic of ongoing debate and medium-term outcomes remain uncertain. METHODS A search for RCTs comparing LRYGB versus LSG was conducted. Pooled outcomes between 2 procedures were compared using pairwise random-effects meta-analysis at 1, 3, and 5-year follow-up time points. Grading of recommendations, assessment, development, and evaluation was used to assess certainty of evidence. RESULTS Thirty-three studies involving 2475 patients were included. LRYGB resulted in greater loss of body mass index compared to LSG at 1 year [mean difference -1.25 kg/m2, 95% confidence interval (CI) -2.01 to -0.49, P = 0.001; moderate certainty of evidence] which persisted at 3 years, but there was insufficient evidence at 5 years. Resolution of dyslipidemia was higher for LRYGB than LSG at 1 year (risk ratio 0.58, 95% CI 0.46-0.73, P < 0.001; moderate certainty of evidence) and 5 years (risk ratio 0.68, 95%CI 0.46-0.99, P = 0.04; low certainty of evidence). There was no difference between LRYGB and LSG for remission of type 2 diabetes, hypertension, and hemoglobin A1c, fasting insulin, homeostatic model assessment of insulin resistance, high-density lipoprotein, and the rate of 30-day major and minor complications. CONCLUSIONS There are insufficient data from RCTs to draw any conclusions regarding the long-term comparative effectiveness beyond 3 years between LRYGB and LSG.

Background/Purpose Appendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system. Methods Using administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression. Results Over the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those > 125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31–4. 02, p = 0.001; and OR 2.55, 95%CI 1.35–4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates. Conclusions In this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada. Level of evidence Prognosis study, level II.

BACKGROUND The purpose of this study was to examine factors affecting morbidity and cost after pediatric appendectomy and particularly the role of adult surgical volume. MATERIALS AND METHODS This was population-based study including all pediatric patients who underwent appendectomy for appendicitis in Canada (excluding Quebec) from 2008 to 2015. All-cause morbidity was the main outcome of interest. Cost of the index admission (in 2014 Canadian dollars) was a secondary outcome. Hierarchal linear and logistic regressions were used to model the outcomes. RESULTS Overall, 41,512 patients were identified. After adjustment, younger patients (OR = 0.98/year, 95%CI 0.97-0.99, p

Background In 2013, 18% of Canadian adults had obesity (body mass index [BMI] >30 kg/m2), compared with 25.7% of Canada's Indigenous population. Bariatric surgery is an effective treatment for obesity, but has not been studied in Canadian Indigenous populations. Objectives To determine the effects of bariatric surgery in the Indigenous Ontario population. Setting Multicenter data from the publicly funded Ontario bariatric program and registry. Methods Prospectively collected data using all surgical patients between March 2010 and 2018 was included in initial analysis and included the following postoperative outcomes: diabetes, hypertension, and gastroesophageal reflux disease. Demographic characteristics, baseline characteristics, and univariate outcomes were assessed using Pearson Χ2 or t tests. Multivariable regression for BMI change was used with complete case analysis and multiple imputation. Results Of 16,629 individuals initially identified, 338 self-identified as Indigenous, 13,502 as Non-Indigenous, and 2789 omitted ethnicity and were excluded. Baseline demographic characteristics were not statistically different; rates of hypertension (P = .03) and diabetes (P Conclusions Weight loss and resolution of obesity-related co-morbidities are similar in Indigenous and Non-Indigenous patients. Access to surgery, patient selection, and long-term results merit further investigation.

OBJECTIVES To systematically review and meta-analyse the impact of bariatric surgery on obese patients with urinary incontinence (UI). METHODS A search of the Medical Literature Analysis and Retrieval System Online (MEDLINE), the Excerpta Medica dataBASE (EMBASE), Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed to June 2018 was performed using methods pre-published on the International Prospective Register of Systematic Reviews (PROSPERO). Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Studies comparing UI status in obese patients before and after bariatric surgery were included. Primary outcomes were the improvement or complete resolution of any UI, stress UI (SUI), and urgency UI (UUI). Secondary outcomes were validated UI questionnaire scores. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach assessed overall quality of evidence. RESULTS In all, 33 cohort studies (2910 patients) were included (median follow-up 12 months). Bariatric surgery resulted in improvement or resolution of any UI in 56% (95% confidence interval [CI] 48-63%), SUI in 47% (95% CI 34-60%), and UUI in 53% (95% CI 32-73%) of patients. Moreover, bariatric surgery significantly decreased (P

BACKGROUND The morbidity and mortality associated with colorectal resections are responsible for significant healthcare use. Identification of efficiencies is vital for decreasing healthcare cost in a resource-limited system. OBJECTIVE The purpose of this study was to characterize the short-term cost associated with all colon and rectal resections. DESIGN This was a population-based, retrospective administrative analysis. SETTINGS This analysis was composed of all colon and rectal resections with anastomosis in Canada (excluding Quebec) between 2008 and 2015. PATIENTS A total of 108,304 patients ≥18 years of age who underwent colon and/or rectal resections with anastomosis were included. MAIN OUTCOME MEASURES Total short-term inpatient cost for the index admission and the incremental cost of each comorbidity and complication (in 2014 Canadian dollars) were measured. Cost predictors were modeled using hierarchical linear regression and Monte Carlo Markov Chain estimation. RESULTS Multivariable regression demonstrated that the adjusted average cost of a 50-year-old man undergoing open colon resection for benign disease with no comorbidities or complications was $9270 ((95% CI, $7146-$11,624; p =

Background Enhanced recovery after surgery (ERAS) protocols after colorectal surgery use several perioperative, intraoperative and postoperative interventions that decrease morbidity, length of stay, and improve patient satisfaction. ERAS is increasingly being considered standard of care; however, uptake of formalized protocols remains low. The objective is to characterize the provincial rates of ERAS utilization after colorectal surgery and identify barriers and limitations to ERAS implementation. Methods A total of 797 general surgeons were identified through the College of Physicians and Surgeons of Ontario. A survey identifying demographics, rates of ERAS utilization, and barriers to implementation was distributed. Logistic regression determined the effects of demographic and hospital covariates on ERAS utilization. Results A total of 235 general surgeons representing 84 Ontario hospitals participated (response rate 29.5%). Surgeons working in academic or large community hospitals represented the majority of the cohort (30.5% and 47.2%, respectively). Multivariable analysis showed no significant effect of surgeon demographics, years in practice, or training details on ERAS protocol utilization; however, practicing in small community hospitals (compared with large and academic hospitals) was significantly associated with not using ERAS protocols (odds ratio, 0.02; 95% confidence interval, 0-0.3; P = 0.005). Over 50% of respondents used ERAS principles but did not have a formal protocol. Barriers to implementing ERAS protocols included patient variability, lack of institutional and nursing support, and poor communication with the care team. Conclusions Small community hospitals are less likely to use formal ERAS protocols; however, most Ontario surgeons are using ERAS principles after colorectal surgery. Barriers to ERAS implementation are broad and the present study has provided a pragmatic solution to change.

Background Intra-abdominal abscesses account for a large proportion of surgical complications and carry high mortality if not promptly controlled. Image-guided percutaneous drainage is standard of care. The objective of the study was to identify factors that predict abscess recurrence after percutaneous drain (PD) removal and determine if imaging before drain removal effects recurrence. Methods A consecutive multicenter retrospective cohort analysis of all patients who underwent PD insertion for abscesses between January 1, 2015, and December 31, 2015, was performed. Patient characteristics, PD details, and abscess recurrence were assessed. Results One hundred eighty-eight patients underwent PD insertion for spontaneous or postoperative abscesses, and overall abscess recurrence was 21%. Drains remained in situ for a median of 21.5 d (interquartile range: 9-42 d) with antibiotics used in 91% of cases. Forty-seven patients (25%) had a sinogram before PD removal, while 22% had computed tomography (CT) scans and 11% had ultrasounds. Hierarchical multivariable regression analysis showed that imaging before PD removal was associated with a 66% reduction in the odds of abscess recurrence (OR 0.34; 95% confidence interval [CI] 0.13-0.70; P = 0.006). Sinogram use was associated with an 86% reduction in the odds of recurrence (OR 0.14; 95% CI 0.02-0.39; P = 0.002) and ultrasound use was associated with a 78% reduction in the odds of recurrence (OR 0.22; 95% CI 0.02-0.76; P = 0.044) while CT use was not associated with a significant reduction in recurrence. Conclusions Imaging before PD removal is associated with a reduction in the rates of abscess recurrence and requirement for additional drainage procedures or surgery. In addition, CT is not superior to ultrasound or sinograms as an imaging modality.

Iron deficiency (ID) and iron deficiency anemia (IDA) are common following bariatric surgery; however, there are limited standardized treatment recommendations for their management. The purpose of this study was to review the current strategies for iron supplementation following bariatric surgery and assess their relative efficacy in managing ID and IDA. MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched to January 2021. Primary outcomes of interest were prevention or improvement in ID or IDA with iron supplementation. Forty-nine studies with 12,880 patients were included. Most patients underwent Roux-en-Y gastric bypass (61.9%). Iron supplementation was most commonly administered orally for prevention of ID/IDA and was effective in 52% of studies. Both IV and oral iron were given for treatment of ID/IDA. Fifty percent (3/6) of the oral and 100% (3/3) of the IV supplementation strategies were effective at treating ID. Iron supplementation strategies employed following bariatric surgery are highly variable, and many do not provide sufficient iron to prevent the development of ID and IDA, potentially due to poor patient adherence. Further high-quality prospective trials, particularly comparing intravenous and oral iron, are warranted in order to determine the ideal dosage, route, and duration of iron supplementation.

Background: Bariatric surgery has been shown to significantly reduce cardiovascular risk factors. However, whether surgery can reduce major adverse cardiovascular events (MACE), especially in patients with established cardiovascular disease, remains poorly understood. The present study aims to determine the association between bariatric surgery and MACE among patients with cardiovascular disease and severe obesity. Methods: This was a propensity score–matched cohort study using province-wide multiple-linked administrative databases in Ontario, Canada. Patients with previous ischemic heart disease or heart failure who received bariatric surgery were matched on age, sex, heart failure history, and a propensity score to similar controls from a primary care medical record database in a 1:1 ratio. The primary outcome was the incidence of extended MACE (first occurrence of all-cause mortality, myocardial infarction, coronary revascularization, cerebrovascular events, and heart failure hospitalization). Secondary outcome included 3-component MACE (myocardial infarction, ischemic stroke, and all-cause mortality). Outcomes were evaluated through a combination of matching via propensity score and subsequent multivariable adjustment. Results: A total of 2638 patients (n=1319 in each group) were included, with a median follow-up time of 4.6 years. The primary outcome occurred in 11.5% (151/1319) of the surgery group and 19.6% (259/1319) of the controls (adjusted hazard ratio [HR], 0.58 [95% CI, 0.48–0.71]; P P P P =0.001) and cardiovascular mortality (HR, 0.35 [95% CI, 0.15–0.80]; P =0.001). Conclusions: Bariatric surgery was associated with a lower incidence of MACE in patients with cardiovascular disease and obesity. These findings require confirmation by a large-scale randomized trial.

Introduction: Obesity (body mass index [BMI] >35 kg/m2) remains a relative contraindication for kidney transplant, while patients after kidney transplantation (KTX) are predisposed to obesity. The present study aims to investigate the role of bariatric surgery in improving transplant candidacy in patients prior to KTX, as well its safety and efficacy in KTX patients postoperatively. Methods: A systematic search was conducted up to March 2020. Both comparative and non-comparative studies investigating the role of bariatric surgery before or after KTX were considered. Outcomes included change in BMI, rates of mortality and complications, and the rate of patients who underwent KTX following bariatric surgery. Pooled estimates were calculated using the random effects meta-analysis of proportions. Results: Twenty-one studies were eligible for final review; 11 studies investigated the role of bariatric surgery before KTX. The weighted mean BMI was 43.4 (5.7) kg/m2 at baseline and 33.9 (6.3) kg/m2 at 29.1 months followup. After bariatric surgery, 83% (95% confidence interval [CI] 57–99) were successfully listed for KTX and 83% (95% CI 65–97) patients subsequently received successful KTX. Ten studies investigated the role of bariatric surgery after kidney transplant. Weighted mean baseline BMI was 43.8 (2.2) kg/m2 and mean BMI at 19.5 months followup was 34.2 (6.7) kg/m2. Overall, all-cause 30-day mortality was 0.5% for both those who underwent bariatric surgery before or after receiving a KTX. The results of this study are limited by the inclusion of only non-randomized studies, limited followup, and high heterogeneity. Conclusions: Bariatric surgery may be safe and effective in reducing weight to improve KTX candidacy in patients with severe obesity and can also be used safely following KTX.

The effect of bariatric surgery on natriuretic peptide levels in patients with obesity is unclear. The purpose of this study was to conduct a systematic review and meta-analysis to determine the effect of bariatric surgery on B-type natriuretic peptide (BNP) and aminoterminal BNP (NT-proBNP) levels. MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched to February 2020. Primary outcomes included change in NT-proBNP or BNP levels following bariatric surgery and change in weight and body mass index. Secondary outcomes included change in blood pressure, echocardiographic findings, and heart failure symptoms. MINORS tool was used to assess quality of evidence. Twelve studies with 622 patients were included. Most patients underwent Roux-en-Y gastric bypass (RYGB) (70.5%). Mean absolute reduction in body mass index was 23%. NT-proBNP levels increased significantly from baseline at 6 months (mean difference [MD] 53.67 pg/mL; 95% confidence interval [CI], 28.72-78.61; P ≤ 0.001, I2 = 99%; 8 studies) and 12 months (MD 51.16 pg/mL; 95% CI, 20.46-81.86; P = 0.001, I2 = 99%; 8 studies) postbariatric surgery. BNP levels also increased significantly at 6 months (MD 17.57 pg/mL; 95% CI, 7.62-27.51; P0.001, I2 = 95%; 4 studies). Systolic and diastolic blood pressure decreased significantly 12 months after surgery. Studies measuring echocardiographic findings saw improvement in left ventricle mass and the E/A ratio, but no significant change in ejection fraction. Bariatric surgery is associated with increased natriuretic peptide levels in the absence of deteriorating cardiac function, and may be associated with improved cardiac and metabolic function after the procedure.

Class 2 obesity or greater (body mass index [BMI] >35 kg/m) is a relative contraindication for heart transplant due to its associated perioperative risks and mortality. Whether bariatric surgery can act as a potential bridging procedure to heart transplantation is unknown. The aim of this systematic review and meta-analysis is to investigate the role of bariatric surgery on improving transplant candidacy in patients with end-stage heart failure (ESHF). MEDLINE, EMBASE, CENTRAL, and PubMed databases were searched up to September 2019 for studies that performed bariatric surgery on patients with severe obesity and ESHF. Outcomes of interest included incidence of patients listed for heart transplantation after bariatric surgery, proportion of patients that successfully received transplant, the change in BMI after bariatric surgery, and 30-day complications. Pooled estimates were calculated using a random effects meta-analysis of proportions. Eleven studies with 98 patients were included. Mean preoperative BMI was 44.9 (2.1) kg/m and BMI after surgery was 33.2 (2.3) kg/m with an absolute BMI reduction of 26.1%. After bariatric surgery, 71% (95% confidence interval [CI], 55%-86%) of patients with ESHF were listed for transplantation. The mean time from bariatric surgery to receiving a heart transplant was 14.9 (4.0) months. Of the listed patients, 57% (95% CI, 39-74%) successfully received heart transplant. The rate of 30-day mortality after bariatric surgery was 0%, and the 30-day major and minor complications after bariatric surgery was 28% (95% CI, 10%-49%). Bariatric surgery can facilitate sustained weight loss in obese patients with ESHF, improving heart transplant candidacy and the incidence of transplantation.

Objective While bariatric surgery induces remission of type 2 diabetes mellitus and reduces other microvascular complications, its impact on diabetic retinopathy (DR) is unclear. Some trials suggest early worsening of DR postsurgery because of rapid improvements in hyperglycemia. This meta-analysis sought to estimate the impact of bariatric surgery on DR for obese patients compared with medical treatment. Design Systematic review and meta-analysis. Methods The Medline, Embase, and PubMed Central databases were searched to March 2020. Primary studies comparing DR in patients undergoing bariatric surgery with those undergoing medical management were included. Results were meta-analyzed using a random-effects model. Primary outcomes included prevalence of all DR and sight-threatening DR after surgery. Secondary outcomes included worsening of DR within and beyond 12 months. Results Overall, 14 studies comprised of 110,300 surgical patients and 252,289 control subjects were included. Surgical patients had a statistically significantly lower postoperative prevalence of all DR (relative risk [RR] 0.17 [95% confidence interval {CI} 0.13-0.22]) and sight-threatening DR (RR 0.47 [95% CI 0.27-0.82]). Early worsening of DR and progression to sight-threatening DR had occurred more often in those with more severe DR initially. However, beyond 12 months, bariatric surgery resulted in significantly fewer patients with worsened DR (RR 0.29 [95% CI 0.16-0.54]). The overall risk of bias was low; estimates of relative effects had low to moderate certainty of evidence. Conclusion While bariatric surgery was associated with fewer cases of all and sight-threatening DR, early worsening was more severe in patients with existing sight-threatening DR. These findings argue for frequent monitoring during the first postoperative year.

Background Mortality after bariatric surgery has been previously studied, but cohort selection bias, completeness of follow-up, and collection of confounders have limited the inference of results. Objective To determine the association between bariatric surgery and all-cause mortality. Design Population-based matched cohort study. Setting Ontario, Canada. Participants 13 679 patients who underwent bariatric surgery from January 2010 to December 2016 and 13 679 matched nonsurgical patients. Intervention Bariatric surgery. Measurements The primary outcome was all-cause mortality, with cause-specific mortality as the secondary outcome. Patients were matched according to age, sex, body mass index, and diabetes duration. Results 13 679 patients who underwent bariatric surgery were matched to 13 679 nonsurgical patients. After a median follow-up of 4.9 years, the overall mortality rate was 1.4% (n = 197) in the surgery group and 2.5% (n = 340) in the nonsurgery group, with a lower adjusted hazard ratio (HR) of overall all-cause mortality (HR, 0.68 [95% CI, 0.57 to 0.81]). Patients aged 55 years or older had an absolute risk reduction of 3.3% (CI, 2.3% to 4.3%), with a lower HR of mortality in the surgery group (HR, 0.53 [CI, 0.41 to 0.69]). Observed relative effects were similar across sex; however, the observed association in absolute terms was greater in men. Surgery also was associated with lower cardiovascular mortality (HR, 0.53 [CI, 0.34 to 0.84]) and lower cancer mortality (HR, 0.54 [CI, 0.36 to 0.80]). Limitation The observational design limits causal inference. Conclusion Bariatric surgery was associated with substantially lower all-cause, cardiovascular, and cancer mortality. The lowered observed mortality of surgery was significant across most subgroups. The largest absolute effects were for men and patients aged 55 years or older. Primary funding source Ontario Bariatric Network.

Bariatric surgery in older patients is safe and effective. Current guidelines do not endorse age limits for surgery; however, older patients may encounter difficulties with access given perceived risks. This study compares the adjusted probability of failing to receive bariatric surgery between older (≥ 60 years) and younger ( 60 years) patients referred to a publicly funded program.This is a retrospective cohort study of adult patients referred to a bariatric surgery program in Ontario from 2010-2016. Ontario health administrative databases and the Ontario Bariatric Registry were used for the analysis. The primary outcome was receipt of bariatric surgery within 3 years of referral. A multivariable logistic regression analysis was performed to determine the adjusted effect of older age (≥ 60 years) on the probability of not receiving surgery. Sensitivity analysis was performed using only healthy patients.Among 19,510 patients referred to the program, 1,795 patients (9.2%) were ≥ 60 years old, of which 60% received bariatric surgery within 3 years compared to 90% in younger patients. The odds older patients do not receive surgery after adjustment were significantly higher compared to younger patients (OR 1.69 [1.52-1.88], P .001). This effect persists even among a subgroup of older patients with a Charlson Comorbidity Index = 0 (OR 1.78 [1.56-2.04], P .001).Age alone, rather than comorbidities had a more significant effect on the access to bariatric surgery in older patients. Given the demonstrated benefits of bariatric surgery in older populations, ensuring equity in access to bariatric surgery should be encouraged. Future research is required to explore the underlying reasons why older patients who could benefit from bariatric surgery may not have the opportunity.

Importance Results of previous studies are mixed regarding the economic implications of a Roux-en-Y gastric bypass (RYGB). Objective To assess the 5-year incremental health care use and expenditures after RYGB. Design, Setting, and Participants This population-based cohort study conducted in Ontario, Canada, used a difference-in-differences approach to compare health care use and expenditures between patients who underwent a publicly funded RYGB from March 1, 2010, to March 31, 2013, and propensity score–matched control individuals who did not undergo a surgical bariatric procedure. The study period allowed for a minimum 60 months of follow-up because, at that time, the most recent date for which administrative data on health care and expenditures were available was March 31, 2018. Data sources included the Ontario Bariatric Registry linked to several Ontario health administrative databases and the Electronic Medical Record Administrative Data Linked Database. Health care use and expenditures data for 5 years before and 5 years after the index date (procedure date for RYGB group; random date for controls) were analyzed. Data analyses were performed March 12, 2019, to March 10, 2020. Intervention RYGB procedure. Main Outcomes and Measures The primary outcome was total health care expenditures. Results The final propensity score–matched cohorts comprised 1587 individuals in the RYGB group (mean [SD] age, 47 [10.2] years) and 1587 controls (mean [SD] age, 47 [12.2] years); each group had 1228 women (77.4%) and a mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 46. Mean total health care expenditures (2017 Canadian dollars) per patient in the RYGB group increased from CAD $15 594 (95% CI, CAD $14 743 to CAD $16 614) (US $12 008 [95% CI, US $11 353 to US $12 794]) in the 5 years before the procedure to CAD $30 389 (95% CI, CAD $28 789 to CAD $32 232) (US $23 401 [95% CI, US $22 169 to US $24 821]) over the 5 years after the procedure, a difference of CAD $14 795 (95% CI, CAD $13 172 to CAD $16 480) (US $11 393 [95% CI, US $10 143 to US $12 691]). For the control group, mean total health care expenditures per individual increased from CAD $16 109 (95% CI, CAD $14 727 to CAD $17 591) (US $12 405 [95% CI, US $11 341 to US $13 546]) 5 years before the index date to CAD $20 073 (95% CI, CAD $18 147 to CAD $22 169) (US $15 457 [95% CI, US $13 974 to US $17 071]) 5 years after the date, a difference of CAD $3964 (95% CI, CAD $2250 to CAD $5875) (US $3053 [95% CI, US $1733 to US $4524]). Overall, the difference-in-differences estimate of the net cost of RYGB was CAD $10 831 (95% CI, CAD $8252 to CAD $13 283) (US $8341 [95% CI, $6355 to $10 229]) over the 5-year period. This amount excluded the mean (SD) cost associated with the index date: CAD $6501 (CAD $1087) (US $5006 [US $837]) for the RYGB cohort and CAD $9 (CAD $72) (US $7 [US $55]) for the controls. The cost differential was primarily associated with increased hospitalizations in the first months immediately after RYGB. Expenditures leveled off in year 3 after the index date; differences in total expenditures between the RYGB and control cohorts were not statistically significantly different in years 4 and 5. Conclusions and Relevance Health care expenditures in the 3 years after publicly funded RYGB were higher in patients who underwent the procedure than in control individuals, but the costs were similar thereafter. This finding suggests the need to decrease hospital and emergency department readmissions after surgical bariatric procedures because such use is associated with increased spending.

Immunosuppressed patients with diverticular disease are at higher risk of postoperative complications, however reported rates have varied. The aim of this study is to compare postoperative outcomes in immunosuppressed and immunocompetent patients undergoing surgery for diverticular disease.Medline, EMBASE, and CENTRAL were searched. Articles were included if they compared immunosuppressed and immunocompetent patients undergoing surgery for diverticular disease.From 204 citations, 11 studies with 2,977 immunosuppressed patients and 780,630 immunocompetent patients were included. Mortality was greater in immunosuppressed patients compared to immunocompetent patients for emergent surgery (RR 1.91, 95%CI 1.24-2.95, p 0.01), but not elective surgery (RR 1.70, 95%CI 0.14-20.47, p = 0.68). Morbidity was greater in immunosuppressed patients compared to immunocompetent patients for elective surgery (RR 2.18, 95%CI 1.02-4.65, p = 0.04), but not emergent surgery (RR 1.40, 95%CI 0.68-2.90, p = 0.37).Increased consideration for elective operation may preclude the need for emergent surgery and the associated increase in postoperative mortality.

Per-oral endoscopic myotomy (POEM) is an effective treatment for achalasia and other esophageal dysmotility disorders. Current practices surrounding post-operative care involve admission and routine esophagogram prior to discharge. This study aims to establish the safety and feasibility of same-day discharge following POEM.Retrospective analysis of prospectively collected data for patients who underwent POEM between November 2013 and June 2019 at a single institution in Ontario, Canada. Patients were discharged home on the same day with controlled pain, when tolerating clear fluids. Patients were admitted if clinically indicated. Esophagography was initially a systematic practice prior to discharge, but later only performed when clinically indicated. Emergency department visits and hospital admissions within 90 days were assessed.In total, 90 patients underwent a successful POEM procedure. A total of 72 patients (79.1%) were discharged on the same day, 14 patients (15.4%) were discharged home the following day, and 5 patients (5.5%) experienced longer admissions to hospital. One POEM was unsuccessful. 22 (24.2%) patients had adverse events, leading to 8 (8.8%) unplanned admissions, with one patient requiring prolonged admission for esophageal leak, identified clinically. Fifty-three patients underwent routine esophagography while part of our protocol, with no identified leak, which prompted our change in practice to only perform esophagography when clinically indicated. In the 90-day post-procedure, ten patients visited the emergency department, of which seven were re-admitted, five for POEM-related issues. Our mean Eckhardt score at 2 weeks was 2.1 from 7.2 preoperatively.This study establishes that same-day discharge is both safe and feasible following POEM and suggests that esophagography should be performed only when clinically indicated. This represents a shift from the routine practice of admission and imaging for patients undergoing POEM, encouraging the transition to outpatient POEM procedures.

INTRODUCTION AND OBJECTIVE:In patients with end-stage renal disease, kidney transplantation improves survival. However, due to safety and increased rates of graft failure, severe obesity (BMI > 35k...

Gastric bypass has a steep learning curve that is associated with increased adverse outcomes and these adverse outcomes are associated with increases in cost. This study sought to quantify the effect of cumulative procedure volume on inpatient cost and characterize the excess cost associated with a surgeon’s learning curve. This was a retrospective study of 29 high-volume surgeons during the first 6 years of performing gastric bypass in a regionalized center of excellence system. Cumulative volume was determined using the procedure date and analyzed in blocks of 25 cases. The main outcomes of interest were inpatient cost for the initial hospital stay in 2014 Canadian dollars as well as prolonged length of stay (≥ 3 days). Overall, 11,684 cases were identified from April 2009 to March 2015. After a surgeon’s 50th case, the adjusted inpatient cost decreased by $2775 (95% CI $− 4352 to $− 1204 p = 0.001) compared to the first 25 cases. Cost savings were maintained through a surgeon’s 400th case. The average cost savings after the 50th case was $2082 (95% CI $− 3194 to $− 962 p

While high-volume Centers of Excellence (COE) for bariatric surgery may have improved clinical outcomes, their disparate distribution results in longer travel distances for patients. The purpose of this study was to investigate effect of distance from COE on outcomes and readmission. This was a retrospective study of all adults, aged 18 years or older, receiving bariatric surgery from April 2009 to March 2012 in the province of Ontario. Main outcomes included 30-day complication rates and readmission. Multivariable logistic regression was used to examine the impact of distance from patients’ primary residence to their bariatric COE on patient outcomes and readmissions. Five thousand and seven patients were identified, two-thirds residing within 100 km of a COE with a mean distance of 117.2 km. The majority of patients did not reside within a Local Integrated Health Network (LHIN) that contained a COE, while 18.3% of patients lived in rural areas. Using multivariable adjustment, for every 10 km increase from the COE where surgery was performed, the Odds Ratio (OR) for complications was 1.00 [95% Confidence Interval (CI) 0.99–1.01; P = 0.747]. Additionally, both residing in a LHIN without a COE, OR 1.10 (95% CI 0.87–1.40; P = 0.434), and rural status, OR 0.97 (95% CI 0.77–1.23; P = 0.821) showed no increase in risk of complication. Similarly, further distances did not influence rate of readmission, OR 0.99 (95% CI 0.98–1.00; P = 0.077) nor did rural status OR 1.31 (95% CI 0.97–1.76; P = 0.076). The COE model, where a few centers in high population areas service a large geographic region, is adequate in ensuring patients that live further away receive appropriate short-term care.