Jerry T. Dang

Gastric Band Removal in Revisional Bariatric Surgery, One-Step Versus Two-Step: a Systematic Review and Meta-analysis

We aimed to systematically review the literature comparing the safety of one-step versus two-step revisional bariatric surgery from laparoscopic adjustable gastric banding (LAGB) to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). There is debate on the safety of removing the gastric band and performing revisional surgery immediately or in a delayed, two-step fashion due to potential higher complications in one-step revisions. A systematic and comprehensive search of the literature was conducted. Included studies directly compared one-step and two-step revisional surgery. Eleven studies were included with 1370 patients. Meta-analysis found comparable rates of complications, morbidity, and mortality between one-step and two-step revisions for both RYGB and SG groups. This suggests that immediate or delayed revisional bariatric surgeries are both safe options for LAGB revisions.

The Effect of Helicobacter pylori on Postoperative Outcomes in Patients Undergoing Bariatric Surgery: a Systematic Review and Meta-analysis

Helicobacter pylori (HP) occurs in 50% of people worldwide with higher rates reported in the bariatric population. HP has been associated with adverse outcomes following bariatric surgery; however, its true impact has not yet been defined. We aimed to systematically review the effect of HP on bariatric surgery outcomes. A comprehensive literature review was conducted yielding seven studies with 255,435 patients. Meta-analysis found comparable rates of bleeding, leak, hospital length of stay, and weight loss between HP-positive and HP-negative patients. HP was, however, found to be the largest independent predictor of marginal ulceration in those undergoing RYGB, with a tenfold increase versus HP-negative patients. Overall, HP is associated with increased marginal ulceration rates, but has little impact on other bariatric surgery outcomes.

Evaluating the safety of intragastric balloon: An analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program

BACKGROUND Laparoscopic bariatric surgery (LBS) is effective for severe obesity but is invasive and costly. Intragastric balloons (IGBs) are increasingly popular as an alternative to LBS with modest short-term weight loss. However, IGBs are associated with complications and a comparison of the safety of IGB to LBS is warranted. OBJECTIVES The objective of this study was to compare the safety profile of IGB with LBS through analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. SETTING The MBSAQIP collects data from 791 bariatric surgery centers in the United States and Canada. METHODS A propensity-matched analysis was performed between IGB and LBS. Multivariable logistic regression analysis was performed to determine if IGBs were independently associated with adverse outcomes. RESULTS A total of 145,408 patients were included, of which 144,627 (99.5%) underwent LBS and 781 (0.5%) underwent IGB therapy. With one-to-one propensity score matching, 684 pairs of IGB and LBS patients were selected. Multivariable logistic regression found that IGB (odds ratio 1.97, confidence interval 1.10-3.52, P = .023) was independently predictive of 30-day adverse outcomes. This was due to a significantly higher nonoperative reintervention rate in the IGB cohort (4.2% versus 1.0%, P < .001) from early balloon removal (2.8%). CONCLUSIONS In this propensity-matched analysis, IGBs were associated with a higher adverse event rate than LBS, due to a 4-times higher nonoperative reintervention rate. The utility of IGB as a primary weight loss intervention should be reconsidered due to its poor safety profile compared with LBS.

The role of antibiotics in acute uncomplicated diverticulitis: A systematic review and meta-analysis

BACKGROUND Antibiotics use in acute uncomplicated diverticulitis (AUD) remains debated despite recent studies suggesting no difference in outcomes for patients treated without antibiotics. DATA SOURCES Systematic review and meta-analysis were performed to determine the role of antibiotics in managing AUD. Literature search was conducted using Medline, EMBASE, Scopus, the Cochrane Library, and Web of Science databases from 1946 to June 2017. Eight studies with 2469 patients were included for review. Overall complication rates were not statistically significant between groups (OR 0.72; CI 0.45 to 1.16; P = 0.18), but antibiotic use was associated with a longer length of stay in hospital. Subgroup analysis revealed no difference in readmission rates, treatment failure rates, progression to complicated diverticulitis, or increased need for elective or emergent surgery between study groups. CONCLUSIONS Antibiotic use in patients with AUD increases length of hospital stay but is not associated with a reduction in overall or individual complication rates.

The impact of traumatic injury in the oil and gas industry

Introduction The oil and gas industry employs approximately 390,000 people in Canada and these workers are often exposed to substantial workplace risks. Trauma centres treat a significant number of industry-related injuries; however, studies characterizing these traumatic events are lacking. Methods A retrospective study was conducted of workers in the oil and gas industry admitted to major trauma centres in Edmonton, Alberta from January 2009 to December 2014. Patients were identified from Alberta Trauma Registry and Workers Compensation Board data. Inclusion criteria were: age ≥16 years, trauma occurring in the oil and gas industry, and Injury Severity Score (ISS) ≥ 12 or Modified Abbreviated Injury Scale (MAIS) ≥ 3. Descriptive analysis and cost estimation were performed. Results There were 182 major traumas occurring primarily in young males. Blunt trauma was the primary mechanism (90.1%), and alcohol levels were positive in 4.8% of patients. The overall complication rate was 32.4% with a mortality rate of 6%. The majority of patients were discharged home (64.3%), however a large proportion (29.7%) required further care at another facility post-acute care. The median days missed from work were 85 (IQR 7–214.5). Total cost of injury from the societal perspective ranged from

Diagnostic evaluation of sentinel lymph node biopsy using indocyanine green and infrared or fluorescent imaging in gastric cancer: a systematic review and meta-analysis

109 965 to

Predicting venous thromboembolism following laparoscopic bariatric surgery: development of the BariClot tool using the MBSAQIP database

332 098 USD per person. Conclusion Oil and gas industry trauma has a high economic and societal cost. Strategies to prevent injuries in this field should be undertaken including promotion and support of drug-free programmes given the rate of positive alcohol screening in this population.

The utility of routine esophagogastroduodenoscopy before laparoscopic Roux-en-Y gastric bypass

BackgroundSentinel node navigation surgery (SNNS) for gastric cancer using infrared visualization of indocyanine green (ICG) is intriguing because it may limit operative morbidity. We are the first to systematically review and perform meta-analysis on the diagnostic utility of ICG and infrared electronic endoscopy (IREE) or near infrared fluorescent imaging (NIFI) for SNNS exclusively in gastric cancer.MethodsA search of electronic databases MEDLINE, EMBASE, SCOPUS, Web of Science, and the Cochrane Library using search terms “gastric/stomach” AND “tumor/carcinoma/cancer/neoplasm/adenocarcinoma/malignancy” AND “indocyanine green” was completed in May 2017. Articles were selected by two independent reviewers based on the following major inclusion criteria: (1) diagnostic accuracy study design; (2) indocyanine green was injected at tumor site; (3) IREE or NIFI was used for intraoperative visualization. 327 titles or abstracts were screened. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2.ResultsTen full text studies were selected. 643 patients were identified with the majority of patients possessing T1 tumors (79.8%). Pooled identification rate, diagnostic odds ratio, sensitivity, and specificity were 0.99 (0.97–1.0), 380.0 (68.71–2101), 0.87 (0.80–0.93), and 1.00 (0.99–1.00), respectively. The summary receiver operator characteristic for ICG + IREE/NIFI demonstrated a test accuracy of 98.3%. Subgroup analysis found improved test performance for studies with low-risk QUADAS-2 scores, studies published after 2010 and submucosal ICG injection. IREE had improved diagnostic odds ratio, sensitivity, and identification rate compared to NIFI. Heterogeneity among studies ranged from low (I2 < 25%) to high (I2 > 75%).ConclusionsWe found encouraging results regarding the accuracy, diagnostic odds ratio, and specificity of the test. The sensitivity was not optimal but may be improved by a strict protocol to augment the technique. Given the number and heterogeneity of studies, our results must be viewed with caution.

Response to the Letter to the Editor—Re: Gastric Band Removal in Revisional Bariatric Surgery, One-Step Versus Two-Step: a Systematic Review and Meta-analysis

BackgroundBariatric surgery is an effective treatment for severe obesity; however, postoperative venous thromboembolism (VTE) remains a leading cause of morbidity and mortality. The objective of this study is to develop a tool to stratify individuals undergoing laparoscopic bariatric surgery according to their 30-day VTE risk.MethodsThis is a retrospective cohort study of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. This registry collects data specific for metabolic or bariatric surgery with 30-day outcomes from 791 centers. Individuals undergoing primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were included. Characteristics associated with 30-day VTE were identified using univariate and multivariable analyses. A predictive model, BariClot, was derived from a randomly-generated derivation cohort using a forward selection algorithm. BariClot’s robustness was tested against a validation cohort of subjects not included in the derivation cohort. The calibration and discrimination of two previously published VTE risk tools were assessed in the MBSAQIP population and compared to BariClot.ResultsA total of 274,221 patients underwent LRYGB or LSG. Overall, 1106 (0.4%) patients developed VTE, 452 (0.2%) developed pulmonary embolism, and 43 (0.02%) died due to VTE. VTE was the most commonly identified cause of 30-day mortality. A prediction model to assess for risk of VTE, BariClot, was derived and validated. BariClot consists of history of VTE, operative time, race, and functional status. It stratifies individuals into very high (> 2%), high (1–2%), medium (0.3–1%), and low risk groups (< 0.3%). This model accurately predicted events in the validation cohort and outperformed previously published scoring systems.ConclusionsBariClot is a predictive tool that stratifies individuals undergoing bariatric surgery based on 30-day VTE risk. Stratifying low- and high-risk populations for VTE allows for informed clinical decision-making and potentially enables further research on customized prophylactic measures for low- and high-risk populations.

Heated insufflation with or without humidification for laparoscopic abdominal surgery.

BACKGROUND The routine use of esophagogastroduodenoscopy (EGD) before laparoscopic Roux-en-y gastric bypass (LRYGB) is debatable. Various studies have reported high diagnostic yield of routine EGD before LRYGB to detect pathologies that could alter surgical management. However, other studies have found that preoperative EGD did not identify significant pathologies that changed clinical management; therefore, it is not indicated in asymptomatic patients. OBJECTIVES We aimed to study the utility of routine EGD in patients before LRYGB. SETTING Academic teaching hospital, (Royal Alexandra Hospital, Canada). METHODS A retrospective review of patients undergoing LRYGB with 1 surgeon at our hospital from May 2014 to March 2016 was completed. EGD findings were compared with surgical gastrojejunal specimen pathology and postoperative complications. RESULTS There were 116 patients who underwent EGD before LRYGB with 113 reported EGDs, of which 46.0% were normal, 40.7% had findings that did not result in a change of management, and 13.3% had findings resulting in a change of management. In the gastrojejunal specimen, 16 patients (14.2%) were found to have chronic gastritis. The relative risk of patients having gastrojejunal gastritis was 5.1 (P<.0005) for patients with gastritis on EGD and 5.1 (P<.0005) for patients with Helicobacter pylori infection on EGD. After surgery, 18 patients (15.9%) had complications. Preoperative EGD findings were not associated with postoperative complications. CONCLUSION Based on the findings from this study, we recommend using less invasive screening in the routine workup of patients awaiting LRYGB and reserving EGD for symptomatic patients.