Noah J. Switzer

Surgical interventions for obesity and metabolic disease.

Obesity continues to be a growing problem in both the developed and the developing world. Its strong link with co-morbid conditions such as type 2 diabetes, hypertension, obstructive sleep apnea, and depression presents an increasing strain on health care systems around the world. Diet and exercise alone has been shown to be largely ineffective at managing obesity. Surgery is the only evidence-based method of allowing morbidly obese patients to lose weight and to maintain this weight loss. Weight-reduction in obese individuals from bariatric surgery has also been found to markedly improve obesity-related co-morbid conditions, particularly, type 2-diabetes. Diabetic remission from bariatric surgery has resulted in the inclusion of bariatric surgery, by the International Diabetes Taskforce, as a treatment modality for type-2 diabetes. This consensus statement named four surgical options that have been found to be effective in both weight-loss and in inducing diabetes remission. These four surgical procedures lead to weight-loss through restrictive and malabsorptive mechanisms. Each specific operation has a different level of efficacy in inducing weight-loss and diabetic remission, as well as distinct types and rates of complications. This article reviews the best evidence that exists for the effectiveness and complications of these four operations.

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.

ATLS adherence in the transfer of rural trauma patients to a level I facility

BACKGROUND Injury sustained in rural areas has been shown to carry higher mortality rates than trauma in urban settings. This disparity is partially attributed to increased distance from definitive care and underscores the importance of proper primary trauma management prior to transfer to a trauma facility. The purpose of this study was to assess Advanced Trauma Life Support (ATLS) guideline adherence in the management of adult trauma patients transferred from rural hospitals to a level I facility. METHODS We performed a retrospective analysis of all adult major trauma patients transferred ≥50km from an outlying hospital to a level I trauma centre from 2007 through 2009. Transfer practices were evaluated using ATLS guidelines. RESULTS 646 patients were analyzed. Mean age was 40.5years and 94% sustained blunt injuries with a median Injury Severity Score (ISS) of 22. Median transport distance was 253km. Among all patients, there were notable deficiencies (<80% adherence) in 8 of 11 ATLS recommended interventions, including patient rewarming (8% adherence), chest tube insertion (53%), adequate IV access (53%), and motor/sensory exam (72%). Patients with higher ISS scores, and those transferred by air were more likely to receive ATLS recommended interventions. CONCLUSIONS Key aspects of ATLS resuscitation guidelines are frequently missed during transfer of trauma patients from the periphery to level I trauma centres. Comprehensive quality improvement initiatives, including targeted education, telemedicine and trauma team training programmes could improve quality of care.

Central venous catheter repair is not associated with an increased risk of central line infection or colonization in intestinal failure pediatric patients

PURPOSE The intestinal failure (IF) population is dependent upon central venous catheters (CVC) to maintain minimal energy requirements for growth. Central venous catheter infections (CVCI) are frequent and an independent predictor of intestinal failure associated liver disease. A common complication in children with long-term CVC is the risk of line breakage. Given the often-limited usable vascular access sites in this population, it has been the standard of practice to perform repair of the broken line. Although widely practiced, it is unknown if this practice is associated with increased line colonization rates and subsequent line loss. METHODS A retrospective review of our institutional IF population over the past 8years (2006-2014) was performed. Utilizing a prospectively constructed database, all pediatric patients (n=13, ages 0-17 years) with CVC dependency enrolled in the Childrens Intestinal Rehabilitation Program with IF were included who underwent a repair and/or replacement procedure of their line. The control replacement group was CVCs that were replaced without being repaired (36), the experimental repair group was CVCs that were repaired (8). The primary outcome of interest was the mean number of days in each group from the intervention (replacement or repair) to line infection/colonization. Mann-Whitney tests for significance were performed with p-values <0.05 being the threshold value for significance. RESULTS There were no catheter repair associated CVCI. The mean number of days from the replacement or repair of a CVC to its removal owing to infection/colonization was 210.0 and 162.8days respectively. There was no statistically significant difference between these groups in time to removal owing to line infection (p=0.55). CONCLUSION Repair of central venous catheters in the pediatric population with intestinal failure does not lead to an increased rate of central venous catheter infection and should be performed when possible.

Research Productivity of Residents and Surgeons With Formal Research Training

OBJECTIVE The spectrum of the surgeon-scientist ranges from a clinician who participates in the occasional research collaboration to the predominantly academic scientist with no involvement in clinical work. Training surgeon-scientists can involve resource-intense and lengthy training programs, including Masters and PhD degrees. Despite high enrollment rates in such programs, limited data exist regarding their outcome. The aim of the study was to investigate the scientific productivity of general surgeons who completed Masters or PhD graduate training compared with those who completed clinical residency training only. DESIGN A retrospective cohort study of graduates of general surgery residency was conducted over 2 decades. Data regarding graduation year, dedicated research training type, as well as publication volume, authorship role, and publication impact of surgeons during and after training, were analyzed. SETTING The study was conducted in 2 general surgery residency training programs in Canada (University of Alberta and University of Toronto). PARTICIPANTS A cohort of 323 surgeons who completed general surgery residency between 1998 and 2012. RESULTS Overall, 25% of surgeons obtained graduate-level research degrees. Surgeons with graduate degrees were proportionately more likely to participate in research publications both during training (100% of PhD, 82% of Masters, and 38% of clinical-only graduates, p < 0.05) and after training (91% of PhD, 81% of Masters, and 44% of clinical-only graduates, p < 0.05). Among surgeons involved in publication, the individual publication volume and impact of publication were highest among those with PhD degrees, as compared with clinical-only or Masters training. CONCLUSIONS The volume and impact of research publication of PhD-trained surgeon-scientists are significantly higher than those having clinical-only and Masters training. The additional 1 or 2 years of training to obtain a PhD over a Masters degree significantly nurtures trainees to hone research skills within a supervised environment and should be encouraged for research-inclined residents.

Long-term hypovitaminosis D and secondary hyperparathyroidism outcomes of the Roux-en-Y gastric bypass: a systematic review

Pre‐operative Vitamin D deficiency is markedly prevalent in prospective bariatric surgery patients. While bariatric surgery leads to significant weight loss, it can exacerbate or prolong Vitamin D deficiency. We systematically reviewed the literature to assess whether secondary hyperparathyroidism is maintained in the medium to long term in patients following the Roux‐en‐Y gastric bypass.

Update on novel endoscopic therapies to treat gastroesophageal reflux disease: A review

Endoscopic treatments for gastroesophageal reflux disease (GERD) have become increasingly popular in recent years. While surgical intervention with the Laparoscopic Nissen Fundoplication remains the gold standard, two endoscopic interventions, specifically, are gaining traction in clinical use (EsophyX and Stretta). The EsophyX (EndoGastric Solutions, Inc., Redmond, WA, United States) was developed as a method of restoring the valve at the GE junction through an endoluminal fundoplication (ELF) technique. Long-term data suggests that transoral incisional fundoplication (TIF) with EsophyX may be effective for symptom control and proton pump inhibitor reduction or cessation for up to 2-6 years. There is no evidence that EsophyX is more effective than surgical intervention. TIF may be most effective for patients with HH < 2 cm and Hill Grade I/II valves. Stretta (Mederi Therapeutics, Greenwich, CT, United States) was approved by the Food and Drug Administration in 2000. It delivers radiofrequency energy to the lower esophageal sphincter and gastric cardia. Published reviews of the literature are conflicted in their recommendations of Stretta in the management of GERD. The literature suggests that the Stretta procedure has an acceptable safety profile and may be effective in reducing symptom burden and quality of life scores up to 8 years post-intervention. However, there does not appear to be any sustained improvement in objective outcomes and there is no evidence that Stretta results in improved outcomes as compared to surgical intervention. Treatment modalities for GERD, as a field, suffer from a lack of standardization in primary and secondary outcomes. Although many studies have looked at health related quality of life, the tools used to do so are markedly heterogeneous. Future directions for the endoscopic treatment of GERD include novel techniques like endoscopic submucosal dissection.

Roux en Y Gastric Bypass: How and Why it Fails?

The Roux-en-Y Gastric Bypass (RYGB) is the most successful bariatric procedure. Despite its successes, a growing number of patients who undergo RYGB present with clinically significant weight regain in the years following their procedure. Anatomical etiologies have been often implicated in this weight regain as either an enlargement of the gastric pouch or gastrojejunostomy, or the presence of a gastro gastric fistula leading to loss of caloric restriction. Surgical or endoscopic revision is an effective means to address this. Behavioral problems can also lead to poor results if patients do not adhere to strict dietary and lifestyle regimens following their procedure. Poor dietary compliance needs to be addressed with behavioral and nutritional counseling at a multidisciplinary clinic. Mental health is an often forgotten etiology for weight recidivism. Especially in high-risk patients – patients with personality disorders and addictions – simply recognizing the possibility of mental health problems during a preoperative assessment is a good start. Lastly, gut hormone imbalances including ghrelin and insulin can lead separately to increased appetite and significant hypoglycemia respectively, which can theoretically lead to RYBG failure. However, more research needs to be devoted to this area in order to be fully comfortable with making a conclusion. Overall, successful strategies for the management and recognition of weight recidivism following RYGB is important as these patients make up an important and growing segment of any bariatric practice.

The Evolution of the Appendectomy: From Open to Laparoscopic to Single Incision

Beginning with its initial description by Fitz in the 19th century, acute appendicitis has been a significant long-standing medical challenge; today it remains the most common gastrointestinal emergency in adults. Already in 1894, McBurney advocated for the surgical removal of the inflamed appendix and is credited with the initial description of an Open Appendectomy (OA). With the introduction of minimally invasive surgery, this classic approach evolved into a procedure with multiple, smaller incisions; a technique termed Laparoscopic Appendectomy (LA). There is much literature describing the advantages of this newer approach. To name a few, patients have significantly less wound infections, reduced pain, and a reduction in ileus compared with the OA. In the past few years, Single Incision Laparoscopic Appendectomy (SILA) has gained popularity as the next major evolutionary advancement in the removal of the appendix. Described as a pioneer in the era of “scarless surgery,” it involves only one transumbilical incision. Patients are postulated to have reduced post-operative complications such as infection, hernias, and hematomas, as well as a quicker recovery time and less post-operative pain scores, in comparison to its predecessors. In this review, we explore the advancement of the appendectomy from open to laparoscopic to single incision.

A Systematic Review and Meta-Analysis of Outcomes for Type 1 Diabetes after Bariatric Surgery.

Background. The utility of bariatric surgery in type 1 diabetes remains controversial. The aim of the present study is to evaluate glycemic control outcomes in obese patients with type 1 diabetes after bariatric surgery. Methods. A comprehensive search of electronic databases was completed. Inclusion criteria included human adult subjects with BMI ≥35 kg/m2 and a confirmed diagnosis of type 1 diabetes who underwent a bariatric surgical procedure. Results. Thirteen primary studies (86 patients) were included. Subjects had a mean age of 41.16 ± 6.76 years with a mean BMI of 42.50 ± 2.65 kg/m2. There was a marked reduction in BMI postoperatively at 12 months and at study endpoint to 29.55 ± 1.76 kg/m2 (P < 0.00001) and 30.63 ± 2.09 kg/m2 (P < 0.00001), respectively. Preoperative weighted mean total daily insulin requirement was 98 ± 26 IU/d, which decreased significantly to 36 ± 15 IU/d (P < 0.00001) and 42 ± 11 IU/d (P < 0.00001) at 12 months and at study endpoint, respectively. An improvement in HbA1c was also seen from 8.46 ± 0.78% preoperatively to 7.95 ± 0.55% (P = 0.01) and 8.13 ± 0.86% (P = 0.03) at 12 months and at study endpoint, respectively. Conclusion. Bariatric surgery in patients with type 1 diabetes leads to significant reductions in BMI and improvements in glycemic control.