Prognosis of Reflux Symptom Resolution After Bariatric Surgery: How Can Preoperative Esophageal Testing Help?

PURPOSE: The incidence of unresolved postoperative reflux after bariatric surgery varies considerably. Consistent perioperative patient characteristics predictive of unresolved reflux remain unknown. We leverage our institution's comprehensive preoperative esophageal testing to identify predictors of postoperative reflux. MATERIALS AND METHODS: We performed a single-center retrospective review of adult patients with preoperative reflux symptoms who underwent either vertical sleeve gastrectomy (VSG) or Roux-en-Y gastric bypass (RYGB) from 2015 to 2021. All patients had pH and high-resolution manometry preoperatively. Predictors of postoperative unresolved reflux at 1 year were explored via Fisher's exact test, Kruskal Wallis test, and univariate logistic regression. RESULTS: Unresolved reflux was higher in patients undergoing VSG (n = 60/129,46.5%) vs. RYGB (n = 19/98, 19.4%). Median DeMeester scores were higher (22 vs. 13, p = .07) along with rates of ineffective esophageal motility (IEM) (31.6 vs. 8.9%, p = .01) in the 19 (19.3%) patients with unresolved postoperative reflux after RYGB compared to the resolved RYGB reflux cohort. Sixty (46.5%) of VSG patients had unresolved postoperative reflux. The VSG unresolved reflux cohort had similar median DeMeester and IEM incidence to the resolved VSG group but more preoperative dysphagia (13.3% vs. 2.9%, p = .04) and higher preoperative PPI use (56.7 vs. 39.1%, p = .05). In univariate analysis, only IEM was predictive of unresolved reflux after RYGB (OR 4.74, 95% CI 1.37, 16.4). CONCLUSION: Unresolved reflux was higher after VSG. Preoperative IEM predicted unresolved reflux symptoms after RYGB. In VSG patients, preoperative dysphagia symptoms and PPI use predicted unresolved reflux though lack of correlation to objective testing highlights the subjective nature of symptoms and the challenges in predicting postoperative symptomatology.

A clinical tip for conservative retrieval of fractured abutment screw.

Fractures of the abutment screw are an extremely dreadful and taxing experience even for experienced clinicians. Retrieval of fractured screw segments due to excessive torque and improperly placed implants pose a great challenge to the clinician. The authors present a case wherein the fractured abutment screw was retrieved successfully with the help of an intraoral plastic mixing tip of light body putty material. The intraoral plastic mixing tips are a more readily available, cost-effective, and feasible alternative to other means of screw retrieval like ultrasonic scalers, endodontic files, and screw retrieval kits.

Telemedicine Use Decreases the Carbon Footprint of the Bariatric Surgery Preoperative Evaluation.

BACKGROUND: Healthcare-associated activity accounts for 10% of the United States' carbon dioxide (CO2) emissions. Using telemedicine for bariatric surgery evaluations decreases emissions and reduces patient burden during the multiple required interdisciplinary visits. After adopting telemedicine during COVID, our clinic continues to utilize telemedicine for preoperative bariatric evaluations. We evaluated the reduced environmental impact associated with this practice. METHODS: A retrospective review of all new evaluations for vertical sleeve gastrectomy (SG) or Roux-en Y gastric bypass (RYGB) from 2019 and 2021 was conducted. The 2019 year represents pre-pandemic, in-person evaluations and 2021 represents telemedicine evaluations during the COVID pandemic. Carbon emissions were calculated using the Environmental Protection Agency's (EPA's) validated formula of 404g CO2 per car-mile. Preoperative evaluation time was calculated from the initial clinic visit to the operation date. RESULTS: There were 51 patients in the 2019 cohort and 55 patients in the 2021 cohort. In the 2019 in-person cohort, there was significantly more kg of estimated CO2 emitted (10,225 vs. 2011.4, p<.001) compared to the 2021 cohort. For time required to complete the preoperative workup, there was no statistically significant difference between the two groups (162 days vs. 193 days, p=.226). The attrition rate was lower in the 2021 cohort (22.22% v. 35.9%, p<.001). CONCLUSIONS: Implementation of telemedicine for bariatric preoperative evaluations reduced patient travel, carbon emissions, and improved attrition rate. We encourage bariatric providers to use telemedicine as we believe this eases patient burdens and, with wider adoption, could significantly reduce our carbon footprint.

Preoperative esophageal testing predicts postoperative reflux status in sleeve gastrectomy patients.

BACKGROUND: Patients who undergo vertical sleeve gastrectomy (VSG) are at risk of postoperative GERD. The reasons are multifactorial, but half of conversions to Roux-en Y gastric bypass are for intractable GERD. Our institution routinely performs preoperative pH and high-resolution manometry studies to aid in operative decision making. We hypothesize that abnormal pH studies in concert with ineffective esophageal motility would lead to higher rates of postoperative reflux after VSG. METHODS: A single institution retrospective review was conducted of adult patients who underwent preoperative pH and manometry testing and VSG between 2015 and 2021. Patients filled out a symptom questionnaire at the time of testing. Postoperative reflux was defined by patient-reported symptoms at 1-year follow-up. Univariate logistic regression was used to examine the relationship between esophageal tests and postoperative reflux. The Lui method was used to determine the cutpoint for pH and manometric variables maximizing sensitivity and specificity for postoperative reflux. RESULTS: Of 291 patients who underwent VSG, 66 (22.7%) had a named motility disorder and 67 (23%) had an abnormal DeMeester score. Preoperatively, reflux was reported by 122 patients (41.9%), of those, 69 (56.6%) had resolution. Preoperative pH and manometric abnormalities, and BMI reduction did not predict postoperative reflux status (p = ns). In a subgroup analysis of patients with an abnormal preoperative pH study, the Lui cutpoint to predict postoperative reflux was a DeMeester greater than 24.8. Postoperative reflux symptoms rates above and below this point were 41.9% versus 17.1%, respectively (p = 0.03). CONCLUSION: While manometry abnormalities did not predict postoperative reflux symptoms, GERD burden did. Patients with a mildly elevated DeMeester score had a low risk of postoperative reflux compared to patients with a more abnormal DeMeester score. A preoperative pH study may help guide operative decision-making and lead to better counseling of patients of their risk for reflux after VSG.

Efficacy of Sodium Bicarbonate-Buffered Local Anesthetic Solution in Cases Requiring Bilateral Maxillary Premolar Orthodontic Extraction: A Comparative Split-Mouth Study.

Aims and objectives This study was carried out to evaluate the efficacy of 8.4% sodium bicarbonate-buffered local anesthetic solution and conventional local anesthetic in patients requiring bilateral maxillary orthodontic extractions in terms of pain on injection, onset of action, and duration of action. Methods 102 patients requiring bilateral maxillary orthodontic extractions were included in the study. Buffered local anesthetic was administered on one side while conventional local anesthesia (LA) was administered on the other side. Pain on injection was measured using a visual analogue scale, while onset of action was measured by probing the buccal mucosa after 30 seconds of administration and duration of action was measured by the time after which the patient experienced pain or took a rescue analgesic. The data was statistically analyzed to determine the significance. Results The pain during injection was found to be lesser at sites where buffered local anesthetic was administered (mean visual analogue scale (VAS) score = 2.4) as compared to conventional local anesthetic (mean VAS score = 3.9). The onset of action was faster with buffered local anesthetic (mean value = 62.3 seconds) as compared to conventional local anesthetic (mean value = 157.16 seconds). Lastly, the duration of action was found to be longer for buffered local anesthetic group (mean value = 225.65 minutes) as compared to conventional local anesthetic (mean value = 187 minutes). Conclusion 8.4% sodium bicarbonate-buffered local anesthetic was found to be more efficient than conventional local anesthetic in terms of reduction in pain on injection as well as faster onset and longer duration of action.

Rehabilitation of Post-traumatic Anterior Maxillary Osseous Deficit Using Iliac Onlay Bone Graft Combined With Dental Implants.

Fracture of the anterior maxilla usually causes a scooped-out defect in this region which leads to loss of lip support and a sub-optimal condition for placement of implants. The iliac crest is a frequently used donor location in oral and maxillofacial procedures for bone augmentation in order to restore jaw deformities brought on by trauma or pathological diseases prior to the placement of dental implants. Here we present the case of a patient who had undergone reconstruction of the maxillary osseous defect caused due to trauma by iliac crest grafting, followed by placement of dental implants after six months.

The impact of socioeconomic status on telemedicine utilization during the COVID-19 pandemic among surgical clinics at an academic tertiary care center.

BACKGROUND: The COVID-19 pandemic caused many surgical providers to conduct outpatient evaluations using remote audiovisual conferencing technology (i.e., telemedicine) for the first time in 2020. We describe our year-long institutional experience with telemedicine in several general surgery clinics at an academic tertiary care center and examine the relationship between area-based socioeconomic measures and the likelihood of telemedicine participation. METHODS: We performed a retrospective review of our outpatient telemedicine utilization among four subspecialty clinics (including two acute care and two elective surgery clinics). Geocoding was used to link patient visit data to area-based socioeconomic measures and a multivariable analysis was performed to examine the relationship between socioeconomic indicators and patient participation in telemedicine. RESULTS: While total outpatient visits per month reached a nadir in April 2020 (65% decrease in patient visits when compared to January 2020), there was a sharp increase in telemedicine utilization during the same month (38% of all visits compared to 0.8% of all visits in the month prior). Higher rates of telemedicine utilization were observed in the two elective surgery clinics (61% and 54%) compared to the two acute care surgery clinics (14% and 9%). A multivariable analysis demonstrated a borderline-significant linear trend (p = 0.07) between decreasing socioeconomic status and decreasing odds of telemedicine participation among elective surgery visits. A sensitivity analysis to examine the reliability of this trend showed similar results. CONCLUSION: Telemedicine has many patient-centered benefits, and this study demonstrates that for certain elective subspecialty clinics, telemedicine may be utilized as the preferred method for surgical consultations. However, to ensure the equitable adoption and advancement of telemedicine services, healthcare providers will need to focus on mitigating the socioeconomic barriers to telemedicine participation.

Evidence of depot-specific regulation of all-trans-retinoic acid biosynthesis in human adipose tissue.

The prevalence of obesity continues to rise, underscoring the need to better understand the pathways mediating adipose tissue (AT) expansion. All-trans-retinoic acid (atRA), a bioactive vitamin A metabolite, regulates adipogenesis and energy metabolism, and, in rodent studies, aberrant vitamin A metabolism appears a key facet of metabolic dysregulation. The relevance of these findings to human disease is unknown, as are the specific enzymes implicated in vitamin A metabolism within human AT. We hypothesized that in human AT, family 1A aldehyde dehydrogenase (ALDH1A) enzymes contribute to atRA biosynthesis in a depot-specific manner. To test this hypothesis, parallel samples of subcutaneous and omental AT from participants (n = 15) were collected during elective abdominal surgeries to quantify atRA biosynthesis and key atRA synthesizing enzymes. ALDH1A1 was the most abundant ALDH1A isoform in both AT depots with expression approximately twofold higher in omental than subcutaneous AT. ALDH1A2 was detected only in omental AT. Formation velocity of atRA was approximately threefold higher (p = 0.0001) in omental AT (9.8 [7.6, 11.2]) pmol/min/mg) than subcutaneous AT (3.2 [2.1, 4.0] pmol/min/mg) and correlated with ALDH1A2 expression in omental AT (ß-coefficient = 3.07, p = 0.0007) and with ALDH1A1 expression in subcutaneous AT (ß-coefficient = 0.13, p = 0.003). Despite a positive correlation between body mass index (BMI) and omental ALDH1A1 protein expression (Spearman r = 0.65, p = 0.01), BMI did not correlate with atRA formation. Our findings suggest that ALDH1A2 is the primary mediator of atRA formation in omental AT, whereas ALDH1A1 is the principal atRA-synthesizing enzyme in subcutaneous AT. These data highlight AT depot as a critical variable for defining the roles of retinoids in human AT biology.

Characteristics and outcomes of patients undergoing paraesophageal hernia repair with selective use of biologic mesh.

BACKGROUND: The use of biologic mesh in paraesophageal hernia repair (PEHR) has been associated with decreased short-term recurrence but no statistically significant difference in long-term recurrence. Because of this, we transitioned from routine to selective use of mesh for PEHR. The aim of this study was to examine our indications for selective mesh use and to evaluate patient outcomes in this population. METHODS: We queried a prospectively maintained database for patients who underwent laparoscopic PEHR with biologic mesh from October 2015 to October 2018, then performed a retrospective chart review. The decision to use mesh was made intraoperatively by the surgeon. Recurrence was defined as the presence of > 2 cm intrathoracic stomach on postoperative upper gastrointestinal (UGI) series. RESULTS: Mesh was used in 61/169 (36%) of first-time PEHRs, and in 47/82 (57%) of redo PEHRs. Among first-time PEHRs, the indications for mesh included hiatal tension (85%), poor crural tissue quality (11%), or both (5%). Radiographic recurrence occurred in 15% of first-time patients (symptomatic N = 2, asymptomatic N = 3). There were no reoperations for recurrence. Among redo PEHRs, the indication for mesh was most commonly the redo nature of the repair itself (55%), but also hiatal tension (51%), poor crural tissue quality (13%), or both (4%). Radiographic recurrence occurred in 21% of patients (symptomatic N = 4, asymptomatic N = 1). There was 1 reoperation for recurrence in the redo-repair group. CONCLUSIONS: We selectively use biologic mesh in a third of our first-time repair patients and in over half of our redo-repair patients when there is a perceived high risk of recurrence based on hiatal tension, poor tissue quality, or prior recurrence. Despite the high risk for radiologic recurrence, there was only 1 reoperation for recurrence in the entire cohort.

Use of post-discharge heparin prophylaxis and the risk of venous thromboembolism and bleeding following bariatric surgery.

INTRODUCTION: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality after bariatric surgery. Roughly 80% of VTEs occur post-discharge. The frequency of post-discharge heparin (PDH) prophylaxis use is unknown, and evidence about benefits and risks is limited. We aimed to determine the rate of use of PDH prophylaxis and evaluate its relationship with VTE and bleeding events. METHODS: Using the Truven Health MarketScan® database, we performed a retrospective cohort study (2007-2015) of adult patients who underwent sleeve gastrectomy or gastric bypass. We determined PDH prophylaxis from outpatient pharmacy claims, and post-discharge 90-day VTE and bleeding events from outpatient and inpatient claims. We used propensity score-adjusted regression models to mitigate confounding bias. RESULTS: Among 43,493 patients (median age 45 years; 78% women; 77% laparoscopic gastric bypass, 17% laparoscopic sleeve gastrectomy, 6% open gastric bypass), 6% received PDH prophylaxis. Overall, 224 patients (0.52%) experienced VTEs, and 806 patients (1.85%) experienced bleeding. The unadjusted VTE rate did not differ between patients who did and did not receive PDH prophylaxis (0.39% vs. 0.52%, respectively; p = 0.347). The unadjusted bleeding rate was higher for the PDH prophylaxis group (2.74% vs. 1.80%, p < 0.001). In our adjusted analysis, a 23% lower risk of VTE in the PDH prophylaxis group was not statistically significant (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.41 to 1.46), whereas the 47% higher risk of bleeding was statistically significant (OR 1.47, 95% CI 1.14 to 1.88). CONCLUSIONS: PDH prophylaxis after bariatric surgery is uncommon. In our analysis, use was not associated with a lower VTE risk but was associated with a higher bleeding risk.

Disclosure at #SAGES2018: An analysis of physician-industry relationships of invited speakers at the 2018 SAGES national meeting.

BACKGROUND: Financial conflicts of interest (COI) have been shown to affect the interpretation of scientific findings. Publications with unreported COI tend to be more favorable to industry. Since 2014 industry payments to United States (US) physicians are publicly reported in the Open Payments Database (OPD). Several studies show high levels of unreported COI in medical literature; however, there is no research examining COI reporting at surgical conferences. We hypothesized that compliance with the COI disclosure requirement would be high at the 2018 SAGES meeting. However, we expected to find significant discrepancy between speaker-reported and OPD-reported COI. A secondary aim was to characterize the amount, source, and variation in industry payments to invited speakers. METHODS: We reviewed all available presentations from SAGES 2018 as recorded and publicly available on YouTube™ for the presence of COI disclosure and the disclosed industry relationships. For US physicians we searched the OPD and recorded all industry payments > $500. We compared the self-disclosed COI for each speaker with OPD records. Presentation topics were divided into ten groups to determine which topics received the most funding. RESULTS: Of the 526 invited presentations, 479 (91%) videos were available. Disclosures were reported by 414 presenters (86.4%). There were 420 unique presenters of which 315 were listed in the OPD. Speaker-reported disclosures were fully concordant with the OPD in 38.3% (121/315) of cases with 39% (123/315) under-reporting disclosures. Of presenters listed in OPD, the median payment was $992 ($0-$374,502) with a total of $6,389,097 paid in 2017. SAGES speakers failed to disclose $2,049,535 worth of industry payments with an average undisclosed payment of $16,662.88 (± $40,733.19). The largest financial contributor was Intuitive Surgical with $1,981,169 paid. Among topics, robotics and hernia received the most funding with $2,593,925 (40.6%) and $2,591,671 (40.5%) paid, respectively. CONCLUSIONS: Overall compliance with SAGES disclosure rules is high. There remains a discrepancy between speaker- and industry-reported disclosures, including a number of undisclosed payments, some of which are substantial. Adjustments to disclosure rules to include the relative amount of compensation may be warranted.

Opioid Use Following Bariatric Surgery: Results of a Prospective Survey.

BACKGROUND: Opioid use after bariatric surgery is not clearly understood. Few guidelines exist to inform opioid-prescribing practices after bariatric surgery. OBJECTIVE: To understand opioid use following bariatric surgery. SETTING: University hospital. METHODS: Bariatric surgery patients at a single center were prospectively surveyed at the time of their post-operative visit (January-May 2018). Patients were asked about their opioid use following surgery, whether they received education about opioid use and what they did with leftover medications. Demographic and operative details were obtained from the medical record. RESULTS: Among 33 patients, the majority (n = 29, 88%) were female with a median age of 40 (20-68) and body mass index of 44.8 (33-78.5). Most patients had leftover narcotics (n = 25, 73%). The median number of pills used was 15 (0-48). Only 12 patients (36%) thought that they had been prescribed "too much" pain medication. Most patients reported receiving education about expectations for post-operative pain (n = 22, 69%); few recalled education about reducing or stopping opioids (n = 13, 40%). More than half of patients (n = 17, 53%) kept their leftover opioids rather than disposing of them or bringing them to an approved turn in location. CONCLUSIONS: Despite most patients having leftover opioids following surgery, few patients recognized possible overprescription. Education regarding opioid use following surgery is inconsistent, potentially contributing to the amount of retained opioids currently available. Future guidelines should focus on determining the appropriate amount of opioids to be prescribed following surgery and standardizing and improving education given to patients.

The impact of bariatric surgery on asthma control differs among obese individuals with reported prior or current asthma, with or without metabolic syndrome.

BACKGROUND: Both obesity and the metabolic syndrome have been independently associated with increased asthma morbidity. However, it is unclear whether metabolic syndrome limits the beneficial effects of weight loss on asthma. OBJECTIVES: To evaluate whether bariatric weight loss is associated with improved asthma control, and whether this association varies by metabolic syndrome status. METHODS: We determined the changes in asthma control, defined by the Asthma Control Test (ACT), before and after bariatric surgery among participants with asthma in the multi-center Longitudinal Assessment of Bariatric Surgery (LABS) study, stratifying our analysis by the presence or absence of metabolic syndrome. RESULTS: Among 2,458 LABS participants, 555 participants had an asthma diagnosis and were included in our analysis. Of these, 78% (n = 433) met criteria for metabolic syndrome (MetSyn) at baseline. In patients without MetSyn, mean ACT increased from 20.4 at baseline to 22.1 by 12-24 months, ending at 21.3 at 60 months. In contrast, among those with MetSyn there was no significant improvement in ACT scores. The proportion of patients without MetSyn with adequate asthma control (ACT >19) increased from 58% at baseline to 78% and 82% at 12 and 60 months, respectively, whereas among those with MetSyn, it was 73.8% at baseline, 77.1% at 12 months, dropping to 47.1% at 60 months (p = 0.004 for interaction between metabolic syndrome and time). Having MetSyn also increased the likelihood of losing asthma control during follow-up (HR = 1.92, 95% confidence interval [CI] 1.24-2.97, p = 0.003). CONCLUSIONS: Metabolic syndrome may negatively modify the effect of bariatric surgery-induced weight loss on asthma control.

Karapandzic Flap: A Useful Option for Reconstruction of Lower Lip.

Lip carcinoma is a common cancer of the head and neck region and it more commonly affects the lower lip (>90%). Out of all the carcinomas affecting the lower lip, squamous cell carcinoma accounts for 95% of the patients. Reconstruction of lower lip is a challenging task, as it requires taking into consideration the restoration of function as well as aesthetics. In this study, a patient for whom successful reconstruction of lower lip defect was done using the Karapandzic flap was presented.

Effect of Low-Dose Aspirin on Bleeding Following Exodontia: A Prospective Clinical Study.

PURPOSE: This research aims to study the effects of low-dose aspirin on bleeding after exodontia and to compare statistically and analyze perioperative blood loss during exodontia in patients on aspirin therapy and healthy patients and also to discuss the various measures if required necessary for controlling postoperative bleeding in simple and uncomplicated exodontia. MATERIALS AND METHODS: The study included 100 patients, ranging in age from 30 to 60 years. The patients were divided into two groups, a test group consisting of 50 patients who were on a daily dose of 75-150 mg of aspirin and a control group consisting of 50 patients not on any antiplatelet therapy. All extraction procedures were performed on outpatient basis. Patients were operated under local anesthesia. Post-extraction sockets were checked for bleeding immediately (30 min) and followed up at 24, 48, and 72 h, and 1 week, after the procedure. RESULTS: Amount of intraoperative blood loss was similar in both test and control groups, and there was no excessive postoperative bleeding in any case. Out of 100 patients, only three patients of test group and two patients of control group required level II hemostatic measures and two patients of test group needed level III measures. CONCLUSION: We could reach a conclusion and recommend that patients on long-term low-dose aspirin (75-150 mg) need not to discontinue their aspirin dose prior to routine exodontia and can be carried out safely with enhanced local hemostatic measures, if required.

The relationship between manometric subtype and outcomes of surgical treatment for patients with achalasia : Achalasia: manometric subtypes.

BACKGROUND: The Chicago Classification describes three distinct subtypes of achalasia and it appears to be a promising tool in predicting results of treatment with standard Heller Myotomy. The aim of this study is to analyze the outcomes of surgical treatment for achalasia using an extended Heller myotomy for each subtype and to identify additional parameters that may predict the success of therapy. METHODS: 72 consecutive patients with achalasia were evaluated at the University of Washington between 2008 and 2013. Symptom duration, patient age, and the degree of esophageal dilation (stage 1-3) as assessed by radiography were determined. We defined treatment failure as no improvement in symptoms and/or need for a second therapy within 1 year. Long-term follow-up data of 25 patients were available in the form of a survey evaluating overall satisfaction with the operation. RESULTS: The distribution of patients according to subtype included 13 with type I, 54 with type II, and 5 with type III. All of the type I patients had some degree of esophageal dilation on radiography, whereas no dilation was found in the type III group. All patients underwent uneventful laparoscopic-extended Heller myotomy. Two patients were classified as failures, including one with type I and one with type II achalasia; however, further investigation revealed the cause of both failures to be the development of peptic stricture. Only one of the 25 patients with long-term follow-up reported dissatisfaction with the treatment result and indicated persistent chest pain without dysphagia. CONCLUSIONS: Laparoscopic-extended Heller myotomy is a highly successful treatment for patients with achalasia and outcomes do not appear to vary significantly according to the manometric subtype. Failures may result from reflux in patients who develop esophagitis or stricture. Chest pain is not always responsive to esophagogastric myotomy despite relief of dysphagia.

Bariatric Surgery in Women of Childbearing Age, Timing Between an Operation and Birth, and Associated Perinatal Complications.

Importance: Metabolic changes after maternal bariatric surgery may affect subsequent fetal development. Many relevant perinatal outcomes have not been studied in this postoperative population, and the risks associated with short operation-to-birth (OTB) intervals have not been well examined. Objective: To examine the risk for perinatal complications in women with a history of bariatric surgery (postoperative mothers [POMs]) by comparing them with mothers without operations (nonoperative mothers [NOMs]) and examining the association of the OTB interval with perinatal outcomes. Design, Setting, and Participants: This investigation was a population-based retrospective cohort study (January 1, 1980, to May 30, 2013) at hospitals in Washington State. Data were collected from birth certificates and maternally linked hospital discharge data. Participants were all POMs and their infants (n = 1859) and a population-based random sample of NOMs and their infants frequency matched by delivery year (n = 8437). Exposures: Bariatric operation before birth or categories of OTB intervals. Main Outcomes and Measures: The primary outcomes were prematurity, neonatal intensive care unit (NICU) admission, congenital malformation, small for gestational age (SGA), birth injury, low Apgar score (≤8), and neonatal mortality. Poisson regression was used to compute relative risks (RRs) and 95% CIs, with adjustments for maternal body mass index, delivery year, socioeconomic status, age, parity, and comorbid conditions. Results: A total of 10 296 individuals were included in the analyses for this study. In the overall cohort, the median age was 29 years (interquartile range, 24-33 years). Compared with infants from NOMS, infants from POMs had a higher risk for prematurity (14.0% vs 8.6%; RR, 1.57; 95% CI, 1.33-1.85), NICU admission (15.2% vs 11.3%; RR, 1.25; 95% CI, 1.08-1.44), SGA status (13.0% vs 8.9%; RR, 1.93; 95% CI, 1.65-2.26), and low Apgar score (17.5% vs 14.8%; RR, 1.21; 95% CI, 1.06-1.37). Compared with infants from mothers with greater than a 4-year OTB interval, infants from mothers with less than a 2-year interval had higher risks for prematurity (11.8% vs 17.2%; RR, 1.48; 95% CI, 1.00-2.19), NICU admission (12.1% vs 17.7%; RR, 1.54; 95% CI, 1.05-2.25), and SGA status (9.2% vs 12.7%; RR, 1.51; 95% CI, 0.94-2.42). Conclusions and Relevance: Infants of mothers with a previous bariatric operation had a greater likelihood of perinatal complications compared with infants of NOMs. Operation-to-birth intervals of less than 2 years were associated with higher risks for prematurity, NICU admission, and SGA status compared with longer intervals. These findings are relevant to women with a history of bariatric surgery and could inform decisions regarding the optimal timing between an operation and conception.

A Rare Simultaneous Occurrence of Odontogenic Keratocyst and Unicystic Ameloblastoma in Mandible: A Case Report.

Odontogenic Keratocyst (OKC) and Ameloblastomas are slow growing benign odontogenic lesions that primarily occur in the molar region of the mandible. Clinically and radiographically both ameloblastoma, especially the Unicystic ameloblastoma and OKC are indistinguishable due to the similar location of occurrence and the age of patients. It is very rare for these lesions to arise simultaneously in a patient's jaw. The co-occurrence of Ameloblastomas with odontogenic cysts or other odontogenic lesions (histologically in a single lesion)have already been described as combined or hybrid lesions. There are very few reported cases in the English literature for simultaneous occurrence of Unicystic Ameloblastoma and OKC as completely distinct lesions. Here we present such a rare case of the simultaneous occurrence of OKC and ameloblastoma in the posterior region of the mandible of a 22-year-old male in close relation.

Task performance in standard laparoscopy in comparison with single-incision laparoscopy in a modified skills trainer.

BACKGROUND: Single-incision laparoscopy (SIL) is similar to conventional laparoscopic surgery (LAP), but carries specific technical challenges due to lack of triangulation, reduced dexterity, conflicts due to inline instrumentation, and impaired visualization. This study was designed to evaluate technical skill performance of SIL versus LAP surgery in a simulated environment. METHODS: We developed a modified laparoscopic skills trainer for SIL based upon the fundamentals of laparoscopic surgery (FLS) model. This includes a standard laparoscopic tower for visualization, allowing replication of the conflicts between scope and instruments. It also has a modified trainer box allowing use of different access devices and instruments for SIL. Sixteen subjects at different levels of training (novice through expert) completed four FLS tasks with standard LAP techniques. They then practiced the same tasks using SIL technique until they reached a steady state of performance. The first and last SIL trials were recorded. RESULTS: Baseline SIL peg transfer was worse than FLS (254 ± 157 s vs 99 ± 27, p < 0.0002). Final SIL time was still significantly worse than FLS (173 ± 130, p < 0.02). FLS, baseline SIL, and final SIL circle cutting were not significantly different (p = 0.058). Final SIL loop ligation was significantly faster than FLS (48 ± 19 vs 70 ± 42, p < 0.05). FLS suturing was faster than SIL suturing (281 ± 188 vs. 526 ± 105, p < 0.01). There was substantial dropout due to frustration with SIL, and only two surgeons were able to successfully complete SIL suturing. CONCLUSIONS: There are technical challenges with SIL that vary depending on task. Peg transfer and suturing were significantly impaired in SIL, while circle cutting was not significantly affected, and ligating loop was faster with SIL than LAP. These challenges may impact clinical outcomes of SIL and should influence training in SIL as well as future product development.

Urinary Incontinence Before and After Bariatric Surgery.

IMPORTANCE: Among women and men with severe obesity, evidence for improvement in urinary incontinence beyond the first year after bariatric surgery-induced weight loss is lacking. OBJECTIVES: To examine change in urinary incontinence before and after bariatric surgery and to identify factors associated with improvement and remission among women and men in the first 3 years after bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS: The Longitudinal Assessment of Bariatric Surgery 2 is an observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Participants were recruited between February 21, 2005, and February 17, 2009. Adults undergoing first-time bariatric surgical procedures as part of clinical care by participating surgeons between March 14, 2006, and April 24, 2009, were followed up for 3 years (through October 24, 2012). INTERVENTION: Participants undergoing bariatric surgery completed research assessments before the procedure and annually thereafter. MAIN OUTCOMES AND MEASURES: The frequency and type of urinary incontinence episodes in the past 3 months were assessed using a validated questionnaire. Prevalent urinary incontinence was defined as at least weekly urinary incontinence episodes, and remission was defined as change from prevalent urinary incontinence at baseline to less than weekly urinary incontinence episodes at follow-up. RESULTS: Of 2458 participants, 1987 (80.8%) completed baseline and follow-up assessments. At baseline, the median age was 47 years (age range, 18-78 years), the median body mass index was 46 kg/m2 (range, 34-94 kg/m2), and 1565 of 1987 (78.8%) were women. Urinary incontinence was more prevalent among women (49.3%; 95% CI, 46.9%-51.9%) than men (21.8%; 95% CI, 18.2%-26.1%) (P < .001). After a mean 1-year weight loss of 29.5% (95% CI, 29.0%-30.1%) in women and 27.0% (95% CI, 25.9%-28.6%) in men, year 1 urinary incontinence prevalence was significantly lower among women (18.3%; 95% CI, 16.4%-20.4%) and men (9.8%; 95% CI, 7.2%-13.4%) (P < .001 for all). The 3-year prevalence was higher than the 1-year prevalence for both sexes (24.8%; 95% CI, 21.8%-26.5% among women and 12.2%; 95% CI, 9.0%-16.4% among men) but was substantially lower than baseline (P < .001 for all). Weight loss was independently related to urinary incontinence remission (relative risk, 1.08; 95% CI, 1.06-1.10 in women and 1.07; 95% CI, 1.02-1.13 in men) per 5% weight loss, as were younger age and the absence of a severe walking limitation. CONCLUSIONS AND RELEVANCE: Among women and men with severe obesity, bariatric surgery was associated with substantially reduced urinary incontinence over 3 years. Improvement in urinary incontinence may be an important benefit of bariatric surgery.