Global 30-Day Morbidity and Mortality of Primary Bariatric Surgery Combined with Another Procedure: The BLEND Study.

BACKGROUND: No robust data are available on the safety of primary bariatric and metabolic surgery (BMS) alone compared to primary BMS combined with other procedures. OBJECTIVES: The objective of this study is to collect a 30-day mortality and morbidity of primary BMS combined with cholecystectomy, ventral hernia repair, or hiatal hernia repair. SETTING: This is as an international, multicenter, prospective, and observational audit of patients undergoing primary BMS combined with one or more additional procedures. METHODS: The audit took place from January 1 to June 30, 2022. A descriptive analysis was conducted. A propensity score matching analysis compared the BLEND study patients with those from the GENEVA cohort to obtain objective evaluation between combined procedures and primary BMS alone. RESULTS: A total of 75 centers submitted data on 1036 patients. Sleeve gastrectomy was the most commonly primary BMS (N = 653, 63%), and hiatal hernia repair was the most commonly concomitant procedure (N = 447, 43.1%). RYGB accounted for the highest percentage (20.6%) of a 30-day morbidity, followed by SG (10.5%). More than one combined procedures had the highest morbidities among all combinations (17.1%). Out of overall 134 complications, 129 (96.2%) were Clavien-Dindo I-III, and 4 were CD V. Patients who underwent a primary bariatric surgery combined with another procedure had a pronounced increase in a 30-day complication rate compared with patients who underwent only BMS (12.7% vs. 7.1%). CONCLUSION: Combining BMS with another procedure increases the risk of complications, but most are minor and require no further treatment. Combined procedures with primary BMS is a viable option to consider in selected patients following multi-disciplinary discussion.

A Multidisciplinary Approach to the Nonambulatory Bariatric Patient With Bilateral Knee Osteoarthritis.

Obesity and lower-extremity arthritis are challenging problems to address as they are often mutually exacerbating. Due to the known perioperative risk of morbid obesity, the modality and timing of weight loss prior to arthroplasty is debated. We present a case of a 55-year-old nonambulatory female patient with an initial body mass index of 80.3 kg/m2. This individual underwent a staged bariatric and joint replacement surgical pathway employing personnel of differing treatment disciplines. Our patient successfully lost a substantial amount of weight and has been able to ambulate, exercise, and engage in new, strenuous physical activities. In the care of the nonambulatory bariatric patient, employing a multidisciplinary treatment plan can produce successful results.

SAGES white paper on the current state of community practice surgeons: re-discovering the value of our community practice surgeons.

BACKGROUND: The Community Practice (CP) surgeon is the first point of access to surgical care globally and performs the majority of procedures in the USA. CP surgeons include those of various practice models, locations and communities, education and training, and much more. It is a diverse group that drives quality, access to care, research, and innovation. The SAGES CP Committee was formed to better define the role and highlight the contribution of the CP surgeon, as well as advocate for the position of CP surgeons in our society. METHODS: In 2018, a survey was distributed to the SAGES membership asking members to self-identify as either a Community Surgeon or Academic Surgeon. RESULTS: The majority (71%) of SAGES members surveyed self-identified as "Community Surgeons." This was in stark contrast to the distribution of Community versus Academic Surgeons in SAGES leadership (25% versus 75%, respectively). CONCLUSION: By better defining the characteristics and role of the CP, SAGES will be better informed on how to effectively engage with this large group within the society and increase its representation within the leadership. The CP Committee met on a biannual basis over a period of two years focusing on assessing their role in the SAGES organization. The committee members created the following initial goals: (1) define in a broad sense the characteristics of a CP Surgeon, (2) discuss and characterize the value of the CP surgeons, (3) highlight past and future areas of contributions of the group, and (4) delineate ways to engage and represent this subgroup. This manuscript is a culmination of the work of this committee while also serving as a way to support the initiatives and direction of SAGES leadership.

The safety of biologic mesh for laparoscopic repair of large, complicated hiatal hernia.

BACKGROUND: Biologic mesh is widely used for repair of large, complicated hiatal hernias. Recently, there have been reports of complications after its implantation. We studied the course of a large group of patients who had undergone hiatal hernia repair with use of biologic mesh to determine the rate of immediate and late complications related to its use. METHODS: All patients who had biologic mesh placed at the hiatus and who had been followed for at least 1 year were included. Perioperative data were reviewed, and a questionnaire was administered, designed to identify symptoms of gastroesophageal reflux, other symptoms such as dysphagia, and all other operative or endoscopic interventions that occurred after mesh implantation. In addition, postoperative radiologic and endoscopic studies were reviewed to assess signs of complications related to use of mesh. RESULTS: There were 126 patients eligible for the study. We were able to contact 73 of these patients, at median follow-up of 45 months. No mesh-related complications were found. The frequency and severity of heartburn, regurgitation, and dysphagia improved significantly compared with preoperative values, and 89% of the patients reported good to excellent results in terms of overall satisfaction. Six patients recorded worsening of dysphagia postoperatively, but after careful work-up and review of each individual case, no case seemed to be directly related to the mesh. No erosions, strictures, or other complications directly related to use of mesh were found. One patient required reoperation due to hiatal hernia recurrence with gastroesophageal reflux disease (GERD) symptoms. CONCLUSIONS: Use of biologic mesh for laparoscopic repair of large, complicated hiatal hernias appears safe. There were no major complications related to the mesh, and overall satisfaction with the operation was very good.

Improvement of respiratory symptoms following Heller myotomy for achalasia.

INTRODUCTION: Although patients with achalasia complain mainly of dysphagia, we have observed that they also have a high rate of respiratory problems. We hypothesized that the latter may be due to poor esophageal clearance leading to aspiration. This study examines the effect of Heller myotomy on these symptoms. METHODS: We studied the course of 111 patients with achalasia who underwent Heller myotomy between 1994 and 2008 and who agreed to participate in this study. All patients completed a questionnaire postoperatively assessing the preoperative and postoperative prevalence and severity of symptoms using visual analog scales. Patients were divided into two groups: one that included all those with respiratory symptoms (dyspnea, hoarseness, cough, wheezing, sore throat, and/or a history of asthma or pneumonia) prior to myotomy and one that included those without those symptoms. RESULTS: All patients presented with dysphagia as their primary complaint, and 63 (57%) reported respiratory symptoms or disease prior to surgery. There were no significant differences in preoperative characteristics between those with and without respiratory manifestations. After a median follow-up of 71 months (range 9-186 months), 55 (87%) patients reported durable improvement of dysphagia. The frequency and severity of all respiratory symptoms decreased significantly. Twenty-four of the 29 patients (82%) who reported a history of pneumonia prior to surgery did not experience recurrent episodes after Heller myotomy. CONCLUSIONS: A Heller myotomy is effective in improving esophageal emptying in patients with achalasia. This results in sustained improvement of dysphagia and associated respiratory symptoms/diseases. This suggests that respiratory symptoms/diseases in these patients are likely caused by esophageal retention of food and secretions, and then aspiration.

Clinical and biochemical impact of the d3 growth hormone receptor genotype in acromegaly.

CONTEXT: Lack of exon 3 of the GH receptor (d3-GHR) has been associated with increased responsiveness to GH therapy. By analogy, we hypothesized that patients with acromegaly bearing the d3-GHR genotype may have a more morbid clinical and biochemical picture. OBJECTIVE: Our objective was to determine whether the GHR genotype, by modifying tissue sensitivity to GH, influences the clinical/biochemical expression of acromegaly and its outcome after treatment. SETTING: The study was conducted at a specialized clinic at a tertiary care hospital. DESIGN, PATIENTS, AND METHODS: We conducted a prospective genotype investigation and retrospective analysis and correlation with clinical, biochemical, and outcome data from a group of 148 patients. Samples from 175 healthy blood donors were used as controls. GHR genotyping was performed by real-time PCR. MAIN OUTCOME MEASURES: We assessed prevalence of the three GHR genotypes (fl/fl, d3/d3, and d3/fl), associations between the genotypes, and baseline as well as post-therapeutic characteristics. RESULTS: Prevalence of the fl/fl, d3/d3, and d3/fl genotypes was 45, 22, and 32%, respectively, similar to what was found in the controls. Baseline characteristics were similar in carriers of the three genotypes. A positive correlation between IGF-I and log GH concentrations was significant only in homo- or heterozygous d3 carriers. Among d3-GHR carriers, diabetes, but no other comorbidities, was more prevalent (odds ratio = 2.02; 95% confidence interval = 0.96-4.2). d3-GHR carriers had significantly higher IGF-I concentrations after treatment. Multiple regression analysis revealed that the homo- or heterozygous lack of exon 3 was the strongest predictor of persistent biochemical activity (odds ratio = 1.29; 95% confidence interval = 0.65-2.58). CONCLUSIONS: The absence of exon 3 of the GHR may be associated with a more morbid acromegalic clinical and biochemical picture and a lower chance of achieving IGF-I normalization after therapy.

[Treatment of acromegaly with octreotide LAR]. / Tratamiento de la acromegalia con octreotida LAR.

BACKGROUND: Treatment of acromegaly with somastostatin analogues, albeit highly effective, is not curative and its elevated cost represents a major disadvantage. Hereby we describe our Center's experience using a fixed, 20 mg q.4 weeks- dose of octreotide LAR. METHODS: 97 patients, 69 females, 71 with macroadenomas, treated with 20-mg im injections of octreotide LAR every 4 weeks, in 23 as primary therapy. No dose escalation was allowed. Patients were evaluated with GH and IGF-1 levels at 4 weeks after the third injection; thereafter, assessments occurred at 3 to 6 months intervals. In 27 unselected patients, evaluations were also performed 6 weeks after the SA injection. RESULTS: A GH concentration < 2.5 ng/mL was reached by 71%, 75% and 83% of patients at the 3rd , 6th and 12th months of follow up respectively, whereas over 30% achieved an IGF-1 index < or = 1.0 at each of these time points, and both biochemical goals were achieved by 30%, 33% and 32% of patients at the same time points. Biochemical success was the same for those patients treated primarily and those treated secondarily and prior radiation made no difference. A baseline GH level > 10 ng/mL was associated with a poor response. CONCLUSIONS: A biochemical control rate comparable with other published series it is feasible to reach with the treatment with a fixed dose of 20 mg.

Estimación de la mortalidad infantil y de la niñez en Bolivia mediante técnicas indirectas 1990-1995 / sss

El presente trabajo forma parte de este esfuerzo y tiene el propósito de mejorar la disponibilidad de información social mediante la realización de un estudio específico referente a la estimación de la tasa de mortalidad infantil y de menores de cino años al más alto grado de desagradación geográfica posible. Constituye un aporte fundamental en lo se refiere a la información geográfica sobre indicadores de impacto como la mortalidad infantil y de la niñez. Los resultados aquí presentados pueden ser útiles para evaluar los programas del sector social en sus componentes relativos a la atención de la población infantil

Sistema de informacion geográfica sobre infraestructura social / System of geographic information on social infrastructure

El documento es proyecto de crecimiento progresivo,el mismo que sera implantado por modulos segun su ritmo de ampliacion de cobertura.Al inicio de sus funciones cubrira los servicos de cuantificacion y localizacion geografica de la infraestructura de los sectores de educacion,salud y saneamiento basico,ampliando su campo de accion a los sectores de vivienda social,caminos vecinales,centros de produccion agropecuario