ABSTRACT
BACKGROUND: Traumatic diaphragmatic injuries (TDIs) are relatively uncommon and require surgical repair to prevent or address herniation. Three quarters of TDIs are due to blunt thoraco-abdominal trauma. In blunt TDIs, variable clinical presentations and frequent concurrent life-threatening injuries may hinder early recognition and treatment, leading to diagnostic delays, which may result in technically more challenging repairs. Right-sided blunt TDIs are much less common than left-sided ones, are difficult to visualize on imaging studies, are more frequently associated with other potentially lethal injuries, and tend to present more subtly, so that diagnostic delays are more likely. CASE PRESENTATION: We report the diagnosis and elective repair of a large right-sided traumatic diaphragmatic hernia resulting from a distant blunt abdominal injury, describing the techniques used to address the challenges presented by the chronic intrathoracic displacement of the entire liver with the gallbladder, as well as the right side of the colon and part of the duodenum. CONCLUSIONS: Early diagnosis of right-sided TDIs can be especially elusive. The management of delayed diaphragmatic hernias can be challenging, but with meticulous planning and a flexible surgical approach, a repair can be achieved resulting in good recovery and low risk of recurrence.
ABSTRACT
BACKGROUND: Some weight regain is expected after bariatric surgery; however, this concept is not well defined. A favorable weight loss response has commonly been defined as 50% excess weight loss (EWL). The medical literature uses %total weight loss (%TWL), which has recently been adopted in some surgical literature. OBJECTIVE: To demonstrate variability in bariatric surgery outcomes based on the definition applied and propose a standardized definition. METHODS: A retrospective review of patients who underwent bariatric surgery from 2001 to 2016 with ≥ 1 year follow-up was completed. Several previously proposed definitions of weight regain were analyzed. RESULTS: One thousand five hundred seventy-four patients met inclusion criteria. Preoperative mean body mass index (BMI) was 47.6 ± 6.4 kg/m2. Increased preoperative BMI was associated with increased mean %TWL at 2 years postoperative (29.3 ± 9.1% for BMI < 40, vs. 37.5 ± 9.5% for BMI > 60; P < 0.001). Based on %EWL, 93% of patients experienced ≥ 50% EWL by 1-2 years, and 61.8% maintained ≥ 50% EWL through the 10-year follow-up period. Similarly, 97% experienced ≥ 20% TWL by 1-2 years and 70.3% maintained ≥ 20% TWL through the 10-year follow-up period. Over 50% of patients maintained their weight based on several proposed definitions through 5 years follow-up. CONCLUSIONS: A high percentage (> 90%) of patients achieve ≥ 20% TWL and ≥ 50% EWL. Increased preoperative BMI was associated with increased %TWL and decreased %EWL at 2 years postoperative. The incidence of weight regain varies depending on the definition. We propose a standardized definition for identifying good responders following bariatric surgery to be ≥ 20% TWL, as this measure is least influenced by preoperative BMI.
