Understanding the burden of traumatic injuries at the United States-Mexico border: A scoping review of the literature.

ABSTRACT: The US-Mexico border is the busiest land crossing in the world and faces continuously increasing numbers of undocumented border crossers. Significant barriers to crossing are present in many regions of the border, including walls, bridges, rivers, canals, and the desert, each with unique features that can cause traumatic injury. The number of patients injured attempting to cross the border is also increasing, but significant knowledge gaps regarding these injuries and their impacts remain. The purpose of this scoping literature review is to describe the current state of trauma related to the US-Mexico border to draw attention to the problem, identify knowledge gaps in the existing literature, and introduce the creation of a consortium made up of representatives from border trauma centers in the Southwestern United States, the Border Region Doing Research on Trauma Consortium. Consortium members will collaborate to produce multicenter up-to-date data on the medical impact of the US-Mexico border, helping to elucidate the true magnitude of the problem and shed light on the impact cross-border trauma has on migrants, their families, and the US health care system. Only once the problem is fully described can meaningful solutions be provided.

Pancreatic Neuroendocrine Tumors: The Effect of Facility Type on Patient Survival.

OBJECTIVES: During the last decades, significant progress has been made in the management of patients with pancreatic neuroendocrine tumors (pNETs). It is unclear how the type of the treating health care facility alters patient outcomes. METHODS: Data from pNETs reported to the National Cancer Database between 2004 and 2016 were examined. Types of institutions were as follows: academic/research cancer program (ARP), comprehensive community cancer program (CCCP), integrated network cancer program (INCP), and community cancer program (CCP). RESULTS: A total of 17,887 patients with pNETs were analyzed. Treatment at ARPs was significantly associated with receipt of surgery (ARP, 61.9%; CCCP, 45.6%; CCP, 29.9%; INCP, 55.5%; P < 0.001), both for patients with very early tumors ≤2 cm (ARP, 74.7%; CCCP, 66.5%; CCP, 52.4%; INCP, 71.6%; P < 0.001) and for patients with liver metastases (ARP, 21.3%; CCCP, 10.6%; CCP, 5%; INCP, 16.8%; P < 0.001). Treatment at ARPs was associated with improved survival (median overall survival: ARP, 91 mo; CCCP, 47 mo; CCP, 24.5 mo; INCP, 72 mo; P < 0.001). CONCLUSIONS: Treatment of pNETs at academic/research programs is associated with more frequent resections and best survival outcomes. This survival benefit exists for early and late stages and after adjusting for known cofactors.

The impact of minimally invasive surgery and frailty on post-hepatectomy outcomes.

BACKGROUND: The impact of patient frailty on post-hepatectomy outcomes is not well studied. We hypothesized that patient frailty is a strong predictor of 30-day post-hepatectomy complications. METHODS: The liver-targeted National Surgical Quality Improvement Program (NSQIP) database for 2014-2019 was reviewed. A validated modified frailty index (mFI) was used. RESULTS: A total of 24,150 hepatectomies were reviewed. Worsening frailty was associated with increased incidence of Clavien-Dindo grade IV complications (mFI 0, 1, 2, 3, 4 was 3.9%, 6.3%, 10%, 8.1%, 50% respectively; p < 0.001). Minimally invasive hepatectomies had a lower rate of Clavien-Dindo grade IV complications for non-frail (Laparoscopic: 1%, Robotic: 2.6%, Open: 4.6%; p < 0.001) and frail patients (Laparoscopic: 3%, Robotic: 2.3%, Open: 7.7%; p < 0.001). Frail patients experienced higher incidence of post-hepatectomy liver failure (5.4% vs 4.1% for non-frail; p < 0.001) and grade C liver failure (28% vs 21.1% for non-frail; p = 0.03). Incorporating mFI to Albumin-Bilirubin score (ALBI) improved its ability to predict Clavien-Dindo grade IV complications (AUC improved from 0.609 to 0.647; p < 0.001) and 30-day mortality (AUC improved from 0.663 to 0.72; p < 0.001). CONCLUSION: Worsening frailty correlates with increased incidence of Clavien-Dindo grade IV complications post-hepatectomy, whereas minimally invasive approaches decrease this risk. Incorporating frailty assessment to ALBI improves its ability to predict major postoperative complications and 30-day mortality.

Evaluating the change in patterns of traumatic injury in the setting of pandemic and social distancing restrictions: An analysis of a level 1 trauma center.

BACKGROUND: Social distancing measures and quarantine during the COVID-19 pandemic have led to reported changes in traumatic injury patterns. We set to examine the effects of these restrictive guidelines in our trauma center. METHODS: This is a retrospective chart review of all patients evaluated for traumatic injuries at a Level 1 trauma center during two time periods: March-June 2020 (COVID) and March-June 2019 (Pre-COVID). RESULTS: Overall trauma volume did not differ significantly between the two time periods. Changes seen during COVID included increases in penetrating injuries (12.5% vs 6.7%, p < 0.001), particularly those due to firearms (7.5% vs 3.7%, p < 0.001). Hospital length of stay, intensive care unit length of stay, and days on the ventilator remained consistent between the two groups. Trends toward increased injuries in the home and non-accidental trauma were not statistically significant. CONCLUSION: Traumatic injury patterns have changed as a result of social distancing in both the adult and pediatric trauma populations. Analyzing the effects of social distancing on trauma can lead to a better development of preventive strategies.

Trends and outcomes of minimally invasive surgery for gastrointestinal stromal tumors (GIST).

OBJECTIVE: Minimally invasive surgery (MIS) is increasingly being utilized for the resection of gastrointestinal cancers. National trends for perioperative and oncologic outcomes of MIS for gastrointestinal stromal tumors (GIST) are unknown. We hypothesized that with increased use of MIS, the perioperative outcomes and survival for GIST are preserved. METHODS: The National Cancer Database (2010-2016) was utilized to assess perioperative and oncologic outcomes for GIST of the stomach and small bowel. Kaplan-Meier method and log rank test were used to compare survival outcomes. RESULTS: Data from 8923 gastric and 3683 small bowel resections were analyzed. Over the study period, MIS became the prevalent modality for gastrectomies (2010: robotic: 2.4%, laparoscopic: 26.1%, open: 71.5% vs. 2016: robotic: 9.6%, laparoscopic: 48.8%, open: 41.6%; p < 0.001), with a smaller increase in enterectomies (2010: robotic: 1%, laparoscopic: 17.3%, open: 81.6% vs. 2016: robotic: 3.9%, laparoscopic: 27.2%, open: 68.9%; p < 0.001). Age and Charlson comorbidity index were similar among groups. MIS approaches were associated with fewer readmissions and lower 90 day mortality for gastrectomies and similar rates for enterectomies. MIS did not compromise patient survival even in patients who underwent neoadjuvant treatment or harbored tumors ≥ 10 cm. CONCLUSION: Minimally invasive surgery is increasingly being utilized for resection of gastric and small bowel GIST, with improved postoperative outcomes. In this retrospective review, overall survival after minimally invasive or open surgery was comparable, even in challenging scenarios of neoadjuvant treatment or large tumors (≥ 10 cm).

Blunt Thoracic Aortic Injury and Contemporary Management Strategy.

Thoracic aortic injury (TAI) is a leading cause of death in blunt chest trauma. Motor vehicle collisions are the commonest cause, and most patients die before receiving medical attention. Survivors who make it to the hospital also typically have other debilitating injuries with high morbidity. It is imperative to understand the nature of these injuries and implement current management strategies to improve patient outcomes. A literature review on contemporary management strategies on blunt thoracic aortic injuries was performed to evaluate the available evidence using online databases (PubMed and Google Scholar). We found that there has been an improved survival owing to the current advancement in diagnostic modalities, the use of contrast-enhanced computed tomography angiography, and contemporary management techniques with an endovascular approach. However, careful assessment of patients and a multidisciplinary effort are necessary to establish an accurate diagnosis. Minimal aortic injuries (intimal tear and aortic hematoma) can be managed medically with careful monitoring of disease progression with imaging. Endovascular approaches and delayed intervention are key strategies for optimal management of high-grade TAI.

Trends in bariatric surgery in Texas: an analysis of a statewide administrative database 2013-2017.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) tracks 30-day outcomes of bariatric patients, but only at accredited centers. Presently, these cases are not broken down by state. Administrative databases can be used to answer some of the questions that are not asked by clinical databases and also to validate those databases. We proposed using the inpatient and outpatient administrative databases in Texas to examine both the numbers and trends of bariatric surgery in Texas over a 5-year period. METHODS: The Texas Inpatient Public Use Data File (IPUDF) and the Texas Outpatient Public Data File (OPUDF) were examined for the years 2013-2017. We searched for patients undergoing laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (SG), laparoscopic Roux-en-Y gastric bypass (LRYGB) and duodenal switch. Robotic assisted cases were also examined. RESULTS: There were 105,199 bariatric cases performed in Texas from 2013 to 2017. There were 173 centers performing bariatric surgery. The most common operation performed was the sleeve gastrectomy at 73,663 case (70% of total). Gastric bypasses were second at 22,890 cases. During this time period, LAGB almost disappeared; dropping from 2090 cases in 2013 to 115 cases in 2017, with removal of 2097 LAGB in the study period in the OPUDF. During this time period, there was a lower growth rate of the number of SG in the IPUDF with a large increase in SG performed with outpatient status, while LRYGB remained relatively stable. CONCLUSION: Rates of bariatric surgery in Texas are increasing slowly. The dominant procedure is the SG with a trend towards being done under outpatient status. LAGB has been essentially phased out. There is an increase in SG being performed under 'outpatient' status.

Facility Type Affects Treatment Outcomes for Patients With Mucinous Cystic Neoplasms and Intraductal Papillary Mucinous Neoplasms of the Pancreas.

OBJECTIVE: Academic centers report better outcomes for pancreatic ductal adenocarcinoma. We hypothesized that treatment outcomes for mucinous cysts differ according to institution type. METHODS: Using the National Cancer Data Base, we analyzed data on patients with mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs). RESULTS: Of 3278 identified patients, 2622 (80%) had IPMNs and 656 (20%) had MCNs. While most academic/research programs (ARCPs, 84.9%) treated more than 10 patients/year, this was true for only 59% of integrated network cancer programs, 37.3% of comprehensive community cancer programs, and 0% of community cancer programs (P < 0.001). Surgery was used more often in ARCPs and for smaller tumors. The ARCPs had higher rates of margin negative resections with retrieval of 15 or more nodes with the lowest 30- and 90-day mortality rates. The median overall survival was better in ARCPs (110.3 months) than comprehensive community cancer programs (75.1 mo), community cancer programs (75.1 mo), or integrated network cancer programs (100.8 mo, P < 0.001). CONCLUSIONS: Treatment of MCNs and IPMNs of the pancreas at academic centers is associated with a higher probability of pancreatectomy, disease identification in a noninvasive stage, and better overall survival. Centralization of care for mucinous pancreatic cysts will lead to improved outcomes.

Mucinous cystic neoplasms of the pancreas in the modern era. Experience with 707 patients.

BACKGROUND: Mucinous Cystic Neoplasms are mucin producing cysts of the pancreas with malignant potential. The existing literature on treatment outcomes is limited to relatively small surgical series. METHODS: We reviewed the National Cancer Database assessing the outcomes of patients with mucinous cystic neoplasms between 2004 and 2016. Kaplan-Meier method and log rank test were used to make survival comparisons. RESULTS: A total of 707 patients were identified; 492(69.6%) underwent pancreatectomies. The majority of patients were women (71.4%), with median age 65 years (range: 22-90). Most common operation was partial pancreatectomy ie distal (48.4%) whereas 21.7% underwent a Whipple. Patients who were not operated were more frequently stage IV (40%) whereas patients who were operated had more frequently invasive adenocarcinoma (74.8%). Patients who underwent pancreatectomy had better survival compared to these who didn't undergo surgery (81.4 vs 6.6 months; p < 0.001). Comparing patients who underwent pancreatectomy and had invasive disease versus patients who had in situ disease the former were older (median age 62 vs 55.5 years p = 0.004) and more frequently men (26.1 vs 16.1%; p = 0.03), however they had similar tumor size (5.5 vs 7 cm respectively; p = 0.14) and similar tumor differentiation (moderately differentiated 50% vs 38.1%; p = 0.49). Patients with non-invasive (in situ) disease had prolonged survival compared to these with invasive disease (median OS not reached vs 50.2months; p < 0.001). After Cox proportional hazard regression nodal positive disease was the most important factor of decreased survival for invasive adenocarcinoma (HR: 2.2; p < 0.001). CONCLUSION: Patients with adenocarcinoma arising from a mucinous cystic neoplasm of the pancreas have excellent survival when they undergo pancreatectomy especially if the disease is still in situ. However, 3/4 of patients who undergo resection have already developed invasive adenocarcinoma and nodal status dominates their prognosis. Advanced age but not the size of the cyst correlate with the presence of invasive disease.

Endoscopy Used as Provocative Testing in Bariatric Surgery: An Analysis of the Texas Public Use Data File.

BACKGROUND: Many bariatric surgeons test the anastomosis and staple lines with some sort of provocative test. This can take the form of an air leak test with a nasogastric tube with methylene blue dye or with an endoscopy. The State Department of Health Statistics in Texas tracks outcomes using the Texas Public Use Data File (PUDF). METHODS: We queried the Texas Inpatient and Outpatient PUDFs for 2013 to 2017 to examine the number of bariatric surgeries with endoscopy performed at the same time. We used the International Classification of Diseases Clinical Modification Version 9 (ICD-9-CM) and ICD-10 procedure codes and Current Procedural Terminology for Sleeve Gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) and endoscopy, and the ICD-9-CM and ICD-10 diagnosis codes for morbid obesity. RESULTS: There were 74,075 SG reported in the Texas Inpatient and Outpatient PUDF for the years 2013-2017. Of the SG performed, 5,521 (7.4%) had an intraoperative endoscopy. For the 19,192 LRYGB reported, 1640 (8.6%) underwent LRYGB + endoscopy. This was broken down by SG only vs SG + endoscopy and LRYGB only vs LRYGB + endoscopy. Overall, SG + endoscopy had a significantly shorter length of stay (LOS) vs LRYGB + endoscopy at 1.74 d vs 2.34 d (P < .001) and a significantly less cost of $71,685 vs $91,093 (P < .001). CONCLUSIONS: A small percentage of SG and LRYGB patients underwent endoscopy for provocative testing over the study period. Provocative testing with endoscopy costs more for SG and LRYGB and was associated with a shorter LOS.

Are Concomitant Operations During Bariatric Surgery Safe? An Analysis of the MBSAQIP Database.

INTRODUCTION: The American College of Surgeons tracks 30-day outcomes using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program (MBSAQIP) database. We examined the short-term outcomes of patients that undergo bariatric surgery concomitantly with other operations such as hernia repairs and cholecystectomy to determine the safety of this practice. METHODS: The MBSAQIP Participant Use Data File for 2015-2017 was examined for differences in primary bariatric operations vs concomitant procedures (CP). We looked for concurrent CPT codes for laparoscopic cholecystectomy (LC) and hernia repairs (ventral, epigastric, incisional, and inguinal). p was significant at < 0.05. RESULTS: There were 464,674 cases, of which 15,614 had CP. For both LRYGB+LC and SG+LC, there were increased operative times and length of stay. There were statistically significant higher rates of readmission, reintervention, and reoperation for SG+LC vs SG alone, as well as for LRYGB+hernia and SG+hernia. There was a higher risk of death (p < 0.001) in LRYGB+hernia patients. Also, LRYGB+hernia patients had statistically significant increases in unplanned admission to the intensive care unit and pulmonary embolus. SG+hernia patients had a higher rate of ventilation > 48 h, unplanned admission to the ICU, pulmonary embolism, deep vein thrombosis, and readmission, reintervention, and reoperation. CONCLUSIONS: There is a statistically higher rate of complications with concomitant procedures in the MBSAQIP database. Length of stay and operative times are increased in concomitant operations as are readmissions, reinterventions, and reoperations. These findings would indicate that additional procedures at the time of bariatric surgery should be deferred if possible.

The MBSAQIP is going viral! 194 hits and still going strong.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) first released its Participant Use Data File in 2015. Since then, surgeons have eagerly evaluated data now available on >750,000 patients, and a yearly increase in the number of publications using the Participant Use File was anticipated. OBJECTIVE: To evaluate the impact of the MBSAQIP in surgical literature. SETTING: University surgical department, United States. METHODS: A literature search was performed to identify articles published using the MBSAQIP database up to March 2019. PubMed, Clinical Key (both indexed for MEDLINE), and Cochrane databases were queried using the keywords "MBSAQIP" and "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program." Abstracts presented at ObesityWeek, SAGES, and the Clinical Congress of the ACS in 2016 to 2019 were also examined. Duplicates, letters to the editor, commentaries, statements, and position pieces were excluded. Articles describing projects that used MBSAQIP data to study <5 accredited centers were also excluded. RESULTS: As of March 2019, there were 114 results in PubMed, 216 results in Clinical Key, and 0 in Cochrane using the search terms. Additionally, 184 abstracts were included from the journal supplements from ObesityWeek, SAGES, and the Clinical Congress of the ACS. After elimination of duplicates, there were 327 total results. After exclusions, 55 published manuscripts and 126 abstracts remained. CONCLUSION: The MBSAQIP is a resounding success. A substantial body of research has already been produced from it and is growing with time. Gaps in current knowledge are being targeted through analyses of this single, large-scale database. The MBSAQIP will remain a valuable leading resource in metabolic and bariatric surgery.

Disparities in Access to Bariatric Surgery in Texas 2013-2017.

BACKGROUND: Access to bariatric care varies across regions, ethnic, and racial groups. Some of these variations may be due to insurance status or socioeconomic status. There are also regional and state variations in access to metabolic and bariatric surgery (MBS). The Texas Inpatient Public Use Data File (IPUDF) and Texas Outpatient Public Use Data File is a state-mandated database that collects information on demographics, procedures, diagnoses, and cost on almost all admissions in Texas. We used them to examine racial disparities in MBS over a 5-y period. METHODS: The IPUDF and Texas Outpatient Public Use Data File were examined from the years 2013 through, 2017. We included all patients undergoing a laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy and examined the demographics of these patients. Race and ethnicity are reported separately. We used U.S. Census Bureau statistics and the Texas Department of State Health Services statistics to determine the crude (unadjusted) and adjusted procedure rates of patients undergoing MBS. RESULTS: In the IUPUDF, the crude unadjusted procedure rate for blacks undergoing MBS was 7.29 per 10,000 population followed by 6.85 per 10,000 for non-Hispanic whites. Hispanics had the lowest rate at 3.20 per 10,000. When adjusted for sex, obesity, age, and race, blacks still had a higher rate of access followed by whites and then Hispanics. CONCLUSIONS: There are disparities to access for bariatric surgery in Texas. Blacks have the greatest access followed by whites. Hispanics have the lowest procedure rate per population.

Trends in revisional bariatric surgery using the MBSAQIP database 2015-2017.

BACKGROUND: The third most common bariatric surgery is revisional bariatric surgery. The American College of Surgeons tracks outcomes using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program database. We used this database to examine trends in revisional bariatric surgery. OBJECTIVE: To evaluate how trends in bariatric revisional surgery have changed in recent years. SETTING: University Hospital, United States. METHODS: The Metabolic and Bariatric Surgery Accreditation Quality Initiative Program database for 2015 to 2017 was examined for revisions of bariatric surgery. Patients who underwent revisional bariatric surgery were identified by the primary Current Procedural Terminology code, the REVCONV and PREVIOUS_SURGERY field as well as secondary Current Procedural Terminology codes. There is no exact code for sleeve gastrectomy (SG) to laparoscopic Roux-en-Y gastric bypass (LRYGB), so we used 43644 (GB)+REVCONV+PREVIOUS_SURGERY for this. RESULTS: For the years 2015 to 2017 there were 57,683 revisions/conversions of 528,081 patients. The number of revisions increased over the study period by 5213 cases. The most common revision was laparoscopic adjustable gastric band (LAGB) to SG with 15,433 cases and the second was LAGB to LRYGB with 10,485 cases. There were 14,715 LAGB removals. It is more difficult to track SG to LRYGB but there were 8491 unlisted cases, which may have been sleeve to bypass. CONCLUSION: LAGBs are being taken out or converted, and this group makes up the largest portion of revisions and conversions. It is difficult to track SG to LRYGB, but the number of unlisted cases continues to climb. This will likely surpass LAGB conversions with time. The Metabolic and Bariatric Surgery Accreditation Quality Initiative Program should be modified to capture revisions/conversions of SG.

How many sleeve gastrectomies are done at nonaccredited centers in Texas?

BACKGROUND: The American College of Surgeons created the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to improve the safety of surgery and track outcomes of patients undergoing metabolic and bariatric surgery. The MBSAQIP captures all surgical procedures performed at accredited centers (AC) but not all metabolic and bariatric surgery cases performed in the United States. Texas has a large statewide administrative database that tracks nearly all surgical procedures performed in the state and we proposed using this database to assess the number of sleeve gastrectomies (SG) and whether they were performed at an AC or not. OBJECTIVE: Our objective was to determine the percentage of SG that are performed in MBSAQIP ACs. SETTING: University surgical department, United States. METHODS: The Texas Inpatient and Outpatient Public Use Data Files (PUDF) for the year 2017 were examined. We used the Current Procedural Terminology and International Classification of Diseases version 10 codes for SG, 43775 and 0 DB64 Z3, respectively. We compared the PUDF facility list to a list of MBSAQIP ACs in Texas. RESULTS: There were 4549 SG performed in Texas in 2017 reported in the Outpatient PUDF. Of these, 80.8% of cases were performed at ACs. Of the 136 facilities in the outpatient PUDF performing SG, 58 were MBSAQIP accredited. In the Inpatient PUDF for 2017 there were 11,287 SG, of which 9829 (87%) were performed at ACs. Of 153 centers performing SG, 77 were MBSAQIP accredited. There was a higher percentage of adjustable band conversions to SG at non-ACs in the Outpatient PUDF than the Inpatient PUDF. CONCLUSION: The MBSAQIP database is missing almost 20% of outpatient SG performed in Texas and 13% of inpatient SG. Administrative databases can be used to externally validate the MBSAQIP.

Conversions to open surgery greatly increase complications: an analysis of the MBSAQIP database.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database tracks patients, techniques, and outcomes for 30 days. The overwhelming majority of cases reported are performed using a laparoscopic technique. Bariatric surgeons rarely have to convert from laparoscopy to open surgery. OBJECTIVES: We examined the MBSAQIP to determine the characteristics of patients who underwent conversion and evaluated their short-term outcomes. SETTINGS: University program in the United States and nationwide clinical database. METHODS: The MBSAQIP Public Use File for 2017 was examined for primary bariatric operations. We identified patients who underwent a sleeve gastrectomy or gastric bypass using a minimally invasive technique. We identified patients who underwent conversion to another operative technique or were converted to open surgery and analyzed preoperative characteristics and postoperative complication rates. Relative risks (RR) were calculated for complications. P value was significant at < .05. RESULTS: There were 186,962 patients in the entire cohort. Six hundred nine patients underwent conversion from the original surgical approach to either open surgery (n = 457) or to another technique (n = 152). Patients with preoperative oxygen dependency, poor functional status, previous foregut/obesity surgery, preoperative renal insufficiency, and anticoagulation were more likely to undergo conversion. Patients who underwent conversion to the open approach had longer operative times (191 versus 86.6 min [P < .001]) and longer time to discharge (6.2 versus 1.6 d [P < .001]). The RR of death was 18.2 (95% confidence interval 8.7-37.6, P < .001) for procedures converted to open. The RR of sepsis was 10.1 (95% confidence interval 4.2-24.2, P < .001) and the RR for all complications was increased throughout for patients undergoing conversion. CONCLUSIONS: Patients in the MBSAQIP database that undergo conversion to the open surgical approach are at a greatly increased risk for death and complications.

Late-term hiatal hernia after gastric bypass: an emerging problem.

BACKGROUND: Gastric bypasses were the most common bariatric surgery for many years, and long-term complications after gastric bypass are known to be relatively common. Symptomatic hiatal hernia (HH) with pouch migration is a less-known complication. However, when these are symptomatic, they require surgical repair. OBJECTIVE: We present a case series of late-term HH after gastric bypass and discuss the common presentation and treatment. SETTING: University program in the United States. METHODS: A retrospective chart review was performed of patients presenting with late-term HH after gastric bypass performed by a single surgeon during 2002 through 2018. The review captured presentation and symptoms, age, body mass index, time from index surgery, radiologic studies, and the reoperative details. If available, the original operative note was reviewed along with any preoperative imaging studies. A review of the literature was also performed. RESULTS: Seven patients were included in the case series. The average time from the index surgery was 11.9 years (range 9-16) and the average age of the patient at time of presentation was 60.1. The average body mass index at the time of the HH repair was 34 kg/m2. The most common presenting symptom was gastroesophageal reflux. Both computed tomography and upper gastrointestinal series were used for diagnosis with a common finding of HH and pouch migration into the mediastinum. HH repair with bioabsorbable mesh was performed in all patients, with an average operative time of 105 minutes. CONCLUSION: HH can present late after gastric bypass become symptomatic. When symptomatic, it needs to be addressed surgically and can usually be done through a minimally invasive approach.

Concomitant Hiatal Hernia Repair with Sleeve Gastrectomy: A 5-Year Analysis.

Background: The sleeve gastrectomy (SG) can be associated with postoperative gastroesophageal reflux and when a hiatal hernia (HH) is present, it should be fixed. Earlier studies have shown that 20% of SG have a concomitant hiatal hernia repair (SG+HHR). The aim of this project is to determine the rate of SG+HHR in a large state administrative database. Methods: The Texas Inpatient Public Use Data File (IPUDF) and Outpatient Public Use Data File (OPUDF) for the years 2013-2017 were examined for patients that underwent SG+HHR at the same time. Patient demographics, diagnosis, and charge data were also examined. A t-test was performed between groups and P was considered significant at < 0.05. Results: In the OPUDF, there were 6,193 (33.7%) patients who underwent SG+HHR out of 18,403 patients who underwent SG. Mean charges were $94,741 [standard deviation (SD) = $87,284]. Length of stay (LOS) was 2.1 (SD = 3.5) vs 2.3 days (SD = 3.3) with a shorter stay for SG+HHR vs SG alone (P < 0.001). In the IPUDF, there were 11,536 (21.1%) patients who underwent SG+HHR out of 54,545 patients who underwent SG. Mean charges were $69,006 (SD = $46,365). LOS was 1.59 days (SD = 3.7) for SG+HHR vs 1.63 days (SD = 1.6) for SG (P = .043). The rate of SG+HHR increased over the study period. Conclusions: SG+HHR is common in both the outpatient and inpatient setting. There is a yearly trend of increasing rates of SG+HHR.

Small bowel obstructions following the use of barbed suture: a review of the literature and analysis of the MAUDE database.

BACKGROUND: Barbed suture has been adopted across all surgical specialties. One of the infrequent complications seen with the use of barbed suture is small bowel obstructions (SBOs). In this study, we perform a review of the literature and the Manufacturer and User Facility Device Experience Database (MAUDE) to characterize SBOs after the use of barbed sutures in a variety of operative procedures. METHODS: A review of the literature was performed by searching PubMed and Ovid. We used the search terms: "barbed," "suture," "bowel," and "obstructions." For each case report, we examined the initial surgical procedure, type of barbed suture used, the type of complication, the time to complication, the presentation, and the type of operative interventions required. We did the same with the MAUDE database. RESULTS: Our review of the literature revealed 18 different cases of SBO secondary to the use of barbed suture. The four most common procedures, with a total of four cases each, were inguinal hernia procedures, myomectomy, hysterectomy, and pelvic floor reconstructive procedures. The average time of presentation to SBO was found to be 26.3 days post-op (1-196 days). A total of 16 patients (88.9%) presented with abdominal pain. Other common complaints included vomiting (33.3%), abdominal distension (27.8%), oral intolerance (22.2%), and constipation (16.7%). A total of 5 cases were also found to have a possible volvulus on computed tomography (CT), and 2 cases were reported to have strangulation. The MAUDE database had 14 cases reporting on obstruction. CONCLUSIONS: Surgeons should have a high index of suspicion for SBO if a patient presents with obstructive symptoms after a surgery that used barbed suture. This will often present as a mesenteric volvulus on CT. These particular SBOs require operative exploration, with laparoscopy being successful in the majority of cases.