Does endoscopy at the time of revisional bariatric surgery decrease complication rates? an analysis of the NSQIP database.

BACKGROUND: Endoscopy is performed routinely during bariatric surgery. It is often used for provocative testing and intraluminal inspection during Roux-en-Y gastric bypass (RNYGB) and sleeve gastrectomy (SG). Recent publications would indicate about one-quarter of bariatric cases are performed with concurrent endoscopy, resulting in a slight increase in time but no increase in complications within 30 days compared with cases where no endoscopy is performed. Do these results persist for endoscopy during revisional bariatric surgery (RBS)? METHODS: An analysis of the American College of Surgeons National Surgical Quality Initiative Program (NSQIP) was conducted for the years 2005-2017. Seventeen postoperative outcomes were analyzed in this database. A 1:1 propensity score matching analysis was completed for 13 patient comorbidities and demographics. A McNemar's test for paired categorical variables and a paired t-test for continuous variables were completed, with a significant P value of 0.05. The results were reported as the frequency and percentage for categorical variables and the mean (± standard deviation) for continuous variables. RESULTS: A total of 7249 RBS cases were identified. After propensity score matching for patient comorbidities and demographics 2329 cases remained. Esophagogastroduodenoscopy (EGD) was performed in 375 (16%) of these patients. There were no differences in complication rates between the two groups. CONCLUSIONS: Similar to non-revisional bariatric surgery, there is no difference in 30-day postoperative complications when endoscopy is performed in RBS. Endoscopy is performed in about one-sixth of RBS cases.

Is fundoplication necessary after paraesophageal hernia repair? A meta-analysis and systematic review.

INTRODUCTION: Paraesophageal hernias are often asymptomatic, but when symptomatic they should be fixed laparoscopically. A cruroplasty of the diaphragmatic pillars is performed and a fundoplication is usually performed at the time. However, there are times, especially in emergency cases, where it is not always possible to perform a fundoplication. We hypothesized there would be no difference in outcomes whether or not a fundoplication is performed as part of a paraesophageal hernia repair. METHODS: A literature review of available clinical databases was performed using PubMed, Clinical Key and Google Scholar. Our search terms were: "paraesophageal hernia" "paraesophageal hernia repair" "fundoplication" "emergency surgery" "no fundoplication" We excluded studies that were in languages other than English, abstracts and small case series. RESULTS: Our search criteria yielded a total of 22 studies published between 1997 and 2020. There were a total of 8600 subjects enrolled into this study. The overall pooled prevalence of fundoplication were estimated as 69% (95% CI: 59%-78%). In patients who underwent fundoplication, the risk of gastroesophageal reflux disease (GERD) was reduced as compared to patients who did not undergo fundoplication (RR: 0.64, 95% CI: 0.40-1.04, p = 0.069, I2 = 47.2%). A similar trend was also observed in recurrence (RR: 0.53, 95% CI: 0.27-1.03, p = 0.061, I2 = 0.0%) and reoperations (RR: 0.25, 95% CI: 0.02-2.69, p = 0.25, I2 = 56.7%). However, patients who underwent fundoplication had an increased risk of dysphagia (RR: 1.68, 95% CI: 0.59-4.81, p = 0.83, I2 = 42%). CONCLUSIONS: There is a higher rate of recurrence of gastroesophageal reflux disease, recurrence of hernia and reoperation when no fundoplication is performed during a paraesophageal hernia repair but a lower risk of dysphagia, but none of these reached statistical significance.(Comment 1) Paraesophageal hernia repair with fundoplication should be performed, but it is acceptable to not do it in certain situations.

Impact of Hepatic Metastasectomy in the Multimodal Treatment of Metastatic Breast Cancer.

BACKGROUND: Surgical management of hepatic metastases in patients with stage IV breast cancer remains controversial. The purpose of this study was to examine the impact of hepatic metastasectomy on long-term outcomes. METHODS: The 2004-2015 National Cancer Database was queried for all patients diagnosed with stage IV breast cancer with metastases isolated to the liver. Patient demographics, disease-, treatment- and outcome-related data were analyzed. RESULTS: Of 2,895 patients, only 90 (3.1%) underwent hepatic resection. Compared to patients who did not undergo metastasectomy, patients treated with metastasectomy tended to be younger (52 ± 12.7 versus 59.2 ± 14.6; P < 0.001) and have private insurance (74.4% versus 45.3%; P < 0.001). Independent predictors of metastasectomy included younger age (OR 0.98; CI 0.96-0.99; P = 0.01), lobular carcinoma (OR 2.26; CI 1.06-4.82; P = 0.03), and prior surgery of the primary site (partial mastectomy (OR 6.96; CI 3.47-13.95; P < 0.001) or total mastectomy (OR 5.74; CI 3.06-10.76; P < 0.001)). Compared to no metastasectomy, hepatic metastasectomy was independently associated with a 37% reduction in the risk of death (HR 0.63; CI 0.44-0.91; P = 0.01). CONCLUSIONS: Stage IV breast cancer with metastases to the liver is rare and few patients undergo hepatic resection. However, in this select patient population, hepatic metastasectomy was associated with a significant survival advantage when included in the multimodal treatment of synchronous stage IV breast cancer.

The safety of additional procedures at the time of revisional bariatric surgery.

BACKGROUND: The third most common bariatric operation is revisions of previous bariatric surgeries. Patients may require revisional bariatric surgery for inadequate weight loss or complications. Patients undergoing revisional bariatric surgery may also have other conditions that require surgery. This study evaluates the 30-day postoperative outcomes of patients undergoing revisional bariatric surgery and additional procedures. METHODS: A retrospective review of the 2005-2017 ACS NSQIP database identified 7249 patients who underwent revisional bariatric surgery with 3115 (48%) occurring with additional procedures. A 1:1 propensity score matching analysis was completed for 13 patient demographics and comorbidities. Postoperative variables were then analyzed as available in the NSQIP database. Subgroup analyses were completed for those undergoing paraesophageal hernia repair and abdominal wall hernia repair at the time of revisional bariatric surgery. RESULTS: The most common bariatric surgery that was converted or revised was the AGB (57%) and the most common additional procedure was paraesophageal hernia repair (n = 181, 15%). When additional procedures were completed at the time of revisional bariatric surgery, overall complications (p < 0.001), major systemic complications (p = 0.009) and mortality/major complications (p = 0.018) were all significantly increased. After matching for operative time, only postoperative sepsis remained significant with additional procedures (p = 0.042). In the subgroup analyses on paraesophageal and abdominal wall hernias there were no differences in postoperative complications after matching for operative time. CONCLUSIONS: Additional procedures, including paraesophageal and abdominal wall hernia repairs at the time of revisional bariatric surgery increase postoperative complications. Operative time was longer when additional procedures were performed. Postoperative sepsis was the only complication which remained significant after propensity matching when additional procedures are completed at the time of revisional bariatric surgery.