RESUMO
BACKGROUND: Body mass index (BMI) thresholds are utilized as a preoperative optimization strategy for obese patients prior to elective abdominal wall hernia repair. The objectives of this study were to determine the proportion of patients at our institution who ultimately underwent hernia repair after initial deferral due to BMI and to evaluate outcomes of those who required emergent repair during the deferral period. METHODS: A retrospective review was performed from 2016 to 2018 to identify all patients with abdominal wall hernias who were deferred surgery due to BMI. Patient characteristics, hernia type, change in BMI, progression to surgery, acuity of surgery (elective or emergent), and postoperative outcomes were examined. RESULTS: 200 patients were deferred hernia repair due to BMI. Of these, 150 (75%) did not undergo repair over a mean period of 27 months. The remaining 50 patients ultimately underwent repair, 36 of which (72%) were elective and 14 (28%) emergent. The mean initial BMI of the elective group was 35.3 ± 1.8, compared to 39.1 ± 5.3 in the no surgery group and 40.6 ± 8.2 in the emergent group (P < .01). While the elective group lost weight before surgery, the other groups did not. Patients who required emergent surgery had worse outcomes than those repaired electively. CONCLUSIONS: Preoperative weight loss is unsuccessful in most obese patients presenting for abdominal wall hernia repair at our institution. Patients who required emergent hernia repair had worse outcomes than those who underwent elective repair. Our institution's BMI threshold is a failed optimization strategy that needs to be reconsidered.
Assuntos
Parede Abdominal , Hérnia Ventral , Humanos , Herniorrafia , Índice de Massa Corporal , Provedores de Redes de Segurança , Hérnia Ventral/cirurgia , Obesidade/complicações , Obesidade/cirurgia , Estudos Retrospectivos , Parede Abdominal/cirurgiaRESUMO
BACKGROUND: The ratio of hernia size to fascial defect size, termed the hernia-to-neck ratio (HNR), has been proposed as a novel predictive factor for umbilical hernia complications. HNR ≥ 2.5 has been suggested to warrant surgery due to association with bowel strangulation, incarceration, and necrosis. The aim of this study was to evaluate the association between HNR and emergent ventral hernia repair at our institution. METHODS: A retrospective cohort study was performed of consecutive patients with ventral hernias evaluated at a large safety-net hospital from 2017 to 2019. Patients who required emergent ventral hernia repair were compared to patients who did not require repair at latest follow-up. HNR was calculated using a previously described method: maximal hernia sac size and maximal fascial defect size (termed "hernia neck size") were measured in the sagittal plane on CT scan. Data are described as mean ± standard deviation and median (interquartile range). RESULTS: A total of 166 patients were included: 84 (51%) required emergent hernia repair and 82 (49%) did not undergo repair. Median follow-up was 19 (8-27) months. Patient groups were similar except the emergent repair group had more males (50% vs. 34%, p = 0.03), umbilical hernias (93% vs. 56%, p < 0.01), recurrent hernias (31% vs. 15%, p < 0.01), and lower mean BMI (34.3 ± 9.9 vs. 39.1 ± 6.5, p < 0.01). Hernia sac size did not differ between groups (5.8 [3.8-8.4] cm vs. 6.1 [3.5-11.8] cm, p = 0.45). Hernia neck size was significantly smaller in the emergent repair group (1.5 [2.3-3.5] cm vs. 3.4 [1.8-6.2] cm, p < 0.01). Hernia-to-neck ratio was significantly higher in the emergent repair group (2.4 [1.8-3.1] vs. 1.7 [1.1-2.9], p < 0.01). CONCLUSION: This study demonstrated an association between higher HNR and increased risk of emergent ventral hernia repair. Future studies will evaluate the use of HNR to risk-stratify patients with ventral hernias in a safety-net hospital.
Assuntos
Hérnia Umbilical , Hérnia Ventral , Laparoscopia , Masculino , Humanos , Herniorrafia , Estudos Retrospectivos , Telas Cirúrgicas , Hérnia Ventral/cirurgia , Hérnia Umbilical/cirurgia , Dor no Peito , RecidivaRESUMO
BACKGROUND: Magnetic sphincter augmentation (MSA) is an effective treatment for gastroesophageal reflux disease (GERD). However, the impact of obesity on MSA outcomes is unknown. The objective of this study was to evaluate the effectiveness of MSA in patients with GERD and obesity. METHODS: A retrospective cohort study was performed of consecutive patients who underwent laparoscopic MSA at three high-volume centers from 2016 to 2019. Patients were grouped into four cohorts according to the World Health Organization body mass index (BMI) classification: BMI < 25 (normal weight), BMI 25-29.9 (overweight), BMI 30-34.9 (obese class I), and BMI > 35 (obese class II-III). Preoperative, operative, and postoperative data were compared between groups. RESULTS: A total of 621 patients underwent laparoscopic MSA during the study period. Follow-up with endoscopy or video esophagram was available for 361 patients (58%) with a median follow-up of 15.4 months. Baseline characteristics of the groups were similar except the BMI > 35 group had more females and a higher preoperative median DeMeester score. There were no significant differences in outcomes between normal weight, overweight, and obese patient groups undergoing MSA. All groups experienced significant reductions in acid suppressive medication use, low GERD-HRQL scores, low DeMeester scores, few intraoperative and postoperative complications, and low rates of hiatal hernia recurrence after MSA. CONCLUSIONS: Magnetic sphincter augmentation is safe and effective in improving GERD symptoms, reducing esophageal acid exposure, and preventing hiatal hernia recurrence, irrespective of patient BMI. MSA should be considered an acceptable treatment option for obese patients with GERD.
Assuntos
Refluxo Gastroesofágico , Hérnia Hiatal , Laparoscopia , Índice de Massa Corporal , Esfíncter Esofágico Inferior/cirurgia , Feminino , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/cirurgia , Hérnia Hiatal/cirurgia , Humanos , Fenômenos Magnéticos , Obesidade/cirurgia , Sobrepeso/complicações , Sobrepeso/cirurgia , Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Few bariatric surgery programs exist at safety net hospitals which often serve patients of diverse racial and socioeconomic backgrounds. A bariatric surgery program was developed at a large urban safety net medical center serving a primarily Hispanic population. The purpose of this study was to evaluate safety, feasibility, and first-year outcomes to pave the way for other safety net bariatric programs. METHODS: The bariatric surgery program was started at a safety net hospital located in a neighborhood with over twice the national poverty rate. A retrospective review was performed for patient demographics, comorbidities, preoperative diet and exercise habits, perioperative outcomes, and 1-year outcomes including percent total weight lost (%TWL) and comorbidity reduction. RESULTS: A total of 153 patients underwent laparoscopic sleeve gastrectomy from May 2017 through December 2019. The average preoperative BMI was 47.9kg/m2, and 54% of patients had diabetes. The 1-year follow-up rate was 94%. There were no mortalities and low complication rates. The average 1-year %TWL was 22.8%. Hypertension and diabetes medications decreased in 52% and 55% of patients, respectively. The proportion of diabetic patients with postoperative HbA1c <6.0% was 49%. CONCLUSION: This is one of the first reports on the outcomes of a bariatric surgery program at a safety net hospital. This analysis demonstrates feasibility and safety, with no mortalities, low complication rates, and acceptable %TWL and comorbidity improvement. More work is needed to investigate the impacts of race, culture, and socioeconomic factors on bariatric outcomes in this population.
Assuntos
Cirurgia Bariátrica , Derivação Gástrica , Laparoscopia , Obesidade Mórbida , Gastrectomia , Hispânico ou Latino , Humanos , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do Tratamento , Redução de PesoRESUMO
INTRODUCTION: COVID-19 emerged as a global pandemic in 2020 and has affected millions of lives. Surgical training has also been significantly affected by this pandemic, but the exact effect remains unknown. We sought to perform a national survey of general surgery residents in the United States to assess the effect of COVID-19 on surgical resident training, education, and burnout. METHODS: An anonymous online survey was created and distributed to general surgery residents across the United States. The survey aimed to assess changes to surgical residents' clinical schedules, operative volume, and educational curricula as a result of the COVID-19 pandemic. Additionally, we sought to assess the impact of COVID-19 on resident burnout. RESULTS: One thousand one hundred and two general surgery residents completed the survey. Residents reported a significant decline in the number of cases performed during the pandemic. Educational curricula were largely shifted toward online didactics. The majority of residents reported spending more time on educational didactics than before the pandemic. The majority of residents feared contracting COVID-19 or transmitting it to their family during the pandemic. CONCLUSIONS: COVID-19 has had significant impact on surgical training and education. One positive consequence of the pandemic is increased educational didactics. Online didactics should continue to be a part of surgical education in the post-COVID-19 era. Steps need to be taken to ensure that graduating surgical residents are adequately prepared for fellowship and independent practice despite the significantly decreased case volumes during this pandemic. Surgery training programs should focus on providing nontechnical clinical training and professional development during this time.