Prevalence, Indications, and Complications of Conversional Surgery After Vertical Banded Gastroplasty: A MBSAQIP Analysis.

PURPOSE: Vertical banded gastroplasty (VBG) was once the most popular bariatric procedure in the 1980's, with many patients subsequently requiring conversional surgery. However, knowledge regarding the prevalence and outcomes of these procedures remains limited. This study aims to determine the prevalence, indications, rate of 30-day serious complications, and mortality of conversional surgery after VBG. MATERIALS AND METHODS: A retrospective analysis of the MBSAQIP database from 2020 to 2022 was conducted. Individuals undergoing conversional or revisional surgery after VBG were included. The primary outcomes were 30-day serious complications and mortality. RESULTS: Of 716 VBG conversions, the common procedures included 660 (92.1%) Roux-en-Y gastric bypass (RYGB) and 56 (7.9%) sleeve gastrectomy (SG). The main indication for conversion was weight gain for RYGB (31.0%) and for SG (41.0%). RYGB had longer operative times than SG (223.7 vs 130.5 min, p < 0.001). Although not statistically significant, serious complications were higher after RYGB (14.7% vs 8.9%, p = 0.2). Leak rates were higher after SG (5.4 vs 3.5%) but this was not statistically significant (p = 0.4). Mortality was similar between RYGB and SG (1.2 vs 1.8%, p = 0.7). Multivariable regression showed higher body mass index, longer operative time, previous cardiac surgery and black race were independently associated with serious complications. Conversion to RYGB was not predictive of serious complications compared to SG (OR 0.96, 95%CI 0.34-2.67, p = 0.9). CONCLUSIONS: Conversional surgery after VBG is uncommon, and the rate of complications and mortality remains high. Patients should be thoroughly evaluated and informed about these risks before undergoing conversion from VBG.

Progression of nodular thyroid disease in Familial Adenomatous Polyposis syndrome: refined surveillance recommendations.

BACKGROUND: Patients with familial adenomatous polyposis (FAP) have an increased risk of thyroid nodular disease. Previous studies demonstrated that screening thyroid ultrasound (US) will allow detection of nodules in 38% and thyroid cancer in 2.6% of patients. The aim of this study is to define the value of serial US evaluation at identifying disease progression in patients with FAP. METHODS: Retrospective review from 2008-2023 at a single referral center. All patients with FAP and screening thyroid US were included. Patient demographics, initial US characteristics, follow-up regarding the development of new nodules and cancer were assessed using a Kaplan-Meier analysis. RESULTS: A total of 556 patients underwent screening. 51% were male. Median age at first screening was 38 years old. 81% underwent longitudinal follow-up for a median length of 7 years. At initial screening, 169 patients (30%) had nodules. For patients with normal baseline US, 14% developed a nodule overtime. A total of 20 patients (3.6%) were diagnosed with thyroid cancer. The cumulative incidence of initial and subsequent cancer was 4% by 5-years and 6% by 10-years, while the cumulative incidence of thyroid nodules was 40% and 48%, respectively. CONCLUSIONS: Based on the Kaplan-Meier analysis, ongoing longitudinal screening is warranted for patients with FAP as they are prone to thyroid cancer and nodule development overtime even when presenting with a baseline normal US. Additionally, these data demonstrate a slow development of thyroid cancer from a normal US, thus it is reasonable to consider selectively extending the screening interval for this population.

Bariatric Surgical Outcomes in the Elderly: A Comparison Study Between Primary and Revisional Procedures in the United Arab Emirates.

PURPOSE: Data reported on comparing primary and revisional procedures in the elderly is still limited. The aim of this study was to compare the efficacy and safety between primary and revisional bariatric surgery in a cohort of older patients. MATERIALS AND METHODS: All patients ≥ 60 years old were divided into two cohorts, primary surgery cohort (PSC) and revisional surgery cohort (RSC). Baseline and perioperative outcomes were analyzed. RESULTS: Fifty-eight patients were included (34 PSC and 24 RSC) in the study. Forty-two (25 PSC and 17 RSC) 72.4% were female. The mean age was 64 (± 3.3 years) in the PSC and 65 (± 4.2 years) in the RSC, the median initial BMI was 46.7 and 47.4 kg/m2 (p < 0.848), respectively. The mean hospital stay was (3 PSC vs. 5 RSC, p < 0.022) days. Readmissions occurred in (1 PSC vs. 3 RSC, p = 0.158) patients within 30 days of discharge. Postoperative major complications included (1 PSC vs. 5 RSC, p < 0.0278) patients. Reoperations were reported in (0 PSC vs. 3 RSC, p < 0.034) patients. Patients who underwent surgery for weight management, the initial mean BMI was (46.7 PSC vs. 47.4 RSC kg/m2, p = 0.848). At 12-months post-procedure, the mean BMI was (34.3 PSC vs. 37.7 RSC kg/m2, p = 0.372) and (23.7 PSC vs. 19.1 RSC, p = 0.231) %TBWL. The mean overall follow-up was (12.4 PSC vs. 27.5 RSC, p < 0.004) months, and one unrelated death (cancer) was reported in the RSC. CONCLUSION: PSC and RSC are effective in the elderly, however postoperative complications occurred more often in the RSC group.

A Comparison of Near-Infrared Autofluorescence Findings in Benign Versus Malignant Adrenal Tumors.

BACKGROUND: Many adrenal tumors are deemed radiologically indeterminate and surgically removed. Adrenal tissue, like parathyroid glands, exhibits near-infrared autofluorescence (NIRAF) properties. This study was designed to investigate the potential of NIRAF to differentiate benign versus malignant adrenal tumors. METHODS: Patients undergoing adrenalectomy between October 2021 and May 2023 were prospectively studied. Adrenalectomy specimens were inspected with NIRAF imaging. Specimen autofluorescence (AF) characteristics were recorded. Comparisons were made between different tumor types and a logistic regression model was constructed to differentiate benign versus malignant tumors. A receiver operating characteristic curve was used to identify an optimal AF threshold differentiating benign versus malignant tumors. RESULTS: A total of 108 adrenal specimens were examined: adrenocortical adenomas/other benign lesions (n = 72), pheochromocytomas (n = 18), adrenocortical neoplasms of uncertain behavior (n = 4), and malignant tumors (n = 14). A significant difference in normalized AF intensity was identified when comparing adrenocortical adenomas (3.08 times background) with pheochromocytomas (1.95, p = 0.001) and malignant tumors (1.11, p < 0.0001). The Area Under the Curve differentiating benign vs malignant tumors was 0.87, with an optimal normalized AF threshold at 1.93. CONCLUSIONS: Different adrenal pathologies exhibit diverse AF properties. These findings suggest a potential intraoperative utility of NIRAF in predicting benign versus malignant nature for radiologically indeterminate adrenal tumors.

The Effects of Post-Surgical Pregnancy on Weight Loss Trajectories after Bariatric Surgery: Are Initial Weight and Age Prognostic Factors?

Introduction: A substantial percentage of patients undergoing bariatric surgery are of childbearing age. Pregnancy outcomes after bariatric surgery are known. However, there are limited data on the impact of pregnancy on weight loss after surgery. Objectives: This study aims to evaluate the effects of pregnancy on post-bariatric surgery weight loss trajectories (WLTs) and to determine the association with age and initial weight. Methods: All who had primary bariatric surgeries (Roux-en-Y gastric bypass or sleeve) between September 2015 and July 2020 were classified into two groups: post-surgery gravid (GG) and post-surgery non-gravid (NG). WLTs were examined using a random intercept mixed-effects model with repeated measures nested within patients. The post-surgery/pre-gravid time phase (PoPG) was modelled using a third-degree polynomial. For GG, two third-degree spline functions modelled the post-surgery while gravid (PoWG) and post-partum (PoPP) time phases. Age and initial weight were used to control for pre-existing differences during PoPG. Weight differences at 6 months PoPP were examined by applying general linear hypothesis testing to the mixed-model results. Results: A total of 508 patients were included, 20 in GG and 488 in NG. The mean age at surgery was 33 years in GG and 37 years in NG. The mean initial BMI was 47 kg/m2 and 43 kg/m2, respectively. During PoPG, adjusted average weight in both groups follows the path across time. For GG, weight decreases and then increases during PoWG. For GG during PoPP, weight immediately decreases after delivery and then increases over time to levels similar to NG. Weight differences at 6 months PoPP for GG and NG were not statistically different. Older age was associated with reduced weight loss during PoPG by Baseline Age, while higher initial weight was associated with increased weight loss during PoPG by Baseline Weight. In both instances, these effects attenuate over time. Conclusions: This model indicates that pregnancy following bariatric surgery affects WLT during PoWG and PoPP, and no difference in weight is expected after 6 months post-gravid. Age and initial weight could be considered prognostic factors during PoPG. Patients wishing to conceive should undergo preconception counselling and be advised to avoid pregnancy during the period of rapid weight loss. They also should be informed that WLT may vary during pregnancy and early post-partum.

Bilateral exploration in primary hyperparathyroidism: Double adenoma distribution and biochemical patterns over two decades.

BACKGROUND: We investigated if anatomic patterns of abnormal parathyroid glands have ch anged for primary hyperparathyroidism (pHPT) as atypical biochemical presentation (normohormonal and normocalcemic) has increased. METHODS: Retrospective review of patients with pHPT who underwent routine bilateral neck exploration. RESULTS: 2762 patients were included. The "late" cohort (2014-2020) exhibited lower preoperative calcium (10.8 vs 11.1 â€‹mg/dL; P â€‹= â€‹0.001) and PTH levels (101 vs. 146 â€‹pg/mL; P â€‹= â€‹0.001) compared to the "early" cohort (2000-2006). Patients with atypical biochemical profiles increased from 25.5% to 31.3% (P â€‹< â€‹0.001). The prevalence of single adenoma (SA) decreased (66.1% vs 58.9%, P â€‹= â€‹0.02) while the proportion of double adenoma (DA) increased (17.3% vs. 22.6%, P â€‹< â€‹0.01). Upper parathyroid adenoma(s) remained the most common finding for SA and DA in both time points. CONCLUSIONS: Despite changes in patient characteristics, single upper adenoma and bilateral double upper adenomas remain the most common findings for patients with pHPT.

Safety of limb lengthening after Roux-en-Y gastric bypass: an analysis of the MBSAQIP database.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) effectively treats severe obesity, but some patients may require revisional surgery like limb lengthening (LL) for postoperative weight gain. OBJECTIVES: This study aims to compare 30-day serious complications and mortality rates between LL and primary RYGB, given limited safety data on LL. METHODS: Patients who underwent LL and RYGB were identified from the 2020 and 2021 MBSAQIP databases, the only years in which LL data were available. Baseline characteristics and 30-day rates of serious complications and mortality were analyzed. RESULTS: A total of 86,990 patients underwent RYGB and 455 underwent LL. Patients undergoing RYGB were younger (44.4 versus 49.8 yr, P < .001), had a higher body mass index (BMI) (45.5 versus 41.8 kg/m2, P < .001) and higher rates of comorbidities including diabetes (30.0 versus 13.6%, P < .001). RYGB and LL had similar operative duration (125.3 versus 123.2 min, P = .5). There were no statistical differences between cohorts for length of stay (LOS) (1.6 RYGB versus 1.6 LL d, P = .6). After LL, there were higher 30-day rates of reoperation (3.3 versus 1.9%, P = .03) and deep surgical site infections (1.3 versus .5%, P = .03) compared to RYGB. There were no differences in overall serious complications (5.1 LL versus 5.0% RYGB, P = 1.0) and mortality (.2 LL versus .1% RYGB, P = .5). Multivariable logistic regression adjustment found that previous venous thromboembolism was associated with serious complications after LL. CONCLUSIONS: When compared to primary RYGB, LL has a favorable safety profile with similar 30-day rates of serious complications and mortality.

Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study.

BACKGROUND: Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. METHODS: A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved. RESULTS: A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. CONCLUSION: This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Assessing the efficacy of thyroid nodule radiofrequency ablation using patient-reported outcome measures.

BACKGROUND: Radiofrequency ablation has recently emerged as an alternative treatment for thyroid nodules. Most studies are centered on volume reduction, whereas a few have assessed symptom improvement mainly with nonstandardized metrics. As experience in the United States is growing, we aim to assess the efficacy of radiofrequency ablation in treating benign thyroid nodules using the validated Patient-Reported Outcomes Measurement for Parathyroid and Thyroid Disease. METHODS: This is a prospective study of a newly established radiofrequency ablation program at a single tertiary referral center in 2022. Patients who underwent radiofrequency ablation were evaluated using the Patient-Reported Outcomes Measurement for Parathyroid and Thyroid Disease, a validated metric ranging from 0 to 100 at baseline, 2 weeks, 3 months, and 6 months. In addition, a thyroid ultrasound was done at those intervals to assess size and volume reduction. Procedure complications were evaluated as well. RESULTS: A total of 25 patients underwent radiofrequency ablation during the study period for a total of 32 nodules treated; 84% were female with a mean age of 51 years. The baseline mean nodule volume and largest dimension were 13 ± 11 mL and 3.4 ± 1 cm, respectively. A significant change in the Patient-Reported Outcomes Measurement for Parathyroid and Thyroid Disease compressive score was seen at 3 months (38.9 ± 26.4 to 21.0 ± 21.4; P = .004) and 6 months (32.7 ± 19.9 to 17.5 ± 21.0; P = .02) but not at 2 weeks (41.0 ± 22.7 to 36.1 ± 21.9; P = .28). Significant volume and size reductions were seen at all 3-time points. Two complications occurred. CONCLUSION: Our initial results of the thyroid radiofrequency ablation program find that it effectively alleviates symptoms by reducing nodule size in patients with symptomatic benign thyroid nodules.

A 1:1 matched comparison of posterior retroperitoneal and lateral transabdominal adrenalectomy using a robotic platform.

BACKGROUND: Posterior retroperitoneal adrenalectomy is considered less invasive compared with lateral transperitoneal counterpart. There is controversy in the literature about how the two approaches compare regarding perioperative outcomes. Moreover, no studies have compared both approaches while incorporating the use of a robotic platform. The aim of this study was to compare the outcomes of robotic posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy using a 1:1 matched propensity analysis. METHODS: Patients who underwent robotic posterior retroperitoneal adrenalectomy were matched 1:1 to patients who underwent robotic lateral transperitoneal adrenalectomy between 2008 and 2022 at a single center. Matching factors included diagnosis, tumor size, Gerota's fascia-to-skin distance, and perinephric fat thickness. Perioperative outcomes were compared between groups using the χ2 analysis and Wilcoxon Rank Sum test. RESULTS: A total of 511 robotic adrenalectomies were performed during the study period, of which 77 patients in each group were matched. There was no difference between posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy groups, respectively, in terms of operative time (134 vs 128 min, P = .64), conversion to open (0% vs 0%, P = .99), pain level on a postoperative day 1 (visual analog scale 5 vs 6, P = .14), morphine milligram equivalents used (18 vs 20 morphine milligram equivalents /day, P = .72), length of stay (1 vs 1 day, P = .48), and 90-day complications (2.6% vs 3.9%, P = .65). Estimated blood loss for posterior retroperitoneal adrenalectomy was statistically lower (5 vs 10 mL, P = .001) but not considered to be clinically significant. CONCLUSION: Perioperative outcomes of lateral transperitoneal adrenalectomy, including those related to recovery, were similar to those of posterior retroperitoneal adrenalectomy when matched for tumor and patient anthropometric parameters.

Machine learning prediction of major adverse cardiac events after elective bariatric surgery.

BACKGROUND: Machine learning (ML) is an emerging technology with the potential to predict and improve clinical outcomes including adverse events, based on complex pattern recognition. Major adverse cardiac events (MACE) after bariatric surgery have an incidence of 0.1% but carry significant morbidity and mortality. Prior studies have investigated these events using traditional statistical methods, however, studies reporting ML for MACE prediction in bariatric surgery remain limited. As such, the objective of this study was to evaluate and compare MACE prediction models in bariatric surgery using traditional statistical methods and ML. METHODS: Cross-sectional study of the MBSAQIP database, from 2015 to 2019. A binary-outcome MACE prediction model was generated using three different modeling methods: (1) main-effects-only logistic regression, (2) neural network with a single hidden layer, and (3) XGBoost model with a max depth of 3. The same set of predictor variables and random split of the total data (50/50) were used to train and validate each model. Overall performance was compared based on the area under the receiver operating curve (AUC). RESULTS: A total of 755,506 patients were included, of which 0.1% experienced MACE. Of the total sample, 79.6% were female, 47.8% had hypertension, 26.2% had diabetes, 23.7% had hyperlipidemia, 8.4% used tobacco within 1 year, 1.9% had previous percutaneous cardiac intervention, 1.2% had a history of myocardial infarction, 1.1% had previous cardiac surgery, and 0.6% had renal insufficiency. The AUC for the three different MACE prediction models was: 0.790 for logistic regression, 0.798 for neural network and 0.787 for XGBoost. While the AUC implies similar discriminant function, the risk prediction histogram for the neural network shifted in a smoother fashion. CONCLUSION: The ML models developed achieved good discriminant function in predicting MACE. ML can help clinicians with patient selection and identify individuals who may be at elevated risk for MACE after bariatric surgery.

High-volume endocrine surgeons perform thyroid surgery at decreased cost despite increased case relative value units.

BACKGROUND: Healthcare systems are transitioning to value-based payment models based on analysis of quality over cost. To gain an understanding of the relationship between surgeon volume and health care costs, we compared the direct costs of thyroidectomy performed by dedicated high-volume endocrine surgeons and low-volume surgeons within a large health care system. METHODS: We evaluated all thyroid surgeries performed within a single billing year at a single health care system. We defined high-volume surgeons as those who treated >50 thyroid cases yearly and compared them to low-volume surgeons. To account for multicomponent procedures, we added the relative value units for the components of the cases. Then, we divided them into low-relative value units, intermediate-relative value units, and high-relative value units groups. We analyzed categorical and continuous variables using the χ2 analysis and Wilcoxon rank sum test, respectively. RESULTS: We identified 674 thyroidectomy procedures performed by 27 surgeons, of whom 6 high-volume surgeons performed 79% of cases. Relative value unit distribution differed between the groups, with high-volume surgeons performing more intermediate-relative value unit (58% vs 34.7%, P < .01) and high-relative value unit (24.6% vs 20.6%, P < .01) cases, whereas low-volume surgeons performed more low-relative value unit cases (45% vs 17%, P < .01). Overall, high-volume surgeons incurred a 26% reduction in total costs (P < .01) and a 33% reduction in discretionary expenses (P < .01) across all relative value unit groups. CONCLUSION: High-volume endocrine surgeons perform thyroid procedures at a lower cost than their low-volume counterparts, a difference that is magnified when stratified by relative value unit groups.

Comparison of incidental parathyroid tissue detection rates on pathology after total thyroidectomy performed with or without near-infrared autofluorescence imaging.

BACKGROUND: Near-infrared autofluorescence imaging is an adjunct to parathyroid identification. As it does not show perfusion, it is important to study its impact during thyroidectomy by measuring quantifiable data on parathyroid detection rather than function. The aim of this study was to compare incidental parathyroidectomy rates in patients undergoing total thyroidectomy with or without near-infrared autofluorescence. METHODS: Retrospective study of patients who underwent total thyroidectomy between 2014 and 2022 at one center. Clinical parameters, including rates of incidental parathyroid tissue on pathology reports, were compared between near-infrared autofluorescence and non-near-infrared autofluorescence groups. Near-infrared autofluorescence was used to guide dissection (identification) and/or to confirm tissue as parathyroid (confirmation). Statistical analysis was done with Wilcoxon rank sum test and χ2 analysis. RESULTS: There were 300 patients in the near-infrared autofluorescence and 750 patients in the non-near-infrared autofluorescence group. The rate of incidental parathyroid tissue detection on final pathology was 13.3% (n = 40) in the near-infrared autofluorescence and 23.2% (n = 174) in the non-near-infrared autofluorescence group (P < .001). The rate of incidental parathyroid tissue detected on pathology with near-infrared autofluorescence decreased when used for identification and confirmation of parathyroid tissue (30.0% to 13.4%, P < .001), but not when used for confirmation only (19.6% to 18.5%, P = .89). Impact of near-infra red autofluorescence in decreasing the rate of incidental parathyroid tissue was more profound for early (38.5% to 17.1%) versus mid-late career surgeons (20% to 13%). CONCLUSION: Our results suggest that the use of near-infrared autofluorescence may help decrease the rate of incidental parathyroid tissue detected on final pathology if used for both identification and confirmation of parathyroid glands during thyroidectomy.

Are 99mTC-Sestamibi Single Photon Emission Computed Tomography Scan Results Associated to the Parathyroid Cell Type in Primary Hyperparathyroidism?

INTRODUCTION: 99mTC-sestamibi scintigraphy (SPECT-CT) is a common imaging modality for parathyroid localization in primary hyperparathyroidism (PHPT). Prior studies have suggested that the cellular composition of parathyroid adenomas influences SPECT-CT imaging results. Other biochemical and anatomical factors may also play a role in false negative results. Therefore, after controlling for confounding variables, we sought to determine whether the histologic composition of parathyroid adenomas is associated to SPECT-CT results in patients with single gland disease causing PHPT. METHODS: A retrospective review of patients with PHPT due to confirmed single gland disease was performed over a 2-y period. A 1:1 propensity score matching was done between patients with positive and negative SPECT-CT results with regard to demographical, biochemical, and anatomical characteristics followed by blinded pathologic examination of cell composition in the matched pairs. RESULTS: Five hundred forty two patients underwent routine four gland exploration and 287 (53%) patients were found to have a single adenoma. Of those, 26% had a negative SPECT-CT result. There were significant differences between groups with regards to biochemical profile, gland location, and gland size. All of which became nonsignificant after propensity score matching. Adenomas were primarily composed of chief cells, with no difference between groups (95% versus 97%, P = 0.30). In the positive SPECT-CT group, chief cells were the dominant cell type in 68% of the cases, followed by mixed type (13%), oxyphil cells (12%), and clear cells (7%). This was similar to the negative SPECT-CT group (P = 0.22). CONCLUSIONS: While certain patient's clinical characteristics are associated with SPECT-CT imaging results, histologic cell type is not significantly associated.

Hiatal hernia repair after previous laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Symptomatic hiatal hernia (HH) with pouch migration after previous laparoscopic Roux-en-Y gastric bypass (RYGB) is an uncommon complication, with limited extant evidence for the utility of surgical repair. OBJECTIVE: To evaluate the presentation and resolution of symptoms in patients with HH repair after previous RYGB. SETTING: Multicenter University Hospital. METHODS: A retrospective review was conducted from 2010 to 2022. Patients with prior RYGB who were undergoing subsequent isolated HH repair were included. Patients undergoing incidental HH repair during concomitant revisional bariatric surgery were excluded. Baseline characteristics and surgical outcomes were evaluated and presented as medians (25th-75th percentile). RESULTS: Forty-four patients met the inclusion criteria. The time from RYGB to HH repair was 59 months (39-88). Body mass index at HH repair was 31 kg/m2 (27-39). The most common presenting symptoms of hernia were dysphagia (52%), gastric reflux (39%), and abdominal pain (36%). All HH repairs were completed with a minimally invasive approach (98% laparoscopic, 2% robotic). Nonabsorbable suture was used in 98% of patients, with bioabsorbable mesh in 30%. At a median 28-day (12-117) follow-up, 70% of patients reported full symptom resolution and 23% partial resolution. At follow-up, 2 patients had radiologic HH recurrence, with 1 requiring reoperation. CONCLUSIONS: This is the largest series of isolated HH repair for symptomatic pouch migration after previous RYGB. Common presenting symptoms are dysphagia and reflux, and surgical repair yields a high rate of symptom resolution in the short term. Longer follow-up is needed to evaluate the durability of this intervention.

Slowly absorbable mesh in sublay ventral hernia repair in contaminated fields.

BACKGROUND: In the past years, there has been increasing evidence that supports the use of permanent mesh in contaminated wounds. Given this increased evidence, the indications to opt for slowly absorbable "biosynthetic" prostheses have been questioned. To address this, we compared the outcomes of slowly absorbable mesh in contaminated cases in a well-matched multicentric cohort. METHODS: The Abdominal Core Health Quality Collaborative (ACHQC) database was queried for patients undergoing elective ventral hernia repair in Centers for Disease Control (CDC)-III operations (2013-2022). We compared demographics, hernia characteristics, and postoperative outcomes among types of mesh. We used propensity score matching to adjust for sex, diabetes, body mass index, smoking status, and operative time between mesh groups. Patients within other CDC classes and those with mesh positioned elsewhere than retro-rectus/preperitoneal space were excluded. RESULTS: A total of 760 patients were included in the analysis. Slowly absorbable synthetic mesh (SA) was utilized in only 7% of the cases, while permanent (P) and biologic (B) mesh in 77% and 16%, respectively. After matching, 255 patients were studied. There was no difference in surgical site occurrence (8% SA, 16% P, 10% B, p = 0.27), surgical site infection (20% SA, 17% P, 12% B p = 0.54), surgical site occurrence requiring intervention (18% SA, 13% P, 14% B p = 0.72), readmission (12% SA, 14% P, 12% B, p = 0.90), or reoperation (8% SA, 2% P, 4% B, p = 0.14) at 30 days. In patients with 1-year follow-up, there was no difference in recurrence among groups (20% SA, 26% P, 24% B p = 0.90). CONCLUSION: Based on our findings, SA has comparable outcomes to other types of mesh, particularly when an optimal retro-rectus repair is performed.

Revisional Procedures after Sleeve Gastrectomy for Weight Recurrence or Inadequate Weight Loss: An Analysis of the MBSAQIP Database.

INTRODUCTION: The safety of conversional bariatric procedures after sleeve gastrectomy (SG) for weight recurrence (WR) or inadequate weight loss (IWL) is debated due to limited evidence. Conversion options include Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileal bypass (SADI), and biliopancreatic diversion with duodenal switch (BPD-DS). We aimed to compare serious complications and mortality rates between these procedures within 30 days. METHODS: Using the 2020 and 2021 MBSAQIP databases, we identified patients who underwent a conversion from SG to RYGB, SADI, or BPD-DS. We performed a multivariable logistic regression to assess predictors of 30-day complications and mortality. RESULTS: Among 7388 patients (77.6% RYGB, 8.7% SADI, 13.7% BPD-DS), those undergoing SADI and BPD-DS had higher preoperative body mass index. Conversion reasons included WR (63.0%) and IWL (37.0%). SADI and BPD-DS patients had longer operative times (p < 0.001) and higher leak rates (p = 0.001). Serious complications, reoperations, readmissions, and 30-day mortality were similar across groups. Conversion procedure type was not an independent predictor of complications. CONCLUSION: RYGB was the most performed conversional procedure after SG. The study indicated a similar safety profile for revisional RYGB, SADI, and BPD-DS, with comparable 30-day complications and mortality rates. However, SADI and BPD-DS patients had longer operative time and higher leak rates.