Use of the barbed suture (V-loc ™) in the laparoscopic gastroyeyunal by-pass: experience in 354 intervened patients

Introduction: The barbed suture is a device developed in recent years to simplify the intracorporeal suture and improve safety in laparoscopic surgery. We describe our experience in the use of V-Loc ™ in Laparoscopic Roux-en-Y gastric bypass (LRYGB). This suture has been used for the closure of enterotomy after mechanical lateral J-J anastomosis (bile limb-alimentary limb), for the closure of the mesenteric defect and, occasionally, for the closure of the Petersen space. It is presented as an observational study from 2012 to 2019 with the results of 354 patients undergoing bypass. Objective: To evaluate the safety of this type of suture by demonstrating the absence of leakage, bleeding, stenosis or other complications associated with its use in bariatric laparoscopic surgery. Material and Methods: Between June 2012 and July 2019, a total of 746 bariatric surgeries were performed in our unit. Of all of them, 354 corresponded to bypass in which barbed suture (V-Loc ™ 3-0 6 ”15cm, non-absorbable Polybutester (PBT), Covidien ™) was used in different phases of surgery. The results of the series are analyzed retrospectively. Results: Of the 354 surgical procedures performed, only one case underwent urgent laparoscopic examination within the next 24 hours after surgery due to a defect in the closure of enterotomy in the J-J anastomosis. There were no short-term or longterm postoperative complications in the rest of the patients operated on. Conclusion: The use of V-Loc ™ is safe, effective and reproducible applied to bariatric surgery, especially LGYB

Cross-sectional analysis of the medium-term impact of bariatric surgery onpharmacological expenditure

Introduction:Obesity and associated diseases represent an important health and economic problem sincepharmacological treatment for many of these pathologies needs lifelong subsidies. Theoretically, bariatric andmetabolic surgery decreases the medication requirements of patients for these diseases but may result in othertypes of pharmacological needs. This study aims to demonstrate whether there is a real decrease in pharma-cological expenditure after bariatric surgery.Material and methods:Retrospective cross-sectional analysis of patients who were treated in our centre between2012 and 2015, comparing different associated comorbidities and pharmacological expenses one month beforeand 2 years after surgery.Results:A total of 280 patients underwent surgery; 36.8% of patients had diabetes, 50% hypertension, 11.1%cardiovascular disease, 13.9% osteoarticular disease, 13.6% endocrine disorders, 30% non-diabetic metabolicdisorders, and 35.4% psychiatric disease. At 2 years after surgery, 12.1% of patients continued medication fordiabetes, and 28.2% for arterial hypertension. Additionally, 9.3% of patients still had cardiovascular disease,7.1% osteoarticular disease, 10.4% endocrine disorder, 13.9% non-diabetic metabolic disorder, and 29.3%psychiatric disease. Median pharmacological expenditure before surgery was 17 euros per month; 2 years aftersurgery, it was 12 euros a month, resulting in a significant decrease (p < 0.001).Conclusions:In a 2-year follow-up after bariatric surgery, a decreased prevalence of obesity-related diseases andassociated pharmacological expenditure was observed, showing the efficiency of this intervention over themedium term and potentially over the long term

Stent management of leaks after bariatric surgery: a systematic review and meta-analysis

BACKGROUND Despite the low rates of complications of bariatric surgery, gastrointestinal leaks are major adverse events that increase post-operative morbidity and mortality. Endoscopic treatment using self-expanding stents has been used in the therapeutic management of these complications with preliminary good results. METHODS We performed a systematic review and meta-analysis of self-expanding stents placement for the management of gastrointestinal leaks after obesity surgery. Overall proportion of successful leak closure, stent migration, and reoperation were analysed as primary outcomes. Secondary outcomes were patients’ clinical characteristics, duration and type of stent, other stent complications, and mortality. RESULTS A meta-analysis of studies reporting stents was performed, including 488 patients. The overall proportion of successful leak closure was 85.89% (95% CI, 82.52–89.25%), median interval between stent placement and its removal of 44 days. Stent migration was noted in 18.65% (95% CI, 14.32–22.98%) and the overall proportion of re-operation was in 13.54% (95% CI, 9.94–17.14%). The agreement between reviewers for the collected data gave a Cohen’s κ value of 1.0. No deaths were caused directly by complications with the stent placement. CONCLUSION Endoscopic placement of self-expanding stents can be used, in selected patients, for the management of leaks after bariatric surgery with a high rate of effectiveness and lowamortality rates. Nevertheless, reducing stent migration and re-operation rates representsaan important challenge for future studies

Análisis del impacto de la cirugía bariátrica en el gasto farmacológico a medio plazo

Introduction: Obesity and associated diseases represent an important health and economic problem since pharmacological treatment for many of these pathologies needs lifelong subsidies. Theoretically, bariatric and metabolic surgery decreases the medication requirements of patients for these diseases but may result in other types of pharmacological needs. This study aims to demonstrate whether there is a real decrease in pharmacological expenditure after bariatric surgery. Material and methods: Retrospective cross-sectional analysis of patients who were treated in our centre between 2012 and 2016, comparing different associated comorbidities and pharmacological expenses one month before and 2 years after surgery. Results: 400 patients were operated. The results were presented, showing the differences between the resolution of the different comorbidities and the pharmacological savings generated for each of the surgical techniques studied. The most cost-effective comorbidity in the study was type 2 diabetes mellitus (DM2). The surgical technique with the best results was metabolic bypass, presenting a cost difference after surgery of 507 euros per month (P < 0.001). Conclusions: In a 2-year follow-up after bariatric surgery, a decreased prevalence of obesity-related diseases and associated pharmacological expenditure was observed, showing the efficiency of this intervention over the medium term.Introducción: La obesidad y las enfermedades asociadas a ella suponen un importante problema, y no solo sanitario, sino también económico, ya que muchas de esas patologías son subsidiarias de tratamiento farmacológico de por vida. La cirugía bariátrica y metabólica, a priori, disminuye la demanda de medicamentos de estos pacientes, pero puede condicionar otro tipo de necesidades farmacológicas. El objetivo del estudio es demostrar si existe un descenso real del gasto farmacológico tras la cirugía bariátrica. Material y métodos: Análisis retrospectivo transversal de los pacientes intervenidos en nuestro centro entre 2012 y 2016, comparando las distintas comorbilidades y los gastos farmacológicos asociados a ellas un mes antes y a los 2 años de la cirugía. Resultados: Fueron intervenidos 400 pacientes. Se presentaron los resultados mostrando para cada una de las técnicas quirúrgicas estudiadas las diferencias entre la resolución de las distintas comorbilidades y el ahorro farmacológico generado. La comorbilidad más coste-efectiva del estudio fue la diabetes mellitus tipo 2 (DM2). La técnica quirúrgica con mejores resultados fue el bypass metabólico, presentando una diferencia de costes tras la cirugía de 507 euros mensuales (p < 0,001). Conclusiones: En un seguimiento de 2 años tras la cirugía bariátrica se produce un descenso en la prevalencia de las enfermedades asociadas a la obesidad y del gasto farmacológico asociado a ellas, lo que demuestra que este tipo de intervención resulta eficiente a medio plazo

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research