Outcomes of Roux-En-Y Gastric Bypass and Sleeve Gastrectomy in the Super-Obese and Super-Super-Obese: An Analysis of the Metabloic and Bariatric Surgery Accreditation and Quality Improvement Program Database

Background: With the increase in the prevalence of obesity and the need for bariatric surgery, there continues to be contradictory evidence for the perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients. The purpose of this is study is to investigate 30-day morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Methods: All patients undergoing LSG and LRYGB between the years 2015 and 2017 in the MBSAQIP database were identified. Patients were divided into three groups based on body mass index (BMI): obese (BMI 35 – 50 kg/m2), SO (BMI 50 – 60 kg/m2), and SSO (BMI ≥ 60 kg/m2). Primary outcomes included the occurrence of any complication or mortality. Secondary outcomes included readmission, reoperation, renal events, cardiac events, respiratory events, unplanned intensive care admission, surgical site infections, venous thromboembolic events, transfusion, and reintervention. These were compared between the BMI groups using Pearson X2 test or Fischer’s exact test. Multivariate logistic regression was then used to adjust for demographics, co-morbidities, and operative variables and adjusted odds ratio (AOR) was reported for each outcome. Results: A total of 356,621 patients met inclusion criteria: 71.6% LSG and 28.4% LRYGB. SSO and SO groups was associated with marginally longer operative times and conversion to open. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for the SO group (AOR = 1.20 for LSG; AOR = 1.08 for LRYGB) and SSO group (AOR = 1.44 for LSG; AOR = 1.31 for LRYGB). Mortality rate was also significantly higher for the SO group (AOR = 1.65 for LSG; AOR = 1.85 for LRYGB) and SSO group (AOR = 3.30 for LSG; AOR = 3.32 for LRYGB). Conclusion: SO and SSO patients are at increased risk of 30-day morbidity and mortality compared to patients with BMI ≤ 50 kg/m2. Despite this statistically significant increase, the risks remain low and acceptable especially that bariatric surgery is the only reliable treatment option for obesity.https://scholarlycommons.henryford.com/merf2019clinres/1054/thumbnail.jp

Necrotizing pancreatitis: A review for the acute care surgeon

BACKGROUND: Necrotizing pancreatitis is a common condition with high mortality; the acute care surgeon is frequently consulted for management recommendations. Furthermore, there has been substantial change in the timing, approach, and frequency of surgical intervention for this group of patients. METHODS: In this article we summarize key clinical and research developments regarding necrotizing pancreatitis, including current recommendations for treatment of patients requiring intensive care and those with common complications. Articles from all years were considered to provide proper historical context, and most recent management recommendations are identified. RESULTS: Epidemiology, diagnosis, treatment in the acute phase, and complications (both short-term and long-term) are discussed. Images of surgical interventions are included from our institutional experience. CONCLUSION: Necrotizing pancreatitis management remains heavily based on clinical judgement, although technological advances and clinical trials have made decision making more straightforward

Low Hydrophobic Mismatch Scores Calculated for HLA-A/B/DR/DQ Loci Improve Kidney Allograft Survival

We evaluated the impact of human leukocyte antigen (HLA) disparity (immunogenicity; IM) on long-term kidney allograft survival. The IM was quantified based on physicochemical properties of the polymorphic linear donor/recipient HLA amino acids (the Cambridge algorithm) as a hydrophobic, electrostatic, amino acid mismatch scores (HMS\AMS\EMS) or eplet mismatch (EpMM) load. High-resolution HLA-A/B/DRB1/DQB1 types were imputed to calculate HMS for primary/re-transplant recipients of deceased donor transplants. The multiple Cox regression showed the association of HMS with graft survival and other confounders. The HMS integer 0-10 scale showed the most survival benefit between HMS 0 and 3. The Kaplan-Meier analysis showed that: the HMS=0 group had 18.1-year median graft survival, a 5-year benefit over HMS\u3e0 group; HMS ≤ 3.0 had 16.7-year graft survival, a 3.8-year better than HMS\u3e3.0 group; and, HMS ≤ 7.8 had 14.3-year grafts survival, a 1.8-year improvement over HMS\u3e7.8 group. Stratification based on EMS, AMS or EpMM produced similar results. Additionally, the importance of HLA-DR with/without -DQ IM for graft survival was shown. In our simulation of 1,000 random donor/recipient pairs, 75% with HMS\u3e3.0 were re-matched into HMS ≤ 3.0 and the remaining 25% into HMS≥7.8: after re-matching, the 13.5 years graft survival would increase to 16.3 years. This approach matches donors to recipients with low/medium IM donors thus preventing transplants with high IM donors

Uveal Melanoma Immunogenomics Predict Immunotherapy Resistance and Susceptibility

Immunotherapy targeting immune checkpoint molecules can induce regression of metastatic cutaneous melanoma and improve patient survival. Unfortunately, this therapeutic approach has not shown comparable activity against most other solid tumors, especially those with low tumor mutational burden. We postulated that focused studies of uveal melanoma (UM), a treatment resistant variant with few somatic mutations, may provide generalized insights to develop improved therapeutics for immunotherapy resistant cancers. Here, we report comprehensive immunogenomic profiling on a large and diverse group of human UM metastases (n=100) using bulk and single cell transcriptomics, T cell receptor (TCR) repertoire analysis, tumor infiltrating lymphocyte (TIL) potency assessment, and analysis of an adoptive transfer clinical trial. Our findings reveal that over half of UM metastases harbor tumor infiltrating lymphocytes (TIL) with potent tumor specificity, despite these samples having low mutational burden and being refractory to immune checkpoint inhibition (ICI) and the bispecific T cell engager, tebentafusp. These T cell-inflamed metastases displayed activated antigen presenting cells, evidence of chronic interferon signaling, and diverse TCR repertoires. However, we found a striking lack of intratumoral TCR clonality indicative of growth suppression within the tumor microenvironment, despite receiving ICI and tebentafusp therapy. To harness the therapeutic potential of these endogenous T cells, we developed an unbiased whole-tumor transcriptomic biomarker to enable rapid in situ identification and ex vivo expansion of tumor reactive TIL. Transcriptomic profiling of metastatic tumor biopsies could accurately identify T cell-inflamed UM metastases that generated TIL with clinical anti-tumor efficacy after adoptive immunotherapy. Taken together, we reveal that metastatic UM is not an immunologically ‘cold’ cancer, but rather one that demonstrates occult immune priming and T cell recruitment that are not sufficiently exploited with current immunotherapies. We anticipate in situ immunogenomic profiling to identify these potent TIL and ex vivo expansion to counteract their suppressed growth will be necessary to promote tumor immunity. We are now prospectively evaluating transcriptomic guided adoptive TIL therapy as a therapeutic approach for metastatic UM and other immunotherapy resistant cancers. This will have public health significance by creating treatment opportunities for a large group of cancer patients who currently lack effective therapeutic options

Risk Factors for Surgical Site Infection After Laparoscopic Colectomy: An NSQIP Database Analysis

BACKGROUND: Surgical site infection (SSI) is a common complication after colon surgery. This study aimed to evaluate risk factors for SSI and its types in laparoscopic colectomy patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. MATERIALS AND METHODS: The NSQIP database was queried for patients undergoing laparoscopic colectomy from 2011 through 2017. Univariate analysis and multivariable logistic regression were used to evaluate risk factors associated with any SSI, superficial SSI, deep-incisional SSI, and organ-space SSI. RESULTS: Of 72,519 patients, 4906 cases of SSI were identified: 2276 superficial SSI, 357 deep-incisional SSI, and 2483 organ-space SSI. Risk factors associated with superficial SSI were admission before procedure (adjusted odds ratio [AOR] = 1.31; 95% confidence interval [CI] 1.17-1.47; P \u3c 0.01), smoking (AOR = 1.29; 95% CI 1.16-1.44; P \u3c 0.01), and higher body mass index (AOR = 1.24 for every 5 kg/m(2) increase; 95% CI 1.20-1.27; P \u3c 0.01). Deep-incisional SSI was associated with steroid use (AOR = 1.81; 95% CI 1.31-2.49; P \u3c 0.01), admission before procedure (AOR = 1.66; 95% CI 1.30-2.13; P \u3c 0.01), and smoking (AOR = 1.50; 95% CI 1.17-1.94; P \u3c 0.01). Risk factors associated with organ-space SSI were wound class (AOR = 2.45 for class 4 versus CONCLUSIONS: SSI types in patients undergoing laparoscopic colectomy have different risk factors. Modifiable risk factors may provide an opportunity to reduce SSI risk and its associated morbidity

Thoracoacromial artery injury after tube thoracostomy for pneumothorax

In this case, a patient presented in a delayed fashion after blunt trauma is found to have a large left-sided pneumothorax, and tube thoracostomy is performed. After placement of the apically oriented tube, he developed haemothorax. CT imaging showed an area of questionable extravasation from the left subclavian artery, directly anterior to the thoracostomy tube. His haemothorax was refractory to adequate drainage with a new thoracostomy tube. He ultimately required angiography, coil embolisation and covered stent placement, followed by thoracoscopic evacuation of the haemothorax

Predictors of postoperative emergency department visits after laparoscopic bariatric surgery

BACKGROUND: Postoperative emergency department (ED) visits are a quality metric for bariatric surgical programs. Predictive factors of ED visits that do not result in readmission are not clear. OBJECTIVES: We aimed to identify predictors of ED visits in patients without readmission after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). SETTING: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: The MBSAQIP database was queried for patients who underwent LSG and LRYGB from 2015 through 2017. Patients were grouped by those who presented to the ED (ED group) and those who did not. ED visits analyzed included only those that did not result in readmission. Multivariable forward selection logistic regression was used to report adjusted odds ratios (AORs) with 95% CIs for ED visits. RESULTS: Of 276,073 patients, 257,985 (93.4%) were in the group who did not present to the ED, and 18,088 (6.6%) were in the ED group. Most underwent LSG (71.9%) versus LRYGB (28.1%). Multivariable forward logistic regression identified outpatient treatment for dehydration (AOR, 22.26; 95% CI, 21.30-23.27; P \u3c .001) as the most predictive factor of an ED visit, followed by urinary tract infection (AOR, 7.25; 95% CI, 6.22-8.46; P \u3c .001), wound disruption (AOR, 4.63; 95% CI, 3.09-6.96; P \u3c .001), and surgical site infection (AOR, 3.80; 95% CI, 3.38-4.28; P \u3c .001). CONCLUSIONS: Postoperative complications were the strongest predictors of ED visits after laparoscopic bariatric surgery. Quality improvement initiatives should target these variables to decrease postoperative ED visits

Emphysematous gastritis: A case series of three patients managed conservatively

INTRODUCTION: Emphysematous gastritis (EG) is a rare condition characterized by air within the gastric wall with signs of systemic toxicity. The optimal management for this condition and the role of surgery is still unclear. We here report three cases of EG successfully managed non-operatively. PRESENTATION OF CASES: All three of our patients were elderly females with several co-morbidities. The chief presenting symptom was abdominal pain with signs of systemic toxicity ranging from tachycardia and hypotension to acute kidney injury. Computed tomography (CT) scan revealed gastric pneumatosis in all patients. One patient had extensive portal venous gas, and another had free intraperitoneal air. All patients were managed with nothing by mouth, proton pump inhibitors, intravenous fluid resuscitation, and antibiotics. Repeat CT scan in two patients in 3-4 days demonstrated resolution of the pneumatosis. They were all discharged home tolerating an oral diet. DISCUSSION: The presentation of EG is non-specific and the diagnosis is primarily established by findings of intramural air in the stomach on CT scan. The initial management of EG should be nothing by mouth, proton pump inhibitor, intravenous fluid resuscitation, and antibiotics with surgical exploration only reserved for cases that fail non-operative management, demonstrate clinical deterioration, or develop signs of peritonitis. CONCLUSION: Early recognition and initiation of appropriate therapy is crucial to prevent the progression of EG. EG, even in the presence of portal venous air or pneumoperitoneum, should not represent a sole indication for surgical exploration and trial of initial non-operative management should be attempted when clinically appropriate

Esophagectomies for Malignancy Among General and Thoracic Surgeons: A Propensity Score Matched National Surgical Quality Improvement Program Analysis Stratified by Surgical Approach

Previous studies of esophagectomy outcomes by surgical specialty do not address malignancy or surgical approach. We sought to evaluate these cases using a national database. The National Surgical Quality Improvement Program (NSQIP)-targeted esophagectomy data set was queried for esophagectomies for malignancy and grouped by surgeon specialty: thoracic surgery (TS) or general surgery (GS). 1:1 propensity score matching was performed. Associations of surgical specialty with outcomes of interest (30-day mortality, anastomotic leak, Clavien-Dindo grade ≥ 3, and positive margin rate) were assessed overall and in surgical approach subsets. 1463 patients met inclusion criteria (512 GS and 951 TS). Propensity score matching yielded matched groups of 512, with similar demographics, preoperative stage, and neoadjuvant therapy rates. All outcomes of interest were similar between TS and GS groups, both overall and when stratified by surgical approach. Esophagectomy for malignancy has a similar perioperative safety profile and positive margin rate among general and thoracic surgeons, regardless of surgical approach