Background
Marginal ulcer formation is a known complication following RYGB. While most respond to medical therapy, many patients have recurrent or chronic MU. Although non-steroidal anti-inflammatory ...drug (NSAID) use, smoking and
Helicobacter pylori
infection are known risk factors of MU, little is known about what increases the likelihood of developing recalcitrant ulcers. The objective of this study is to identify risk factors for marginal ulcer (MU) formation, including recalcitrant ulcers requiring surgical revision, and to define the incidence and outcomes of revisional surgery.
Methods
All patients who underwent RYGB between 2011 and 2017 at a high-volume academic center were included. Patients with a postoperative diagnosis of MU were identified from the institution’s bariatric database. Patient characteristics, operative data and surgical outcomes were analyzed using data collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and the Ontario Bariatric Registry.
Results
A total of 2830 RYGB were performed during the study period. The incidence of MU was 6.9% with 1% of patients requiring revisional surgery for a recalcitrant ulcer. Patients with a history of smoking (HR 5.03), immunosuppression (HR 4.60) and preoperative NSAID use (HR 3.11) were significantly more likely to develop a MU requiring surgical revision. Patients undergoing revision reported resolution of their symptoms in only 36% of cases with 57% developing a recurrent ulcer.
Conclusion
Patients with a history of smoking and use of immunosuppressive medication were at significantly higher risk of developing MU that failed medical therapy. Additional evidence is needed to inform perioperative management of bariatric patients.
Elderly patients undergo bariatric surgery less frequently than younger patients. Short- and medium-term outcomes after bariatric surgery in the elderly population remain largely unknown. The ...objective of the present retrospective, registry-based cohort study was to compare short- and medium-term outcomes between patients <65 and ≥65 years undergoing bariatric surgery, hypothesizing similar outcomes between groups.
In this retrospective, registry-based cohort study, the Ontario Bariatric Registry was used to compare data of patients <65 and ≥65 years who underwent Roux-en-Y gastric bypass and sleeve gastrectomy between January 2010 and August 2019 in all accredited bariatric centers of excellence in Ontario, Canada. Primary outcomes were overall postoperative complications. Secondary outcomes included early (<30 days) complications, readmissions, reoperations, mortality, weight loss and comorbidities improvement at 1 and 3 year after surgery.
Data of 22,981 patients <65 and 532 patients ≥65 years were analyzed. Overall postoperative complications were similar between patients <65 and ≥65 years (3388/22,981 14.7% vs. 73/532 13.7%, p = 0.537). Early (<30 days) postoperative complications, readmissions, reoperations, and mortality rates were also similar between groups. Both groups had significant weight loss and comorbidities improvement at 1- and 3-year follow-up. Patients <65 years had superior weight loss (+3.5%, 95% CI: 1.6-5.4, p < 0.001) and higher rates of remission for diabetes mellitus (63.8% vs. 39.3%, p < 0.001), hypertension (37.9% vs. 14.5%, p < 0.001), dyslipidemia (28.2% vs. 9.5%, p < 0.001) and gastroesophageal reflux (65.1% vs. 24.0 %, p < 0.001) compared to patients ≥65 years at 3 year.
Patients <65 and ≥65 years had similar perioperative morbidity and mortality after bariatric surgery. Even though patients <65 years had overall better medium-term outcomes, bariatric surgery is safe and yields significant weight loss and comorbidities improvement in patients ≥65 years.
Dissemination of new surgical knowledge, skills, and techniques across the wide spectrum of practicing surgeons in the community is often difficult and slow. This is even more problematic in ...countries such as Canada, where geographic distances separate a large portion of community surgeons from the large teaching centers. As an example, the penetration of advanced minimally invasive techniques in Canada has been severely hampered by the inability to provide adequate training opportunities and support for community surgeons, many of whom live in remote regions of the country. In an attempt to overcome the barriers that exist, the Centre for Minimal Access Surgery (CMAS) at McMaster University has been using broadband Internet and telecommunication systems to provide distance training and mentoring to community surgeons living in remote northern communities of Canada. This article describes our experience with telementoring and robot‐assisted remote telepresence surgery and assisting, between a teaching hospital in Hamilton and two community hospitals in northern Ontario and Quebec.
Background
Bariatric surgery is in high demand and patients generally undergo an extensive work-up process to maximize the success of surgery, especially in universal healthcare systems. Although ...valuable, this work-up process can lead to attrition before surgery. Therefore, we aim to assess patient and health system factors associated with attrition after bariatric surgery referral in a universal healthcare system.
Methods
This was a population-based study of all patients aged ≥ 18 referred for bariatric surgery in Ontario, Canada from 2009 to 2015. Primary outcome was patients who dropped out of bariatric surgery after referral. Predictors of attrition after referral included patient demographics, clinical, institutional, and socioeconomic variables. Odds ratios and 95% CIs were estimated by multilevel logistic regression models.
Results
From 17,703 patients that were referred for bariatric surgery, 4122 patients dropped after the initial referral. Male patients, increasing age, and longer wait times for surgery were significantly (
P
< 0.0001) associated with higher odds of attrition. Additionally, smoker status, immigration status, unemployment, and disability were significant factors (
P
< 0.0001) predicting attrition. Patients who lived in lowest income quintile neighborhoods, when compared to those from the richest neighborhoods, had significantly higher odds of attrition (
P
= 0.02). Sleep apnea was associated with lower odds of attrition while diabetes and heart failure both with higher odds of attrition.
Conclusion
Even in a universal healthcare system, there are various factors that could lead to increased odds of attrition before bariatric surgery. Clear disparities exist for certain marginalized populations. Further studies are warranted to ensure equitable utilization of bariatric surgery for all patients.
Background
To determine if self-reported baseline psychological distress moderates the association between lifetime psychiatric diagnosis and weight loss 1 year after bariatric surgery. An ...exploratory analysis assessed change in psychological distress from baseline on weight loss at 1 year.
Methods
A retrospective cohort study using data from the Ontario Bariatric Registry for all individuals undergoing surgery between January 1, 2012, and December 31, 2018, with a complete baseline psychological assessment and 1-year post-operative weight recorded (
N
= 11,159).
Multiple linear regressions assessed the relationship between psychiatric diagnosis and percentage of excess body mass index loss (%EBMIL) at 1-year post-surgery, controlling for baseline body mass index, socio-demographics, medical co-morbidities, and surgical complications. Baseline psychological distress, measured with the EQ-5D-5L anxiety/depression rating, was examined as a moderator of this relationship. %EBMIL was separately regressed on change in psychological distress from baseline to 1 year, controlling for psychiatric diagnosis.
Results
In the adjusted model, psychiatric diagnosis was associated with lower %EBMIL at 1 year (
B
= − 1.00,
P
= .008). Baseline psychological distress was not a moderator, but had a significant main effect on %EBMIL (
B
= − .84,
P
= .001). Those who experienced a decrease in psychological distress at 1 year, or remained low throughout, fared better than those who increased or had persistently high symptoms.
Conclusions
These findings support use of a self-report assessment for psychological distress prior to bariatric surgery. Addressing active psychological distress prior to and/or following surgery may increase the likelihood of successful outcomes.
Graphical abstract
Background
Bariatric surgery is proven to be the most effective strategy for management of obesity and its related comorbidities. However, in Canada, patients awaiting bariatric surgery can be ...subjected to prolonged wait times, thereby subjecting them to increased morbidity and mortality, as well as decreased psychosocial well-being.
Objective
To assess the factors associated with prolonged wait times for bariatric surgery within a publicly funded, provincial bariatric network.
Methods
This was a retrospective population-based study of all patients aged
>
18 years who were referred for bariatric surgery from April 2009 to May 2015 using linked administrative databases to capture patient demographic data, socioeconomic variables, healthcare utilization, and institutional factors. The main outcome of interest was a wait time greater than 18 months. Multivariate logistic regression modeling was used to estimate odds ratios (OR) and 95% confidence intervals (CI).
Results
A total of 18,854 patients underwent bariatric surgery from April 2009 to December 2016, of which 2407 patients experienced wait times of > 18 months. On average, yearly wait times have increased for patients receiving surgery with wait times of 10.98 months (SD 5.48) in 2010 and 13.09 (SD 6.69) in 2016 (
p
< 0.001). Increasing age (OR 1.12, 95% CI 1.05–1.19,
p =
0.0004), BMI (OR 1.08, 95% CI 1.04–1.11,
p
< 0.001), and male gender (OR 1.47, 95% CI 1.28–1.70,
p
< 0.001) were significantly associated with increased bariatric surgery wait times. Additionally, smoking status (OR 1.46, 95% CI 1.09–1.97,
p
= 0.0118) and obesity-related comorbidities particularly diabetes (OR 1.29, 95% CI 1.14–1.44,
p
< 0.001) and heart failure (OR 1.72, 95% CI 1.43–2.07,
p
< 0.001) were correlated with prolonged wait times for surgery. Socioeconomic variables including disability (OR 1.64, 95% CI 1.38–1.92,
p
< 0.001) and immigration status (OR 1.35, 95% 1.11–1.64,
p
= 0.003) were correlated with increased odds of longer wait times, as were regions with regionalized assessment and treatment centres (RATC) when referenced against centers of excellence (COEs) in number of days added with 20.45 (95% CI 13.20–27.70,
p
< 0.001).
Conclusion
Wait times for bariatric surgery in a publicly funded, regionalized bariatric program are influenced by certain patient characteristics, socioeconomic variables, and institutional factors. This warrants further intervention and study to help improve these inequities when encountering potentially vulnerable populations awaiting bariatric surgery.
Single-anastomosis duodenal switch (SADS) has emerged in recent years as an alternative to the standard double-anastomosis duodenal switch (DADS). The objective of this study was to compare short- ...and medium-term outcomes between SADS and DADS.
Data collected in the Ontario Bariatric Registry between 2010 and 2019 were used for this retrospective study to determine outcomes of patients undergoing primary laparoscopic SADS versus DADS at a Canadian tertiary hospital and bariatric center of excellence. The primary outcome was weight loss at 1 and 2 years after surgery. Short-term secondary outcomes included operative times, intra- and early postoperative complications, hospital length of stay (LOS), and 30-day readmissions. Medium-term secondary outcomes included late postoperative complications as well as nutritional deficiencies and persistent diarrhea at 1 and 2 years after surgery. Subgroup analyses were performed to compare patients undergoing one- and two-stage procedures.
Data of 107 patients who underwent SADS (n = 25) or DADS (n = 82) were included in the study. Follow-up data were available for 59/107 (55.1%) patients at 1 year and 47/107 (43.9%) at 2 years after surgery. Patients in the SADS and DADS groups had similar %TBWL at 1 year (23.6 versus 26.2, P = 0.617) and 2 years (24.8 versus 30.2, P = 0.116) after surgery. Short- and medium-term outcomes were similar between groups. There was no difference between patients undergoing one- versus two-stage procedures.
This study showed that patients undergoing SADS and DADS had similar weight loss at 1 and 2 years. Early and late postoperative morbidity, operative times, early readmissions, and LOS were also similar between groups. Further studies with longer follow-up are required to confirm these results.
Surgical trials pose many methodological challenges often not present in trials of medical interventions. If not properly accounted for, these challenges may introduce significant biases and threaten ...the validity of the results.
We systematically reviewed the significance of randomized controlled trials in the evaluation of surgical interventions, discussed the methodological challenges encountered in designing and conducting randomized controlled trials of surgical treatments, and proposed possible solutions to overcome these challenges.
Many barriers and issues of surgical trials affecting internal validity can be overcome with proper methodology, and in most cases these issues do not restrict their conduct. Researchers should consider their research question carefully and design a surgical trial that contains features appropriate for the question. In doing so, they must ensure that the trial is valid, feasible, and affordable--a difficult feat, but one well worth the challenge.
PDF
