Purpose
Obesity is a major risk factor for end-stage kidney disease (ESKD) and is often a barrier to kidney transplantation. However, limited evidence exists evaluating postoperative bariatric ...surgery outcomes in patients with chronic kidney disease (CKD) and ESKD.
Materials and Methods
We performed a retrospective cohort study of patients who underwent bariatric surgery in 2015–2016 using the national Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program dataset. Propensity score matching was used to balance characteristics across patients with CKD and ESKD vs. those without CKD.
Results
There were 323,034 patients without CKD, 1694 patients with CKD, and 925 patients with ESKD who underwent bariatric surgery. Patients with CKD and ESKD had a significantly increased risk of 30-day reoperation (CKD odds ratio OR 2.25 95% confidence interval CI 1.45–3.51; ESKD OR 3.10, 95% CI 1.72–5.61) and readmission (CKD OR 1.98, 95% CI 1.53–2.56; ESKD OR 2.97, 95% CI 2.05–4.31) compared to patients without CKD; mortality risk was elevated in patients with ESKD (OR 11.59, 95% CI 6.71–20.04) but not in those with CKD (OR 1.00, 95% CI 0.32–3.11). Rates of adverse outcomes were < 15% across all groups. There were 12, 50, and 172 deaths per 1000 person-years among patients without CKD, with CKD, and with ESKD, respectively.
Conclusion
Patients with CKD and ESKD experienced higher risk of postbariatric surgery complications compared to those without kidney disease, although absolute complication rates were low across all groups. CKD and ESKD should not be perceived as contraindications to bariatric surgery.
Severe obesity is frequently a barrier to kidney transplantation, and kidney transplant recipients often have significant weight gain following transplantation.
The goals of this study were to ...evaluate the long-term risks and benefits of bariatric surgery before and after kidney transplantation.
University Hospital, United States.
We performed a retrospective cohort study of 43 patients who had pretransplantation bariatric surgery and 21 patients who had posttransplantation bariatric surgery from 1994 to 2017 with propensity-score matching to identify matched controls using national registry data.
Body mass index at the time of transplantation was similar in patients who underwent bariatric surgery before versus after transplantation (32 versus 34 kg/m
, P = .172). There was no significant difference in body mass index in the 5 years after bariatric surgery among patients who underwent bariatric surgery before versus after kidney transplantation (36 versus 32 kg/m
, P = 0.814). Compared with matched controls, bariatric surgery before (n = 38) and after (n = 18) kidney transplantation was associated with a decreased risk of allograft failure (hazard ratio .31 95% confidence interval .29-0.33 and .85 95% confidence interval .85-.86 for pre- and posttransplant, respectively) and mortality (hazard ratio .57 95% confidence interval .53-.61 and .80 95% confidence interval .79-.82 for pre- and posttransplant, respectively).
Bariatric surgery before and after kidney transplantation results in similar maintenance of weight loss and improved long-term allograft survival compared with matched controls. Bariatric surgery appears to be a safe and reasonable approach to weight loss both before and after transplantation.
Idiopathic achalasia is an archetype esophageal motor disorder, causing significant impairment of eating ability and reducing quality of life. The pathophysiological underpinnings of this condition ...are loss of esophageal peristalsis and insufficient relaxation of the lower esophageal sphincter(LES). The clinical manifestations include dysphagia for both solids and liquids, regurgitation of esophageal contents, retrosternal chest pain, cough, aspiration, weight loss and heartburn. Even though idiopathic achalasia was first described more than 300 years ago, researchers are only now beginning to unravel its complex etiology and molecular pathology. The most recent findings indicate an autoimmune component, as suggested by the presence of circulating anti-myenteric plexus autoantibodies, and a genetic predisposition, as suggested by observed correlations with other well-defined genetic syndromes such as Allgrove syndrome and multiple endocrine neoplasia type 2 B syndrome. Viral agents(herpes, varicella zoster) have also been proposed as causative and promoting factors. Unfortunately, the therapeutic approaches available today do not resolve the causes of the disease, and only target the consequential changes to the involved tissues, such as destruction of the LES, rather than restoring or modifying the underlying pathology. New therapies should aim to stop the disease at early stages, thereby preventing the consequential changes from developing and inhibiting permanent damage. This review focuses on the known characteristics of idiopathic achalasia that will help promote understanding its pathogenesis and improve therapeutic management to positively impact the patient’s quality of life.
Purpose
To evaluate the association between body mass index (BMI) and postoperative outcomes in elective paraesophageal hernia (PEH) repairs.
Methods
A retrospective review of patients who underwent ...elective PEH repair in the ACS NSQIP database (2005–2015) was performed. Patients were stratified into BMI groups (< 18.5, 18.5–24.9, 25.0–29.9, 30.0–34.9, 35–39.9, and ≥ 40.0 kg/m
2
) according to the World Health Organization classification criteria. A multivariable logistic regression model was developed to characterize the association between BMI class and outcomes, including readmission, reoperation, postoperative complications, and mortality.
Results
The median (IQR) age of the 9641 patients who met inclusion criteria was 64 (55–72) and 72.7% were women. Across each BMI class, age, race, gender, type of procedure, frailty index, smoking, and ASA class varied (
p
< 0.05). Underweight patients (BMI < 18.5 kg/m
2
) had an increased risk of mortality (OR = 6.35,
p
< 0.05). Patients with a BMI 35–39.9 kg/m
2
(OR = 0.65,
p
< 0.05) and ≥ 40 kg/m
2
(OR = 0.36,
p
< 0.001) were associated with a decreased risk for readmissions.
Conclusion
Underweight patients have an increased risk for postoperative mortality after elective PEH repair. Higher BMI was associated with a diminished risk for readmission, but not for mortality, reoperations, or overall complications.
Long‐term dietary and pharmacological treatments for obesity have been questioned, particularly in individuals with severe obesity, so a new approach may involve adipose tissue transplants, ...particularly autologous transplants. Thus, the aim of this study was to evaluate the metabolic effects of autologous subcutaneous adipose tissue (SAT) transplants into two specific intraabdominal cavity sites (omental and retroperitoneal) after 90 days. The study was performed using two different diet‐induced obesity (DIO) rat models: one using a high‐fat diet (HFD) and the other using a high‐carbohydrate diet (HCHD). Autologous SAT transplant reduced hypertrophic adipocytes, improved insulin sensitivity, reduced hepatic lipid content, and fasting serum‐free fatty acids (FFAs) concentrations in the two DIO models. In addition, the reductions in FFAs and glycerol were accompanied by a greater reduction in lipolysis, assessed via the phosphorylation status of HSL, in the transplanted adipose tissue localized in the omentum compared with that localized in the retroperitoneal compartment. Therefore, the improvement in hepatic lipid content after autologous SAT transplant may be partially attributed to a reduction in lipolysis in the transplanted adipose tissue in the omentum due to the direct drainage of FFAs into the liver. The HCHD resulted in elevated fasting and postprandial serum insulin levels, which were dramatically reduced by the autologous SAT transplant. In conclusion, the specific intraabdominal localization of the autologous SAT transplant improved the carbohydrate and lipid metabolism of adipose tissue in obese rats and selectively corrected the metabolic parameters that are dependent on the type of diet used to generate the DIO model.
Autologous subcutaneous adipose tissue transplanted into two specific intraabdominal cavity sites (omental and retroperitoneal adipose tissue) improved insulin sensitivity, reduced hypertrophic adipocytes, and reduced hepatic lipid content and fasting serum‐free fatty acid concentrations in obese rats induced by high‐fat or high‐carbohydrate diets. Moreover, part of the metabolic improvement was mediated by changes in the adipose tissue lipolytic metabolism. The transplant procedure, which is an innovate method, permits to integrate physically and metabolically the transplanted adipose tissue.
The rapid and dynamic surgical environment requires leaders that can help guide their teams to desired outcomes while delivering patient-centered care. The need for early implementation of leadership ...curricula has been identified; however, most available leadership curricula are tailored for faculty and not embedded within surgery training. The ideal intervention(s) to close this gap while addressing the unique challenges of the demanding surgical training are yet to be identified. This manuscript reviews the current status of residency leadership programs and the relationship of leadership to other essential aspects for optimal training of future surgeon leaders. The use of best practice medical education frameworks is key to help guide effective and sustainable evidence-based leadership curricula. The collaboration, standardization, and publication of leadership curricula for surgery residents can serve as prototypes to address specific needs at different training institutions with the aim of equipping surgeons with the necessary leadership tools for their success.
•Current status of leadership programs in general surgery.•Education frameworks and evidence-based leadership curricula.•Leadership, well-being, and patient safety.
De-novo malignancies carry an incidence ranging between 3%-26% after transplant and account for the second highest cause of post-transplant mortality behind cardiovascular disease. While the majority ...of de-novo malignancies after transplant usually consist of skin cancers, there has been an increasing rate of solid tumor cancers over the last 15 years. Although, recurrence of hepatocellular carcinoma(HCC) is well understood among patients transplanted for HCC, there are increasing reports of de-novo HCC in those transplanted for a non-HCC indication. The proposed pathophysiology for these cases has been mainly connected to the presence of advanced graft fibrosis or cirrhosis and always associated with the presence of hepatitis B or C virus. We report the first known case of de-novo HCC in a recipient, 14 years after a pediatric living related donor liver transplantation for end-stage liver disease due to biliary atresia without the presence of hepatitis B or C virus before and after transplant. We present this case report to increase the awareness of this phenomenon and address on the utility for screening and surveillance of hepatocellular carcinoma among these individuals. One recommendation is to use similar guidelines for screening, diagnosis, and treatment for HCC as those used for primary HCC in the pre-transplant patient, focusing on those recipients who have advanced fibrosis in the allograft, regardless of etiology.
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