Outcomes in Bariatric and Metabolic Surgery: an Updated 5-Year Review

PURPOSE OF REVIEW

Knowledge regarding postoperative outcomes after bariatric and metabolic surgery continues to evolve. This review highlights key findings in outcomes research over the last 5 years related to weight loss, remission of obesity-related disease, reflux, revisional surgery, robotic-assisted surgical platforms, and adolescent populations.

RECENT FINDINGS

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) produce similar weight loss patterns at 5 years, while duodenal switch (BPD/DS) and related procedures are associated with maximal weight loss overall and optimal resolution of obesity-related comorbidities. Remission of type 2 diabetes mellitus (T2DM) following surgery is more likely in patients who are not insulin dependent prior to surgery. Bariatric and metabolic surgery offers a significant protective effect against coronary artery disease (CAD) and associated interventions in both diabetic and nondiabetic patients, as well as heart failure (HF). Gastroesophageal reflux disease (GERD) and dysphagia following SG are common, and routine endoscopic surveillance for Barrett's esophagus may be of significant utility. Robotic-assisted laparoscopic platforms concur similar outcomes to laparoscopic intervention, with a potential benefit in high BMI patients. Revisional surgery is most commonly performed for weight regain and/or inadequate weight loss following an index procedure, or reflux, and generally characterized by higher postoperative complication rates and longer inpatient lengths of stay (LOS). Surgical intervention in adolescent populations has similar weight loss and postoperative complication profiles to those seen in adult populations, with improved outcomes related to T2DM. Bariatric and metabolic surgery continues to evolve as a treatment for obesity and obesity-related comorbidities. While effective for weight loss and remission of obesity-related disease, SG is associated with high rates of postoperative GERD.

The Effect of Smallpox and Bacillus Calmette-Guérin Vaccination on the Risk of Human Immunodeficiency Virus-1 Infection in Guinea-Bissau and Denmark

Background

The live smallpox and Bacillus Calmette-Guérin (BCG) vaccinations have been associated with better adult survival in both Guinea-Bissau and Denmark. In Guinea-Bissau, human immunodeficiency virus (HIV)-1 became an important cause of death after smallpox vaccination was phased out globally in 1980. We hypothesised that smallpox and BCG vaccinations were associated with a lower prevalence of HIV-1 infection, and we tested this hypothesis in both Guinea-Bissau and Denmark.

Methods

We conducted 2 studies: (1) a cross-sectional study of HIV infection and vaccination scars in Guinea-Bissau including 1751 individuals and (2) a case-base study with a background population of 46239 individuals in Denmark. In Guinea-Bissau, HIV-1 transmission was almost exclusively sexually transmitted. In Denmark, we excluded intravenous drug users. Data were analyzed using logistic regression.

Results

Bacillus Calmette-Guérin and/or smallpox vaccination compared with neither of these vaccines was associated with an adjusted odds ratio (aOR) for HIV-1 of 0.62 (95% confidence interval [CI], 0.36–1.07) in Guinea-Bissau and 0.70 (95% CI, 0.43–1.15) in Denmark. We combined the results from both settings in a meta-analysis (aOR = 0.66; 95% CI, 0.46–0.96). Data from Guinea-Bissau indicated a stronger effect of multiple smallpox vaccination scars (aOR = 0.27; 95% CI, 0.10–0.75) as follows: women, aOR = 0.18 (95% CI, 0.05–0.64); men, aOR = 0.52 (95% CI, 0.12–2.33); sex-differential effect, P = .29.

Conclusions

The studies from Guinea-Bissau and Denmark, 2 very different settings, both suggest that the BCG and smallpox vaccines could be associated with a decreased risk of sexually transmitted HIV-1. It might be informative to pursue this observation and explore possible protective mechanisms as part of the search for an HIV-1 vaccine.

Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation

Organ shortage is the major limitation to kidney transplantation in the developed world. Conversely, millions of patients in the developing world with end-stage renal disease die because they cannot afford renal replacement therapy-even when willing living kidney donors exist. This juxtaposition between countries with funds but no available kidneys and those with available kidneys but no funds prompts us to propose an exchange program using each nation's unique assets. Our proposal leverages the cost savings achieved through earlier transplantation over dialysis to fund the cost of kidney exchange between developed-world patient-donor pairs with immunological barriers and developing-world patient-donor pairs with financial barriers. By making developed-world health care available to impoverished patients in the developing world, we replace unethical transplant tourism with global kidney exchange-a modality equally benefitting rich and poor. We report the 1-year experience of an initial Filipino pair, whose recipient was transplanted in the United states with an American donor's kidney at no cost to him. The Filipino donor donated to an American in the United States through a kidney exchange chain. Follow-up care and medications in the Philippines were supported by funds from the United States. We show that the logistical obstacles in this approach, although considerable, are surmountable.

Incentivizing Authorization for Deceased Organ Donation With Organ Allocation Priority: The First 5 Years

The allocation system of donor organs for transplantation may affect their scarcity. In 2008, Israel's Parliament passed the Organ Transplantation Law, which grants priority on waiting lists for transplants to candidates who are first-degree relatives of deceased organ donors or who previously registered as organ donors themselves. Several public campaigns have advertised the existence of the law since November 2010. We evaluated the effect of the law using all deceased donation requests made in Israel during the period 1998-2015. We use logistic regression to compare the authorization rates of the donors' next of kin in the periods before (1998-2010) and after (2011-2015) the public was made aware of the law. The authorization rate for donation in the period after awareness was substantially higher (55.1% vs. 45.0%, odds ratio [OR] 1.43, p = 0.0003) and reached an all-time high rate of 60.2% in 2015. This increase was mainly due to an increase in the authorization rate of next of kin of unregistered donors (51.1% vs. 42.2%). We also found that the likelihood of next-of-kin authorization for donation was approximately twice as high when the deceased relative was a registered donor rather than unregistered (89.4% vs. 44.6%, OR 14.27, p < 0.0001). We concluded that the priority law is associated with an increased authorization rate for organ donation.

Structure and coarsening at the surface of a dry three-dimensional aqueous foam

We utilize total-internal reflection to isolate the two-dimensional surface foam formed at the planar boundary of a three-dimensional sample. The resulting images of surface Plateau borders are consistent with Plateau's laws for a truly two-dimensional foam. Samples are allowed to coarsen into a self-similar scaling state where statistical distributions appear independent of time, except for an overall scale factor. There we find that statistical measures of side number distributions, size-topology correlations, and bubble shapes are all very similar to those for two-dimensional foams. However, the size number distribution is slightly broader, and the shapes are slightly more elongated. A more obvious difference is that T2 processes now include the creation of surface bubbles, due to rearrangement in the bulk, and von Neumann's law is dramatically violated for individual bubbles. But nevertheless, our most striking finding is that von Neumann's law appears to holds on average, namely, the average rate of area change for surface bubbles appears to be proportional to the number of sides minus six, but with individual bubbles showing a wide distribution of deviations from this average behavior.

Bubble statistics and coarsening dynamics for quasi-two-dimensional foams with increasing liquid content

We report on the statistics of bubble size, topology, and shape and on their role in the coarsening dynamics for foams consisting of bubbles compressed between two parallel plates. The design of the sample cell permits control of the liquid content, through a constant pressure condition set by the height of the foam above a liquid reservoir. We find that in the scaling regime, all bubble distributions are independent not only of time, but also of liquid content. For coarsening, the average rate decreases with liquid content due to the blocking of gas diffusion by Plateau borders inflated with liquid; we achieve a factor of 4 reduction from the dry limit. By observing the growth rate of individual bubbles, we find that von Neumann's law becomes progressively violated with increasing wetness and decreasing bubble size. We successfully model this behavior by explicitly incorporating the border-blocking effect into the von Neumann argument. Two dimensionless bubble shape parameters naturally arise, one of which is primarily responsible for the violation of von Neumann's law for foams that are not perfectly dry.

Coarsening of a two-dimensional foam on a dome

In this paper we report on bubble growth rates and on the statistics of bubble topology for the coarsening of a dry foam contained in the narrow gap between two hemispheres. By contrast with coarsening in flat space, where six-sided bubbles neither grow nor shrink, we observe that six-sided bubbles grow with time at a rate that depends on their size. This result agrees with the modification to von Neumann's law predicted by J. E. Avron and D. Levine [Phys. Rev. Lett. 69, 208 (1992)]. For bubbles with a different number of sides, except possibly seven, there is too much noise in the growth rate data to demonstrate a difference with coarsening in flat space. In terms of the statistics of bubble topology, we find fewer three-, four-, and five-sided bubbles, and more bubbles with six or more sides, in comparison with the stationary distribution for coarsening in flat space. We also find good general agreement with the Aboav-Weaire law for the average number of sides of the neighbors of an n-sided bubble.

Call to develop a standard acquisition charge model for kidney paired donation

We propose a Medicare Demonstration Project to develop a standard acquisition charge for kidney paired donation. A new payment strategy is required because Medicare and commercial insurance companies may not directly pay living donor costs intended to lead to transplantation of a beneficiary of a different insurance provider. Until the 1970s, when organ procurement organizations were empowered to serve as financial intermediaries to pay the upfront recovery expenses for deceased donor kidneys before knowing the identity of the recipient, there existed similar limitations in the recovery and placement of deceased donor organs. Analogous to the recovery of deceased donor kidneys, kidney paired donation requires the evaluation of living donors before identifying their recipient. Tissue typing, crossmatching and transportation of living donors or their kidneys represent additional financial barriers. Finally, the administrative expenses of the organizations that identify and coordinate kidney paired donation transplantation require reimbursement akin to that necessary for organ procurement organizations. To expand access to kidney paired donation for more patients, we propose a model to reimburse paired donation expenses analogous to the proven strategy used for over 30 years to pay for deceased donor solid organ transplantation in America.

Nonsimultaneous chains and dominos in kidney- paired donation-revisited

Since 2008, kidney exchange in America has grown in part from the incorporation of nondirected donors in transplant chains rather than simple exchanges. It is controversial whether these chains should be performed simultaneously 'domino-paired donation', (DPD) or nonsimultaneously 'nonsimultaneous extended altruistic donor, chains (NEAD). NEAD chains create 'bridge donors' whose incompatible recipients receive kidneys before the bridge donor donates, and so risk reneging by bridge donors, but offer the opportunity to create more transplants by overcoming logistical barriers inherent in simultaneous chains. Gentry et al. simulated whether DPD or NEAD chains would produce more transplants when chain segment length was limited to three transplants, and reported that DPD performed at least as well as NEAD chains. As this finding contrasts with the experience of several groups involved in kidney-paired donation, we performed simulations that allowed for longer chain segments and used actual patient data from the Alliance for Paired Donation. When chain segments of 4-6 transplants are allowed in the simulations, NEAD chains produce more transplants than DPD. Our simulations showed not only more transplants as chain length increased, but also that NEAD chains produced more transplants for highly sensitized and blood type O recipients.

Abrasion of flat rotating shapes

We report on the erosion of flat linoleum "pebbles" under steady rotation in a slurry of abrasive grit. To quantify shape as a function of time, we develop a general method in which the pebble is photographed from multiple angles with respect to the grid of pixels with a digital camera. This reduces digitization noise and allows the local curvature of the contour to be computed with a controllable degree of uncertainty. Several shape descriptors are then employed to follow the evolution of different initial shapes toward a circle, where abrasion halts. The results are in good quantitative agreement with a simple model, where we propose that points along the contour move radially inward in proportion to the product of the radius and the derivative of radius with respect to angle.

Toward a theory of bargaining: an experimental study in economics

Contemporary economic theories of bargaining depend on aspects of the bargainers' preferences that are difficult to observe. This makes these theories difficult to test in natural environments. It has proved possible, however, to design experiments to test these theories in a controlled, laboratory environment. The results of these experiments reveal shortcomings and incompleteness in the descriptive power of currently available theories of bargaining. However, these results also suggest important regularities in bargaining behavior. Together with recent theoretical developments, these results suggest some directions in which a more descriptively powerful theory of bargaining might be developed.

Kidneys for sale: who disapproves, and why?

The shortage of transplant kidneys has spurred debate about legalizing monetary payments to donors to increase the number of available kidneys. However, buying and selling organs faces widespread disapproval. We survey a representative sample of Americans to assess disapproval for several forms of kidney market, and to understand why individuals disapprove by identifying factors that predict disapproval, including disapproval of markets for other body parts, dislike of increased scope for markets and distrust of markets generally. Our results suggest that while the public is potentially receptive to compensating kidney donors, among those who oppose it, general disapproval toward certain kinds of transactions is at least as important as concern about specific policy details. Between 51% and 63% of respondents approve of the various potential kidney markets we investigate, and between 42% and 58% want such markets to be legal. A total of 38% of respondents disapprove of at least one market. Respondents who distrust markets generally are not more disapproving of kidney markets; however we find significant correlations between kidney market disapproval and attitudes reflecting disapproval toward certain transactions-including both other body markets and market encroachment into traditionally nonmarket exchanges, such as food preparation.

Utilizing list exchange and nondirected donation through 'chain' paired kidney donations

In a list exchange (LE), the intended recipient in an incompatible pair receives priority on the deceased donor waitlist (DD-waitlist) after the paired incompatible donor donates a kidney to a DD-waitlist candidate. A nondirected donor's (ND-D) kidney is usually transplanted directly to a DD-waitlist candidate. These two established practices would help even more transplant candidates if they were integrated with kidney paired donation (KPD). We consider a scenario in which the donor of an LE intended recipient (LE-IR) donates to a compatible KPD intended recipient (KPD-IR), and the KPD donor (KPD-D) donates to the waitlist (an LE-chain). We consider a similar scenario in which an ND-D donates to a KPD-IR and the KPD-D donates to the DD-waitlist (an ND-chain). Using data derived from the New England Program for Kidney Exchange (NEPKE) and from OPTN/SRTR recipient-donor distributions, simulations are presented to evaluate the potential impact of chain exchanges coordinated with KPD. LE donors (LE-D) and ND-D who are ABO-O result in the highest number of additional transplants, while results for ABO-A and B donors are similar to each other. We recommend that both LE and ND donations be utilized through chain exchanges.

The effects of the change in the NRMP matching algorithm. National Resident Matching Program

CONTEXT

Following 2 years of heated controversy about the resident match, the National Resident Matching Program (NRMP) recently voted to replace the existing matching algorithm with a newly designed applicant-proposing algorithm.

OBJECTIVE

To design an applicant-proposing algorithm for the match and compare it with the existing NRMP algorithm to determine how many applicants and residency programs could be expected to receive better or worse matches from the 2 algorithms, how the different algorithms influence the opportunity for strategic behavior, and what advice can be given to participants.

DESIGN

Computational experiments compared the newly designed applicant-proposing algorithm with the existing NRMP algorithm on the rank order lists (ROLs) submitted by all applicants and residency programs in the 1987 and 1993 through 1996 NRMP matches.

RESULTS

Differences in the matchings produced by the 2 algorithms are small: fewer than 1 in 1000 applicants would have received a different match. Most (but not all) of the few applicants who are matched to different positions by the 2 algorithms do better when the applicant-proposing algorithm is used; the opposite is true for programs. Opportunities for profitable strategic behavior are very rare for both applicants and programs under either algorithm. With either algorithm, both applicants and programs can be advised that trying to get a preferred match by behaving strategically is far more likely to harm than to help them.

CONCLUSIONS

The existing NRMP algorithm and the newly designed applicant-proposing algorithm perform similarly. Both algorithms make it sensible for applicants and residency programs to arrange their ROLs based solely on their preferences for possible matches. The choice of algorithms will systematically affect the matches of only a small group of applicants (<0.1%). The NRMP's recent decision to use the applicant-proposing algorithm starting in 1998 reflects a judgment about the impact of this difference on applicants and programs.

The two nonallelic Xenopus insulin genes are expressed coordinately in the adult pancreas

We have previously shown that the two nonallelic insulin genes in Xenopus laevis are expressed differentially during neurulation in prepancreatic embryos (Shuldiner et al., 1991, Proc. Natl. Acad. Sci. USA 88, 7679-7683). We now examine pancreatic expression with alterations in ambient temperature, glucose administration, fasting and feeding, somatostatin analog treatment, as well as during postmetamorphic growth. Insulin I and II mRNAs were quantitated by slot blot hybridization with specific probes and were expressed as the number of copies (x 10(8)) per 5 micrograms total RNA +/- SEM. Frogs maintained at 12 degrees showed no significant changes when compared to frogs maintained at 20 degrees. There was a coordinate decrease in insulin I and II mRNA levels in frogs maintained at 29 degrees (Ins I 20, 3.41 +/- 0.34 vs Ins I 29, 2.39 +/- 0.17; Ins II 20, 2.59 +/- 0.36 vs Ins II 29, 1.67 +/- 0.09; P < 0.05). When compared to fasting animals, both insulin I and II mRNA levels decreased slightly in frogs given repeated intraperitoneal injections of glucose and in those fed ad libitum; there were no changes after a single dose of glucose or in frogs given somatostatin. When compared to young frogs (6 to 24 months), older frogs (36 months) had higher insulin I and II mRNA levels (e.g., Ins I 6mo, 2.14 +/- 0.15 vs Ins I 36mo, 3.68 +/- 0.43; Ins II 6mo, 1.21 +/- 0.06 vs Ins II 36mo, 3.26 +/- 0.38; P < 0.05). Further, there was a modest reduction in the percentage of insulin I mRNA with aging (e.g., 6 months 63.6 +/- 3.1% vs 36 months 53.9 +/- 2.7%; P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

A natural experiment in the organization of entry-level labor markets: regional markets for new physicians and surgeons in the United Kingdom

The histories of seven regional markets for new physicians and surgeons in the United Kingdom are considered. Like the American market, these markets have experienced failures that led to the adoption of centralized market mechanisms. Because different regions employ different centralized mechanisms, these markets provide a test of the hypothesis that the success of the American market is related to the fact that it produces matches which are stable in the sense that no two agents mutually prefer to be matched to one another than to their assigned partners. Even in the more complex U.K. markets, this kind of stability plays an important role. Centralized markets that produced unstable matches in environments in which agents could act upon instabilities fared no better than the decentralized markets they replaced.

New physicians: a natural experiment in market organization

The National Resident Matching Program is a centralized clearinghouse through which new medical graduates in the United States obtain their first positions. The history of this market, from the market failures that the centralized system was designed to address, to the present, is discussed, and a hypothesis about the behavior of such markets is presented. New evidence is then presented from a set of similar centralized markets in the United Kingdom. Because some of these latter markets have failed, while others have succeeded, they provide a natural experiment that permits the hypothesis to be tested. The new evidence also suggests directions in which modifications of existing procedures might be considered.

Plasmodium ovale malaria acquired in Viet-Nam

Four cases of Plasmodium ovale malaria are reported among US servicemen stationed in Viet-Nam between January 1966 and March 1969. Taken together with other cases cited by the authors, these provide strong evidence of the existence (sometimes disputed) of this Plasmodium in continental South-East Asia.None of the men had served in any other area of endemic malaria and their travel and medical histories suggest that all 4 infections were acquired by mosquito transmission. They constitute only 0.066% of the 6036 malaria cases reported among servicemen returning from Viet-Nam during this period and represent only 0.11% of the blood films from 3686 individuals examined at the US National Malaria Repository during the same period.Serological testing for malaria antibodies with the indirect fluorescent technique corroborated the diagnosis of P. ovale in 1 case. Speciation was not possible in the other 3 cases since titres to P. vivax and P. ovale antigens were identical. Only 1 of the patients reported previous experience with vivax malaria.Most of the parasites seen in thin blood films were developing trophozoites and immature schizonts; ring forms and gametocytes were rare; mature schizonts were not found. The morphology of the parasites was typical of P. ovale, with more than 50% of the infected cells showing fimbriations, an oval shape or both.