30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

Laparoscopic Roux-en-Y gastric bypass in intestinal non-rotation

There are some incidental findings during bariatric surgery. Some of these findings may make the operation more challenging than routine surgery. Intestinal malrotation/non-rotation are rare congenital anomalies that may remain asymptomatic until bariatric surgery. Here we report a 30-year-old female patient with unknown intestinal congenital anomaly which was diagnosed during surgery and she underwent Roux-en-Y gastric bypass, which can be a challenging procedure in intestinal malrotation/non-rotation and conversion may be needed.

Revisional surgery after one anastomosis/mini gastric bypass: A narrative review

One anastomosis gastric bypass (OAGB)/mini gastric bypass is now considered to be a safe and efficient method for morbidly obese patients but has complications and adverse events such as other surgical procedures. The present paper outlines the need for and the nature of revisional surgery in the long-term following OAGB in accordance with the preferred reporting items for systematic reviews and meta-analysis guidelines. A literature search was carried out in PubMed. All articles on OAGB for which the authors described a patient needing revisional surgery in the long term after OAGB were examined.

The effect of Punica granatum L. flower extract on post-surgical peritoneal adhesions in a rat model

OBJECTIVE

Peritoneal adhesions may develop after every abdominopelvic surgery. Many agents and technical modifications have been investigated to minimize adhesions. Punica granatum (pomegranate) flower has some anti-inflammatory and antioxidative effects that would reduce the formation of peritoneal adhesions. In the present study, the effects of different doses of oral Punica granatum flower extract on postoperative peritoneal adhesions were evaluated in a rat model.

STUDY DESIGN

Thirty-two female Wistar rats were divided into four groups: one control group (CG) and three experimental groups, treated with 100 (EG100), 200 (EG200), and 400 (EG400) mg/kg/day Punica granatum extract orally for eight days. Induction of peritoneal adhesions was done in all groups using the same method. Two weeks after the first surgery, all rats re-operated and adhesions were evaluated via both macroscopic and microscopic changes.

RESULTS

We observed that rats in the control group had statistically higher adhesion area and more severe adhesions when compared to all experimental groups. Besides, those in the EG-400 group had a significantly lower rate of foreign body reaction in serosal layer when compared to the other three study groups. Other microscopic findings were comparable between the four groups.

CONCLUSION

Administration of the oral Punica granatum flower extract was associated with a decreased quantity and quality of the adhesions in the animal model of rat in this study. This therapy might be an effective and safe strategy to reduce intraperitoneal adhesion after abdominal surgeries in animal models.

Evaluation of routine postoperative chest roentgenogram for determination of the correct position of permanent central venous catheters tip

BACKGROUND

Proper placement of central venous catheter (CVC) tip could reduce early and late catheter-related complications. Although the live fluoroscopy is standard of care for placement of the catheter, it is not available in many centers. Therefore, the present study evaluated the sensitivity and specificity of bedside chest X-ray (CXR) for proper positioning of the catheter tip.

MATERIALS AND METHODS

A total of 82 adult patients undergoing elective placement of tunneled CVC were enrolled in this study during 2010-2012. The catheter tip position was evaluated by postoperative bedside chest radiographs as well as trans-thoracic echocardiogram as definite diagnostic tool. The catheter position was considered correct if the tip was positioned in the right atrium both in CXR or echocardiography. Finally, CXRs interpreted by expert radiologist. Thus findings were compared by echocardiography. Sensitivity, specificity, accuracy, positive, and negative predictive values were calculated. Data were analyzed using SPSS version 16 (SPSS Inc., Chicago, IL), and P < 0.05 considered as significant.

RESULTS

The patients were 57.37 ± 18.91 years of age, weighed 65.79 ± 15.58 kg and were 166.36 ± 9.91 cm tall. Sensitivity and specificity of CXR for proper catheter tip position were 74.3% and 58.3%, respectively. Positive and negative predictive values were 91.2% and 28%. In addition accuracy, positive likelihood ratio, and negative likelihood ratio were 71.9%, 1.78, and 2.27 respectively.

CONCLUSION

Bedside CXR alone does not reliably predict malpositioning after CVC placement.

Bronchial stump closure with amniotic membrane in animal model

BACKGROUND

Coverage of the bronchial stumps (BSs) with adjacent tissues can improve healing and reduce bronchial complications in complex thoracic surgery. There is no evidence for the application of human amnion allograft for prevention of air leak from the BS. The comparison of the amniotic membrane (AM) and pleural patch for BS healing after lobectomy in dogs was our aim in this study.

MATERIALS AND METHODS

A total of eight males and females 12-24-month-old dogs between 17 and 22 kg body-weight were used in this study in 2010, Isfahan University of Medical Sciences. Animals were separated into two groups: group A (n = 4; amniotic membrane) and group P (n = 4; pleural patch) according to the BS closure technique performed. After lobectomy of the right middle lobe, the BS was closed, while a small bronchopleural fistula (BPF) was created by inserting a catheter via edges of closed stump. Then, it was covered with a piece of AM3 × 3 cm in group A and with a pedicle graft of pleura in group P. Rethoracotomy was performed after 15 days of observation, and the BS was removed for histological examination. Histological healing was classified as complete or incomplete healing. Neoangiogenesis was measured by Von Willebrand expression using immunohistochemistry (IHC). Data were analyzed by SPSS version 15 using Fisher's exact test, Mann-Whitney test, and T tests.

RESULTS

BPF complications were not seen during observation period. There was no significant difference in histological healing between two groups. Similarly, no significant difference was observed between the groups in terms of neoangiogenesis based on IHC examination (P value = 0.69).

CONCLUSION

Human amnion allograft could be as effective as pleural patch for BS wrapping following pulmonary resections.

How effective are alprostadil and hydrocortisone on reperfusion injury in kidney after distant organ ischemia?

BACKGROUND

After reestablishment of blood flow to ischemic limb recirculation of free radicals may cause ischemia-reperfusion injury in many organs. This study designed to investigate effects of hydrocortisone and alprostadil distant injury to kidneys by both measuring biochemical markers of oxidative stress and histopathologic examination in an experimental rat model of hind limb ischemia-reperfusion.

MATERIALS AND METHODS

This study conducted in Isfahan University of Medical Sciences during 2011-2012. Ischemia was established by infra renal aortic clamping for 60 min in 32 male Wistar rats. Animals were divided into those receiving alprostadil (group ischemia-reperfusion plus alprostadil (IR/A), n = 8), those receiving hydrocortisone (group ischemia-reperfusion plus hydrocortisone (IR/H), n = 8), control group (group ischemia-reperfusion (IR), n = 8), and sham group (n = 8). After 120 min of reperfusion both kidneys were removed. Levels of superoxide dismutase (SOD), malondialdehyde (MDA), and glutathione (GSH) as indirect markers of oxidative injury was measured. Finally all data in different groups were compared using the analysis of variance (ANOVA) test by Statistical Package for Social Sciences (SPSS) version 16.

RESULTS

Administration of alprostadil or hydrocortisone does not improve the biochemical parameters of oxidative injury including MDA and SOD. However, statistically significant difference was seen in GSH level among sham and IR groups. Mean (± standard deviation (SD)) concentration of GSH in IR, IR/A, IR/H, and sham groups were 1028.77 (72.65), 924.82 (70.66), 1000.28 (108.77), and 846.69 (163.52), respectively (P = 0.015). Histopathological study of specimens did not show any significant changes between groups.

CONCLUSION

Alprostadil and hydrocortisone do not improve the kidney GSH, SOD, and MDA level and kidney releases its GSH reserve during ischemia-reperfusion event, and another point is that, 3 h of ischemia-reperfusion does not develop injury in kidney.

The mid-sternal length, a practical anatomical landmark for optimal positioning of long-term central venous catheters

BACKGROUND

Long-term tunneled catheters are used for the hemodialysis or chemotherapy in many patients. Proper placement of the catheter tip could reduce early and late catheter related complications. Aim of the present study was to evaluate a new formula for proper placement of tunneled hemodialysis or infusion port device by using an external anatomic landmark.

MATERIALS AND METHODS

A total of 64 adult patients undergoing elective placement of tunneled Central Venous Catheter (CVC) requiring hemodialysis or chemotherapy were enrolled in this prospective study during 2011-2012 in the university hospital. The catheter length to be inserted in the right internal jugular vein (IJV) was calculated by adding two measurements (the shortest straight length between the insertion point of the needle and the suprasternal notch plus and half of sternal length). The catheter position was considered correct if the tip was positioned in the right atrium (RA) or Superior vena cava (SVC)-RA junction.

RESULTS

The patients were 55.28 ± 19.85 years of age, weighed 5.78 ± 16.62 kg and were 166.07 ± 10.27 cm tall. Catheters were inserted successfully in 88% of patients (n = 56). Catheter tip positions in the failures were SVC (n = 5), tricuspid valve (n = 2), and right ventricle (n = 1) in our patients.

CONCLUSION

Long-term hemodialysis or port CVC could easily insert in the right IJV by using half of the sternal length as an external land marks among adult patients.

Micrometastasis in non-small-cell lung cancer: Detection and staging

BACKGROUND:

The clinical relevance of bone marrow micrometastasis (BMM) in non–small-cell lung cancer is undetermined, and the value of such analyses in advanced stage patients has not been clearly assessed previously. This study was conducted to estimate the accuracy of both polymerase chain reaction (PCR) and immunohistochemistry (IHC) in micrometastases detection and determine the best site for bone marrow biopsy in order to find micrometastasis.

METHODS:

This prospective cross-sectional study was performed in the Department of Thoracic Surgery, Alzahra University Hospital from September 2008 to June 2009. To evaluate the bone marrow, a 3-cm rib segment and an aspirated specimen from the iliac bone prior to tumor resection were taken. PCR and IHC were performed for each specimen to find micrometastasis.

RESULTS:

Of 41 patients, 14 (34%) were positive for BMM by PCR compared with two positive IHC (4.8%). All BMMs were diagnosed in rib segments, and iliac specimens were all free from metastatic lesion. Our data showed no significant association between variables such as age, sex, histology, tumor location, side of tumor, involved lobe, smoking, or weight loss and presence of BMM.

CONCLUSION:

PCR could use as a promising method for BMM detection. BMM in a sanctuary site (rib) is not associated with advanced stages of lung cancer. In addition, when predictor variables such as age, sex, histology, tumor location, smoking, or weight loss are analyzed, no correlation can be found between micrometastasis prevalence and any of those variables.

Zinc sulfate for relief of pruritus in patients on maintenance hemodialysis

Pruritus is a common complaint in patients undergoing maintenance hemodialysis. The pathophysiology of pruritus in these patients is not well known, but the role of histamine release from mast cells has been reported. According to the inhibitory effects of zinc on histamine release and reported low levels of serum zinc in hemodialysis patients, we aimed to evaluate the effects of zinc sulfate for the relief of pruritus in these patients. This double-blind, randomized, placebo-controlled trial was conducted on 40 adults with end stage renal disease (ESRD) who were on maintenance hemodialysis in two university hospitals in Isfahan, Iran. Patients were randomized to receive either zinc sulfate (440 mg/day) or placebo for two consecutive months. Pruritus was assessed at baseline and then every two weeks using a numerical rating scale from 0 to 10 until one month after treatment. Drug side effects were also assessed along with pruritus. There were 40 patients with a mean age of 55.5 ± 15.2 (72.5% male) who completed the study. The two groups were similar in baseline characteristics. Pruritus was decreased in both groups after treatment but there was a significantly greater decrease in the zinc sulfate group compared with placebo (P = 0.018). Patient compliance was good and no severe side effects were observed. Zinc sulfate (440 mg/day) is more effective than placebo for the relief of pruritus in patients under maintenance hemodialysis. Further studies with larger sample size, longer treatment duration and follow-up and with various dosages of zinc sulfate are recommended.

Successful prevention of tunneled, central catheter infection by antibiotic lock therapy using cefotaxime

BACKGROUND

Chronic hemodialysis patients frequently require vascular access through central venous catheters (CVCs). The most significant complication of these catheters is infection. This risk can be lowered by the use of an antibiotic-Heparin lock. This study focuses on hemodialysis patients using Tunneled-cuffed catheters (TCC), to assess the rate of catheter-related infections (CRI) in catheter-restricted filling with Cefotaxime and Heparin in end stage renal disease patients.

METHODS

A double-blind randomized study was conducted to compare 5000 U/ml Heparin plus10 mg/ml cefotaxime (CE/HS) as catheter-lock solutions, with Heparin (5000 U/ml) alone. A total of 30 patients with end-stage renal disease and different etiologies, were enrolled for chronic hemodialysis with permanent catheters from December 2009 to March 2010. These patients were randomly assigned to two groups of 15 members. Blood samples were collected for culture, sensitivity, and colony count, from the catheter lumen and the peripheral vein. CRI was considered as the end point.

RESULTS

The rate of CRI was significantly lower in the cefotaxime group versus control group (p < 0.001). No exit site infection was occurred in both groups. Infection-free survival rates at 180 days were 100% for the CE/HS group, and 56% for the HS group.

CONCLUSIONS

Antibiotic lock therapy using cefotaxime reduces the risk of CRI in hemodialysis patients.

A randomized controlled trial: efficacy and safety of azithromycin, ofloxacin, bismuth, and omeprazole compared with amoxicillin, clarithromycin, bismuth, and omeprazole as second-line therapy in patients with Helicobacter pylori infection

BACKGROUND

Helicobacter pylori infection of the stomach is widespread among human populations and is considered to play a major role in the pathogenesis of various diseases such as peptic ulcer, adenocarcinoma, and mucosa associated lymphoid tissue (MALT) lymphoma of the stomach. To increase H. pylori eradication rate without increasing bacterial resistance, various regimens have been recommended. Commonly the association of at least two antibiotics with a proton-pump inhibitor is used. The treatment regimens for second-line therapy, suggested in studies from the western world may not be ideal in Iran.

AIM

In this study, we evaluated the safety and efficacy of a new quadruple therapy regimen and compared it with the standard second-line treatment for H. pylori eradication.

METHODS

We selected 220 H. pylori positive patients, with a clear indication of eradication therapy, who did not respond to a 2 weeks treatment with metronidazole, amoxicillin, omeprazole, and bismuth. They were randomized into two groups. Group A (n = 110) were treated with azithromycin, ofloxacin, bismuth, and omeprazole and group B (n = 110) with amoxicillin, clarithromycin, bismuth, and omeprazole for 2 weeks. Four weeks after the end of treatment, urea breath test was performed for all subjects to confirm eradication.

RESULTS

In intention-to-treat analysis, the rate of H. pylori eradication in groups A and B was 77.3% (85/110) and 64.5% (71/110) respectively (p = .027). In per-protocol analysis, the rate of H. pylori eradication in groups A and B was 86.7 and 74.7%, respectively (p = .026). The incidence of poor compliance was lower, although not significantly so, in group A than group B (3.5 vs 4.3%). No major adverse events occurred in both groups.

CONCLUSION

Two weeks of treatment with ofloxacin, azithromycin, omeprazole, and bismuth is an effective and safe regimen for H. pylori eradication as second-line therapy.

Pamidronate therapy for hypercalcemia and congenital mesoblastic nephroma: a case report

Hypercalcemia can causes life threatening complications. We report an infant with severe hypercalcemia due to congenital mesoblastic nephroma. Hypercalcemia was corrected before nephrectomy by pamidronate. According to our knowledge this is a rare case with severe neoplasm induced hypercalcemia among neonates who treated by bisphosphonates. The aim of this report is to define new approach to neoplasm induced neonatal hypercalcemia.