Safety of limb lengthening after Roux-en-Y gastric bypass: an analysis of the MBSAQIP database

BACKGROUND

Roux-en-Y gastric bypass (RYGB) effectively treats severe obesity, but some patients may require revisional surgery like limb lengthening (LL) for postoperative weight gain.

OBJECTIVES

This study aims to compare 30-day serious complications and mortality rates between LL and primary RYGB, given limited safety data on LL.

METHODS

Patients who underwent LL and RYGB were identified from the 2020 and 2021 MBSAQIP databases, the only years in which LL data were available. Baseline characteristics and 30-day rates of serious complications and mortality were analyzed.

RESULTS

A total of 86,990 patients underwent RYGB and 455 underwent LL. Patients undergoing RYGB were younger (44.4 versus 49.8 yr, P < .001), had a higher body mass index (BMI) (45.5 versus 41.8 kg/m2, P < .001) and higher rates of comorbidities including diabetes (30.0 versus 13.6%, P < .001). RYGB and LL had similar operative duration (125.3 versus 123.2 min, P = .5). There were no statistical differences between cohorts for length of stay (LOS) (1.6 RYGB versus 1.6 LL d, P = .6). After LL, there were higher 30-day rates of reoperation (3.3 versus 1.9%, P = .03) and deep surgical site infections (1.3 versus .5%, P = .03) compared to RYGB. There were no differences in overall serious complications (5.1 LL versus 5.0% RYGB, P = 1.0) and mortality (.2 LL versus .1% RYGB, P = .5). Multivariable logistic regression adjustment found that previous venous thromboembolism was associated with serious complications after LL.

CONCLUSIONS

When compared to primary RYGB, LL has a favorable safety profile with similar 30-day rates of serious complications and mortality.

Gastric sleeve as an extra-anatomical roux for biliary reconstruction in a pediatric third liver transplant

BACKGROUND

Sir Roy Calne in 1976 described "Biliary reconstruction is the Achilles heel of liver transplantation," and it remains true. In some patients, such as those with short-gut syndrome and concomitant biliary atresia, neither duct to duct nor Roux biliary reconstruction is feasible.

METHODS

We present a case of child's third liver transplant (LT), where an innovative extra-anatomical biliary bypass was created using a sleeve from greater curvature of the stomach.

RESULTS

The patient is well nearly 10 years following the LT.

CONCLUSIONS

This technique could prove to be an important addition to the armamentarium of a surgeon in difficult retransplants and in patients with short-gut syndrome as it provides a viable option with good long-term outcome.

Goldthwait technique for patellar instability: surgery of the past or here to stay procedure? A systematic review of the literature

Patellar instability is the pathologic condition where the patella is prone to recurrent lateral dislocation. The clinical results on large series of patients and long-term outcome of Goldthwait techniques have not been described in the literature. The aim of this systematic review is: (1) to analyze and summarize the available literature focused on Goldthwait procedure in the treatment of recurrent patellar dislocation and (2) to evaluate the clinical and functional outcomes of patients treated with this surgical procedure. A systematic review of the literature was performed to investigate the results of Goldthwait procedure according to the PRISMA 2009 guidelines. A total of 7 articles published were systematically reviewed. A total of 197 knees (182 patients: 86 males and 96 females) have been treated with Goldthwait procedure. The mean reported follow-up was 6.8 years. The mean age at surgery was 18 years old. The Goldthwait procedure was associated with open lateral retinacular release in 127 (64.5%) knees to arthroscopic lateral retinacular release in 20 (10.1%) knees, and with retinacular plasty and a vastus medialis advancement in 33 (16.7%) knees. Only in 17 (8.6%) knees the Goldthwait procedure was performed as an isolated procedure. Poor standardization of methodological assessment has been observed. Despite the limitations of the available literature, the Goldthwait technique provides satisfying results for the treatment of patellar instability even in pediatric population. More high-quality studies are necessary to evaluate the long-term complications and the real incidence of long-term PF osteoarthritis.

The 15-cm Roux Limb: a Technical Misadventure

BACKGROUND

Despite effectively treating obesity and its comorbidities, only a fraction of the growing obese population is evaluated for bariatric surgery. Aside from barriers including resources and social support, patients report personal experience with friends and relatives suffering poor outcomes after bariatric surgery. Rates of mortality, leaks, and strictures have decreased over the past 20 years, but few instances of gross surgeon error have been reported in the literature. Our objective is to report and demonstrate the revision of a critically shortened Roux limb in a patient with chronic nausea and dysphagia found to have a 15-cm Roux limb and briefly discuss its implications.

METHODS

We performed a successful laparoscopic revision of this patient's previous Roux-en-Y gastric bypass, with creation of a 125-cm Roux limb.

RESULTS

Total operative time was 87 min, there were no major intraoperative complications, and the post-operative course was unremarkable. At one-month follow-up, the patient reported complete resolution of all prior symptoms. At three-month follow-up, BMI decreased from 37 prior to revision to 31.

CONCLUSIONS

Reducing complications and improving quality of care will support the necessary growth of bariatric surgery. Standards set forth by accreditation bodies such as the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) assist in this endeavor, and technical errors, though difficult to evaluate, should be monitored.

Four Thousand Years of Concepts Relating to Rabies in Animals and Humans, Its Prevention and Its Cure

The epitome of the One Health paradigm-and of its shortcomings-rabies has been known to humankind for at least 4000 years. We review the evolution through history of concepts leading to our current understanding of rabies in dogs and humans and its prevention, as transmitted by accessible and surviving written texts. The tools and concepts currently available to control rabies were developed at the end of the 19th Century, including the first live, attenuated vaccine ever developed for humans and the first post-exposure prophylaxis (PEP) regimen. No progress, however, has been made in etiological treatment, leaving clinicians who provide care to animals or patients with symptomatic rabies as powerless today as their colleagues in Mesopotamia, 40 centuries ago. Rabies remains to date the most lethal infectious disease known to humans. Widespread access to timely, effective, and affordable PEP in rural areas of developing countries is urgently needed.

Virus is a Signal for the Host Cell

Currently, the concept of the cell as a society or an ecosystem of molecular elements is gaining increasing acceptance. The basic idea arose in the 19th century, from the surmise that there is not just a single unit underlying an individual's appearance, but a plurality of entities with both collaborative and conflicting relationships. The following hypothesis is based around this model. The incompatible activities taking place between different original elements, which were subsumed into the first cell and could not be eliminated, had to be controlled very closely. Similarly, a strong level of control had to be developed over many cellular elements after the cell changed its genome to DNA. We assume that at least some of those original RNA agents and other biomolecules which carry incompatibilities and risks, are retained within current cells, although they are now under strict control. A virus functions as a signal informing these repressed cellular RNAs and other elements of ancient origin how to restore suppressed degrees of molecular freedom, favoring pre-existing molecular affinities and activities, re-establishing ancient molecular webs of interactions, and giving fragments of ancient coded information (mostly in the form of RNA structural motifs) the opportunity to be re-expressed. Collectively, these newly activated mechanisms lead to different possibilities for pathological cell states. All these processes are opposed by cell-control mechanisms. Thus, in this new scenario, the battle is considered intracellular rather than between the virus and the cell. And so the virus is treated as the signal that precipitates the cell's change from a latent to an active pathological state.