Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.
January 11, 2022
Pessoa BM, Browning MG, Mazzini GS, et al. Factors Mediating Type 2 Diabetes Remission and Relapse after Gastric Bypass Surgery. J Am Coll Surg. 2020;230(1):7-16.
One of the major benefits of bariatric surgical procedures is remission of diabetes mellitus. Relapse after remission is possibly due to regain of weight or loss of insulin sensitivity. The study reported in this article sought to identify factors associated with remission and relapse of type 2 diabetes mellitus in patients who had undergone Roux-en-Y gastric bypass. Consecutive patients from a single center over the interval 1993 to 2017 were included in the study cohort (n = 620). Remission was defined as medication discontinuation or a persistent HgbA1c or < 6.5%; relapse was defined as resumption of antidiabetic medication or a persistent HgbA1c of > 6.5%.
The data analysis showed that remission rates were 74% at one year, 73% at 3 years, and 47% at more than 10 years. Relapse rate was 25%; factors associated with relapse were preoperative insulin use, lower 1-year weight loss, and greater regain of weight during long-term follow up. The authors noted that other data have supported similar outcomes for laparoscopic sleeve gastrectomy and biliopancreatic diversion. Because one mechanism of lower rates of remission and higher rates of relapse may be loss of insulin sensitivity and β-cell mass, the authors recommended bariatric procedures in obese diabetic patients be performed before there is a need for insulin therapy.
Hornor MA, Ma M, Zhou L, et al. Enhancing the American College of Surgeons NSQIP Surgical Risk Calculator to Predict Geriatric Outcomes. J Am Coll Surg. 2020;230(1):88-100 e1.
To enhance the risk prediction accuracy of the ACS NSQIP® Surgical Risk Calculator (SRC) for geriatric patients, the authors compared risk prediction accuracy for the original SRC with a version of the SRC that included six geriatric-specific variables. Data from more than 38,000 patients were analyzed. Outcomes particularly relevant to geriatric patients included living situation, fall history, mobility aid use, cognitive impairment, need for surrogate-signed consent, and palliative care on admission.
Data analysis showed that the predictive value for the regular SRC was > 0.8 and this was improved by adding the geriatric prediction factors. Impaired cognition, fall history, and mobility aid use were the most important geriatric factors associated with improved risk prediction. The authors concluded that addition of geriatric risk factors to the SRC could potentially improve shared decision making and the quality of geriatric surgical care.
Jajja MR, Laboe A, Hashmi S, Nadeem SO, Sayed BA, Sarmiento JM. Standardizing Diagnostic and Surgical Approach to Management of Bile Duct Injuries After Cholecystectomy: Long-Term Outcomes of Patients Treated at a High-Volume HPB Center. J Gastrointest Surg. 2021;25(11):2796-2805.
The authors examined data from 107 patients who underwent repair of bile duct injuries sustained during cholecystectomy. The intent of the study was to determine the optimal approach for accurate diagnosis of bile duct and hepatic arterial injury and the operative approach that produced the best long-term outcomes. The analysis showed that bile duct repair at the index operation was performed in 38% of patients. The remaining patients were treated initially with biliary drainage; magnetic resonance (MR) imaging was the most accurate method for determining biliary anatomy and the risk of arterial injury.
Angiography was used to definitively diagnose hepatic arterial injury that was discovered in 30 patients. Selective liver resection was performed in 18 patients. The Hepp-Couinaud longitudinal left hepatic duct to jejunum anastomosis was the preferred repair technique; biliary patency rate at 5 years was 87%. The authors concluded that: (1) patients with bile duct injuries that cannot be repaired successfully at the time of the index operation should be referred to an experienced biliary surgeon; (2) magnetic resonance imaging is the most accurate means of defining biliary anatomy and determining the risk of arterial injury; and (3) the Hepp-Couinaud biliary repair technique is associated with excellent long-term biliary patency.