INTRODUCTION:

The laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric surgery. Due to its relative safety and low complication rate, it has been more commonly performed as an ambulatory surgery. "Outpatient" or discharge from postanesthesia care unit within 23 h has been well studied in the civilian sector and has been shown to result in reduced costs, hospital-acquired infections, and improved patient satisfaction. Although there are numerous benefits to outpatient LSG, the military health system has been slow to adopt this practice. This study represents the first and only series on same day (SD)-LSG within the military and demonstrates our protocol, experience, and initial outcomes at Madigan Army Medical Center.

METHODS:

Twenty-eight patients underwent SD-LSG between April 28, 2021, and May 22, 2023. Before initiation of the SD-LSG, a multidisciplinary protocol to include all phases of care (surgical clinic, operating room, and the postanesthesia care unit) was created. Data were prospectively collected. Exclusion criteria included patients with BMI >50 kg/m2, expected operative time >2 h, nonambulatory, intermediate or high cardiac risk, severe obstructive sleep apnea, immunocompromised, or dialysis dependent. The primary outcomes included mortality, complications, and readmission rates. The secondary outcomes included patient satisfaction, operating room and postanesthesia care unit times, pIV patency rates, and percent excess body weight loss.

RESULTS:

Our patient demographics were similar to national demographics for all LSG in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program reported for the same period, with the exception of being slightly younger. During the study period in our institution, 76 LSG were performed in total, 46 of which were performed by participating surgeons and therefore included in the study. Of those included, 28 (61%) were same-day LSG, and 18 (39%) were inpatient LSG, as they did not qualify for the same-day protocol. Of the same-day group, none required unplanned postoperative admission. We had no mortality, reoperations, or readmissions. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data for the same time frame showed 2.4% readmissions, 0.4% reoperations, and 0.1% mortality. We had one Clavien-Dindo class 2 complication of postoperative hematoma requiring transfusion (3.6%, n = 1/28), which is comparable to reported minor complication rates for LSG, ranging from 2.5% to 5.8% in the literature.

CONCLUSIONS:

SD-LSG can be a safe and feasible practice in the military health system, helping to offload the inpatient census. Initiating this protocol requires careful patient selection, a multidisciplinary approach, and appropriate coordination with all phases of patient care. SD-LSG has comparable risks to inpatient LSG while reducing inpatient hospital care burden and improving patient satisfaction.

Multiple myeloma (MM) is a hematological malignancy that poses significant treatment challenges due to its heterogeneity and propensity for relapse and progression. In the last two decades, the therapeutic landscape of MM has changed dramatically, but the disease remains largely incurable, with many patients facing treatment resistance. This review evaluates the current status of MM treatments, emphasizing the limitations of traditional therapies and the emerging role of immunotherapy in improving patient outcomes. It highlights the importance of achieving and maintaining minimal residual disease negativity and a balanced immune response as key treatment goals. Furthermore, it discusses the advancements in immunotherapies that are improving the prospects for patients, particularly those with relapsed or refractory disease. Innovative strategies, such as chimeric antigen receptor T-cell therapy, bispecific antibodies, and bispecific T cell engagers, have shown significant promise by targeting the malignant cells and the bone marrow microenvironment, which are essential for disease persistence and resistance to therapy. Future research should focus on refining MM treatment strategies, including the integration of immunotherapy into earlier treatment lines and the development of predictive biomarkers for personalized treatment approaches, ultimately enhancing patient outcomes.

BACKGROUND/OBJECTIVES:

Bariatric surgery changes food handling and entero-pancreatic endocrine dynamics. We aimed at understanding the influence of anatomical reorganization of the gastrointestinal tract induced by metabolic and bariatric surgery (BS) on glycemic variability and the extent to which glycemic variability reflects the underlying entero-pancreatic hormone dynamics.

SUBJECTS:

We performed a cross-sectional study on glycemic variability after four different BS procedures in comparison with non-operated matched controls (n = 8). The surgical groups were the classic Roux-en-Y gastric bypass (C-RYGB, n = 8), a modified long biliopancreatic limb RYGB (M-RYGB, n = 7), a single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S, n = 8) and a biliopancreatic diversion with duodenal switch (BPD-DS, n = 7).

METHODS:

Participants completed 14 days of intermittently scanned continuous glucose monitoring (isCGM). The surgical groups also underwent a mixed-meal test with hormone profiling. Our primary outcome was the mean absolute glucose change (MAG change) in the operated vs non-operated individuals. Additionally, we developed, validated and herein release an automated tool, Gluc4all, for personalized and automated continuous glucose monitoring data analysis, particularly relevant when evaluating the glycemic profile of individuals without diabetes.

RESULTS:

All surgical interventions were associated with an increase in the magnitude of postprandial glucose excursions, in anatomy-specific patterns (MAG change was 2.0-fold higher after C-RYGB and M-RYGB and 1.6-fold higher after SADI-S and BPD-DS than in non-operated controls). These isCGM findings matched the postprandial glucose, glucose-dependent insulinotropic peptide (GIP), glucagon-like peptide-1 (GLP-1) and insulin profiles documented in the meal test.

CONCLUSIONS:

Overall, we show that BS interventions are associated with higher glycemic variability. Moreover, depending on the type of gastrointestinal anatomical reconstruction, BS yields procedure specific glycemic variability patterns. This might be due to faster glucose absorption, impaired amino acid absorption, and/or altered entero-pancreatic hormone profiles, including GLP-1 and insulin secretion.

OBJECTIVE:

To investigate intraoperative and postoperative outcomes following primary inflatable penile prosthesis (IPP) implantation among patients with or without prior history of pelvic radiation therapy (RT).

METHODS:

We conducted a multicenter, retrospective analysis of men undergoing primary IPP placement between July 2016 and July 2021. Among 3,530 patients, 211 had a history of RT. After 1:1 propensity score matching for all confounding variables, we compared intraoperative and postoperative outcomes between irradiated and non-irradiated cohorts. Chi-square and Mann-Whitney U tests were used for statistical analysis for categorical and continuous variables respectively. For multivariable analysis, we used a multivariate logistic regression model. Kaplan-Meier analysis was used to evaluate postoperative complication-free survival.

RESULTS:

Patients with prior RT had higher intraoperative complication rates (4.3% vs 0.9%, p=0.032), particularly distal crossover events (1.9% vs 0%, p=0.044). On multivariable analysis, history of prior RT in the setting of radical prostatectomy (OR 5.95, 95% CI 1.17-30.3, p=0.032) and history of diabetes mellitus (OR 9.09, 95% CI 2.29-37.0, p=0.002) were associated with increased odds of intraoperative complications. Conversely, obesity was associated with reduced odds (OR 0.10, 95% CI 0.01-0.82, p=0.032). No significant differences were observed in postoperative complications or reoperation rates over 24 months.

CONCLUSION:

Prior RT is associated with an increased rate of intraoperative IPP complications. Postoperative complication and reoperation rates were similar to control cases.

OBJECTIVES:

This study aims to evaluate 30-day postoperative complications and hospital readmissions across different body mass index (BMI) categories and diabetic statuses following primary total knee arthroplasty (TKA).

PATIENTS AND METHODS:

Between January 2013 and December 2022, a total of 502 patients (100 males, 402 females; mean age: 68.8±7.7 years; range, 45 to 91 years) who underwent primary TKA for knee osteoarthritis were retrospectively analyzed. Data collected included basic demography, BMI, diabetes mellitus (DM) status, and 30-day postoperative complications such as venous thromboembolism (VTE), infections, neurological events, cardiac events, and renal issues. Readmissions due to operative or medical complications were recorded.

RESULTS:

Of the patients, 141 (28.1%) had DM and 186 (37.1%) patients were classified as obese. The obese group experienced the highest incidence of VTE (1.6%), whereas overweight patients exhibited a higher rate of renal events (1.0%). All non-diabetic underweight patients (n=2) developed postoperative hypoglycemia. Diabetic patients had significantly increased odds of VTE compared to non-diabetics (odds ratio=6.74; p=0.009). Normal BMI diabetic patients demonstrated the highest incidence of surgical site infections (7.4%), while normal BMI non-diabetic patients were more prone to foot drop (1.1%) and cardiac events (4.5%).

CONCLUSION:

Elevated BMI and DM independently or in combination, contribute to higher rates of postoperative complications and readmissions following TKA.

INTRODUCTION:

Cervical esophageal stenosis is a complex surgical problem when endoscopic treatment fails. The distance between the stenosis and the dental arch (AD) determines the need for a longer flap, with an increased risk of ischemia. Our group proposed the use of an esophageal advancement jejunoplasty (JAE) in patients with esophageal stenosis less than 17 centimeters from the AD to "lengthen" the residual esophagus and, in a second stage, complete the reconstruction of digestive transit with a gastroplasty or coloplasty.

MATERIAL AND METHOD:

Descriptive and retrospective analysis of a prospective database of patients who had esophageal stenosis less than 17 centimeters from the dental arch (DA), who were indicated a JAE between November 2020 and May 2024.

RESULTS:

A total of 16 patients with a mean age of 52 years were included. In 13 cases the stenosi was secundary to càustics and 3 to radiotherapy; the mean distance between AD and stenosis was 14 cm. Five cases were reoperated and two esophageal-jejunal fistulas were diagnosed. There was no mortality. The second stage of reconstruction was completed in 10 patients (5 gastroplasties and 5 coloplasties). Two jejuno-ileal stenosis and one esophageal-jejunal stenosis were diagnosed. Functionally, 5 patients are exclusively nourished orally, 2 through a mixed diet and 3 exclusively enterally.

CONCLUSION:

We believe that JAE can be a technically feasible option, with acceptable morbidity, in patients with upper esophageal stenosis to minimize the risk of ischemia that involves a longer flap.

Preeclampsia (PE) is a complex hypertensive disorder and a leading cause of maternal and perinatal morbidity worldwide. Emerging evidence suggests that exposure to endocrine-disrupting chemicals (EDCs) may contribute to the etiology of PE, yet this association remains underexplored. This review aimed to investigate epidemiological and experimental studies assessing the potential link between EDC exposure and PE development. A literature search was conducted across PubMed, ScienceDirect, and Google Scholar for original articles published in the last ten years. Forty studies were selected, including epidemiological cohorts, in vivo, and in vitro models, focusing on the association between EDCs and PE or related biomarkers. Epidemiological findings were heterogeneous: while large cohorts often showed no association, several case-control studies linked specific EDCs, such as bisphenol A, phthalates, cadmium, and PFOS, to increased PE risk and elevated blood pressure. Experimental evidence revealed that EDCs impair key placental processes, including decidualization, angiogenesis, and trophoblast invasion. These disruptions were often accompanied by oxidative stress, hormonal imbalances, and endothelial dysfunction, central features in PE pathogenesis. In vivo models also replicated PE-like syndrome after EDC exposure. Although current epidemiological evidence remains inconsistent, mechanistic studies strongly support the biological plausibility of EDC involvement in PE. This review highlights that the contribution of EDCs to PE may be underestimated and calls for multidisciplinary research to clarify exposure thresholds, vulnerable windows, and population-specific susceptibilities.

In 2022, 48.7 million people in the United States (17.3% of the population aged 12 or older), met criteria for substance use disorder (SUD). Nearly 40% of people with opioid use disorder (OUD) are Medicaid recipients, making Medicaid the largest single source of OUD treatment insurance coverage. Despite this crucial importance, there remain two major barriers to expanding access to treatment for persons with SUD baked into the program: the Institutions for Mental Diseases (IMD) exclusion and the Medicaid inmate exclusion. In this essay we first provide a timeline of these two waiver reforms to illustrate the variation in waivers over time and across states. Second, we assess the evidence to date on how well the SUD waivers are working to accomplish these goals in states that have adopted them. This review will focus on the SUD waivers that address the IMD exclusion, because the MIE waivers are too new for any systematic evidence. We will then consider outstanding implementation challenges and policy risks associated with the IMD and MIE waivers, and conclude by considering challenges these waivers do not address and therefore demand particular attention to properly serve persons living with SUD.

INTRODUCTION:

Alpha-blockers are considered an additional option when the major antihypertensive drug classes are insufficient in reducing blood pressure. While the impact of alpha-blockers on blood pressure control seems comparable, data evaluating their effects on renal outcomes are lacking. This systematic review and meta-analysis assess the impact on renal function from a medium to long-term perspective.

METHODS:

A search and analysis according to the PRISMA statement across Medline, the Web of Science, and ScienceDirect was conducted, covering articles in English on adult populations without time restrictions to December 14, 2023, including all types of studies with a minimum follow-up of 12 weeks.

RESULTS:

Seventeen studies were included in the review, encompassing a total of 26,170 patients treated with alpha-blockers. Most studies were performed in the 20th century and often lacked an adequate number of participants and sufficient follow-up duration. Bayesian meta-analysis showed neutral effects of alpha-blockers on eGFR and serum creatinine, comparable with those of other antihypertensive agents. Compared with baseline, the data suggests an overall small but clinically unimportant increase in creatinine clearance in patients treated with alpha-blockers (95% credible interval: 1.61 to 9.97 ml/min/1.73 m2).

CONCLUSION:

A significant dearth of evidence concerning the long-term impact of alpha-blockers on renal function was revealed. The available evidence suggests that alpha-blockers have a neutral or non-inferior effect on renal function in comparison with other antihypertensive agents. Further research is needed to evaluate the role of alpha-blockers and their impact on preserving renal function.

OBJECTIVE:

To highlight the experiences of trainees with disabilities in surgical and procedural specialties to encourage the development of inclusive training opportunities within surgical specialties.

DESIGN:

PRISMA guidelines were used to search PubMed, Medline, Embase, and Cochrane databases in October 2024. Studies that focused on trainees with motor or sensory disabilities (MSD) in medical school or graduate medical training were included. Studies not specifying learners' experience navigating training were excluded. Data extraction included trainee level, specialty, type of disability, and solutions implemented.

SETTING:

This review includes research conducted in academic settings.

PARTICIPANTS:

Participants in the included studies were medical students, residents, and fellows in various specialties.

RESULTS:

Of 621 initial studies, 5 met inclusion criteria. Total number of trainees included 4 medical students, and 1 resident. Three (66.7%) learners had spinal cord injuries, one (16.7%) had Osteogenesis Imperfecta, and one (16.7%) had severe bilateral sensorineural hearing loss. Three studies (50%) described medical students' and a resident's experience in surgical fields of OBGYN and Surgery clerkship, and Neurosurgery residency respectively. One study (16.7%) described a student's experience in Emergency Medicine, and the final study (16.7%) described a student's experience navigating medical school and all clerkships. All 4 medical students passed their clerkships, with honors awarded for those in Emergency Medicine and Surgery. The resident in Neurosurgery successfully completed the program.

CONCLUSION:

Trainees with disabilities in surgical fields remain underrepresented. This review highlights the capacity for resilience among trainees in surgical and procedural fields, showing that students with disabilities can excel in surgical training. These findings emphasize the need for surgical programs to adopt practices that accommodate diverse needs among trainees and foster a more accessible and supportive learning environment for all aspiring surgeons.