Abdominoplasties and Suppurative Hydradenitis (Acne inversa) in Patients after Massive Weight Loss

PURPOSE: Massive weight loss can result in whole-body deformities that often are addressed with body contouring. However, even after weight loss, many patients have residual obesity. In this study, we aim to determine the effect of BMI on post-bariatric reconstructive surgery complications. METHODS: Patients undergoing body contouring from 2002-2018 after massive weight loss (≥50 pounds) were retrospectively reviewed. Variables of interest include pre and post weight loss BMI, post-operative complications, and procedures per case. RESULTS: In this cohort, 942 massive weight loss patients underwent 1,063 cases involving 1,814 procedures. 884 patients were female while 58 were male. Mean pre-weight loss BMI, or max BMI, was 51.9 ±9.8 while mean post weight loss BMI was 30.5 ±6.0. For all cases, an increased maximum BMI (p=0.006), but not current BMI, was associated with a higher rate of post-operative complications. Increased current BMI significantly amplified the risk of post-operative fat necrosis (p<0.01) while elevated maximum BMI increased the risk of seroma (p<0.01) and wound infection (p<0.05). In patients with multiple procedures (n= 502), increased maximum and current BMI were associated with higher risk of seroma formation (p<0.05), but neither was associated with risk of seroma for single procedures cases (n=561). CONCLUSION: Both pre and post weight loss BMIs play a role in complication rate and type, while only max BMI plays a role in multiple procedure cases. These findings indicate that pre and post weight loss BMI should be assessed, in addition to number of procedures, to optimize outcomes after body contouring.

To evaluate percutaneous transhepatic biliary drainage (PTBD) safety and efficacy in patients with perihilar cholangiocarcinoma (PCCA). This retrospective observational study included patients with PCCA and obstructive cholestasis referred for a PTBD in our institution between 2010 and 2020. Technical and clinical success rates and major complication and mortality rates one month after PTBD were used as main variables. Patients were divided and analyzed into two groups: > 30 and < 30 Comprehensive Complication Index (CCI). We also evaluated post-surgical outcomes in patients undergoing surgery. Out of 223 patients, 57 were included. Technical success rate was 87.7%. Clinical success at 1week was 83.6%, before surgery 68.2%, 80.0% at 2weeks and 86.7% at 4weeks. Mean total bilirubin (TBIL) values were 15.1mg/dL (baseline), 8.1mg/dL one week after PTBD), 6.1mg/dL (2weeks) and 2.1mg/dL (4weeks). Major complication rate was 21.1%. Three patients died (5.3%). Risk factors for major complications after the statistical analysis were: Bismuth classification (p = 0.01), tumor resectability (p = 0.04), PTBD clinical success (p = 0.04), TBIL 2weeks after PTBD (p = 0.04), a second PTBD (p = 0.01), total PTBDs (p = 0.01) and duration of drainage (p = 0.03). Major postoperative complication rate in patients who underwent surgery was 59.3%, with a median CCI of 26.2. PTBD is safe and effective in the management of biliary obstruction caused by PCCA. Bismuth classification, locally advanced tumors, and failure to achieve clinical success in the first PTBD are factors related to major complications. Our sample reported a high major postoperative complication rate, although with an acceptable median CCI.

1127 MAJOR COMPLICATIONS OF ROBOT-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY SIGNIFICANTLY DECREASE AFTER 100 CASES

BackgroundThere has been an increase in body contouring procedures following massive weight loss (MWL), including male breast reduction procedures. Treating male chest deformity after MWL using standard mastopexy techniques often leads to suboptimal results.ObjectivesThe authors describe a technique to treat pseudogynecomastia using a modified elliptical excision and nipple-areola complex (NAC) transposition on a thinned inferior dermal pedicle as an alternative to conventional techniques.MethodsA retrospective chart review from January 2011 to January 2019 identified a total of 14 male patients who underwent excision of pseudogynecomastia using the described technique. ResultsPatients were characterized by age, method of weight loss, pre-weight loss body mass index (BMI), post-weight loss BMI, total weight loss, grade of pseudogynecomastia, and concurrent procedures performed. Patients were followed for a period ranging from 3 months to 1.5 years (average, 8.1 months). Pre-weight loss BMI and post-weight loss BMI averaged 52.0 kg/m2 and 29.6 kg/m2, respectively. The average weight lost was 79.72 kg and the average total amount of tissue removed was 2615 g. All patients had concurrent procedures with an average operative time of 274 minutes. Four out of 14 patients (28.6%) experienced minor complications, which included asymmetry, delayed wound healing, seroma, and hyperpigmentation. There were no wound infections, hematomas, flap necrosis, or dysesthesia. ConclusionsDue to several cosmetic advantages and low complication profile, our technique using a modified elliptical excision and NAC transfer on an inferior dermal pedicle is an attractive option for treating male chest deformity after MWL.Level of Evidence: 4

A leadless pacemaker in the real-world setting: The Micra Transcatheter Pacing System Post-Approval Registry

Body contouring surgery after massive weight loss was shown to ameliorate the patient's quality of life and to enhance physical and psychological well-being. However, numerous patients are still obese when presenting for body contouring surgery, not able to lose additional weight for various reasons. Data regarding general feasibility, outcome, and postoperative complications in obese patients is rare. The aim of this study was to investigate the outcome in body contouring procedures in obese patients. A retrospective chart review of 65 cases in 42 patients was performed. Patients with a body mass index (BMI) > 35kg/m2 at the time of operation were enrolled and all different types of body contouring surgery were included. Complications were classified as major (need for surgical intervention) and minor complications. The median BMI of all patients was 38kg/m2 (range 35.1-65.1kg/m2). The majority of performed types of body contouring was abdominal body contouring (panniculectomy n = 27 (42%), abdominoplasty n = 12 (18%)). Complications occurred in 27 cases (41.5%). Twenty-one cases (32.3%) were classified as minor complications, six (9.2%) as major complications. The most common major complications were hematoma and wound dehiscence; the most common minor complication was seroma. A reasonable risk for complications is well known in body contouring surgery especially in obese patients. It is imperative to discuss related risks and expected results. Taking several points into account concerning the perioperative management, reduction of major complications is possible even in still obese patients, making body contouring surgery a discussible option.

Purpose: To evaluate the utility of artificial ascites induction for radiofrequency ablation (RFA) of peridiaphragmatic hepatocellular carcinoma (HCC) through retrospective cohort analysis comparing characteristics and complications of peridiaphragmatic HCC without the use of artificial ascites to non-peridiaphragmatic HCC. Materials and Methods: IRB approval was obtained. From September 2003 to December 2008, 150 consecutive patients with hepatic tumors received percutaneous RFA. 110 patients had presumed HCC, and of those 21 had lesions abutting the diaphragm. Of the remaining 89 patients with non-peridiaphragmatic HCC lesions, 21 were randomly selected for the comparison group. RFA volume, major and minor complication rates, pain, technical success, and recurrence rates were compared between the two groups. Results: There was no statistical difference in RFA volume (P = 0.962), overall major complication rate (P = 0.343) and minor complication rate (P = 0.118) between the two groups. However, the peridiaphragmatic group that underwent RFA with a clustered-needle demonstrated a statistically significant higher proportion of major complications compared to the non-peridiaphragmatic clustered-needle group (P = 0.033). There was no statistical difference in pain severity (P = 0.8802) or pain location (P = 0.15). There was no statistical difference in technical success rates (P = 1), local tumor progression rates (P = 1), or time to local tumor recurrence (P = 0.67). Conclusion: Artificial ascites induction for RFA of HCC lesions adjacent to the diaphragm may not be necessary, although clustered electrode technique should be avoided in this location as they present with a higher complication rate.

To examine intraoperative and postoperative complication rates for surgical staging combined with panniculectomy for endometrial cancer. A prospectively collected institutional surgical database was used to identify patients with endometrial cancer who underwent hysterectomy-based surgical staging between December 2008 and August 2014 (n = 551). The cases were grouped into surgical staging with panniculectomy (panniculectomy group, n = 11 [2.0%]), laparotomy without panniculectomy (laparotomy group, n = 208 [37.7%]), and laparoscopy (minimally invasive surgery group, n = 332 [60.3%]). Major complication and surgical wound complication rates within 30 days from surgery were compared. The panniculectomy group had a significantly higher body mass index compared with other approaches (panniculectomy group, laparotomy group, and minimally invasive surgery group: 60.4, 35.7, and 34.1; P < 0.001) and had a high stage I disease rate (90.9%, 61.5%, and 88.3%; P < 0.001). Mean pannus weight was 5733 g (4.4% of body weight). Intraoperative major complication rates were statistically nonsignificant across the groups (0%, 7.2%, and 4.2%; P = 0.23); however, the panniculectomy group had a significantly higher postoperative major complication rate compared with other approaches (36.4%, 16.3%, and 5.1%; P < 0.001). In multivariate analysis controlling for age, ethnicity, body habitus, medical comorbidities, and tumor factors, panniculectomy remained an independent predictor for increased risk of postoperative major complications (adjusted odds ratio, 4.37; P = 0.043). Surgical mortality rates were similar across the groups (0%, 0.5%, and 0%; P = 0.44). Among superobese patients (n = 50), intraoperative and postoperative complication rates were statistically similar across the 3 groups (all, P > 0.05). Although panniculectomy-combined surgical staging is associated with an increased risk of postoperative complications, the majority recovered uneventfully, making this approach a feasible treatment option, especially for superobese patients with endometrial cancer.

Male patients after massive weight loss often suffer from redundant skin and soft tissue in the anterior and lateral chest region, causing various deformities of pseudogynecomastia. Techniques with free or pedicled nipple-areola complex (NAC) transposition are widely accepted. The authors present their approach to male breast reduction with preservation of the NAC on a central dermoglandular pedicle and a wide elliptical tissue excision of breast and lateral thorax tissue in combination with liposuction. Male breast reduction was performed on patients after moderate to massive weight loss due to diet or bariatric procedures. Former procedures included free nipple-areola grafts or inferior pedicled techniques for NAC preservation. As a modification, we performed a central pedicled breast reduction on nine male patients with excessive liposuction of the pedicle and a horizontal elliptical skin removal, allowing for sufficient tissue removal at the lateral thorax. From October 2010 until June 2011, nine male patients had central pedicled breast reconstructions after massive weight loss. Mean age was 29.1years, mean preoperative body mass index was 29.2, and mean preoperative weight loss was 63.9kg. The chest wall improvement was rated "very good" by eight patients. No major complications occurred in all nine patients. Male chest deformities after massive weight loss can be dealt by several approaches. The optimal scar positioning and the preservation of NAC may be the most challenging aspects of these procedures. Therefore, the preservation of the NAC on a central dermoglandular pedicle with a horizontal submammary scar course may optimize the esthetic outcome.

Medial thigh lift procedures in the massive weight loss population have been associated with significant complication rates. Liposuction-assisted medial thighplasty has recently been introduced as a technical advancement to improve outcomes. To date, no study is available directly comparing the traditional approach and this new technique. Here, the authors evaluate outcomes and complications of both techniques in a retrospective cohort study. Outcomes of 59 patients undergoing vertical medial thighplasty at the authors' institution between 2008 and 2014 were assessed retrospectively. Evaluated parameters include age, sex, body mass indices, method of weight loss, comorbidities, and complications (e.g., seroma, infection, wound dehiscence, hematoma, and surgical revision). Appropriate statistical analysis was performed. There were 29 patients in the excision-only group and 30 patients in the liposuction-assisted group (all women; average age, 41.5 years). The overall complication rate was significantly reduced in the liposuction-assisted group (13 percent versus 59 percent; p < 0.001). The incidence of individual complications such as seroma formation (zero patients versus 10 patients; p < 0.001) and wound infection (one patient versus eight patients; p = 0.01) was significantly less in the liposuction-assisted group. In addition, we observed a significantly shorter hospital stay (6.0 days versus 7.8 days), reduced number of follow-up visits (2.0 versus 4.4), and reduced time to drain removal (1.8 days versus 4.1 days; p < 0.001) in the liposuction-assisted group. Liposuction-assisted medial thighplasty led to a significant reduction of complications and faster recovery in the massive weight loss patient population. As a consequence, the excision-only vertical thigh lift has been completely abandoned in the authors' clinical practice. Therapeutic, III.

BackgroundImplantable cardioverter-defibrillators (ICDs) have been shown to reduce cardiac mortality, although transvenous ICDs cause lead-related complications over time. The extravascular ICD (EV-ICD) system was developed to address the need for a device similar in size to transvenous devices that avoids the vasculature and provides antitachycardia pacing. Pre-market clinical trials have shown the EV-ICD system to provide effective therapy with a low complication rate, but its performance in the real-world is unknown.PurposeReport on the periprocedural safety and performance of the EV-ICD system from the post-market Enlighten study and compare results with a pooled pre-market cohort.MethodsEnlighten is an ongoing, global, prospective, post-market registry study, enrolling patients with a class I or IIa indication for an ICD and a planned implantation of the EV-ICD system. A meta-analysis was performed to compare acute safety and efficacy outcomes between Enlighten patients and the pooled pre-market cohort that included patients from the EV-ICD Pilot, Pivotal, and Continued Access studies. Baseline characteristics, procedural details, defibrillation testing success, and rate of major complications through discharge were analyzed in both cohorts.ResultsFrom SEP 2023 to JUN 2024 there were 228 Enlighten patients with an implant attempt performed by 81 implanters. For the pre-market studies, there were 370 implant attempts by 59 implanters. Compared to the pooled pre-market cohort, Enlighten patients were significantly younger (49.4 ± 15.4 vs 53.4 ± 13.2; P<0.001), had a higher mean left ventricular ejection fraction (43.5 ± 16.1 vs 39.5 ± 15.8; P=0.004), and had proportionally fewer patients with a cardiomyopathy, coronary artery disease, or hypertension (P<0.001 for all). Tunneling and substernal lead placement were successful in 227/228 (99.6%) Enlighten patients and 369/370 (99.7%) pre-market patients. After electrical testing, 221 (96.9%) and 347 (93.8%) patients remained implanted with the EV-ICD and proceeded to follow-up for Enlighten and pre-market cohorts, respectively. Defibrillation testing, if performed, was successful in 191/193 (99.0%) Enlighten patients compared to 346/354 (97.7%) pre-market patients according to study protocol. The rate of system- or procedure-related major complications at discharge was 3.9% for Enlighten and 2.4% for the pre-market group (P=0.329).ConclusionsIn a global, real-world cohort, the EV-ICD system demonstrated a high rate of success for terminating induced ventricular arrhythmias and a low rate of periprocedural major complications through discharge comparable to the pre-market experience.

BackgroundImage-guided percutaneous lung biopsy (PLB) may lead to major complications requiring hospitalization. This study aims to evaluate the rate of major PLB complications and determine a predictive computed tomography (CT) score to define patients requiring hospitalization due to these complications.MethodsThis single-center retrospective study included all PLBs performed from July 2019 to December 2020 in Nimes University Hospital, France. Patients who were undergoing thermo-ablation during the same procedure or for whom PLB procedure data were not available were excluded. All major complications leading to hospitalization were recorded. A Percutaneous Image-guided Lung biopsy In/out Patient score (PILIP) based on variables significantly associated with major complications was calculated by multivariate analysis.ResultsA total of 240 consecutive patients (160 men, 80 women; mean age: 67.3±10.5 years) were included. The major complication rate was 10.4%. Length of lung parenchyma traversed <20 vs. 20–40 mm [P=0.017, odds ratio (OR) =5.02; 95% confidence interval (CI): 1.33–18.92] and vs. >40 mm (P=0.010, OR =6.15; 95% CI: 1.54–24.53), middle vs. superior lobar location (P=0.011, OR =6.34; 95% CI: 1.53–26.31), emphysema along the needle pathway (P<0.0001, OR =10.96; 95% CI: 3.61–33.28), and pleural/scissural attraction (P=0.023, OR =3.50; 95% CI: 1.19–10.32) were independently associated with major complications. Based on these parameters, the PILIP made it possible to differentiate low-risk patients (PILIP <4) from those at high risk (PILIP ≥4) of major complications with 0.40 sensitivity (95% CI: 0.21–0.59), 0.95 specificity (95% CI: 0.93–0.98), a positive predictive value of 0.50 (95% CI: 0.28–0.72) and a negative predictive value of 0.93 (95% CI: 0.90–0.97).ConclusionsPLB showed a major complication rate of 10.4%. The PILIP is an easy-to-use CT score for differentiating patients at a low or high risk of complications requiring hospitalization.

To develop and validate a simple prognostic score to predict major postoperative complications after pancreaticoduodenectomy (PD). PD still carries a high rate of severe postoperative complications. No specific score is currently available to stratify the patient's risk of major morbidity. Between 2002 and 2010, preoperative, intraoperative, and outcome data from 700 consecutive patients undergoing PD in our institution were prospectively collected in an electronic database. Major complications were defined as levels III to V of Clavien-Dindo classification. On the basis of a multivariate regression model, the score was developed using a random two-thirds of the population (n = 469) and was validated on the remaining 231 patients. Major complication rate was 16.7% (117/700). Significant predictors included in the scoring system were: pancreas texture, pancreatic duct diameter, operative blood loss, and ASA score. The mean risk of developing major postoperative complications was 7% in patients with score 0 to 3, 13% in patients with score 4 to 7, 23% in patients with score 8 to 11, and 36% in patients with score 12 to 15. In the validation population, the predicted risk of major complications was 15.2% versus a 16.9% observed risk (C-statistic index = 0.743). This new score may accurately predict a patient's postoperative outcome. Early identification of high-risk patients could help the surgeon to adopt intraoperative and postoperative strategies tailored on individual basis.

Research Article| February 01 2014 Outcomes of Bariatric Surgery in Adolescents AAP Grand Rounds (2014) 31 (2): 18. https://doi.org/10.1542/gr.31-2-18 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Outcomes of Bariatric Surgery in Adolescents. AAP Grand Rounds February 2014; 31 (2): 18. https://doi.org/10.1542/gr.31-2-18 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: bariatric surgery Source: Inge TH, Zeller MH, Jenkins TM, et al. Perioperative outcomes of adolescents undergoing bariatric surgery: the teen-longitudinal assessment of bariatric surgery (Teen-LABS) study. JAMA Pediatr. 2014; 168(1): 47– 53; doi: https://doi.org/10.1001/jamapediatrics.2013.4296Google Scholar Investigators from multiple institutions prospectively enrolled a consecutive sample of patients <19 years old undergoing weight loss surgery (WLS) at one of 5 US academic referral centers. Although data collection was standardized, medical and surgical procedures varied across institutions. Preoperatively, investigators collected demographic and clinical data, including BMI, comorbid conditions, and laboratory measures relevant to cardiovascular risk and general health status. Investigators also collected data regarding the type of WLS performed and the occurrence of perioperative (time of surgery to hospital discharge) and postoperative (time of discharge to 30 days postdischarge) complications. The major goals of this study were to evaluate the clinical characteristics of adolescents undergoing WLS and to assess the short-term safety of the procedure in this population by measuring major perioperative and postoperative complications. A major perioperative complication was defined as an adverse event that was life-threatening or resulted in death, had potential for permanent harm, resulted in organ loss, led to reoperation or blood transfusion, or represented a deviation in anesthetic or surgical management. Major postoperative complications included those that were life-threatening or resulted in death, had potential for permanent harm, or required abdominal reoperation. Of 277 eligible patients, 242 were enrolled. The mean age of participants was 17.1 years (range 13–19); 72% were white and 76% were female. The median BMI was 50.5. Overall, 49% of study participants had ≤3 comorbidities, 39% had 4 to 5 comorbidities, and 12% had 6 or more. The most common comorbidities were dyslipidemia (74%), sleep apnea (57%), joint pain (46%), hypertension (45%), and back pain (45%). The most common preoperative laboratory abnormalities included elevated C-reactive protein (75%), hyperinsulinemia (71%), low high-density lipoprotein (64%), and hypertriglyceridemia (40%). Microalbuminuria was detected in 18% of patients. Most participants (67%) had a Roux-en-Y gastric bypass (RYGB). The remainder either had a vertical sleeve gastrectomy (28%) or adjustable gastric banding (5%). All procedures were laparoscopic; only 1 required conversion to an open laparotomy. There were 19 participants (7.9%) who experienced 20 major complications perioperatively and 7 participants (2.9%) who experienced 7 major complications postoperatively. Major perioperative complications included splenectomy secondary to intraoperative splenic injury (n = 1) and early reoperation for intestinal obstruction, bleeding, or gastrointestinal leak (n = 7). Major postoperative complications included pulmonary embolus (n = 2) and reoperation secondary to gastrointestinal leak (n = 2). There were no deaths. Procedure-specific rates of patients with major complications were highest with RYGB both peri- and postoperatively. The authors conclude that WLS in obese adolescents has a low rate of major perioperative and postoperative complications. Dr Snyder has disclosed no financial relationship relevant to this commentary. The commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. This is a well-planned and well-executed study... You do not currently have access to this content.

Hidradenitis suppurativa (HS), or Verneuil’s disease, is characterized by recurrent chronic inflammation involving apocrine glands. It typically develops after puberty, greatly hampering the patient’s quality of life. The axilla, groin, buttocks, perineum, and inframammary areas are among the most typical sites for HS. Atypical HS is defined as HS that occurs at atypical sites such as scalp, eyelids, retro-auricular and preauricular skin, chest, thighs, abdomen, posterior neck, and legs. Lesions can also appear less frequently in areas with few or no apocrine glands. Ayurvedic classical texts described the disease Nadivrana (~fistula/sinus wound), having clinical features mimicking HS. This is the case of a 28-year-old young female with both typical and atypical sites presentation of HS for 12 years, which grew worse with the use of yeast products such as bakery items (bread, biscuits, and cake), during her periods, under stress, and improved with rest. Elimination of infection through Shodhana (~purification therapy) is the treatment principle of Nadivrana management . The patient was treated with Ayurveda therapies and oral medications to balance out the Dosha (~regulatory functional factors of the body) vitiation. After four months of treatment and six months of continuous follow-up, the symptoms of HS in terms of flaring, discharge, and redness subsided and no recurrence was noted until reporting this case.