Objective: To assess the safety and efficacy of bariatric surgery in patients with cirrhosis. Summary Background Data: Bariatric surgery may be a viable option for patients with cirrhosis and extreme obesity. However, the risk of liver decompensation after surgery is not thoroughly investigated. Methods: We conducted a case-controlled study with 106 obese patients with cirrhosis (cases) and 317 age, sex, body mass index-, and type of surgerymatched obese patients without cirrhosis (controls) who underwent bariatric surgery. Results: Patients with cirrhosis were predominantly Child-Pugh class A (97%) with the diagnosis established prior to surgery in only 46%. In the cirrhosis group, there was no death in the first 30 days compared with 1 patient in the control group. At 90 days there was 1 death in the cirrhosis group but no additional deaths in the control group. In total, 12 months after the surgery, there were 3 deaths in the cirrhosis group and 1 in the control group (2.8% vs 0.6%, P ¼ 0.056). The surgery-related length of stay was significantly longer in patients with cirrhosis (3.7 AE 4.0 vs 2.6 AE 2.4 d, P ¼ 0.001), but the 30-day readmission rate was lower (7.5% vs 11.9%, P ¼ 0.001). The percent of total weight loss at 30 and 90-days was not significantly different between the groups and remained that way even at 1 year (29.1 AE 10.9 vs 31.2 AE 9.4%, P ¼ 0.096). Conclusions: Bariatric surgery in obese cirrhotic patients is not associated with excessive mortality compared with noncirrhotic obese patients.
Background and study aims Palliative treatment of malignant gastric outlet obstruction (GOO) has conventionally been with surgical gastrojejunostomy (SGJ). Advent of devices like lumen apposing metal stents has made endoscopic ultrasound-guided gastroenterostomy (EUS-GE) a potential alternative to SGJ for these patients. We performed a systematic review and meta-analysis of studies that compared outcomes of EUS-GE versus SGJ.
Methods We performed a comprehensive systematic search of multiple electronic databases and conference proceedings through January 2021 and identified six studies that compared outcomes of EUS-GE versus SGJ in the management of malignant GOO. The rates of technical success, clinical success, and AEs were analyzed, and pooled odds ratios were calculated using random effects model.
Results Six studies were included in our analysis with a total of 484 patients, of which 291 underwent EUS-GE and 193 underwent SGJ. The technical success rate of SGJ was superior to EUS-GE (OR = 0.195; 95 %CI:0.054–0.702; P = 0.012; I2 = 0). The clinical success of EUS-GE was statistically similar to SGJ (OR = 1.566; 95 %CI:0.585–4.197; P = 0.372; I2 = 46.68 %). EUS-GE had significantly fewer AEs compared to SGJ (OR = 0.295; 95 %CI:0.172–0.506; P < 0.005; I2 = 0). Among studies which reported reintervention rates, EUS-GE was statistically similar to SGJ (OR = 0.587; 95 %CI:0.174–1.979; P = 0.390, I2 = 54.91). Minimal to moderate heterogeneity was noted in the analyses.
Conclusions EUS-GE has equivalent clinical success and reintervention rates, but significantly lower adverse events compared to SGJ. When feasible, EUS-GE appears to be an effective and safe alternative to SGJ for palliative management of malignant GOO.
Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders causing substantial morbidity in the United States. 1 GERD symptoms occur when stomach contents are refluxed into the esophagus, which results in dis-Background/Aims: Transoral incisionless fundoplication (TIF) is an accepted anatomic treatment for gastroesophageal reflux disease in selected patients. In this report, we analyze our institution's programmatic allocation of resources during the safe implementation of TIF as a new procedure. Methods: A retrospective analysis of all patients who underwent TIF from January 2020 to February 2021 at our institution was performed. The process of initially allocating the operating room (OR) with overnight admission and postoperative esophagram (EG) for added safety, and subsequently transitioning TIF to the endoscopy suite (ES) as an outpatient procedure was described. Patient safety and outcomes were evaluated during transition. Results: Thirty patients who underwent TIF were identified. The mean age was 51.2±16.0 years. TIF was performed in an OR in nine patients (30%) and 21 (70%) in the ES. All the OR patients were admitted overnight and had routine EG. In contrast, four (19%) from the ES group required clinically-indicated admission and three (14.2%) required EG. The mean procedure duration was significantly lower in the ES group (65.7 min vs. 84 min, p=0.02). Conclusions: A stepwise, resource-efficient process was described that allowed safe initiation of TIF as a new technique and its effective transition to a fully outpatient procedure.
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