March 2021

Synopsis: The prevalence of obesity in the United States is currently greater than 40%. This has increased from 30.5% to 42.4% over the last decade, with the prevalence of severe obesity rising from 4.7% to 9.2% over the same time-period. Average annual healthcare costs are an estimated $1500 higher for obese patients than for non-obese patients, and in 2008, the estimated annual medical cost of obesity in the United States was 147 billion dollars. Obesity is associated with higher rates of cardiovascular disease including cerebrovascular disease, type II diabetes, and various types of cancer, all of which increase the risk for preventable and premature death in comparison to the general, non-obese population. Obesity is clearly an epidemic that is getting worse. Bariatric surgery results in significant and durable weight loss superior to medical management alone. In addition to marked improvement, and sometimes cure, of obesity-related conditions, some data has shown that bariatric surgery is associated with improved overall survival among obese patients; however, prospective studies with long-term follow-up evaluating this end point are lacking.

The Swedish Obesity Subjects (SOS) study is an ongoing prospective cohort study following 2010 participants who underwent bariatric surgery in comparison to 2037 patients who have undergone medical management alone for obesity. Patients were initially enrolled between September 1, 1987, and January 31, 2001, and inclusion/exclusion criteria for both groups were identical and were selected to enroll patients fit to undergo surgery. In the present study, Carlsson et al. compared the bariatric surgery and medically managed cohorts to assess the primary study end point of long-term overall survival. Secondary endpoints included changes in BMI over the follow-up period, evaluation of specific causes of death and assessment of complications in the bariatric surgery group. Patients in the surgery group underwent banding (18%), vertical banded gastroplasty (69%), or gastric bypass (13%). In comparison to the medically managed group, the surgical group was younger (mean age 47.2 vs. 48.7 years), had a higher mean BMI (42.4 vs. 40.1), and had higher a prevalence of hypertension and diabetes, higher mean insulin levels and total cholesterol, and higher history of smoking. Median follow-up was 24 years in the surgery group and 22 years in the medical group. The number of deaths per 1000 person-years over this follow-up period was 10.7 and 13.2 in the surgery and control groups, respectively. Following adjustment for baseline risk factors with multivariable analysis, the hazard ratio for all-cause death in the surgery group compared to the medically managed group was 0.70 (95% CI, 0.61 to 0.81; P<0.001), and the median life expectancy was 2.4 years (95% CI, 1.2 to 3.5) longer in the surgery group than in the medical group (P<0.001). The most common causes of death in the study were cardiovascular disease and cancer, both of which were lower among the surgery group (any cardiovascular disease related death, hazard ratio 0.70 [95% CI 0.57-0.85]; any cancer related death, hazard ratio 0.77 [95% CI 0.61-0.96]). Mean BMI was 7 points lower in the surgery group than the medical group at final follow-up. Within the surgery group, 292 patients (14.5%) had at least one complication, 59 (2.9%) of which required a repeat operation, and 5 (0.2%) of which resulted in mortality. 

Although some data has shown decreased mortality in obese patients who undergo bariatric surgery in comparison to medically managed patients, the SOS study showed that this survival benefit exists over an impressively long follow-up period, and that life expectancy is more than 2 years higher for obese patients who undergo surgery. Furthermore, mortality from both cardiovascular disease and cancer was lower among obese patients who undergo bariatric surgery. These findings add to the growing body of evidence supporting the major benefits of bariatric surgery for those in which it is indicated. 

Synopsis: With the emergence of ERAS protocols and the focus on limiting opioid use in the setting of the opioid crisis, multimodal pain management is a mainstay of perioperative care. The use of gabapentinoids (gabapentin and pregabalin) is recommended by the American Pain Society, yet is not endorsed by its European counterpart. The results of exhaustive trials and analyses surrounding their use are equally heterogenous.

This meta-analysis compiles results from almost 300 randomized controlled trials in which gabapentinoids were compared to any other pain regimen, placebo, or usual care in patients undergoing elective or emergent surgery. Importantly, this analysis defines ‘minimally clinically important difference’ as a 10 point difference on a 100-point pain scale. This is in addition to the use of statistical significance, which may not always portend a practical difference. The primary outcome was acute post-operative pain intensity at 6, 12, 24, 48, and 72 hours. Secondary outcomes included subacute pain (lasting 4-12 weeks postoperatively), chronic pain (lasting greater than 3 months postoperatively), cumulative opioid use, length of stay, and adverse effects. 

A slightly lower pain intensity was reported up to 48h after surgery in patients receiving gabapentinoids; however, this effect was not clinically significant (differences fell below the minimally important difference of 10%). In a subgroup analysis of those patients who did report a greater than 10% improvement in pain intensity, this difference was not noted beyond the first 24 hours after surgery. There was also no difference in subacute or chronic pain noted with the use of gabapentinoids. At 24h, the patients who received gabapentinoids had a slightly lower total opioid requirement, though the total difference only equates to ~1.2mg IV dilaudid or 7mg PO oxycodone. Use of gabapentinoids was associated with a longer hospital stay, though the average was only 3 hours and therefore not clinically significant. Gabapentinoids did decrease the incidence of postoperative nausea and vomiting; however, there was also a significant increase in reported dizziness as well as visual disturbances. 

Though extensive in number (25,000 patients examined), the limitation may be the generalizability of results to any one patient cohort. Of the examined studies, approximately 25% included open abdominal procedures, 15% laparoscopic procedures, 25% orthopedic procedures, 10% ENT procedures, and the remainder <10% each vascular, breast, plastic, thoracic, cardiac, neurosurgery procedures. Furthermore, 70% of trials examined the effect of only one dose and only 25% of trials examined the use of gabapentinoids used in both the preoperative and postoperative settings, both of which are incongruent with many of our ERAS protocols. 

Multimodal non-opioid approaches to postoperative analgesia are integral in the management of surgical patients. However, each pharmaceutical technique has a unique efficacy as well as safety profile, highlighting the need for appropriate analgesia selection for every patient. Additionally, this study emphasizes the difficulty of assessing the relative importance of any one component of an ERAS protocol. 

Synopsis: Myelomeningoceles are a congenital abnormality caused by incomplete neural tube closure during embryonic development. Recent studies have focused on differences in outcomes between myelomeningoceles repaired prenatally versus those repaired in the postnatal period. These studies, Management of Myelomeningocele Study (MOMS) and MOMS2, demonstrated improved outcomes for children who had prenatal repairs. More specifically, the MOMS2 study compared adaptive behavior, neurocognition, urologic function, physical functional, and quality of life at up to 30 months of age and found that those with prenatal repairs tended to score better on the assessments focusing on self-care and mobility.

This study was a secondary analysis of the MOMS2 trial, which was conducted between 2012 and 2017. The children, who were now ages 5-10, were evaluated using a comprehensive study visit which included a physical examination and functioning assessment by a physical therapist. Physical functioning outcomes were measured including the following: functional skills assessing self-care, motor, and recreational activities, a walking and ambulation assessment, sitting assessment, advanced motor skills (for those who ambulate), wheelchair transfer (for those wheelchair bound), and a motor level assessment. 

There were 154 children included, 78 of whom underwent postnatal repair and 76 underwent prenatal repair. In terms of self-care skills, children in the prenatal repair group performed a higher overall percentage of age-appropriate self-care skills (using a toothbrush or fork, washing/drying hands, doffing clothing, etc., RR 1.04, CI 0.08-3.00). Children in the prenatal repair group also performed better in the motor category of the FRESNO scale than the postnatal repair group (RR 5.7, CI 1.97-11.18). In terms of functional mobility, children in the prenatal repair group were more likely to be independent with ambulation. Among those children who do ambulate, prenatal repair group children were twice as likely to walk without bracing (RR 2.4, CI 1.05-5.49). In terms of gait quality, most children in the prenatal repair group had symmetric strides compare with the postnatal repair group (RR 1.26, CI 1.03-1.54). Most children in the prenatal repair group had stable gaits (86.7%) as opposed to the postnatal repair group (49.1%) (RR 1.87, CI 1.35-2.58). In terms of motor skills and motor levels, children in the prenatal repair group could perform higher level mobility skills (RR 5.7, CI 1.97-11.18) and were more likely to be independent with several motor skills. Lastly, children in the prenatal repair group were less than half as likely to have motor levels that were worse than their anatomic level compared with those in the postnatal repair group (RR 0.44, CI 0.25-0.77). 

Bottom Line: At ages 5-10, children with prenatal repair of myelomeningocele had superior self-care, motor function, and mobility skills compared to those with postnatal repair, demonstrating that the benefits of prenatal repair persist beyond 30 months of age.