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SOARD Category 1 CME Credit Featured Articles, Volume 13, September 2017
SOARD Category 1 CME Credit Featured Articles, Volume 13, September 2017 A Multicenter Study of Routine Versus Selective Intraoperative Leak Testing for Sleeve Gastrectomy Jason Bingham, Jedediah Kaufman, Kai Hata, James Dickerson, Alec Beekley, Gordon Wisbach, Jacob Swann, Eric Ahnfeldt, Devon Hawkins, Yong Choi, Robert Lim, Matthew Martin Surg Obes Relat Dis 2017;13;1469-1475
Sociodemographic and Lifestyle Factors as Determinants of Energy Intake and Macronutrient Composition: A 10-year Follow-up After Bariatric Surgery Noora Kanerva, Ingrid Larsson, Markku Peltonen, Anna-Karin Lindroos, Lena M. Carlsson Surg Obes Relat Dis 2017;13;1572-1583
Objectives: After reading the featured articles published in this issue of Surgery for Obesity and Related Diseases (SOARD) participants in the SOARD CME program should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with three to five response choices, and a critique discussing the objective. Disclosure Statement: It is the policy of the American Society for Metabolic and Bariatric Surgery that speakers and/or anyone in control of content of a CME Category 1 event must disclose any financial or other relationship with (1) any manufacturer(s) of commercial products that may be discussed in the speaker’s presentation and/or (2) commercial supporters of the event. All disclosures are included under the list of author names. There was no commercial support received for this activity. Accreditation Statement: The American Society for Metabolic and Bariatric Surgery (ASMBS) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American Society for
Metabolic and Bariatric Surgery (ASMBS) designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. SOARD CME Online provides two articles from each issue for 2 credits per month; 1 credit per article. The articles this month on SOARD CME Online are: A Multicenter Study of Routine Versus Selective Intraoperative Leak Testing for Sleeve Gastrectomy Jason Bingham, Jedediah Kaufman, Kai Hata, James Dickerson, Alec Beekley, Gordon Wisbach, Jacob Swann, Eric Ahnfeldt, Devon Hawkins, Yong Choi, Robert Lim, Matthew Martin Surg Obes Relat Dis 2017;13;1469-1475 Sociodemographic and Lifestyle Factors as Determinants of Energy Intake and Macronutrient Composition: A 10-year Follow-up After Bariatric Surgery Noora Kanerva, Ingrid Larsson, Markku Peltonen, Anna-Karin Lindroos, Lena M. Carlsson Surg Obes Relat Dis 2017;13;1572-1583
http://dx.doi.org/10.1016/j.soard.2017.08.022 1550-7289/r 2017 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
Continuing Medical Education Program / Surgery for Obesity and Related Diseases 13 (2017) 1638–1640
VOLUME 13
NUMBER 9
ARTICLE 1 A Multicenter Study of Routine Versus Selective Intraoperative Leak Testing for Sleeve Gastrectomy Jason Bingham, Jedediah Kaufman, Kai Hata, James Dickerson, Alec Beekley, Gordon Wisbach, Jacob Swann, Eric Ahnfeldt, Devon Hawkins, Yong Choi, Robert Lim, Matthew Martin Surg Obes Relat Dis 2017;13;1469-1475
1639
SEPTEMBER 2017
insufflation leak test was performed and is negative. A negative leak test: A. Eliminates the risk of postoperative staple line leak B. Is Associated with a significantly decreased risk of postoperative leak C. Has no affect on the risk of postoperative leak D. Is associated with a significantly increased risk of postoperative leak 2. Which of the following is likely the least common cause of a postoperative staple line leak following sleeve gastrectomy?
Learning objectives • The widespread acceptance of sleeve gastrectomy as a “simpler” bariatric option is unfounded, as there are many subtle technical nuances and potential pitfalls that may result in the dreaded postoperative staple line leak. • Staple line leaks following sleeve gastrectomy tend occur proximally near the GE junction and are notoriously difficult manage. Most leaks develop several days to weeks following the procedure, and likely result from ischemia, thermal injury, staple line encroachment on the weak-walled esophagus, or due to increased backpressure resulting from narrowing at the incisura angularis. • Routine intraoperative leak test with insufflation of either air or methylene blue, although widely practiced, is ill suited to detect staple line deficiencies and has limited utility during sleeve gastrectomy. • A negative intraoperative leak test should be interpreted with caution, as it does not indicate a lower risk of postoperative leak development. CME Questions 1. A 37-year-old male with a BMI of 42 undergoes an uncomplicated sleeve gastrectomy. An intraoperative air
A. Stapler misfire B. Thermal Injury C. Narrowing of the incisura angularis D. Ischemia 3. The most common location and time for a staple line leak to develop following sleeve gastrectomy is: A. Proximal staple line – Postoperative day 1 B. Proximal staple line – Postoperative day 5 C. Distal staple line – Postoperative day 1 D. Distal staple line – Postoperative day 5. 4. A 33-year-old female, BMI 41, undergoes an uneventful sleeve gastrectomy with a negative intraoperative leak test. On POD 1, she is started on a liquid diet and develops immediate epigastric pain, nausea, and dyspnea. Her vitals demonstrate a Temp of 99.3, HR 116, RR 28, BP 97/55, and Sp02 93%. Which diagnostic test would most likely identify her underlying pathology. A. Spiral CT of the chest B. CXR C. Acute abdominal series x-ray D. Oral contrast abdominal CT
1640
Continuing Medical Education Program / Surgery for Obesity and Related Diseases 13 (2017) 1638–1640
ARTICLE 2 Sociodemographic and Lifestyle Factors as Determinants of Energy Intake and Macronutrient Composition: A 10-year Follow-up After Bariatric Surgery Noora Kanerva, Ingrid Larsson, Markku Peltonen, Anna-Karin Lindroos, Lena M. Carlsson Surg Obes Relat Dis 2017;13;1572-1583 Learning objectives • Identify the pre-surgical socio-demographic and lifestyle predictors of durable weight outcomes after bariatric surgery. • Determine the ideal time points for counseling patients on adequate bariatric diets and for reinforcing such counseling. • Determine the particular characteristics and factors that call for additional attention in counseling postoperative patients. CME Questions 1. According to the findings of this 10-year follow up study of patients in the Swedish Obesity Subjects registry, which 2 time points were the most effective in achieving durable positive change in postoperative diet? A. At 3 months and within 1 year B. At 6 months and within 4 years
C. At 1 month and within 2 years D. At 6 months and within 2 years 2. Which one of the following factors was not predictive of increased alcohol intake over the 10-year follow up? A. B. C. D.
Younger age Male gender Vertical-banded gastroplasty Sedentary activity
3. At 10 year follow up, which one of the following surgical treatments predicted that the largest proportion of energy will be derived from carbohydrates? A. B. C. D.
Adjustable gastric band Vertical banded gastroplasty Gastric bypass Sleeve gastrectomy
4. Which one of the following statements is false? A. At the 6-month follow up, the reported energy intake was, on average, 35% - 45% lower than at baseline. B. At the end of follow up (10 years), the reported energy intake was, on average, 15%-25% lower than at baseline. C. Men, compared to women, reported significantly lower energy intake at both the 6-month and 10-year follow up time-points. D. Women reported better maintained changes in carbohydrate, protein, and fiber intake, compared to men.
Sociodemographic and Lifestyle Factors as Determinants of Energy Intake and Macronutrient Composition: A 10-year Follow-up After Bariatric Surgery Noora Kanerva, Ingrid Larsson, Markku Peltonen, Anna-Karin Lindroos, Lena M. Carlsson Surg Obes Relat Dis 2017;13;1572-1583
Objectives: After reading the featured articles published in this issue of Surgery for Obesity and Related Diseases (SOARD) participants in the SOARD CME program should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with three to five response choices, and a critique discussing the objective. Disclosure Statement: It is the policy of the American Society for Metabolic and Bariatric Surgery that speakers and/or anyone in control of content of a CME Category 1 event must disclose any financial or other relationship with (1) any manufacturer(s) of commercial products that may be discussed in the speaker’s presentation and/or (2) commercial supporters of the event. All disclosures are included under the list of author names. There was no commercial support received for this activity. Accreditation Statement: The American Society for Metabolic and Bariatric Surgery (ASMBS) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American Society for
Metabolic and Bariatric Surgery (ASMBS) designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. SOARD CME Online provides two articles from each issue for 2 credits per month; 1 credit per article. The articles this month on SOARD CME Online are: A Multicenter Study of Routine Versus Selective Intraoperative Leak Testing for Sleeve Gastrectomy Jason Bingham, Jedediah Kaufman, Kai Hata, James Dickerson, Alec Beekley, Gordon Wisbach, Jacob Swann, Eric Ahnfeldt, Devon Hawkins, Yong Choi, Robert Lim, Matthew Martin Surg Obes Relat Dis 2017;13;1469-1475 Sociodemographic and Lifestyle Factors as Determinants of Energy Intake and Macronutrient Composition: A 10-year Follow-up After Bariatric Surgery Noora Kanerva, Ingrid Larsson, Markku Peltonen, Anna-Karin Lindroos, Lena M. Carlsson Surg Obes Relat Dis 2017;13;1572-1583
http://dx.doi.org/10.1016/j.soard.2017.08.022 1550-7289/r 2017 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
Continuing Medical Education Program / Surgery for Obesity and Related Diseases 13 (2017) 1638–1640
VOLUME 13
NUMBER 9
ARTICLE 1 A Multicenter Study of Routine Versus Selective Intraoperative Leak Testing for Sleeve Gastrectomy Jason Bingham, Jedediah Kaufman, Kai Hata, James Dickerson, Alec Beekley, Gordon Wisbach, Jacob Swann, Eric Ahnfeldt, Devon Hawkins, Yong Choi, Robert Lim, Matthew Martin Surg Obes Relat Dis 2017;13;1469-1475
1639
SEPTEMBER 2017
insufflation leak test was performed and is negative. A negative leak test: A. Eliminates the risk of postoperative staple line leak B. Is Associated with a significantly decreased risk of postoperative leak C. Has no affect on the risk of postoperative leak D. Is associated with a significantly increased risk of postoperative leak 2. Which of the following is likely the least common cause of a postoperative staple line leak following sleeve gastrectomy?
Learning objectives • The widespread acceptance of sleeve gastrectomy as a “simpler” bariatric option is unfounded, as there are many subtle technical nuances and potential pitfalls that may result in the dreaded postoperative staple line leak. • Staple line leaks following sleeve gastrectomy tend occur proximally near the GE junction and are notoriously difficult manage. Most leaks develop several days to weeks following the procedure, and likely result from ischemia, thermal injury, staple line encroachment on the weak-walled esophagus, or due to increased backpressure resulting from narrowing at the incisura angularis. • Routine intraoperative leak test with insufflation of either air or methylene blue, although widely practiced, is ill suited to detect staple line deficiencies and has limited utility during sleeve gastrectomy. • A negative intraoperative leak test should be interpreted with caution, as it does not indicate a lower risk of postoperative leak development. CME Questions 1. A 37-year-old male with a BMI of 42 undergoes an uncomplicated sleeve gastrectomy. An intraoperative air
A. Stapler misfire B. Thermal Injury C. Narrowing of the incisura angularis D. Ischemia 3. The most common location and time for a staple line leak to develop following sleeve gastrectomy is: A. Proximal staple line – Postoperative day 1 B. Proximal staple line – Postoperative day 5 C. Distal staple line – Postoperative day 1 D. Distal staple line – Postoperative day 5. 4. A 33-year-old female, BMI 41, undergoes an uneventful sleeve gastrectomy with a negative intraoperative leak test. On POD 1, she is started on a liquid diet and develops immediate epigastric pain, nausea, and dyspnea. Her vitals demonstrate a Temp of 99.3, HR 116, RR 28, BP 97/55, and Sp02 93%. Which diagnostic test would most likely identify her underlying pathology. A. Spiral CT of the chest B. CXR C. Acute abdominal series x-ray D. Oral contrast abdominal CT
1640
Continuing Medical Education Program / Surgery for Obesity and Related Diseases 13 (2017) 1638–1640
ARTICLE 2 Sociodemographic and Lifestyle Factors as Determinants of Energy Intake and Macronutrient Composition: A 10-year Follow-up After Bariatric Surgery Noora Kanerva, Ingrid Larsson, Markku Peltonen, Anna-Karin Lindroos, Lena M. Carlsson Surg Obes Relat Dis 2017;13;1572-1583 Learning objectives • Identify the pre-surgical socio-demographic and lifestyle predictors of durable weight outcomes after bariatric surgery. • Determine the ideal time points for counseling patients on adequate bariatric diets and for reinforcing such counseling. • Determine the particular characteristics and factors that call for additional attention in counseling postoperative patients. CME Questions 1. According to the findings of this 10-year follow up study of patients in the Swedish Obesity Subjects registry, which 2 time points were the most effective in achieving durable positive change in postoperative diet? A. At 3 months and within 1 year B. At 6 months and within 4 years
C. At 1 month and within 2 years D. At 6 months and within 2 years 2. Which one of the following factors was not predictive of increased alcohol intake over the 10-year follow up? A. B. C. D.
Younger age Male gender Vertical-banded gastroplasty Sedentary activity
3. At 10 year follow up, which one of the following surgical treatments predicted that the largest proportion of energy will be derived from carbohydrates? A. B. C. D.
Adjustable gastric band Vertical banded gastroplasty Gastric bypass Sleeve gastrectomy
4. Which one of the following statements is false? A. At the 6-month follow up, the reported energy intake was, on average, 35% - 45% lower than at baseline. B. At the end of follow up (10 years), the reported energy intake was, on average, 15%-25% lower than at baseline. C. Men, compared to women, reported significantly lower energy intake at both the 6-month and 10-year follow up time-points. D. Women reported better maintained changes in carbohydrate, protein, and fiber intake, compared to men.