[Show abstract][Hide abstract] ABSTRACT: To compare bariatric surgery versus intensive medical weight management (MWM) in patients with type 2 diabetes mellitus (T2DM) who do not meet current National Institutes of Health criteria for bariatric surgery and to assess whether the soluble form of receptor for advanced glycation end products (sRAGE) is a biomarker to identify patients most likely to benefit from surgery.
Annals of Surgery 10/2014; 260(4):617-624. · 6.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to determine the diagnostic accuracy of positron emission tomography (PET) in cancer patients undergoing adrenalectomy for presumed metastatic disease, utilizing the gold standard of histopathology.
Annals of Surgical Oncology 08/2014; · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Bariatric surgery is the most effective treatment for patients suffering from obesity-related comorbidities. There is little data regarding how patients choose one particular bariatric procedure over another. This study aimed to better define the relationship between preferences of patients considering bariatric surgery and the procedure patients undergo.
A bilingual questionnaire was administered to all prospective patients seen between March 1 and August 31, 2012. The questionnaire assessed basic knowledge of bariatric surgery (based on the information seminar) as well as patient preferences of the various outcomes and complications for sleeve gastrectomy, gastric bypass, and gastric banding.
One hundred seventy-two patients completed the questionnaire. Fifty-eight percent of patients chose "maximum weight loss" as the most important outcome, and 65 % chose "leak" as the most concerning complication. Subgroup analysis of patients with diabetes revealed that 58 % chose "curing diabetes" as the most important outcome. Nineteen percent of patients were either not sure which procedure they wanted or changed their decision after consultation with the surgeon.
The decision to choose one bariatric procedure over another is complex and is based on factors beyond absolute patient preferences. Although maximum weight loss is a commonly reported preference for patients seeking bariatric surgery, patients with diabetes are more focused on diabetes remission. Most patients have already decided which procedure to undergo prior to surgeon consultation. Patients may benefit from shared decision making, which integrates patient values and preferences along with current medical evidence to assist in the complex bariatric surgery selection process.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine the impact of bariatric surgery on employment status in underserved, unemployed patients with severe obesity.
A retrospective review of all unemployed severely obese patients seen in our urban safety-net bariatric surgery program was performed. Preoperative patient questionnaires and medical records were reviewed to evaluate patient employment status at the time of initial evaluation by the multidisciplinary bariatric surgery team. Follow-up data was obtained on all available patients (including those who did not undergo surgery), including weight and employment status. A standardized telephone questionnaire was administered to supplement details regarding employment. Changes in employment status and body weight were determined in both groups.
Here, 193 unemployed severely obese patients were evaluated by the multidisciplinary obesity team. The vast majority of patients (>80 %) were minorities (primarily Hispanic) and publicly insured. Seventy-two underwent bariatric surgery and 121 did not. Twenty-four percent of the surgical patients and 9 % of the non-surgical patients had acquired full-time employment at least one year postoperatively (p = 0.043). There was a 10-point body mass index reduction in the surgical group, compared to 1-point reduction in the non-surgical group after one year.
Bariatric surgery may improve employment status in an unemployed severely obese patient cohort. Future research in this area should collect detailed prospective data on employment prior to surgery and assess changes longitudinally to provide a more complete picture of the impact of bariatric surgery on employment.
[Show abstract][Hide abstract] ABSTRACT: Purpose: To determine whether a discordance exists between the bariatric procedures patients choose (gastric bypass, gastric band, or sleeve gastrectomy) and their treatment-related values (outcomes and complications).
Methods: An anonymous bilingual (English/Spanish) questionnaire was administered to new patients at the Bellevue Hospital Bariatric Surgery Program. The Bariatric Clinic requires patients to attend an information seminar and consult with a multidisciplinary team before making a surgical choice. The questionnaire was administered after the seminar, but before the consultation, and included knowledge questions on the outcome and complication profiles of the 3 surgical treatments and questions about the patients' treatment-related values.
Results: 64 patients completed the questionnaire. The mean Body Mass Index (BMI) was 44.5 kg/m2 and 25.0% were diabetic. Patients answered correctly an average 62.9% of the knowledge questions. 42.2% of patients chose gastric bypass, 40.6% sleeve gastrectomy, and 17.2% gastric banding (Table 1). 29% of patients changed their surgical choice following consultation with the multidisciplinary team. In patients who chose gastric banding, 36.4% selected weight loss as their most important outcome (gastric banding affords the least weight loss of the 3 procedures). In diabetic patients, 36.4% cared more about weight loss than curing their diabetes. When patients' target BMI was calculated using preoperative BMI and evidence-based estimates of excess body weight loss for each of the 3 bariatric procedures, 66.7% of those who chose gastric banding had a target BMI above 35, meaning they would remain severely obese postoperatively.
Conclusions: This study found that many patients choose a bariatric procedure with an outcome and complication profile that is inconsistent with their values, and that a significant subgroup of patients (29.0%) change their surgical choice after consultation with the medical team. These results strongly indicate that patients and physicians would benefit from a decision-making model, which integrates patient values, to assist in the complicated surgery selection process. Table 1. Outcome and complication profile for all patients
Most important outcome
Most worrisome complication
#Diabetic patients (%)
Least weight regain
The 34th Annual Meeting of the Society for Medical Decision Making; 10/2012
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE:: To conduct a systematic review to identify surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy (LSG). BACKGROUND:: LSG is growing in popularity as a primary bariatric procedure. Technical aspects of LSG including bougie size remain controversial. METHODS:: Our systematic review yielded 112 studies encompassing 9991 LSG patients. A general estimating equation (GEE) model was used to calculate the odds ratio (OR) for leak based on bougie size, distance from the pylorus, and use of buttressing on the staple line. Baseline characteristics, including age and body mass index (BMI), were included. A linear repeated measures regression model compared excess weight loss (%EWL) between bougie sizes. RESULTS:: A total of 198 leaks in 8922 patients (2.2%) were identified. The GEE model revealed that the risk of leak decreased with bougie ≥40 Fr (OR = 0.53, 95% CI = [0.37-0.77]; P = 0.0009). Buttressing did not impact leak. There was no difference in %EWL between bougie <40 Fr and bougie ≥40 Fr up to 36 months (mean: 70.1% EWL; P = 0.273). Distance from the pylorus did not affect leak or %EWL. CONCLUSIONS:: Utilizing bougie ≥40 Fr may decrease leak without impacting %EWL up to 3 years. Distance from the pylorus does not impact leak or weight loss. Buttressing does not seem to impact leak; however, if surgeons desire to buttress, bioabsorbable material is the most common type used. Longer-term studies are needed to definitively determine the effect of bougie size on weight loss after LSG.
[Show abstract][Hide abstract] ABSTRACT: Surgical correction of hiatal hernia (HH) during bariatric surgery has been found to improve patient outcomes and decrease reoperation rate. Although barium esophagram is more sensitive than endoscopy for detection of HH, accurate preoperative diagnosis remains a challenge. The aim of this study is to determine whether diagnostic accuracy improves by utilizing right anterior oblique (RAO) esophagram technique instead of the commonly used upright technique when comparing to the gold standard of intraoperative detection.
All patients undergoing bariatric surgery were prospectively evaluated for HH by barium esophagram. After the first 69 patients, the technique was changed from upright to RAO. Hiatal hernia was assessed intraoperatively by laxity of the phrenoesophageal ligament and, if present, was repaired posteriorly. Two board-certified radiologists specializing in gastrointestinal radiology, who were blinded to the intraoperative results, retrospectively reviewed the esophagrams. Consensus reads were utilized for divergent opinions. Sensitivity and specificity were calculated for each technique.
Between 2008 and 2010, a total of 388 patients underwent preoperative esophagrams (69 upright, 388 RAO). For upright esophagram, sensitivity was 50 % and specificity was 97 %. For RAO esophagram, sensitivity was 70 % and specificity was 77 %. RAO had a lower percentage of false negatives (11 vs. 21 %) than upright esophagram.
The use of RAO technique for preoperative esophagram is more sensitive for diagnosis of hiatal hernia than upright esophagram. If surgeons desire routine preoperative esophagram, RAO technique is the best.
Obesity Surgery 07/2012; 22(11):1730-3. · 3.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Previous studies have shown accelerated gastric emptying after sleeve gastrectomy. This study aimed to determine whether a correlation exists between immediate postoperative gastroduodenal transit time and weight loss after laparoscopic sleeve gastrectomy (LSG). Specifically, correlation tests were conducted to determine whether more rapid transit after LSG correlated with increased weight loss. METHODS: Data were collected from an institutional review board-approved electronic registry. All LSGs were performed over a 40-Fr bougie, starting 5 to 7 cm proximal to the pylorus. Gastroduodenal transit time (antrum to duodenum) was calculated from a postoperative day 1 esophagram. Pearson's correlation coefficient was used for statistical analysis. RESULTS: The analysis included 62 consecutive LSG patients. The mean gastroduodenal transit time was 12.3 ± 19.8 s. Almost all the patients (99 %) had a transit time less than 60 s. The mean percentage of excess weight loss (%EWL) was 23.8 ± 9.8 % at 3 months, 37.9 ± 11.8 % at 6 months, and 52.2 ± 10.8 % at 12 months. No correlation was found between gastroduodenal transit time and %EWL at 3, 6, or 12 months. CONCLUSION: No correlation was found between gastroduodenal transit time and weight loss after LSG.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Genetic factors likely play a role in obesity and the outcomes after bariatric surgery. Single nucleotide polymorphisms in or near the insulin-induced gene 2 (INSIG-2), fat mass and obesity-associated gene (FTO), melanocortin 4 receptor gene (MC4R), and proprotein convertase subtilisn/kexin type 1 gene (PCSK-1) have been associated with class III obesity in whites. Minimal data are available regarding the genetic susceptibility to obesity in class III obese nonwhites, especially Hispanics. Our objective was to perform a comparative analysis of 4 common genetic variants (INSIG-2, FTO, MC4R, and PCSK-1) associated with obesity in a diverse population of bariatric surgery patients to determine whether a difference exists by ethnicity (white versus Hispanic). The setting of the study was 2 university hospitals in the United States. METHODS: Bariatric surgery patients from 2 different institutions were enrolled prospectively, and genotyping was performed. Differences in the distribution of INSIG-2, FTO, MC4R, and PCSK-1 single nucleotide polymorphisms among the different ethnicities (whites and Hispanics) were compared using an additive model (0, 1, or 2 risk alleles). A propensity-matched analysis was used to account for cohort differences. RESULTS: A total of 1276 bariatric patients were genotyped for the INSIG-2, FTO, MC4R, and PCSK-1 obesity single nucleotide polymorphisms. Statistically significant differences in FTO, INSIG-2, MC4R, and PCSK-1 were seen using an additive model. FTO, PCSK-1, and MC4R (test for trend) remained significantly different in the propensity analysis. CONCLUSION: Significant differences in the frequencies of several common obesity susceptibility variants in or near FTO, PCSK-1, and MC4R were found in white and Hispanic patients with class III obesity undergoing bariatric surgery. Larger studies in more class III obese Hispanics of different nationalities are needed.
Surgery for Obesity and Related Diseases 05/2012; · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Many insurance payors mandate that bariatric surgery candidates undergo a medically supervised weight management (MSWM) program as a prerequisite for surgery. However, there is little evidence to support this requirement. We evaluated in a randomized controlled trial the hypothesis that participation in a MSWM program does not predict outcomes after laparoscopic adjustable gastric banding (LAGB) in a publicly insured population.
This pilot randomized trial was conducted in a large academic urban public hospital. Patients who met NIH consensus criteria for bariatric surgery and whose insurance did not require a mandatory 6-month MSWM program were randomized to a MSWM program with monthly visits over 6 months (individual or group) or usual care for 6 months and then followed for bariatric surgery outcomes postoperatively. Demographics, weight, and patient behavior scores, including patient adherence, eating behavior, patient activation, and physical activity, were collected at baseline and at 6 months (immediately preoperatively and postoperatively).
A total of 55 patients were enrolled in the study with complete follow-up on 23 patients. Participants randomized to a MSWM program attended an average of 2 sessions preoperatively. The majority of participants were female and non-Caucasian, mean age was 46 years, average income was less than $20,000/year, and most had Medicaid as their primary insurer, consistent with the demographics of the hospital's bariatric surgery program. Data analysis included both intention-to-treat and completers' analyses. No significant differences in weight loss and most patient behaviors were found between the two groups postoperatively, suggesting that participation in a MSWM program did not improve weight loss outcomes for LAGB. Participation in a MSWM program did appear to have a positive effect on physical activity postoperatively.
MSWM does not appear to confer additional benefit as compared to the standard preoperative bariatric surgery protocol in terms of weight loss and most behavioral outcomes after LAGB in our patient population.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE/AIM
Laparoscopic surgeries are increasingly performed and produce unique postoperative imaging findings which may be misdiagnosed as complications. The purpose of this exhibit is to provide an interactive case-based guide to identifying normal post-surgical changes, complications, and diagnostic pitfalls specific to laparosopic surgery.
1. Update on laparoscopic techniques including types of entry and trocars, along with expected postoperative changes on CT after laparoscopic surgery compared with open approach. 2. Pictorial review of potential pitfalls in interpretation leading to overdiagnosis of surgical complications, which may be avoided with knowledge of surgical approach and correlative clinical history. 3. Case-based quiz on post-operative findings, complications, and diagnostic pitfalls unique to laparoscopic surgery.
Laparoscopic techniques are increasingly replacing open approaches to intra-abdominal procedures. Knowledge of the expected postoperative changes and complications unique to laparoscopic surgery may aid in accurate interpretation of CT scans in such patients and avoidance of unnecessary intervention.
Radiological Society of North America 2011 Scientific Assembly and Annual Meeting; 11/2011
[Show abstract][Hide abstract] ABSTRACT: Weight regain after Roux-en-Y gastric bypass (RYGB) is increasingly reported in the bariatric literature. Laparoscopic sleeve reduction of the gastrojejunal complex is a surgical option to revise a dilated gastric pouch. We report our short-term results.
Sleeve reduction entails serial firing of a linear stapler along the jejunal alimentary limb, across the gastric pouch and towards the left crus, with a bougie in place, thus, creating a new 20-25-cm reduced gastrojejunal complex. Data analyzed included age, body mass index (BMI), excess weight loss (EWL), comorbidity resolution, and any other simultaneous operative procedures.
Fourteen patients were identified, all done laparoscopically. Nine underwent gastrojejunal sleeve reduction alone and five underwent additional lengthening of the Roux limb. There were no mortalities. Mean age at revision was 43 years (31-59). Mean BMI and EWL prior to revision were 35.5 ± 4.0 kg/m² and 48.9 ± 15.8%, respectively. Nine of 14 patients (64%) had obesity-related comorbidities prior to the revision. Average BMI decrease was 2.7 kg/m². Post-revision mean BMI and %EWL were 32.9 ± 4.7 kg/m² and 12.0 ± 13.9%, respectively, with mean follow-up of 12 months. Three of nine patients (33%) experienced improvement and/or resolution of comorbidities. We did not find a significant difference between pre-and post-revision mean BMI and %EWL (p = 0.13) even after separately evaluating those patients who underwent Roux limb lengthening (p = 0.16).
For RYGB patients who regained weight, laparoscopic gastrojejunal sleeve reduction does not seem to offer a major therapeutic benefit. Additional malabsorptive Roux lengthening also does not provide a significant benefit. Other options should be considered, such as placing a band on the gastric pouch or conversion to duodenal switch.
Obesity Surgery 05/2011; 21(5):650-4. · 3.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evidence of the positive effects of gastric banding on patients with diabetes has continued to increase. The long-term follow-up of such patients, however, has been limited. The purpose of the present study was to provide the long-term outcomes of patients with diabetes undergoing laparoscopic adjustable gastric banding at our institution.
From January 2002 through June 2004, 102 patients with type 2 diabetes mellitus underwent laparoscopic adjustable gastric banding. The study parameters included preoperative age, gender, race, body mass index, duration of diabetes before surgery, fasting glucose level, hemoglobin A1c (HbA1c), and medications used. Preoperative data from all patients were collected prospectively and entered into an institutional review board-approved database. Beginning in 2008, efforts were made to collect the 5-year follow-up data.
Of the 102 patients, 7 were excluded because they had not reached the 5-year follow-up point (2 patients had had the band removed early and 5 patients had died; 2 of cancer and 3 of unknown causes), leaving 95 patients for the present study. The mean preoperative age was 49.3 years (range 21.3-68.4). The mean preoperative body mass index was 46.3 kg/m(2) (range 35.1-71.9) and had decreased to 35.0 kg/m(2) (range 21.1-53.7) by 5 years of follow-up, yielding a mean percentage of excess weight loss of 48.3%. The mean duration of the diabetes diagnosis before surgery was 6.5 years. Of 94 patients, 83 (88.3%) were taking medications preoperatively, with 14.9% overall taking insulin. At 5 years postoperatively, 33 (46.5%) of 71 patients were taking medications, with 8.5% taking insulin. The mean fasting preoperative glucose level was 146.0 mg/dL. The glucose level had decreased to 118.5 mg/dL at 5 years postoperatively (P = .004). The mean HbA1c level was 7.53 preoperatively in 72 patients and was 6.58 at 5 years postoperatively in 64 patients (P <.001). Overall, diabetes had resolved (no medication requirement, with HbA1c <6 and/or glucose <100 mg/dL) in 23 (39.7%) of 58 patients and had improved (use of fewer medications and/or fasting glucose levels of 100-125 mg/dL) in 41 (71.9%) of 57 patients. The combined improvement/remission rate was 80% (64 of 80 patients).
Our data have demonstrated that laparoscopic adjustable gastric banding results in a substantial sustained positive effect on diabetes in morbidly obese patients, with a significant reduction in HbA1c and an 80% overall rate of improvement/remission.
Surgery for Obesity and Related Diseases 01/2010; 6(4):373-6. · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Many mildly to moderately obese individuals with a body mass index (BMI) lower than 35 kg/m(2) have serious diseases related to their obesity. Nonsurgical therapy is ineffective in the long term, yet surgery has never been made widely available to this population.
Between 2002 and 2007, 53 patients with a BMI lower than 35 kg/m(2) underwent laparoscopic adjustable gastric banding at our institution. Data on all these patients were collected prospectively and entered into an institutional review board-approved electronic registry. The study parameters included preoperative age, gender, BMI, presence of comorbidities, percentage of excess weight loss (%EWL), and resolution of comorbidities.
The mean preoperative age of the patients was 46.9 years (range, 16-68 years), and the mean preoperative BMI was 33.1 kg/m(2) (range, 28.2-35.0 kg/m(2)). Of the 53 patients, 49 (92%) had at least one obesity-related comorbidity. The mean BMI decreased to 28.1 +/- 2.4 kg/m(2), 25.8 +/- 2.9 kg/m(2), and 25.8 +/- 3.1 kg/m(2) and mean %EWL was 48.3 +/- 17.6, 69.9 +/- 28.0, and 69.7 +/- 31.7 at 0.5, 1, and 2 years, respectively. Substantial improvement occurred for the following comorbidities evaluated: hypertension, depression, diabetes, asthma, hypertriglyceridemia, obstructive sleep apnea, hypercholesterolemia, and osteoarthritis. There was one slip, two cases of band obstruction (from food), two cases of esophagitis, and two port leaks, but no mortality.
The authors are very encouraged by this series of low-BMI patients who underwent laparoscopic adjustable gastric banding. Their weight loss has been excellent, and their complications have been acceptable. Their comorbidities have partially or wholly resolved. With further study, it is reasonable to expect alteration of the weight guidelines for bariatric surgery to include patients with a BMI lower than 35 kg/m(2).