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ABSTRACT: All patients at our academic medical center complete a mandatory bariatric surgery information session before scheduling their first clinic visit. The patients could attend an in-person information session or view a prerecorded information session through our Web site. The study aimed to compare the information retention after both delivery methods using an institutional review board-approved test in an academic medical center in the United States.
From February 2010 through March 2011, 338 tests were voluntarily completed by new preoperative bariatric patients at their clinic visit. The patients provided basic demographic information, co-morbid medical conditions, and identified which bariatric procedures they were interested in. The test assessed the retention of information delivered during the information session, including knowledge of the risks and benefits of bariatric surgery, the surgical options available at our center, and the steps commonly required for insurance approval. The patients and surgeons were kept unaware of the results.
Of the patients, 54% attended the on-line information session; 80% of these participants were women, and their mean body mass index was 48.09 kg/m(2). The remaining 46% attended the in-person information session, and 83% of these participants were women and their mean body mass index was 49.08 kg/m(2). The average test score was 85.69% for the on-line group and 80.32% for the in-person group. The difference in test scores for the on-line and in-person groups was statistically significant (P = .003).
Internet-based training is rapidly becoming a key educational tool. Our results suggest that on-line training has the potential to be as effective as traditional in-person training in educating patients about bariatric surgery. Bariatric surgery centers might consider incorporating on-line training into their educational programs as a convenient and potentially effective way to educate patients.
Surgery for Obesity and Related Diseases 11/2011; 8(2):225-9; discussion 229. · 3.93 Impact Factor
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ABSTRACT: While bariatric surgery has proved highly successful at producing sustained weight loss, variability in treatment response persists. A better understanding of the pathophysiology of appetite and obesity may improve patient selection and management. Research into feeding behavior and satiety has focused on the role of dopamine in reward-based behaviors. Specifically, positron-emission computed tomography (PET) has demonstrated reduced brain dopamine receptor availability in obese subjects compared to controls. This may be due to a primary deficiency in dopamine receptors or to secondary dopamine receptor downregulation. We performed a preliminary study to investigate dopamine D2 receptor activity in obese subjects before and after laparoscopic Roux-en Y gastric bypass (LGBP).
Five female subjects, ages 20 to 38 years old with a mean body mass index of 45, underwent PET with [C-11] raclopride injection. Five regions of interest were studied: ventral striatum, anterior and posterior putamen, and anterior and posterior caudate nucleus. Repeat PET was performed at 6 weeks following LGBP. D2 receptor binding was compared within subjects pre- and post-surgery. Baseline D2 binding was also compared to historical nonobese controls.
D2 receptor availability increased 6 weeks after gastric bypass surgery. The increase in receptor availability appeared roughly proportional to the amount of weight lost. No significant difference in D2 binding was seen between the obese subjects and historical nonobese controls.
Brain available dopamine D2 binding appears to increase following GBP. This preliminary finding needs to be replicated in a larger population but suggests that diminished D2 binding in the obese may be due to D2 receptor downregulation. Changes in available dopamine receptor binding may play an important role in centrally mediated appetite suppression and resultant weight loss after LGBP.
Obesity Surgery 10/2009; 20(3):369-74. · 3.29 Impact Factor
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ABSTRACT: Paraesophageal hernia (PEH) repair is a technically challenging operation. These patients are typically older and have more co-morbidities than patients undergoing anti-reflux operations for gastroesophageal reflux disease (GERD), and these factors are usually cited as the reason for worse outcomes for PEH patients. Clinically, it would be useful to identify potentially modifiable variables leading to improved outcomes.
We performed a retrospective analysis of a representative sample from 37 states, using the Nationwide Inpatient Sample database over a 5-year period (2001-2005). Patients undergoing any anti-reflux operation with or without hiatal hernia repair were included, and comparison was made based on primary diagnoses of PEH or GERD. Exclusion criteria were diagnosis codes not associated with reflux disease or diaphragmatic hernia, emergency admissions, and age <18. Primary outcome was in-hospital mortality. Two sets of multivariate analyses were performed; one set adjusting for pre-treatment variables (age, gender, race, Charlson Comorbidity Index, hospital teaching status, hospital volume of anti-reflux surgery, calendar year) and a second set adjusting further for post-operative complications (splenectomy, esophageal laceration, pneumothorax, hemorrhage, cardiac, pulmonary, and thromboembolic events, (VTE)).
Of the 23,458 patients, 6,706 patients had PEH. PEH patients are older (60.4 vs. 49.1, p < 0.001) and have significantly more co-morbidities than GERD patients. On multivariate analysis, adjusting for pre-treatment variables, PEH patients are more likely to die and have significantly worse outcomes than GERD patients. However, further adjustment for pulmonary complications, VTE, and hemorrhage eliminates the mortality difference between PEH and GERD patients, while adjustment for cardiac complications or pneumothorax did not eliminate the difference.
While PEH patients have worse post-operative outcomes than GERD patients, we note that differences in mortality are explained by pulmonary complications, VTE, and hemorrhage. The impact of hemorrhagic complications on this group underscores the importance of careful dissection. Additionally, age and co-morbidities alone should not preclude a patient from PEH repair; rather, attention should be focused on peri-operative optimization of pulmonary status and prophylaxis of thromboembolic events.
Journal of Gastrointestinal Surgery 10/2008; 12(12):2119-24. · 2.83 Impact Factor
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ABSTRACT: Venous thrombolism (VTE) is a significant cause of morbidity for surgical patients. Comparative risk across major procedures is unknown.
Retrospective analysis of the Nationwide Inpatient Sample (2001-2005) was conducted. Eight surgeries were identified: bariatric surgery, colorectal surgery, esophagectomy, gastrectomy, hepatectomy, nephrectomy, pancreatectomy, splenectomy. Age < 18, patients with multiple major surgeries, and those admitted for treatment of VTE were excluded. Primary outcome was occurrence of VTE. Independent variables included age, gender, race, Charlson score, hospital teaching status, elective procedures, cancer/metastasis, trauma, and year.
Patients, 375,748, were identified, 5,773 (1.54%) with VTE. Overall death rate was 3.97%, but 13.34% after VTE. Unadjusted rate (0.35%) and adjusted risk for VTE were lowest among bariatric patients. On multivariate analysis, highest risk for VTE was splenectomy (odds ratio 2.69, 95% CI 2.03-3.56). Odds ratio of in-hospital mortality following VTE was 1.84 (1.65-2.05), associated with excess stay of 10.88days and $9,612 excess charges, translating into $55 million/year nationwide.
Highest risk for VTE was associated with splenectomy, lowest risk with bariatric surgery. Since bariatric patients are known to have greater risk for this complication, these findings may reflect better awareness/prophylaxis. Further studies are necessary to quantify effect of best-practice guidelines on prevention of this costly complication.
Journal of Gastrointestinal Surgery 07/2008; 12(11):2015-22. · 2.83 Impact Factor
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ABSTRACT: Brachial artery vasoactivity (BAVA) is a reliable, noninvasive method of assessing endothelium-dependent vasodilatation (EDV) in vivo. Acute hyperglycemia, impaired glucose tolerance (IGT), and diabetes mellitus impair EDV, a precursor to atherosclerosis. Thiamine is a coenzyme important in intracellular glucose metabolism. The purpose of this study was to evaluate the effect of thiamine on BAVA in the presence of hyperglycemia. Ten healthy subjects (group H, mean age 27 years), 10 patients with impaired glucose tolerance by World Health Organization criteria (group IGT, mean age 65 years), and 10 patients with non-insulin-dependent diabetes mellitus (group NIDDM, mean age 50 years) were studied. Duplex ultrasound was used to measure brachial artery flow changes in response to reactive hyperemia following brachial artery tourniquet occlusion for 5 min. This test was performed after a 10 hr fast and at 30, 60, and 120 min after a 75 g oral glucose challenge along with measurements of blood glucose level (BGL). A week later, BAVA evaluation was repeated after administration of 100 mg of intravenous thiamine. BAVA (% increased blood flow) at peak and trough BGL was compared with and without thiamine. BAVA at peak glucose improved from 69.0 +/- 6.4% to 152.8 +/- 22.9% in group H (p < 0.005), from 57.6 +/- 12.6% to 139.7 +/- 12.4% in group IGT (p < 0.005), and from 57.8 +/- 8.3% to 167.8 +/- 11.6% in group NIDDM (p < 0.005) following administration of thiamine. On the other hand, at trough glucose levels, BAVA remained essentially unchanged in group H (prethiamine 83.8 +/- 6.5% vs. post-thiamine 83.8 +/- 17.0%, p > 0.05) as well as group IGT (prethiamine 96.7 +/- 8.5% vs. post-thiamine 104.0 +/- 17.4%, p > 0.05). BAVA at trough glucose was not measured in group NIDDM secondary to trough BGL > 140 mg/dL. EDV was improved by thiamine in the presence of hyperglycemia in healthy subjects and in patients with IGT and NIDDM. The mechanism by which thiamine improves EDV is not due to a glucose-lowering effect as thiamine had no effect on EDV under normoglycemic conditions. Routine administration of thiamine might improve endothelial function and therefore slow the development and progression of atherosclerosis, especially in patients with IGT and NIDDM who are prone to develop accelerated atherosclerosis.
Annals of Vascular Surgery 09/2006; 20(5):653-8. · 1.03 Impact Factor
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ABSTRACT: Laparoscopic Roux-en-Y gastric bypass is quickly replacing open techniques in the morbidly obese patient who presents for surgical treatment. Safety concerns about the laparoscopic technique have arisen in the literature with gastrojejunostomy leak rates of 5% or greater reported in several series.
A total of 251 consecutive gastric bypass operations were performed from August 2001 to January 2004 by a single surgeon with over 6 years' experience. A double layer technique was used for every gastrojejunostomy anastomosis. This consisted of end-to-side stapled anastomosis using only 30 mm of a 45 mm blue (3.5 mm) staple cartridge that was fired inside the gastric pouch and Roux limb. A posterior running suture was then used to reinforce the back wall. An intraluminal 32F bougie was placed before the stapler opening was closed. Finally, 2 running sutures were used to reinforce the anterior and lateral sides of the anastomosis.
The average patient age was 43 years (range, 18-67 years), 89% were female, average preoperative weight was 137 kg (range, 89.5-214.5 kg), and average body mass index of 49 kg/m2 (range, 35-75). One hundred forty-two cases were performed with the Ethicon endoscopic linear stapler and 109 with the United States Surgical endoscopic linear stapler. There were no anastomotic leaks, staple line leaks, pulmonary emboli, or in-hospital deaths recorded. Endoscopic dilation successfully treated 10 (4%) cases of stomal stenosis. Eleven (4%) patients developed marginal ulcers that were easily treated with a proton pump inhibitor. Average excess weight loss at 12 months and 18 months was 63% and 71%, respectively.
Laparoscopic results are as good as or better than open surgery in the morbidly obese patient. The learning curve for this operation is steep and this may be reflected in the higher leak rates reported in earlier series. However, the technique used to create the gastrojejunostomy anastomosis may also account for a lower leak rate. The two-layer gastrojejunostomy anastomotic technique combines an inner stapled layer and outer sutured layer that yields excellent results.
Journal of Laparoendoscopic & Advanced Surgical Techniques 05/2006; 16(2):83-7. · 1.40 Impact Factor
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ABSTRACT: Bariatric surgery is currently the only effective long-term treatment of morbid obesity and its related co-morbidities. Gastric bypass, adjustable gastric banding, and duodenal switch with biliopancreatic diversion are the three most common operations performed in the United States to induce sustained weight loss. Patient selection is important since compliance postoperatively leads to a successful outcome in over 80% of patients. Preoperative psychological and behavioral problems may lead to maladaptive eating habits postoperatively that defeat the purpose of the surgery. To date, we do not have a 100% reliable method of profiling patients who will fail to keep weight off for the long term. It is therefore important that patients who have preoperative psychological problems that may lead to failure to lose or keep weight off after surgery are offered postoperative counseling along with group support.
Advances in psychosomatic medicine 02/2006; 27:53-60.
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Surgery for Obesity and Related Diseases 2(3):413. · 3.93 Impact Factor
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Surgery for Obesity and Related Diseases 2(6):661-3. · 3.93 Impact Factor
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Surgery for Obesity and Related Diseases 2(5):536-7. · 3.93 Impact Factor
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ABSTRACT: Purpose: The management of infected femoral artery pseudoaneurysms (IFAPs) is difficult and controversial. Use of synthetic or autologous conduit during arterial revascularization in these cases is complicated by the presence of sepsis and unavailability of autologous venous conduit. We present the results of common femoral artery (CFA) ligation and local drainage with debridement for the treatment of IFAP. Methods: A retrospective chart review of six consecutive patients from 1995 to 1999 who presented with IFAP from intravenous drug abuse was performed. Inpatient records, anesthesia records, and outpatient clinic charts were reviewed. All patients were men with right-sided lesions. All six patients abused heroin, and five (83%) abused heroin and cocaine. All six patients had a duplex ultrasound scan, and five (83%) patients had a digital subtraction angiogram to confirm the clinical diagnosis. Proximal vascular control was achieved retroperitoneally through an oblique suprainguinal incision. After vascular isolation and test clamping of the distal external iliac artery (EIA), the pedal pulses were examined with continuous wave Doppler scan. If a Doppler signal was present, this was followed with CFA ligation and local drainage and debridement of the IFAP. Results: Pain at injection site and fever with chills were present in five (83%) and three (50%) patients, respectively. A pulsatile groin mass and thigh or leg edema were present in five (83%) patients. Three patients (50%) had a palpable pedal pulse, and all six had a Doppler signal over a pedal artery at presentation. The mean white cell count was 15.6 thousand per cubic millimeter (range, 9.2-19.3). All patients had a Doppler signal over a pedal artery after distal EIA/CFA test occlusion and ligation. None of the patients required an amputation, and all six patients regained their preoperative ambulatory status. The mean follow-up period was 25 months. Two patients had mild claudication (5-6 blocks) at 18 months and 2 years after surgery. All six patients received drug rehabilitation, but they admitted to drug abuse after surgery and rehabilitation. Conclusion: CFA ligation and local debridement are safe treatment modalities for IFAP, if there is an intraoperative Doppler signal over a pedal artery during test occlusion of the distal EIA/CFA. CFA ligation avoids the use and therefore the risk of synthetic conduit infection, because there is a high incidence of postoperative drug injection despite aggressive drug rehabilitation. (J Vasc Surg 2001;33:990-3)
Journal of Vascular Surgery.
