-
[show abstract]
[hide abstract]
ABSTRACT: In selected patients with chronic pancreatitis, total pancreatectomy with islet autotransplantation can be effective for the treatment of intractable pain while ameliorating postoperative diabetes. Improved quality of life scores and decreased daily narcotic use, as indicators of successful pain relief, are expected after total pancreatectomy. These outcomes and their relationship have not been well examined in this patient group.
A prospectively collected database of patients undergoing extensive pancreatectomy with islet autotransplantation for pancreatitis was reviewed. Data pertaining to daily oral morphine equivalents (MEs) and quality of life (QOL), as measured by the SF-12 questionnaire, in the preoperative and postoperative period were reviewed. Approval from the IRB for the evaluation of human subjects was obtained.
Over a 20-month period, 33 patients (25 women, median age 42) underwent extensive pancreatectomy with islet autotransplantation for pancreatitis. Mean follow-up was 9 months with a range of 6-12 months. Postoperative complications occurred in 16 patients (48%). Preoperative QOL scores were a mean 25 for physical component and 32 for mental health component. Postoperatively, physical component scores averaged 33 at 6 months (p = 0.025) and 36 at 12 months (mean increase of 11); the mental health component scores averaged 43 at 6 months (p = 0.007) and 44 at 12 months (mean increase of 12). Preoperative MEs averaged 357 mg daily. At discharge from the hospital, this number increased to 536 mg average MEs daily, a 50% increase, as expected after major surgery in the chronic pain patient. At 6 months, 15 out of 31 patients (48%) required less daily MEs than preoperatively and averaged 161 mg daily (-55%). By 12 months, 11 out of 17 patients (65%) required less daily MEs than preoperatively and averaged 128 mg daily (-64%); four were narcotic-free (23%). Of the six patients who did not decrease their analgesic requirements at 1 year, five (83%) still had an improved physical QOL score (one patient was unchanged) and all six had an improved mental health QOL.
Total pancreatectomy with islet autotransplant is an effective surgery for end-stage chronic pancreatitis. Quality of life improves early postoperatively while decreased narcotic analgesia requirements occur later. Both improved quality of life and decreased narcotic analgesia requirements continue to occur at least up to 1 year postoperatively. Further investigation is needed to assess the durability of total pancreatectomy with islet autotransplantation for severe chronic pancreatitis with respect to pain relief and improved quality of life.
Journal of Gastrointestinal Surgery 01/2012; 16(1):129-33; discussion 133-4. · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In surgical patients, statins have been shown to have beneficial effects independent of the lipid-lowering properties. Statin use has not been well studied in the bariatric patient. The objective of this study was to characterize the use of statins in the bariatric surgery patient and compare outcomes, including complications, weight loss, and changes in comorbidities. A retrospective chart review of patients undergoing bariatric surgery between 2005 and 2008 was conducted. Four hundred forty surgical patients charts were reviewed, of which 151 (34%) were taking a perioperative statin. The two groups were similar in length of stay, baseline body mass index, type of procedure, smoking status, and hospital charges. However, the statin group was older, more likely male, and with more baseline comorbidities, including hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), coronary artery disease, and obstructive sleep apnea (OSA). There was no statistical significance noted in the any complication or death. There was no difference in weight loss over time between the two groups. The statin group was more likely to report resolution in HLD (27.5 vs 9.5%, P = 0.004), but not DM, HTN, or OSA. In summary, there are differences in bariatric patients who take statins compared with their counterparts. Statins with gastric bypass may improve resolution of HLD, which may eventually alter long-term cardiac risk in these patients.
The American surgeon 01/2011; 77(1):44-7. · 1.28 Impact Factor
-
Journal of Gastrointestinal Surgery 07/2010; · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Damage control laparotomy (DCL) has been a major advance in modern trauma care. The principles of damage control which include truncation of operation to correct acidosis, hypothermia, and coagulopathy with subsequent planned definitive repair are applicable in managing patients undergoing abdominal operations. In order to define indications, technique, and outcome, we undertook a retrospective review and analysis of pancreatic surgery patients in whom DCL was utilized.
In a cohort of 835 patients who underwent elective pancreatic operations at the Medical University of South Carolina from 2001 to 2007, eight patients were identified who required DCL. Under Institutional Review Board approval, records were reviewed to define intraoperative blood loss, acidosis, hypothermia, coagulopathy, operative techniques, timing of definitive operation, and hospital outcome.
There were five men and three women with a mean age of 51 years. The diagnosis was chronic pancreatitis in seven patients and cancer in one. The index operation was pancreatoduodenectomy in four patients, distal pancreatectomy in three, and total pancreatectomy in one. In four patients undergoing elective pancreatic resection intraoperative portal vein hemorrhage initiated damage control laparotomy. Four patients had damage control utilized at reoperation for abdominal sepsis (two) and hemorrhage (two). DCL techniques included external tube drainage (eight), abdominal packing (seven), staple closure of open bowel (four), and rapid abdominal closure (four). Operative blood loss ranged from 300 to 12,000 cc. Operative transfusions ranged from 0 to 44 U of packed red cells. Intraoperative INR was greater than 1.5 in four patients, pH ranged from 7.08 to 7.45, and temperature ranged from 34.8 to 38.8 degrees C. Laparotomy for pack removal and intestinal reconstruction was undertaken 1 to 7 days after DCL. Length of hospital stay ranged from 7 to 80 days. Hospital mortality was zero.
Patients with exsanguinating hemorrhage and severe sepsis related to pancreatic surgery can be successfully managed with principles of DCL. Truncation of operation with abdominal packing, bowel closure, external drainage of bile and pancreatic ducts, and rapid abdominal closure with planned subsequent completion laparotomy should be considered in pancreatic operations when patients risk intraoperative acidosis, hypothermia, and coagulopathy due to sepsis or hemorrhage.
Journal of Gastrointestinal Surgery 03/2010; 14(5):768-72. · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Adhesions are common after conventional surgery; natural orifice transluminal endoscopic surgery (NOTES) avoids peritoneal disruption and may reduce adhesions.
To determine whether adhesions (and peritoneal contamination) are less common with NOTES transgastric colon injury and repair (TGCR) than with laparoscopic colon repair (LCR).
Porcine survival study.
After colon preparation and administration of antibiotics, forty 25-kg male pigs were randomly assigned to either TGCR or LCR. TGCR involved an endoscopic gastrotomy (needle-knife plus balloon dilation), CO(2) pneumoperitoneum, and a 2-cm needle-knife transmural incision of spiral colon. Colotomies were repaired with clips; gastrotomies were closed with clips and a detachable snare.
Adhesions were assessed at necropsy at 21 days; biopsy specimens were blindly reviewed. A 9-point adhesion score (density/vascularity, width, and extent) was averaged from 3 reviewers. Peritoneal lavage was sent for cell count and culture.
Two of 20 TGCR pigs died immediately (unrecognized preoperative autopsy-proven pneumonia). The median procedure times were 70.5 and 19.0 minutes for TGCR and LCR, respectively; weight gains were 7.1 and 8.2 kg, respectively. The median adhesion scores were 4.3 and 3.7, respectively (P = .26); subscores were similar (1.9, 1.5, 1.3 vs 1.7, 1.1, 1.0, respectively (P = .3-.6)). Peritoneal lavage bacterial growth was nonsignificantly lower after TGCR than after LCR (38.9% vs 60.0%, respectively; P = .30); administration of intragastric antibiotics did not decrease contamination. Three TGCR (vs no LCR) pigs had histologic peritonitis.
Animal model, colon prepped, injury immediately recognized.
NOTES colon repair is feasible after transmural injury. Adhesions, histologic peritonitis, and contamination were similar to those with laparoscopy and were not helped by intragastric antibiotics.
Gastrointestinal endoscopy 02/2010; 71(4):817-23. · 6.71 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In a recent preliminary trial in 20 patients after gastric bypass surgery, 20 minutes of repetitive transcranial magnetic stimulation (TMS) over the left prefrontal cortex was associated with a 40% reduction in postoperative patient-controlled morphine use. As is the case with all novel scientific findings, and especially those that might have an impact on clinical practice, replicability is paramount. This study sought to test this finding for replication and to more accurately estimate the effect size of this brief intervention on postoperative morphine use and postoperative pain and mood ratings.
Twenty participants who underwent gastric bypass surgery completed this replication and extension study. Beck Depression Inventory and Center for Epidemiological Studies Depression scale scores were collected before surgery and at the time of discharge from the hospital. Immediately after surgery, participants were randomly assigned to receive 20 minutes of real or sham repetitive TMS (rTMS) (10 Hz, 10 seconds-ON, 20 seconds-OFF for a total of 4000 pulses). Patient-controlled morphine pump usage was tracked throughout each participant's postoperative hospital stay. In addition, pain and mood ratings were collected via visual analogue scales twice per day.
Findings from the original postoperative TMS trial were replicated, as cumulative morphine usage curves were significantly steeper among patients receiving sham TMS, and participants receiving real TMS had used 35% less morphine at the time of discharge than participants receiving sham TMS. At the time of discharge, subjects who had received real TMS had used 42.50 mg of morphine, whereas subjects receiving sham TMS had used an average of 64.88 mg. When the data from the original preliminary trial were combined with the data from this replication trial, a significant difference in cumulative morphine usage was observed between subjects receiving real and sham TMS. Overall, participants who received real TMS used 36% less morphine and had significantly lower ratings of postoperative pain-on-average, and pain-at-its-worst than participants receiving sham. In addition, participants who received real TMS rated their mood-at-its-worst as significantly better than participants receiving sham. The effect of a single 20-minute session of TMS on postoperative pain and morphine use appears to be large (Cohen's d = 0.70) and clinically meaningful. Lastly, cross-lag correlational analyses indicate that improvements in mood follow improvements in pain by approximately 12 hours, supporting the notion that postoperative analgesic TMS effects are not driven by antidepressant effects.
Although more research is needed to verify these observed effects independently, findings from the original postoperative TMS trial were replicated. TMS may have the potential to significantly improve current standards of postoperative care among gastric bypass patients, and further studies may be warranted on other surgical populations. Future investigations should use methodology that permits more definitive conclusions about causal effects of TMS on postoperative pain (for example, double-blinding, sham stimulation that is matched with real TMS with respect to scalp discomfort).
Brain Stimulation 04/2008; 1(2):122-7. · 3.76 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The purpose of the study was to examine demographic, immune, endocrine, stress and health characteristics of depressed mothers, measured between 4 and 6 weeks postpartum, and compare them to non-depressed mothers. The top decile (N=25) of Profile of Mood States depression scores was used to categorize mothers as depressed and these data were then compared to means of the remaining mothers (N=175) in a study of stress and immunity during the postpartum. Depressed mothers were younger, had smaller birth weight infants, and their babies experienced more illness symptoms at 4-6 weeks postpartum. Depressed mothers were less likely to be breastfeeding and had lower serum prolactin levels. Depressed mothers were more likely to smoke, to have daytime sleepiness, and more symptoms of infection than non-depressed mothers. Depressed mothers also had higher perceived stress, postpartum stress, and negative life event reports. There was evidence suggesting that depressed mothers had a downregulated hypothalamic-pituitary-adrenocortical (HPA) axis, in that salivary cortisol was lower in depressed mothers. Depressed mothers also had lower serum levels of Interferon-gamma (IFN-gamma) and a lower IFN-gamma/Interleukin-10 (IL-10) ratio in both sera and in whole blood stimulated cultures, suggesting a depressed Th1/Th2 ratio in depressed mothers. The data supports the possibility that postpartum depression may be associated with a dysregulated HPA axis and possible depressed cellular immunity.
Psychoneuroendocrinology 03/2007; 32(2):133-9. · 5.81 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To evaluate predictors of endoscopic findings in symptomatic patients after Roux-en-Y gastric bypass (RYGBP) for obesity.
A retrospective chart review of 1,001 RYGBP procedures was performed. Two hundred twenty-six (23%) patients were identified as having endoscopy to evaluate upper gastrointestinal symptoms following surgery. Polychotomous logistic regression analysis was used to assess predictors of normal endoscopy, marginal ulcers, stomal stenosis, and staple-line dehiscence.
The most common endoscopic findings were 99 (44%) normal postsurgical anatomy, 81 (36%) marginal ulcer, 29 (13%) stomal stenosis, and 8 (4%) staple-line dehiscence. Factors that significantly increase the risk of marginal ulcers following surgery include smoking (AOR = 30.6, 95% CI 6.4-146) and NSAID use (AOR = 11.5, 95% CI 4.8-28). PPI therapy following surgery was protective against marginal ulcers (AOR = 0.33, 95% CI 0.11-0.97). Median time for diagnosis of marginal ulcers following surgery was 2 months, and 77 of 81 (95%) presented within 12 months.
Following RYGBP surgery for obesity, smoking and NSAID use significantly increase the risk of marginal ulceration, and PPI therapy is protective. Because a significant majority of marginal ulcers present within 12 months of surgery, it may be reasonable to consider prophylactic PPI therapy during this time period, especially for high risk patients.
The American Journal of Gastroenterology 11/2006; 101(10):2194-9. · 7.28 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Several recent studies suggest that repetitive transcranial magnetic stimulation can temporarily reduce pain perception in neuropathic pain patients and in healthy adults using laboratory pain models. No studies have investigated the effects of prefrontal cortex stimulation using transcranial magnetic stimulation on postoperative pain.
Twenty gastric bypass surgery patients were randomly assigned to receive 20 min of either active or sham left prefrontal repetitive transcranial magnetic stimulation immediately after surgery. Patient-controlled analgesia pump use was tracked, and patients also rated pain and mood twice per day using visual analog scales.
Groups were similar at baseline in terms of body mass index, age, mood ratings, pain ratings, surgery duration, time under anesthesia, and surgical anesthesia methods. Significant effects were observed for surgery type (open vs. laparoscopic) and condition (active vs. sham transcranial magnetic stimulation) on the cumulative amount of patient-delivered morphine during the 44 h after surgery. Active prefrontal repetitive transcranial magnetic stimulation was associated with a 40% reduction in total morphine use compared with sham during the 44 h after surgery. The effect seemed to be most prominent during the first 24 h after cortical stimulation delivery. No effects were observed for repetitive transcranial magnetic stimulation on mood ratings.
A single session of postoperative prefrontal repetitive transcranial magnetic stimulation was associated with a reduction in patient-controlled analgesia pump use in gastric bypass surgery patients. This is important because the risks associated with postoperative morphine use are high, especially among obese patients who frequently have obstructive sleep apnea, right ventricular dysfunction, and pulmonary hypertension. These preliminary findings suggest a potential new noninvasive method for managing postoperative morphine use.
Anesthesiology 10/2006; 105(3):557-62. · 5.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Bleeding in the early postoperative period after gastric bypass surgery is a rare complication reported in 1-4% of cases. In most cases, the bleeding will be self-limited, resolving after discontinuation of anticoagulation for deep venous thrombosis prophylaxis. Occasionally, however, bleeding can be problematic, resulting in significant postoperative morbidity or even mortality. The purpose of the present study was to review cases of early postoperative gastrointestinal bleeding after gastric bypass to identify possible risk factors and examine outcomes.
A prospective weight loss surgery patient database was reviewed to examine the cases occurring from January 2005 to July 2008. Patients with early postoperative bleeding were identified. The demographics and co-morbidities were compared between those with and without postoperative bleeding. The outcomes of interest included the transfusion requirement, postoperative morbidity, need for reoperation, length of hospital stay, intensive care unit admission, and 30-day mortality.
A total of 776 patients had undergone gastric bypass during the study period. Of these, 26 (3.3%) were identified with early postoperative bleeding. No significant differences were found in the demographics between the patients with early postoperative bleed and those without. Of the patients with early postoperative bleeding, the most common presenting sign or symptom was tachycardia (46%) followed by melena (32%) and hematemesis (18%). The transfusion requirement range was 0-11 U (average 3.2 U/patient). Of the 26 patients, 4 (15%) required intensive care unit admission and 8 (31%) required reoperation. Four gastrointestinal leaks, one stomal ulceration, and one gastrogastric fistula were identified in the early postoperative bleeding group. One patient (3.8%) in the early postoperative bleeding group died. Compared with nonbleeding patients, those with early postoperative bleeding had a significantly longer hospital stay (4.8 versus 3, P <.0001) and greater mortality rate (7.1% versus .9%, P <.01).
Postoperative bleeding is a significant complication after gastric bypass surgery. Although in many cases, the bleeding will be self-limited, it can result in additional notable complications. In the present study, postoperative bleeding contributed to significantly longer hospital stays and resulted in 1 death. A patient with bleeding after gastric bypass should raise due concern, with attention to the potential attendant complications.
Surgery for Obesity and Related Diseases 6(6):643-7. · 3.93 Impact Factor
