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ABSTRACT: BACKGROUND: Acute respiratory failure (ARF) can be a life-threatening postoperative complication after bariatric surgery and is defined as the presence of acute respiratory distress or pulmonary insufficiency. We sought to identify predictors of ARF in patients who underwent bariatric surgery. METHODS: Using the Nationwide Inpatient Sample database, from 2006 to 2008, the clinical data from morbidly obese patients who underwent bariatric surgery were examined. Multivariate regression analysis was performed to identify the independent factors predictive of ARF. The factors examined included patient characteristics, co-morbidities, payer type, teaching status of hospital, surgical techniques (laparoscopic versus open), and type of bariatric operation (gastric bypass versus nongastric bypass). RESULTS: A total of 304,515 patients underwent bariatric surgery during the 3-year period. The overall ARF rate was 1.35%. The greatest rate of ARF (4.10%) was observed after open gastric bypass surgery. The ARF rate was lower after laparoscopic than after the open surgical technique (.94% versus 3.87%, respectively; P < .01) and after nongastric bypass versus gastric bypass (.82% versus 1.54%, respectively; P < .01). Using multivariate regression analysis, congestive heart failure (adjusted odds ratio [AOR] 5.1), open surgery (AOR 3.3), chronic renal failure (AOR 2.9), gastric bypass (AOR 2.5), peripheral vascular disease (AOR 2.4), male gender (AOR 1.9), age >50 years (AOR 1.8), Medicare payer (AOR 1.8), alcohol abuse (AOR 1.8), chronic lung disease (AOR 1.6), diabetes mellitus (AOR 1.2), and smoking (AOR 1.1) were factors associated with greater rates of ARF. Compared with patients without ARF, patients with ARF had significantly greater in-hospital mortality (5.69% versus .04%, P < .01). CONCLUSION: We identified multiple risk factors that have an effect on the development of acute respiratory failure after bariatric surgery. Surgeons should consider these factors in surgical decision-making and inform patients of their risk of this potentially life-threatening complication.
Surgery for Obesity and Related Diseases 03/2012; · 3.93 Impact Factor
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The Journal of the American Academy of Orthopaedic Surgeons 10/2011; 19(10):644-7. · 2.66 Impact Factor
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ABSTRACT: Patient characteristics and comorbidities, payer type, and operative technique (laparoscopic vs open) predict the risk of gastrointestinal (GI) tract leak in patients with morbid obesity undergoing gastric bypass.
Retrospective database analysis.
Nationwide Inpatient Sample.
Between January 1, 2006, and December 31, 2008, patients who underwent open or laparoscopic gastric bypass to treat morbid obesity.
Factors predictive of GI tract leak using multivariate regression analyses.
A total 226,452 patients underwent laparoscopic (81.2%) or open (18.8%) gastric bypass during the 3-year period. Most patients were female (80.5%) and of white race/ethnicity (73.6%). The mean age of patients was 43.6 years; 30.0% of patients were older than 50 years. The overall prevalence of in-hospital GI tract leak was 0.7%. The GI tract leak rate was significantly lower in laparoscopic compared with open gastric bypass (0.3% vs 2.0%, P < .01). Using multivariate regression analysis, factors associated with higher risk of GI tract leak were open gastric bypass (adjusted odds ratio [aOR], 4.85), congestive heart failure (aOR, 3.04), chronic renal failure (aOR, 2.38), age older than 50 years (aOR, 1.82), Medicare payer (aOR, 1.54), male sex (aOR, 1.50), and chronic lung disease (aOR, 1.21). The GI tract leak rate was unaffected by race/ethnicity, hypertension, diabetes mellitus, sleep apnea, hyperlipidemia, liver disease, peripheral vascular disease, or smoking.
We identified multiple factors associated with the higher risk of GI tract leak after gastric bypass. Surgeons should use this knowledge to counsel patients and possibly alter operative plans in high-risk patients to minimize this risk.
Archives of surgery (Chicago, Ill.: 1960) 09/2011; 146(9):1048-51. · 4.32 Impact Factor
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Journal of cardiothoracic and vascular anesthesia 08/2011; · 1.06 Impact Factor
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ABSTRACT: Certain clinical environments, including military field hospitals or rural medical centers, lack readily available surgical subspecialists. We hypothesized that telementoring by a surgical subspecialist using a robotic platform is feasible and can convey subspecialty knowledge and skill to a remotely located general surgeon.
Eight general surgery residents evaluated the effect of remote surgical telementoring by performing 3 operative procedures, first unproctored and then again when teleproctored by a surgical subspecialist. The clinical scenarios consisted of a penetrating right ventricular injury requiring suture repair, an open tibial fracture requiring external fixation, and a traumatic subdural hematoma requiring craniectomy. A robotic platform consisting of a pan-and-tilt camera with laser pointer attached to an overhead surgical light with integrated audio allowed surgical subspecialists the ability to remotely teleproctor residents. Performance was evaluated using an Operative Performance Scale. Satisfaction surveys were given after performing the scenario unproctored and again after proctoring.
Overall mean performance scores were superior in all scenarios when residents were proctored than when they were not (4.30 +/- 0.25 versus 2.43 +/- 0.20; p < 0.001). Mean performance scores for individual metrics, including tissue handling, instrument handling, speed of completion, and knowledge of anatomy, were all superior when residents were proctored (p < 0.001). Satisfaction surveys showed greater satisfaction and comfort among residents when proctored. Proctored residents believed the robotic platform facilitated learning and would be feasible if used clinically.
This study supports the use of surgical teleproctoring in guiding remote general surgeons by a surgical subspecialist in the care of a wounded patient in need of an emergency subspecialty operation.
Journal of the American College of Surgeons 09/2010; 211(3):400-11. · 4.55 Impact Factor
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ABSTRACT: Intraluminal pancreatic enzymes have been shown in animal models to be associated with multiple organ failure after hemorrhagic shock, independent of pancreatitis. The translocation of these enzymes into the circulation may serve as a marker of hemorrhagic shock-induced gut ischemia in critically injured trauma patients. We hypothesized that serum amylase and lipase would be significantly elevated in patients presenting in hemorrhagic shock and in those who develop organ failure.
: Review of a prospective database at a level-1 trauma center from 2000 to 2005. Two thousand seven hundred eleven critically injured trauma patients without pancreatic injuries were evaluated for shock (systolic pressure <90 mm Hg in the emergency department), massive transfusion (10 units of packed red blood cells within the first 24 hours), and organ failure (standard criteria for acute pulmonary, cardiovascular, renal, and hepatic system failure were used). Serum levels >2 times the upper limit of normal for amylase (30-130 U/L) and lipase (7-60 U/L) were defined as elevated. Univariate analyses were performed with the Pearson's chi, and binary logistic regression was used to determine significant risk factors for organ failure. Results with a p value <0.05 were considered significant and are reported.
: Patients with elevated amylase (n = 481, 18%) were more likely to present in shock (16% vs. 8%), require massive transfusion (19% vs. 9%), develop organ failure (34% vs. 16%), and die (23% vs. 13%). Patients with elevated lipase (n = 288, 11%) were more likely to require massive transfusion (18% vs. 10%) and develop organ failure (43% vs. 16%). Independent predictors of organ failure were age (odds ratio [OR] = 1.016), Injury Severity Score (OR = 1.02), massive transfusion (OR = 3.1), elevated amylase (OR = 1.9), and elevated lipase (OR = 3.2). Elevated amylase was also an independent predictor of mortality (OR = 1.3).
: Serum levels of pancreatic enzymes are elevated in patients who present in shock or require a massive transfusion and are independent predictors of organ failure. Whether these elevations are caused by ischemic pancreatitis or the translocation of intraluminal enteric pancreatic enzymes is uncertain and future studies are needed. Trauma patients with elevated pancreatic enzymes in the absence of a pancreatic injury have an increased risk of morbidity and mortality.
The Journal of trauma 09/2009; 67(3):445-9. · 2.48 Impact Factor
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ABSTRACT: Accurate evaluation of programmed cell death, or apoptosis, in chondrocytes is essential to studying cartilage injury. We evaluated four methods of detecting chondrocyte-programmed cell death in formalin-fixed, paraffin-embedded cartilage after experimental osteochondral fracture. Human osteochondral explants were subjected to experimental fracture in a manner known to induce high levels of chondrocyte-programmed cell death. After 4 days in culture, specimens were fixed and analyzed for programmed cell death using: (1) terminal deoxynucleotidyl transferase end labeling; (2) DNA denaturation analysis using an antibody specific for single-stranded DNA; (3) immunohistochemistry using antisera specific for active caspase-3; and (4) in situ oligonucleotide ligation. Quantitative analysis of programmed cell death levels for each technique was performed comparing injured and uninjured areas of cartilage. We observed differences between injured and uninjured areas of cartilage using the four methods. Human cartilage fixed in zinc-formalin and embedded in paraffin is amenable to programmed cell death analysis using any of four independent methods, each of which ostensibly has some advantages in terms of assaying different steps along the apoptotic pathway. Using the protocols described in this article, investigators may have additional tools to identify and quantify chondrocytes undergoing programmed cell death after experimental cartilage injury.
Clinical Orthopaedics and Related Research 05/2009; 467(7):1877-84. · 2.53 Impact Factor
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ABSTRACT: Managing articular cartilage injury continues to be a difficult challenge for the clinician. Although the short- and intermediate-term results of autologous chondrocyte implantation appear to be favorable, resources are being directed toward research to improve the technology. One promising area of investigation is the combination of cultured chondrocytes with scaffolds. Clinicians desire techniques that may be implanted easily, reduce surgical morbidity, do not require harvesting of other tissues, exhibit enhanced cell proliferation and maturation, have easier phenotype maintenance, and allow for efficient and complete integration with surrounding articular cartilage. The characteristics that make scaffolds optimal for clinical use are that they be biocompatible, biodegradable, permeable, reproducible, mechanically stable, noncytotoxic, and capable of serving as a temporary support for the cells while allowing for eventual replacement by matrix components synthesized by the implanted cells. Clinical experience is growing with three scaffold-based cartilage repair techniques, each using a different type of scaffold material: matrix-induced autologous chondrocyte implantation, a hyaluronic acid-based scaffold, and a composite polylactic/polyglycolic acid polymer fleece. Clinical results are encouraging. Future directions in scaffold-based cartilage repair include bioactive and spatially oriented scaffolds.
The Journal of the American Academy of Orthopaedic Surgeons 06/2008; 16(6):306-11. · 2.66 Impact Factor
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ABSTRACT: The specialty of trauma is at a crossroads. Choosing a career in trauma is associated with concerns related to lifestyle issues and maintenance of adequate operative experience. Trauma and critical care surgeons in the U.S. have reexamined their role based on these concerns and the realization that surgeon resources for the injured patient are in jeopardy. After much work over the past five years, a model of "Acute Care Surgery" has emerged and a training curriculum has been proposed. This article reviews the evolution of a new specialty and identifies some of the challenges and opportunities associated with the implementation of this model.
World Journal of Surgery 05/2008; 32(8):1630-5. · 2.36 Impact Factor
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The Journal of Bone and Joint Surgery 06/2004; 86-A(5):1051-6. · 3.27 Impact Factor
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The Journal of Bone and Joint Surgery 02/2003; 85-A(1):126-8. · 3.27 Impact Factor
