Effects of increased intra-abdominal pressure in severe obesity

Effect of patient positioning on intra-abdominal pressure monitoring

BACKGROUND

Intra-abdominal hypertension affects multiple organ systems. Current measurement standard requires supine positioning, which jeopardizes patient safety by increasing the risk for ventilator-associated pneumonia. This study evaluated the relationship between intra-abdominal pressure (IAP) and head-of-bed (HOB) positioning in critically ill intubated patients.

METHODS

IAP measurements were performed using intravesical catheters with manometry. IAP was measured in a range of patient HOB increases from 0 degrees to 45 degrees. Multivariable generalized estimating equation modeling was performed to describe the relationship between IAP and HOB positioning.

RESULTS

Three hundred (300) observations were performed on 37 patients. In multivariable modeling, HOB increase was significantly associated with IAP. Body mass index, positive end-expiratory pressure, temperature, and diagnostic category were significant in this model, whereas age and Riker sedation score were not.

CONCLUSIONS

There is a significant, positive association between IAP and HOB positioning in critically ill patients. Clinically relevant changes in IAP occur at HOB increases >20 degrees.

Quality of Life After Roux-en-Y Gastric Bypass Surgery

The incidence of obesity is rising worldwide, leading to a related increase in obesity-associated comorbidities that directly affect longevity and quality of life. Surgical interventions, including the Roux-en-Y gastric bypass procedure, are available for those who have increased risk for morbidity and mortality as a result of repeatedly failed medical management of obesity. Three months after undergoing gastric bypass surgery, patients were sent a survey based on the Impact of Weight on Quality of Life-Lite instrument. The survey results demonstrated marked improvement in overall quality of life and physical function in this population, as well as the ability to decrease or discontinue medications for obesity-related comorbid conditions.

Obesity and obesity-initiated metabolic syndrome: mechanistic links to chronic kidney disease

There is an epidemic of obesity and the metabolic syndrome in the United States and across the world. Both entities are associated with high mortality, mainly as a result of cardiovascular disease. The epidemic of obesity has been paralleled by an increase in the incidence of chronic kidney disease (CKD). Several recent epidemiologic studies have shown that obesity and the metabolic syndrome are independent predictors of CKD. In addition to diabetes and hypertension, several other mechanisms have been postulated to initiate and maintain kidney injury in patients with obesity and the metabolic syndrome. This article reviews the recent epidemiologic data linking obesity and the metabolic syndrome to CKD and summarizes the potential mechanisms of renal injury in this setting, with a focus on the role of inflammation, lipotoxicity, and hemodynamic factors. Potential preventive and therapeutic modalities based on the limited evidence available are discussed.

Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual

BACKGROUND

The purpose of this study was to analyze the published perioperative results and outcomes of laparoscopic (LVHR) and open (OVHR) ventral hernia repair focusing on complications and hernia recurrences.

METHODS

Data were compiled from all English-language reports of LVHR published from 1996 through January 2006. Series with fewer than 20 cases of LVHR, insufficient details of complications, or those part of a larger series were excluded. Data were derived from 31 reports of LVHR alone (unpaired studies) and 14 that directly compared LVHR to OVHR (paired studies). Chi-squared analysis, Fisher's exact test, and two-tailed t-test analysis were used.

RESULTS

Forty-five published series were included, representing 5340 patients (4582 LVHR, 758 OVHR). In the pooled analysis (combined paired and unpaired studies), LVHR was associated with significantly fewer wound complications (3.8% vs. 16.8%, p < 0.0001), total complications (22.7% vs. 41.7%, p < 0.0001), hernia recurrences (4.3% vs. 12.1%, p < 0.0001), and a shorter length of stay (2.4 vs. 4.3 days, p = 0.0004). These outcomes maintained statistical significance when only the paired studies were analyzed. In the pooled analysis, LVHR was associated with fewer gastrointestinal (2.6% vs. 5.9%, p < 0.0001), pulmonary (0.6% vs. 1.7%, p = 0.0013), and miscellaneous (0.7% vs. 1.9%, p = 0.0011) complications, but a higher incidence of prolonged procedure site pain (1.96% vs. 0.92%, p = 0.0469); none of these outcomes was significant in the paired study analysis. No differences in cardiac, neurologic, septic, genitourinary, or thromboembolic complications were found. The mortality rate was 0.13% with LVHR and 0.26% with OVHR (p = NS). Trends toward larger hernia defects and larger mesh sizes were observed for LVHR.

CONCLUSIONS

The published literature indicates fewer wound-related and overall complications and a lower rate of hernia recurrence for LVHR compared to OVHR. Further controlled trials are necessary to substantiate these findings and to assess the health care economic impact of this approach.

Determinants of success in endoscopic cerebrospinal fluid leak repair

OBJECTIVES

To identify factors influencing success in endoscopic repair of CSF leaks of the anterior skull base.

METHODS

Through retrospective chart review, 24 endoscopic closures of anterior skull base CSF leaks were analyzed for factors correlating with initial repair outcome.

RESULTS

Thirteen patients with either spontaneous leaks or iatrogenic leaks arising from FESS were repaired with significantly lower recurrence rate (8%) than 11 patients with leaks induced by skull base procedures (45%). However, in the latter group, only 14% recurred when the dural defect was directly visualized, whereas leaks always recurred when bony dehiscences were patched in the absence of visible dural defects. Such defects were least frequently localized in patients with craniotomy-induced leaks. A trend toward morbid obesity was also noted among repair failures.

CONCLUSIONS

Direct visualization of the dural defect is essential for endoscopic repair of anterior skull base CSF leaks, with craniotomy-induced leaks being the most challenging to localize. Obesity is another likely factor contributing to repair failure.

Creep behavior of commonly used suture materials in abdominal wall surgery

BACKGROUND

The incidence of incisional hernia after abdominal wall closure is high. Furthermore, recurrence is a significant complication after correction of all abdominal wall hernias. Besides surgeon- and patient-related factors, in this experimental study a third factor, i.e., creep behavior of suture materials, is introduced and evaluated.

MATERIALS AND METHODS

Creep measurements were performed on 0 and 2-0 Prolene (Ethicon, Johnson & Johnson Intl., Somerville, NJ) and 1 and 2-0 PDSII (Ethicon, Johnson & Johnson Intl.) sutures. Two different loads were used representing normal intra-abdominal pressure (IAP) and pathological IAP. A mean percentage of elongation was calculated for each type of suture material. Statistical analysis was performed using analysis of variance.

RESULTS

All suture materials showed significant (3-51%) creep behavior. Prolene sutures showed more creep than PDSII sutures in both loading conditions.

CONCLUSIONS

As significant creep was demonstrated for commonly used suture materials, creep might be a significant influential factor with regard to the etiology of incisional hernias and recurrence after abdominal wall hernia repair.

Body mass index and gastroesophageal reflux disease: a systematic review and meta-analysis

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common cause of morbidity and health-care utilization in many countries. Obesity is a potentially modifiable risk factor, but existing studies have conflicting results, possibly due to differences in study design, definitions, or populations.

METHODS

We performed a systematic review and meta-analysis of studies identified using MEDLINE, the Web of Science electronic database, manual literature review, and a review of expert bibliographies. Studies were included if they: (1) evaluated obesity, body mass index (BMI), or another measure of body size; (2) included data on reflux symptoms, esophagitis, or a GERD-related hospitalization; and (3) reported a relative risk or odds ratio (OR) with confidence intervals or provided sufficient data to permit their calculation.

RESULTS

We identified 20 studies that included 18,346 patients with GERD. Studies from the United States demonstrated an association between increasing BMI and the presence of GERD (95% confidence interval [CI]= 1.36-1.80, overweight, OR = 1.57, P value homogeneity = 0.51, 95% CI = 1.89-2.45, obese, OR = 2.15, P= 0.10). Studies from Europe provided heterogeneous results despite stratification for several factors; individual studies demonstrated both positive associations and no association.

CONCLUSIONS

This analysis demonstrates a positive association between increasing BMI and the presence of GERD within the United States; this relationship became apparent only after stratification by country and level of BMI. These results support the evaluation of weight reduction as a potential therapy for GERD. Further studies are needed to evaluate potential mechanisms and any differences in this relationship among different study populations.

Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions

OBJECTIVE

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. The variety of definitions proposed has led to confusion and difficulty in comparing one study to another.

DESIGN

An international consensus group of critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to standardize definitions for IAH and ACS based upon the current understanding of the pathophysiology surrounding these two syndromes.

METHODS

Prior to the conference the authors developed a blueprint for the various definitions, which was further refined both during and after the conference. The present article serves as the final report of the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of Abdominal Compartment Syndrome (WSACS).

RESULTS

IAH is redefined as an intra-abdominal pressure (IAP) at or above 12 mmHg. ACS is redefined as an IAP above 20 mmHg with evidence of organ dysfunction/failure. ACS is further classified as either primary, secondary, or recurrent based upon the duration and cause of the IAH-induced organ failure. Standards for IAP monitoring are set forth to facilitate accuracy of IAP measurements from patient to patient.

CONCLUSIONS

State-of-the-art definitions for IAH and ACS are proposed based upon current medical evidence as well as expert opinion. The WSACS recommends that these definitions be used for future clinical and basic science research. Specific guidelines and recommendations for clinical management of patients with IAH/ACS are published in a separate review.

Emerging global epidemic of obesity: the renal perspective

Obesity, as a core component of the metabolic syndrome, is among the top ten global health risks classified by the World Health Organization (WHO) as being strongly associated with the development and progression of chronic renal disease--a widely prevalent but often silent condition. Obesity carries elevated risks of cardiovascular morbidity and mortality besides having an array of metabolic complications. Maladaptive glomerular hemodynamics with increased intraglomerular pressure in association with vasoactive, fibrogenic substances released from adipocytes, in addition to cytokines and hormones, are the key factors in the causation of renal injury and the progression of nephron loss among obese subjects.

[Does bariatric surgery cure the metabolic syndrome?]

Metabolic syndrome (MS) is a risk condition for the development of systemic atherosclerotic disease. Morbid obesity is a state of insulin resistance (IR) associated with visceral fat accumulation, which is involved in the development of MS. In severe obesity, conservative therapies promote an improvement of MS, but weight regain is frequent, whereas bariatric surgery promotes a more significant and sustained weight loss. Bariatric surgery is recommended for patients with unsatisfactory response to clinical treatment and with IMC > 40 kg/m(2) or > 35 in case of co-morbidities. In those cases, surgical risk must be acceptable and patients submitted to surgery must be informed about complications and postoperative care. Prevention, improvement and reversion of diabetes (DM2) (70 to 90% of cases) are seen in several bariatric surgery modalities. Disabsorptive are more efficient than restrictive procedures in terms of weight reduction and insulin sensitivity improvement, but chronic complications, such as malnutrition, are also more frequent. Vertical gastroplasty with jejunoileal derivation is a mixed surgery in which the restrictive component predominates. In this modality, reversion of DM2 is due to an increase in insulin sensitivity associated with improved beta cell function. Reversion of MS and its manifestations after bariatric surgery are associated with reduction of cardiovascular mortality and, thus, in severe obesity cases, MS can be considered a surgical condition.

Neurologic complications after surgery for obesity

Bariatric surgical procedures are increasingly common. In this review, we characterize the neurologic complications of such procedures, including their mechanisms, frequency, and prognosis. Literature review yielded 50 case reports of 96 patients with neurologic symptoms after bariatric procedures. The most common presentations were peripheral neuropathy in 60 (62%) and encephalopathy in 30 (31%). Among the 60 patients with peripheral neuropathy, 40 (67%) had a polyneuropathy and 18 (30%) had mononeuropathies, which included 17 (94%) with meralgia paresthetica and 1 with foot drop. Neurologic emergencies including Wernicke's encephalopathy, rhabdomyolysis, and Guillain-Barré syndrome were also reported. In 18 surgical series reported between 1976 and 2004, 133 of 9996 patients (1.3%) were recognized to have neurologic complications (range: 0.08-16%). The only prospective study reported a neurologic complication rate of 4.6%, and a controlled retrospective study identified 16% of patients with peripheral neuropathy. There is evidence to suggest a role for inflammation or an immunologic mechanism in neuropathy after gastric bypass. Micronutrient deficiencies following gastric bypass were evaluated in 957 patients in 8 reports. A total of 236 (25%) had vitamin B(12) deficiency and 11 (1%) had thiamine deficiency. Routine monitoring of micronutrient levels and prompt recognition of neurological complications can reduce morbidity associated with these procedures.

Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach

This paper discusses the behavioral evaluation of patients who seek bariatric surgery and the psychosocial complications most frequently observed in these individuals. The effects of such complications on surgical outcome are briefly examined, as is the challenge of predicting therapeutic response on the basis of preoperative variables. The paper concludes with a description of the goals and methods of a behavioral assessment used at the University of Pennsylvania. This evaluation includes the use of the Weight and Lifestyle Inventory, a questionnaire that guides our interview with patients.

Abdominal Obesity Is an Independent Risk Factor for Chronic Heart Failure in Older People

OBJECTIVES

To examine whether total and abdominal adiposity are risk factors for the development of chronic heart failure (CHF) in older men and women.

DESIGN

Prospective, longitudinal cohort: The Health, Aging and Body Composition study.

SETTING

Memphis, Tennessee, and Pittsburgh, Pennsylvania, metropolitan areas.

PARTICIPANTS

Three thousand seventy-five well-functioning community-dwelling older adults aged 70 to 79.

MEASUREMENTS

Body composition using dual energy X-ray absorptiometry, visceral adipose tissue area using computed tomography, adjudicated CHF.

RESULTS

Of the remaining (640 participants excluded from original group of 3,075) 2,435 participants (1,081 men, 1,354 women) without coronary heart disease or CHF at baseline, there were 166 confirmed diagnoses of CHF during the median+/-standard deviation (SD) follow-up of 6.1+/-1.4 years. After adjustment for age, race, sex, site, education, smoking, and chronic obstructive pulmonary disorder, all adiposity variables (body mass index (BMI), adipose tissue mass, percentage body fat, waist-to-thigh ratio, waist circumference, and visceral and subcutaneous abdominal adipose tissue) were significant predictors of the development of CHF. In a model that included waist circumference and BMI, waist circumference was associated with incident CHF (hazard ratio (HR)=1.27, 95% confidence interval (CI)=1.04-1.54 per SD increase, P=.02), but BMI was not (HR=1.08, 95% CI=0.86-1.35). When waist circumference and percentage fat were included together, both variables were significant predictors of CHF (waist: HR=1.17, 95% CI=1.00-1.36 per SD increase, P=.05; percentage fat: HR=1.47, 95% CI=1.16-1.87 per SD increase, P=.002). Stepwise adjustment for inflammation, hypertension, insulin resistance, and diabetes mellitus did not decrease the relative risk of a greater waist circumference for the development of CHF (all HR=1.27-1.32, 95% CI=1.02-1.61 per SD increase).

CONCLUSION

Abdominal body fat distribution may be a stronger risk factor for CHF than overall obesity.

Obesity and outcome following renal transplantation

Single institution series have demonstrated that obese patients have higher rates of wound infection and delayed graft function (DGF), but similar rates of graft survival. We used UNOS data to determine whether obesity affects outcome following renal transplantation. From the UNOS database, we identified patients who underwent primary kidney-only transplantation between 1997 and 1999. Recipient and donor body mass index (BMI) was categorized as underweight (BMI < 18.5), normal (BMI 18.5-24.9), overweight (BMI 25-29.9), obese (BMI 30-34.9) or morbidly obese (BMI > or = 35). We correlated BMI with intermediate measures of graft outcome and overall graft survival, and created multivariate models to evaluate the independent effect of BMI on graft outcome, adjusting for factors known to affect graft success. The study sample comprised 27,377 recipients. Older age, female sex, African American race and increased comorbidity were associated with obesity (p < 0.001). Compared with normal weight patients, morbid obesity was independently associated with an increased risk of DGF (p < 0.001), prolonged hospitalization (p < 0.001), acute rejection (p = 0.006) and decreased overall graft survival (p = 0.001). Donor BMI did not affect overall graft survival (p > or = 0.07). Recipient obesity is associated with an increased risk of DGF and decreased graft survival following renal transplantation.

Laparoscopic Heller myotomy and Roux-en-Y gastric bypass: a novel operation for the obese patient with achalasia

Morbid obesity is a disease encompassing multiple, significant comorbidities. The only current, reliable, durable treatment of obesity is surgical intervention, most commonly gastric bypass. Achalasia, a swallowing disorder of esophageal motility and failure of the lower esophageal sphincter (LES) to relax, is rarely seen in the morbidly obese patient. Treatment is directed at disruption of the LES to allow passage of food. As medical management usually fails in both disease processes, surgical treatment is often chosen. The patient with both morbid obesity and achalasia presents an unusual challenge for surgical treatment. The standard surgical approach for each disease does not address the other, and may have deleterious consequences on the other condition if approached unilaterally. We present the first case of a patient treated with a concomitant laparoscopic esophagogastric myotomy (LEM) and laparoscopic Roux-en-Y gastric bypass (LRYGBP).

Is Roux-en-Y gastric bypass safe after previous antireflux surgery? Technical feasibility and postoperative symptom assessment

BACKGROUND

Clinically significant morbid obesity is associated with an increased risk of gastroesophageal reflux disease. Vertical Roux-en-Y gastric bypass (RYGBP) is known to eliminate acid (and bile) in the pouch of cardia, which would provide control of reflux symptoms. The aim of our study was to assess the technical considerations, morbidity, and safety of RYGBP after previous antireflux surgery and evaluate postoperative reflux symptoms.

METHODS

Retrospective review of all patients undergoing RYGBP after previous antireflux surgery from three institutions. Follow-up (mean 18 months) data were obtained from medical records and by questionnaire.

RESULTS

A total of 19 patients (18 women and 1 man) underwent standard (n = 18) or distal (n = 1) RYGBP 8 +/- 1 years after Nissen (n = 18) or Toupet (n = 1) fundoplication. Open RYGBP was undertaken in 17 of 19 patients. No postoperative deaths occurred. Substantive complications occurred in 4 patients (21%) and included hemorrhage requiring transfusion, concomitant splenectomy, and reoperation for suspected leak in 2. Of the 19 patients, 16 returned the questionnaire, 15 of whom reported subjective improvement in reflux symptoms after RYGBP compared with after antireflux surgery. No patient in this series required medical therapy for reflux symptoms at the last follow-up visit. The body mass index decreased from 42 +/- 2 kg/m(2) to 32 +/- 2 kg/m(2) (mean +/- SEM); all patients with >or=1 year of follow-up had a body mass index of <or=32 kg/m(2). At last follow-up, 88% of patients were very satisfied subjectively with their outcome.

CONCLUSIONS

RYGBP after previous antireflux surgery is technically feasible and safe, but it is associated with greater complication rates than those seen with other forms of reoperative bariatric procedures. RYGBP results in effective weight loss, controls reflux symptoms, and may be the procedure of choice in morbidly obese patients with previous antireflux surgery, and obese patients requiring surgical treatment for gastroesophageal reflux disease.

Subxiphoid incisional hernias after median sternotomy

BACKGROUND

Subxiphoid hernias are difficult to repair. This study attempts to identify risk factors associated with incisional hernia formation after median sternotomy.

STUDY DESIGN

A retrospective review was conducted on patients undergoing subxiphoid incisional hernia repair between 1995 and 2002. The study group was compared with a group undergoing similar cardiothoracic procedures as to body mass index (BMI), comorbidities, complications, tobacco use, length of stay, ICU stay, bypass time, transfusion requirements, and wound infections. Statistical analysis utilized Student's t-test, chi-square, and Kaplan-Meier analysis.

RESULTS

A total of 117 subxiphoid hernias were repaired; 45 were used for comparison with a matched cohort of 79 patients. Average time between sternotomy and hernia repair was 24.3 months (+/-16.8) with 22 (49%) patients developing hernias within 2 years. Mean followup was 48 months. The study group differed significantly from the nonhernia group in age (56.6 +/- 13.0 versus 62.2 +/- 8.9, p = 0.01), mean length of stay (16.3 +/- 22.8 versus 10.2 +/- 6.7, p = 0.03), BMI (29.6 +/- 4.5 versus 27.2 +/- 4.5, p = 0.01), number of transplantation patients (10 versus 1, p = 0.0003), and presence of sternal wound infection (18% versus 3.9%, p = 0.02). Multivariate analysis revealed significance in regard to transfusion requirements (p = 0.015) and approached statistical significance with BMI (p = 0.058). Of the 45 patients undergoing hernia repair, 31(69%) had a mesh repair and 10 (32%) patients recurred. Six (43%) patients without a mesh repair recurred. Seventy-five percent of the patients with sternal wound infections developed recurrent hernias.

CONCLUSIONS

Transfusion requirements, BMI, and sternal wound infections might be associated with subxiphoid hernias after median sternotomy. Sternal wound infection increases the risk of recurrent incisional hernia.

Association of nausea and vomiting in pregnancy with lower body mass index

OBJECTIVE

To assess the effect of body mass index (BMI) on the tendency of pregnant women to vomit and on their general condition during pregnancy.

STUDY DESIGN

We included patients in this study who presented to our gynecological emergency room and clinic during their first trimester of pregnancy. All women completed a questionnaire assessing obstetrical and physical characteristics, including gravidity, parity, gestational age, height and weight for BMI calculation. Women were requested to report the number of vomiting episodes per day and their general condition using a 1 to 10 scale (1-good, 10-bad). Patients were allocated to either a low-frequency group (0-1 vomiting episodes per day) or to a high-frequency group (2 and more vomiting episodes per day).

RESULTS

Sixty-one consecutive women were included in the study. The low frequency group consisted of 35 women and the high frequency group included the remaining 26 women. The BMI was significantly lower in the high frequency group as compared to the low frequency group (21.8 +/- 3.5 versus 24.4 +/- 4.7, respectively; P <0.05). Patients in the high frequency group also reported a worse general condition than those in the low frequency group (7.6 +/- 2.2 versus 3.5 +/- 2.1, respectively; P <0.05).

CONCLUSION

Patients with higher frequency of vomiting episodes during the first trimester of pregnancy tend to have a lower BMI score and a worse general condition than patients with low frequency of vomiting episodes.

Prospective Evaluation of Higher Energy Great Saphenous Vein Endovenous Laser Treatment

PURPOSE

In this study, the hypothesis that higher energy dose improves procedural success without increasing complications was prospectively evaluated by performing endovenous laser therapy (ELT) at energies greater than 80 J/cm.

MATERIALS AND METHODS

One hundred consecutive great saphenous (GSV), anterior accessory great saphenous (AAGSV), or posterior accessory great saphenous (PAGSV) veins were treated with the intent to deliver an energy dose of greater than 80 J/cm. Eighty-one patients (64 women, 17 men) were treated. Mean age was 49 years (range, 25-77 years; SD, 12 years). Ultrasound (US) and clinical follow-up was performed at 1 week, 3, 6, 9, and 12 months until all veins had at least 3 months of follow-up. Success was defined as absence of reflux throughout the entire treated segment on follow-up US and clinical resolution of symptoms. Incomplete vein ablation was defined as US evidence of flow in a segment of a treated vein at any point during the follow-up period.

RESULTS

One hundred veins were treated with an average energy of 95 J/cm (range, 57-145 J/cm; SD, 16 J/cm). Follow-up and success at 1 week was 100%. Four veins could not be followed up beyond 1 week. Of the 96 remaining veins all had 3 months follow-up with an average follow-up of 9 months (range, 3-13 months; SD, 4 months). There were five failures and 91 successes for a success rate of 95%. Four of the treatment successes demonstrated segmental patency but no reflux on US for a complete vein ablation rate of 91%. No major complications occurred. The treatment failures occurred at an average energy dose of 98 J/cm. Two of the three failures were AAGSVs, one was a GSV ipsilateral to one of the failed AAGSVs, and two were bilateral GSVs treated during the same procedure. Average body mass index (BMI) was 30 for the successes and 46 for the failures. This difference was statistically significant (P = .0009). The mean length of the failed treatments from the saphenofemoral junction to their termination into a varicose tributary was 10.9 (range, 8-15 cm; SD, 3.7 cm). This was significantly less than the length of the successful treatments (P = .000003).

CONCLUSION

Higher energy GSV ELT is safe and highly successful.

The impact of laparoscopy on bariatric surgery

The rising popularity of bariatric surgery over the past several years is attributable in part to the development of laparoscopic bariatric surgery. Morbidly obese patients have associated comorbid conditions that may predispose them to postoperative morbidity. The laparoscopic approach to bariatric surgery offers a minimally invasive option that reduces the physiologic stress and provides clinical benefits, as compared with the open approach. This review summarizes the impact of laparoscopic surgery on bariatric surgery, the various risk factors that could potentially predispose morbidly obese patients to postoperative morbidity, the fundamental differences between laparoscopic and open bariatric surgery, and the physiology of reduced tissue injury associated with laparoscopic bariatric surgery.

Mesenteric venous thrombosis with transmural intestinal infarction: a population-based study

OBJECTIVE

To determine the cause-specific mortality from and incidence of transmural intestinal infarction caused by mesenteric venous thrombosis (MVT) in a population-based study and to evaluate the findings at autopsy by evaluating autopsies and surgical procedures.

METHODS

All clinical (n = 23,446) and forensic (n = 7569) autopsies performed in the city of Malmö between 1970 and 1982 (population 264,000 to 230,000) were evaluated. The autopsy rate was 87%. The surgical procedures were performed in 1970, 1976, and 1982. Autopsy protocols coded for intestinal ischemia or mesenteric vessel occlusion, or both, were identified in a database. In all, 997 of 23,446 clinical and 9 of 7,569 forensic autopsy protocols were analyzed. A 3-year sample of the surgical procedures, comprising 21.3% (11,985 of 56,251) of all operations performed during the entire study period, was chosen to capture trends of diagnostic and surgical activity. In a nested case-control study within the clinical autopsy cohort, four MVT-free controls, matched for gender, age at death, and year of death were identified for each fatal MVT case to evaluate the clinical autopsy findings.

RESULTS

Four forensic and 23 clinical autopsies demonstrated MVT with intestinal infarction. Seven patients were operated on, of whom six survived. The cause-specific mortality ratio was 0.9:1000 autopsies. The incidence was 1.8/100,000 person years. At autopsy, portal vein thrombosis and systemic venous thromboembolism occurred in 2 of 3 and 1 of 2 of the cases, respectively. Obesity was an independent risk factor for fatal MVT (P =.021).

CONCLUSIONS

The estimated incidence of MVT with transmural intestinal infarction was 1.8/100,000 person years. Portal vein thrombosis, systemic venous thromboembolism and obesity were associated with fatal MVT.

The Midabdominal TRAM Flap for Breast Reconstruction in Morbidly Obese Patients

The transverse rectus abdominis myocutaneous (TRAM) flap is ideal for postmastectomy reconstruction but is tenuous in morbidly obese patients. Because of their relatively high incidence of postoperative complications, morbidly obese patients are often not considered candidates for autogenous reconstruction. The midabdominal TRAM flap has a more favorable anatomy and may represent an alternative technique in this patient population. The records of 18 morbidly obese patients who underwent postmastectomy reconstruction using a mid-abdominal TRAM flap from 1998 through 2002 were retrospectively reviewed. The mid-abdominal TRAM flap territory includes more of the supraumbilical region than the traditional TRAM flap, corresponding to an area with more abundant musculocutaneous perforators and greater dependence on the superior epigastric vascular system. All patients underwent unipedicled mid-abdominal TRAM flap surgery. Four patients with previous subumbilical midline incisions had a delay procedure with ligation of the inferior epigastric vessels. Complications investigated were flap necrosis greater than 10 percent or sufficient to require surgical revision, abdominal donor-site breakdown, seroma formation, umbilical necrosis, abdominal wall bulging or hernia, deep vein thrombosis, infected mesh, surgical revisions, fat necrosis, and extended hospital stay. At a mean follow-up time of 15.6 months (range, 12 to 24 months), three patients had postoperative complications requiring surgical revision. Two of these patients had previous midline abdominal incisions. One patient had both partial flap necrosis and a donor-site complication. The second patient had partial flap necrosis, and the third had an abdominal donor-site complication. No occurrences of abdominal wall hernia, total flap loss, deep vein thrombosis, infected mesh, extensive surgical revision, or extended hospitalization were noted in this series. The mid-abdominal TRAM flap represents an alternative method for postmastectomy breast reconstruction in morbidly obese patients. Autologous reconstruction using a midabdominal TRAM flap may be considered in this patient population; however, additional research is required to conclusively demonstrate an improved outcome when compared with traditional reconstructive methods.

Resolution of pseudotumor cerebri after bariatric surgery for related obesity

✓ Two obese women, both of whom were 42 years of age, were examined for pseudotumor cerebri. Intracranial venography revealed increased pressure in the dural venous sinuses and the right atrium. The increased right atrial pressure was attributable to the patients' obesity. Both patients underwent bariatric surgery to achieve weight loss. Approximately 1 year later, a clinical evaluation showed that in both women the pseudotumor cerebri had resolved. Repeated measurements of dural venous pressure indicated that the patients' pressures had returned to normal. Obese patients with pseudotumor cerebri and stable visual symptoms are best treated with weight loss to avoid shunt placement or optic nerve sheath fenestration.

Behavioral Therapies at the Primary Care Level

Urinary incontinence, the complaint of any involuntary loss of urine, is a troubling symptom experienced by men and women of all ages. Options for treatment include a range of behavioral, pharmacologic, and surgical therapies. Behavioral therapies, such as dietary modification, pelvic floor muscle training, and bladder training, are noninvasive, with little risk of side effects, and experts agree they should represent the first line of treatment whenever possible. These therapies can be initiated and monitored at the primary care level, thereby enhancing the accessibility of care for those affected. The purpose of this article is to methodically review what is and is not known about behavioral therapies, with attention to research needs. Although there is clear evidence for pelvic floor muscle training in women with urinary incontinence and modest evidence in men for a short time after radical prostatectomy, less is known about bladder training, prompted voiding, habit retraining, and timed voiding. Additional research is required to enhance our understanding of the comparative efficacy of behavioral interventions in specific populations. This research must take an increasingly long-term focus, given the potentially chronic nature of urinary incontinence.

A 25-year experience with open primary transthoracic repair of paraesophageal hiatal hernia

OBJECTIVE

The optimal surgical treatment of paraesophageal hiatal hernia is in debate. Our experience with a traditional transthoracic approach was reviewed to provide "benchmark" data against which newer surgical techniques can be measured.

METHODS

Between 1977 and 2001, 240 patients had primary transthoracic repair of paraesophageal hiatal hernia. Presenting complaints included reflux (69%), pain (67%), dysphagia (36%), and bleeding or anemia (33%). Preoperative esophageal function testing showed abnormal reflux in 86%. Hernia types were combined (type III) in 92% and type IV in 8%. All patients had reduction of the hernia and a concomitant antireflux procedure. An esophageal lengthening Collis gastroplasty was performed in 96%.

RESULTS

There were 3 perioperative deaths (1.7%). The median length of hospital stay was 7 days. Early complications requiring reoperation occurred in 12 patients (5%) and included recurrent hernia in 4, leak in 3, and a tight hiatal closure in 3. Mean follow-up in 226 patients was 42 months (median 27.8 months). Satisfactory results were obtained in 86% of patients. Follow-up complaints (moderate or persistent symptoms) included dysphagia (4), reflux (1), dumping (3), and post-thoracotomy pain (1). Routine postoperative barium radiographs showed intact repair in 71% (108/153). Of 19 patients with an anatomic recurrence, 4 (2%) had more than a partial asymptomatic migration of the fundoplication and required reoperation. Postoperative esophageal function testing, obtained in 28% of the patients, showed abnormal gastroesophageal reflux in 2.

CONCLUSION

Open transthoracic repair of paraesophageal hiatal hernia provides good to excellent long-term control of both the hernia and gastroesophageal reflux with relatively low early morbidity.

Gastrointestinal symptoms are more intense in morbidly obese patients

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass is an effective treatment for morbid obesity. However, little information is available on gastrointestinal (GI) symptomatology in this population. This study compares GI symptoms in morbidly obese patients to that of control subjects.

METHODS

A previously validated, 19-point GI symptom questionnaire was administered prospectively to each patient seen for surgical consultation for morbid obesity. The symptoms were then grouped into 6 clusters as follows: (1) abdominal pain, (2) irritable bowel, (3) GERD, (4) reflux, (5) sleep disturbance, (6) dysphagia. The result of each cluster of symptoms expressed as mean +/- standard deviation of obese versus control is compared using student's t-test with significance p = 0.05.

RESULTS

Forty-three patients (40 female, 3 male) age 37.3 +/- 8.6 with BMI 47.8 +/- 4.9, and 36 healthy control subjects (23 female, 13 male), age 39.8 +/- 11.2, completed the questionnaire. Results of each cluster for morbid obese vs control subjects are expressed as mean +/- standard deviation: Abdominal pain 25.3 +/- 18.0 vs 12.1 +/- 11.4, p = 0.0002; irritable bowel 23.0 +/- 14.8 vs 15.6 +/- 13.3, p = 0.02; GERD 40.3 +/- 18.9 vs 22.3 +/- 16.1, p = 0.0001; reflux 29.9 +/- 19.0 vs 11.8 +/- 13.4, p = 0.0001; sleep disturbance 50.6 +/- 28.9 vs 32.9 +/- 26.8, p = 0.006; dysphagia 10.9 +/- 15.6 vs 7.2 +/- 10.6, p = NS.

CONCLUSIONS

Morbidly obese patients experience more intense GI symptoms than normal subjects, whereas dysphagia is equivalent to normal subjects. These data may be important in counseling patients and understanding that their complaints are legitimate. Follow-up in the postoperative period is needed to determine if these symptoms are improved with an operation.

Application of laparoscopy for bariatric surgery in adolescents

An epidemic increase in adolescent obesity in the United States has resulted in significant obesity-related comorbidities, previously seen only in adults. Although bariatric surgery is an acceptable alternative for weight loss in severely obese adults, no conclusions have been made about the appropriateness of bariatric surgery for individuals younger than 18 years old. Nonetheless, bariatric surgery is increasingly being performed on adolescents with clinically severe obesity and experience suggests that it is effective and safe. Application of the principles of adolescent growth, development, and compliance is essential to avoid adverse physical, cognitive, and psychosocial outcomes following bariatric surgery. Bariatric surgery should be part of a multidisciplinary approach to the management of adolescents with clinically severe obesity and should be performed by specialists dedicated to pediatric care, in institutions capable of meeting the guidelines for surgical treatment outlined by the American Society of Bariatric Surgery.

Conditions of iodine contrast transfer from lumbosacral CSF to blood

PURPOSE

To determine conditions which influence transfer of iopamidol from lumbosacral cerebrospinal fluid (CSF) to blood.

METHODS

Iopamidol transfer was measured in 32 patients over 180 min after radiculography and compared with patient variables.

RESULTS

Iopamidol transfer began early in 12 patients, more slowly in 13 patients, and was not detected during sample period in 7 patients. Transfer of sequential samples correlated highly with each other (r>0.8). Transfer was more pronounced in patients with prominent nerve root sleeves on radiculogram (p=0.006, t test), and correlated inversely with body weight (r=-0.4258), and with albumin CSF/serum quotient (r=-0.4702).

CONCLUSION

Early iopamidol transfer probably indicates transfer through spinal arachnoid villi and granulations with CSF bulk flow. Prominent nerve root sleeves may facilitate access to transfer sites. No transfer during sample period suggests no such spinal transfer, possibly due to sparse access to or presence of spinal transfer sites. Inverse correlation of transfer with body weight may reflect influence of body weight on retroperitoneal venous pressure, which regulates outflow of CSF and of compounds dissolved in it. Awareness of wide interindividual transfer variation and steady intraindividual transfer may help to specify dosage and effect expectation of intrathecal drug therapy.