Technical and practical considerations involved in operations on patients weighing more than 270 kg

What is the role of selection bias in quality comparisons between the Veterans Health Administration and community care? Example of elective hernia surgery

OBJECTIVE

To investigate the relationship between community care (CC) treatment and a postoperative surgical complication in elective hernia surgery among Veterans using multiple approaches to control for potential selection bias.

DATA SOURCES AND STUDY SETTING

Veterans Health Administration (VHA) data sources included Corporate Data Warehouse (VHA encounters and patient data), the Program Integrity Tool and Fee tables (CC encounters), the Planning Systems Support Group (geographic information), and the Paid file (VHA primary care providers).

STUDY DESIGN

Prior works suggest patient outcomes are better in VHA than in CC settings; however, these studies may not have appropriately accounted for the selection of higher-risk cases into CC. We estimated (1) a naïve logistic regression model to calculate the effect of CC setting on the probability of a complication, controlling for facility fixed effects and patient and procedure characteristics, and (2) a 2-stage model using the hernia patient's primary care provider's 1-year prior CC referral rate as the instrument.

DATA COLLECTION

We identified patients residing ≤40 miles from a VHA surgical facility with elective VHA or CC hernia surgery from 2018 to 2019.

PRINCIPAL FINDINGS

Of 7991 hernia surgeries, 772 (9.7%) were in CC. The overall complication rate was 4.2%; 286/7219 (4.0%) among VHA surgeries versus 51/5772 (6.6%, p < 0.05) in CC. We observed a 2.8 percentage point increase in the probability of postoperative complication given CC surgery (95% confidence interval: 0.7, 4.8) in the naïve model. After accounting for the VHA provider's historical rate of CC referral, we no longer observed a relationship between surgery setting and risk of postoperative complication.

CONCLUSIONS

After accounting for the selection of higher-risk patients to CC settings, we found no difference in hernia surgery postoperative complications between CC and VHA. Future VHA and non-VHA comparisons should account for unobserved as well as observed differences in patients seen in each setting.

The Impact of BMI on Adult Blunt Trauma Outcomes

Traumatic injuries account for 10% of all mortalities in the United States. Globally, it is estimated that by the year 2030, 2.2 billion people will be overweight (BMI ≥ 25) and 1.1 billion people will be obese (BMI ≥ 30). Obesity is a known risk factor for suboptimal outcomes in trauma; however, the extent of this impact after blunt trauma remains to be determined. The incidence, prevalence, and mortality rates from blunt trauma by age, gender, cause, BMI, year, and geography were abstracted using datasets from 1) the Global Burden of Disease group 2) the United States Nationwide Inpatient Sample databank 3) two regional Level II trauma centers. Statistical analyses, correlations, and comparisons were made on a global, national, and state level using these databases to determine the impact of BMI on blunt trauma. The incidence of blunt trauma secondary to falls increased at global, national, and state levels during our study period from 1990 to 2015, with a corresponding increase in BMI at all levels ( P < 0.05). Mortality due to fall injuries was higher in obese patients at all levels ( P < 0.05). Analysis from Nationwide Inpatient Sample database demonstrated higher mortality rates for obese patients nationally, both after motor vehicle collisions and mechanical falls ( P < 0.05). In obese and nonobese patients, regional data demonstrated a higher blunt trauma mortality rate of 2.4% versus 1.2%, respectively ( P < 0.05) and a longer hospital length of stay of 4.13 versus 3.26 days, respectively ( P = 0.018). The obesity rate and incidence of blunt trauma secondary to falls are increasing, with a higher mortality rate and longer length of stay in obese blunt trauma patients.

Bariatric surgery operating room time--size matters

BACKGROUND

The goal of this study was to document the relationship between BMI and the components of bariatric surgical operating room (OR) time.

METHODS

The Stanford Translational Research Integrated Database Environment identified all patients who underwent laparoscopic Roux-en-Y gastric bypass procedures at Stanford University Medical Center between May 2008 and November 2013. The 434 patients were divided into 3 groups: group 1 (n = 213) BMI ≥35 to <45 kg/m(2), group 2 (n = 188) BMI ≥45.0 to <60 kg/m(2), and group 3 (n = 33) BMI ≥60 kg/m(2). The primary variable measured was total operating room time, defined as beginning when the patient entered the OR until the moment the patient physically left the OR. Secondary variables were anesthetic induction time, nursing preparation time, operation time, time for emergence from anesthesia, and total length of hospital stay.

RESULTS

Increasing BMI was associated with increased total OR time (group 1 = 202 min, group 2 = 215 min, group 3 = 235 min), mainly due to longer operation time (group 1 = 147 min, group 2 = 154 min, group 3 = 163 min). Anesthetic induction (group 1 = 17 min, group 2 = 18 min, group 3 = 23 min) and emergence times (group 1 = 12 min, group 2 = 12 min, group 3 = 22 min) were also significantly longer in the largest patients.

CONCLUSIONS

Operating room schedules and plans for resource utilization should recognize that the same bariatric procedure will require more time for patients with BMI >60 kg/m(2) than for smaller bariatric patients.

Body Mass Index is Predictive of Higher In-hospital Mortality in Patients Undergoing Laparoscopic Gastric Bypass but Not Laparoscopic Sleeve Gastrectomy or Gastric Banding

High body mass index (BMI) has been shown to be a factor predictive of increased morbidity and mortality in several single-institution studies. Using the University HealthSystem Consortium clinical database, we examined the impact of BMI on in-hospital mortality for patients who underwent laparoscopic gastric bypass, sleeve gastrectomy, and gastric banding between October 2011 and February 2014. Outcomes were examined within each procedure according to BMI groups of 35 to 49.9, 50.0 to 59.9, and 60.0 kg/m2 or greater. Outcome measures included in-hospital mortality, major complications, length of hospital stay, 30-day readmission, and cost. A total of 40,102 bariatric procedures were performed during this time period. For gastric bypass, there was an increase of in-hospital mortality (0.01 and 0.02 vs 0.34%; P < 0.01) and major complications (0.93 and 0.99 vs 2.62%; P < 0.01) in the BMI 60 kg/m2 or greater group. In contrast, sleeve gastrectomy and gastric banding had no association between BMI and rates of mortality and major complications. Cost increased with increasing BMI groups for all procedures. A strong association was found between BMI 60 kg/m2 or greater and higher in-hospital mortality and major complication rates for patients who underwent laparoscopic gastric bypass but not in patients who underwent sleeve gastrectomy or gastric banding.

Challenges in the surgical management of spine trauma in the morbidly obese patient: a case series

Object

The treatment of morbidly obese individuals with spine trauma presents unique challenges to spine surgeons and trauma staff. This study aims to increase awareness of current limitations in the surgical management of spine trauma in morbidly obese individuals, and to illustrate practical solutions.

Methods

Six morbidly obese patients were treated surgically for spine trauma over a 2-year period at a single trauma center in Australia. All patients were involved in high-speed motor vehicle accidents and had multisystem injuries. All weighed in excess of 265 pounds (120 kg) with a body mass index ≥ 40 (range 47.8–67.1). Cases were selected according to the considerable challenges they presented in all aspects of their management.

Results

Best medical and surgical care may be compromised and outcome adversely affected in morbidly obese patients with spine trauma. The time taken to perform all aspects of care is usually extended, often by many hours. Customized orthotics may be required. Imaging quality is often compromised and patients may not fit into scanners. Surgical challenges include patient positioning, surgical access, confirmation of the anatomical level, and obtaining adequate instrument length. Postoperative nursing care, wound healing, and venous thromboembolism prophylaxis are also significant issues.

Conclusions

Management pathways and hospital guidelines should be developed to optimize the treatment of morbidly obese patients, but innovative solutions may be required for individual cases.

Specialized Staff and Equipment for Weight Loss Surgery Patients: Best Practice Guidelines

OBJECTIVE

To provide evidence-based guidelines on the specialized personnel, equipment, and physical plant required for safe and effective care of severely obese weight loss surgery (WLS) patients.

RESEARCH METHODS AND PROCEDURES

We examined MEDLINE (Ovid and PubMed) and the Cumulative Index of Nursing and Allied Health Literature for articles on facilities resources for care of WLS patients published in English between January 1980 and March 2004. We queried several web sites for appropriate references; these included the Agency for Healthcare Research and Quality and the American College of Surgeons. The majority of reference material was descriptive and not specific to facilities resources for WLS patients. We identified a substantial body of literature on the general subject of patient safety; three of these articles were used to develop recommendations on the use of technology for medical error reduction. All other recommendations are based on 11 expert opinion reports.

RESULTS

We recommended adequate training and credentialing for all medical staff; dedicated support and administrative personnel; and specialized interventional, diagnostic, operating room, and transport equipment. We specified needed adaptations to the physical plant and developed evidence-based guidelines for medical error reduction and systems improvements.

DISCUSSION

Specialized resources and dedicated staff are needed to protect the health of WLS surgery patients and staff. Adaptations include preoperative preparation for safe means of patient transport; techniques of anesthesia and intraoperative exposure; provisions for postoperative recovery; and measures to assure postoperative patient safety, hygiene, and comfort.

[Operative management and fracture care of the lower leg with the Ilizarov fixator in morbidly obese patients: literature review and results]

Given the rising prevalence of obesity, surgeons and hospitals must become more familiar with the treatment and operative management of obese patients. Several additional pre- and postoperative considerations must be involved such as appropriate assessment of comorbidities and requirements for special equipment. There are still very few data regarding morbidly obese patients with BMIs >50 kg/m(2). After a general literature review of operative management of obese patients, we report on fracture care of the lower limb in such patients with custom-made Ilizarov ring fixators. We found them suited to bear enormous weight-loading but that associated comborbidities can limit successful fracture care.

Nephrolithiasis after bariatric surgery for obesity

Surgical intervention has become an accepted therapeutic alternative for the patient with medically complicated obesity. Multiple investigators have reported significant and sustained weight loss after bariatric surgery that is associated with improvement of many weight-related medical comorbidities, and statistically significant decreased overall mortality for surgically treated as compared with medically treated subjects. Although the Roux-en-Y gastric bypass (RYGB) is considered an acceptably safe treatment, an increasing number of patients are being recognized with nephrolithiasis after this, the most common bariatric surgery currently performed. The main risk factor appears to be hyperoxaluria, although low urine volume and citrate concentrations may contribute. The incidence of these urinary risk factors among the total post-RYGB population is unknown, but may be more than previously suspected based on small pilot studies. The etiology of the hyperoxaluria is unknown, but may be related to subtle and seemingly subclinical fat malabsorption. Clearly, further study is needed, especially to define better treatment options than the standard advice for a low-fat, low-oxalate diet, and use of calcium as an oxalate binder.

Emergency department equipment for obese patients: perceptions of adequacy

AIM

This study reports an investigation to assess patients' and nurses' perceptions of equipment adequacy for obese patients presenting at an emergency department and to assess nurses' knowledge of equipment weight limits in the emergency department.

BACKGROUND

The increasing weight of populations in many societies is a challenge to healthcare providers and facilities. Emergency department equipment, specifically, may be inadequate for patient care.

METHODS

Two questionnaires were developed. One was administered to 134 emergency department patients with suspected cardiac ischaemia; the other was administered to their respective nurses. Patient and nurse equipment adequacy scores were computed. Patients' self-reported height and weight were used to calculate body mass index. Waist circumference was measured. The data were collected in Canada in 2005.

FINDINGS

Patient equipment adequacy scores correlated inversely with both body mass index (r = -0.55, 95% CI = -0.70 to -0.41, P < 0.01) and waist circumference (r = -0.62, 95% CI = -0.75 to -0.48, P < 0.01). Nurse equipment adequacy scores were also inversely related to patient body mass index (r = -0.34, 95% CI = -0.50 to -0.18, P < 0.01) and waist circumference (r = -0.40, 95% CI = -0.56 to -0.24, P < 0.01). There was a weak correlation between nurse and patient equipment adequacy scores (r = 0.27, 95% CI = -0.44 to -0.10, P < 0.01). Small minorities of nurses reported accurate knowledge of weight limits for beds, commodes and toilets.

CONCLUSION

Specialized equipment and staff education are needed for adequate management of obese patients in the emergency department.

Hyperoxaluric nephrolithiasis is a complication of Roux-en-Y gastric bypass surgery

Roux-en-Y bypass surgery is the most common bariatric procedure currently performed in the United States for medically complicated obesity. Although this leads to a marked and sustained weight loss, we have identified an increasing number of patients with episodes of nephrolithiasis afterwards. We describe a case series of 60 patients seen at Mayo Clinic-Rochester that developed nephrolithiasis after Roux-en-Y gastric bypass (RYGB), including a subset of 31 patients who had undergone metabolic evaluation in the Mayo Stone Clinic. The mean body mass index of the patients before procedure was 57 kg/m(2) with a mean decrease of 20 kg/m(2) at the time of the stone event, which averaged 2.2 years post-procedure. When analyzed, calcium oxalate stones were found in 19 and mixed calcium oxalate/uric acid stones in two patients. Hyperoxaluria was a prevalent factor even in patients without a prior history of nephrolithiasis, and usually presented more than 6 months after the procedure. Calcium oxalate supersaturation, however, was equally high in patients less than 6 months post-procedure due to lower urine volumes. In a small random sampling of patients undergoing this bypass procedure, hyperoxaluria was rare preoperatively but common 12 months after surgery. We conclude that hyperoxaluria is a potential complicating factor of RYGB surgery manifested as a risk for calcium oxalate stones.

The effect of obesity on outcomes among injured patients

INTRODUCTION

The potential consequences of obesity in trauma patients are significant, yet incompletely defined by previous studies.

OBJECTIVES

To evaluate the effect of obesity on morbidity and mortality among injured patients.

METHODS

Medical records of all trauma patients evaluated at an American College of Surgeons verified Level I trauma center over a 1-year period were retrospectively reviewed. Morbidity and mortality were assessed after patients were stratified according to body mass index (BMI=kilograms/meters) and injury severity score.

RESULTS

The mortality of patients with a BMI > or =35 (obese patients) was 10.7% versus 4.1% for patients with a BMI<35 (lean patients, p = 0.003). Nearly 27% of obese patients versus 17.6% of lean patients experienced one or more complications while in the hospital (p = 0.02).

CONCLUSIONS

Obese patients are significantly more likely than lean patients to experience complications and death after a traumatic event. This effect is enhanced with higher levels of injury.

Bariatric Implications of Critical Care Nursing

The delivery of optimum nursing care to morbidly obese patients in critical care presents unique challenges in critical thinking, planning, and teamwork. The purpose of this article is to review the special needs of this patient population and to provide a template to guide proactive nursing care planning in critical care settings.

Management of the bariatric surgery patient

Morbid obesity has reached epidemic proportions in the United States. Unfortunately, medical interventions have been largely ineffective in this growing population. Currently bariatric surgery is the most effective intervention in managing morbid obesity and its comorbidities. As more patients become eligible for and pursue weight reduction surgery, it becomes important for the clinician to possess a thorough understanding of the different procedures available and the management of patients before, during, and after these surgeries. Significant weight loss and improvement in weight-related comorbidities are possible, with the best results available to the well-informed patient whose care is provided by a dedicated multidisciplinary team.

Trauma in patients who are morbidly obese

Trauma is the fifth leading cause of death in the United States. There is an eight-fold increase in mortality rates among victims of blunt trauma who are morbidly obese. Airway, circulation, and breathing mechanisms are altered in patients who are morbidly obese, which makes assessment and treatment difficult. Normal diagnostic and treatment procedures performed in the field and hospital must be modified. Some treatments or diagnostic procedures cannot be performed in the average hospital setting on patients who are obese; therefore, perioperative nurses must modify OR routines to provide care.

Spine surgery in morbidly obese patients

OBJECT

The diagnosis, treatment, and postoperative care of morbidly obese patients undergoing spinal surgery require modifications for body habitus. With a growing percentage of the United States population becoming morbidly obese, the surgeon may need elective or emergency treatment plans that address the special needs of these patients. The authors retrospectively reviewed the diagnosis, treatment, and postoperative care of the severely obese patient undergoing spinal surgery.

METHODS

To assess the associated results and complications of management that required modification for body habitus, 12 patients were included in the study (nine females); the mean age was 50 years and mean weight was 320 lb. Cases of cervical (two cases), thoracic (four cases), and lumbar surgeries (six cases) were included. The follow-up period ranged from 6 months to 2 years. Patients presented with myelopathy (five cases), radicular pain and weakness (four cases), radiculopathy (two cases), and cauda equina syndrome (one patient). Chronic progressive neurological deterioration secondary to spinal cord compression was demonstrated in nine patients and acute pain and/or weakness secondary to nerve root compression was observed in three patients.

CONCLUSIONS

The authors found that although morbidly obese patients may present late in the course of their symptoms and require modifications in the use of standard neuroimaging, operative facilities, and treatment plans, open mindedness and persistence can yield satisfactory results in most cases.

Appropriate use, complications and advantages demonstrated in 500 consecutive needle catheter jejunostomies

BACKGROUND

The ability to deliver nutrition enterally after operation has been a significant advance in managing patients after major intra-abdominal operations.

METHODS

The experience of a single surgeon at a tertiary referral hospital over a 10-year period with insertion and use of 500 consecutive needle catheter jejunostomies (NCJs) was reviewed critically from prospectively collected data.

RESULTS

The NCJ was used to deliver nutrition in 93 per cent, fluid and electrolytes in 95 per cent, and various medications in the postoperative period in the majority of patients. There were three major complications: small bowel obstruction and pneumatosis intestinalis in one and two patients respectively. Minor complications included diarrhoea (15 per cent), abdominal distension (15 per cent), abdominal cramps (3 per cent), subcutaneous infection at the insertion site (1 per cent) and catheter occlusion precluding use (1 per cent). In 16 patients, the NCJ was replaced percutaneously with a larger-bore catheter for more prolonged enteral feeding at home after discharge.

CONCLUSION

Through the experience gained, indications are offered for the placement of NCJs and cautions are provided concerning appropriate use of an NCJ to provide nutritional support, fluid and electrolyte replacement or maintenance, and safe enteral administration of medication. Overall, an NCJ appears to allow safer, cheaper and equally effective delivery of nutrition compared with total parenteral nutrition after major intra-abdominal operations.