Effects of increased intra-abdominal pressure in severe obesity

Body Mass Index and Levonorgestrel Device Expulsion in Adolescents and Young Adults

STUDY OBJECTIVE

To evaluate the relationship between body mass and levonorgestrel intrauterine device (LNG-IUD) expulsion in adolescents and young adults (AYA).

DESIGN, SETTING, PARTICIPANTS & INTERVENTIONS

A retrospective chart review was conducted of nulliparous females aged 10-24 years who had a 52-milligram LNG-IUD placed between November 2017 and May 2021 by pediatric and adolescent gynecology providers at a tertiary children's hospital, including those who underwent metabolic and bariatric surgery (MBS). Primary analysis focused on 10-19 year olds as they had comparable anthropometrics (namely BMI percentile [BMIP] as defined by the Centers for Disease Control). Descriptive statistics included means, standard deviations (SD), and ranges for continuous variables counts and percentages for categorical variables. Chi-square or Fisher's exact tests were used to assess associations. Logistic regressions were fit to test the associations between BMIP, MBS, and the odds of expulsion.

MAIN OUTCOME MEASURES & RESULTS

A total of 588 patients were included in the primary analysis (10-19 years). Mean age was 15.8 years (±2.0). Using BMIP, 15.5% (n = 91) of the sample was overweight and 22.3% (n = 131) were obese. Within 12 months, 33 patients (5.6%) experienced expulsion. Every one-unit increase in BMIP was associated with a 3% increase in the odds of expulsion (P = .008), and each increase in BMIP category (eg, overweight vs average/underweight) was significantly associated with increased odds of expulsion (OR = 2.77-4.28). Patients who had LNG-IUD placement during MBS (n = 43) had higher odds of expulsion (OR = 3.23; P = .024) than other patients.

CONCLUSION

AYA with higher BMIP and/or who undergo MBS are at increased risk of LNG-IUD expulsion within one year of placement.

Awareness of Hernias and Their Risk Factors Among Adults in the Western Region of Saudi Arabia

Objective To assess the awareness of hernia and its risk factors among adults in the western region of Saudi Arabia. Our hypothesis was that the studied population was in need of education regarding this matter.  Methods This cross-sectional study was conducted in the western region of Saudi Arabia from November to December 2022, using a Google form. The generated questionnaire consisting of two parts was distributed electronically through social media platforms. The targeted population included adults from the western region of Saudi Arabia. The data were obtained using Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) v. 26 software (IBM Corp., Armonk, NY). Results A total of 1570 adults from the western region of Saudi Arabia were included in our study. We found that 13% of the participants had good overall knowledge about hernia, 31% had poor knowledge, and 56% had moderate knowledge. Alarmingly, 55% of the participants had a poor attitude, and 27% were evaluated as having poor practice. In addition, we found a significant association between people's level of knowledge and multiple factors, including age (p-value < 0.001), marital status (p-value< 0.001), and occupation (p-value< 0.001).  Conclusion Based on our research, more than half of our population had a moderate level of knowledge regarding hernias including their risk factors and complications, with alarming levels of poor attitudes toward the disease. Healthcare workers were our participants' leading source of medical information, which directs us towards fully equipping them with the knowledge to educate the public effectively.

Reproductive Surgery in Females with Obesity: Reproductive Consequences of Obesity and Applications for Surgical Care

Obesity is the most common medical problem in women of reproductive age. The surgical applications for this population, many of who are interested in current or future fertility, are critical to safe and effective evaluation and management of issues that impact the reproductive system. As rates of obesity continue to rise worldwide, it is projected that one in two individuals will have obesity by 2030 leading to increasing numbers of individuals affected by a disease process that has implications for their gynecologic surgical care, fertility-related assessment, and infertility treatment. Offering patients with obesity access to safe reproductive surgery is a cornerstone of reproductive autonomy. This review will summarize current recommendations regarding surgical concepts for the operating room, office hysteroscopy, oocyte retrieval, and embryo transfer in female patients with obesity.

Ventral hernia repair with enhanced-view totally extraperitoneal technique after a massive weight loss by laparoscopic sleeve gastrectomy

BACKGROUND

Ventral hernia repair (VHR) for obese patients is often associated with an increased risk of postoperative complications and hernia recurrences. Achieving preoperative weight loss is ideal before VHR; however, it is difficult to attain with medical treatment. Metabolic and bariatric surgery (MBS) offers the most effective and durable treatment for obesity. Therefore, massive weight loss occurring after MBS will improve the outcome of VHR.

CASE PRESENTATION

A 49-year-old man (122.9 kg, BMI 39.1 kg/m²) presented to our hospital wishing to undergo laparoscopic sleeve gastrectomy and VHR. Physical examination revealed a tennis ball-sized lower midline defect. Computed tomography (CT) scans revealed a hernia orifice 5 cm in width and 10 cm in height. As the hernia orifice was large, mesh reinforcement was essential. We planned for him to undergo VHR after massive weight loss was achieved by MBS. VHR was performed using the enhanced-view totally extraperitoneal (eTEP) technique after weight loss of 38 kg was achieved 9 months following laparoscopic sleeve gastrectomy. His postoperative course was uneventful, and neither recurrence nor seroma was observed at 1 year follow-up.

CONCLUSIONS

eTEP repair of a ventral hernia after massive weight loss following MBS would appear to be the best combination treatment for obese patients with ventral hernias. However, long-term follow-up is necessary to establish its safety and efficacy.

Comparing the Efficacy and Safety of Apixaban Versus Warfarin in Morbidly Obese Patients

This study was conducted to evaluate the efficacy and safety of apixaban versus warfarin in morbidly obese patients. A total of 250 morbidly obese patients with a body mass index (BMI) higher than 40 kg/m² or a body weight higher than 120 kg who were on anticoagulation therapy with either apixaban or warfarin for over one month were included in the study. This retrospective cohort, multicenter study was executed using the medical records of 125 morbidly obese patients treated with apixaban, while patients on warfarin were selected using a systemic random sampling to match the sample size of the apixaban group. There was no significant difference between apixaban and warfarin in the development of thromboembolic events and major bleeding. However, incidences of minor bleeding significantly decreased in the apixaban group compared to patients treated with warfarin. This difference was overcome by controlling serum creatinine and nonsteroidal anti-inflammatory drugs (NSAIDs). In conclusion, apixaban efficacy and safety are nearly the same as that of warfarin in morbidly obese patients with a lower incidence of minor bleeding with apixaban. Controlling serum creatinine and NSAIDs use may improve warfarin safety and decrease its complications.

Association between gynaecological disorders and body mass index in a South African cohort: a retrospective observational study

A retrospective observational study of new patients who visited the gynaecology outpatient clinic at Tygerberg Hospital, South Africa, between February and June 2019 was conducted to determine the association between body mass index (BMI) and gynaecological disorders. BMI was calculated and analysed concerning the presenting complaint and final diagnosis. From the sample of 651 patients, 18.4% had a normal BMI and 47.3% were classified as overweight or obese class 1. Older age was associated with a higher BMI (p = .013). Hypertension was most prevalent (26.7%) and associated with excess weight (p < .001). Disorders significantly associated with obesity were infertility (odds ratio [OR] 1.013, 95% confidence interval [CI] 0.992-1.033, p = .001), polycystic ovarian syndrome (OR 1.058, 95% CI 1.028-1.089, p = .006), pelvic organ prolapse (OR 1.027, 95% CI 0.995-1.060, p = .0291) and postmenopausal bleeding (OR 1.038, 95% CI 1.009-1.068, p = .048). Chronic pelvic pain and endometriosis were associated with a low BMI. IMPACT STATEMENTWhat is already known on this subject? It is well known that obesity has multiple negative effects on health. It affects women's health on many levels including their endocrine balance as well as pressure effects on the pelvic floor. The association between gynaecological disorders and excess weight has been described mainly in the context of separate gynaecological conditions.What the results of study add? This study described the large numbers of women with obesity in the South African context. It adds to the body of knowledge by looking at the association of BMI, not only obesity, and a large range of the most seen gynaecological conditions in the study setting.What the implications are of these findings for clinical practice and/or further research? This study highlights the importance of lifestyle and nutritional implications on women's health. For clinical practice, this knowledge needs to be applied with every opportunity to counsel women on how their weight can affect their gynaecological health. The focus of further research should focus on the most effective strategies to combat obesity in a holistic patient-centered approach.

Gastrointestinal Quality of Life in Morbidly Obese Patients Undergoing One Anastomosis Gastric Bypass (OAGB): Derivation of a "Mini GIQLI" Score

BACKGROUND

One anastomosis gastric bypass (OAGB) is now one of the mainstream bariatric surgical procedures with proven safety and efficacy. However, data on the gastrointestinal quality of life following OAGB is lacking.

METHODS

This is a retrospective analysis of a prospectively collected database, performed at a single tertiary care teaching hospital from January 2016 until March 2021. All patients undertook the Gastrointestinal Quality of Life Index (GIQLI) questionnaire. GIQLI was correlated with various parameters. Principal component analysis (PCA) was used to assess the importance of each question in the questionnaire and devise a "Mini GIQLI score".

RESULTS

A total of 60 patients were included. The %TWL at 3 and 5 years was 26.2 ± 11.9%, 31.7 ± 11 respectively. The mean weight regain was 5.6 ± 8.5 kg. The mean GIQLI score was 125 ± 13.1. The mean scores for questions pertaining to gastrointestinal, social, psychological, and physical domains were 3.49, 3.7, 3.45, and 3.27 respectively. Scree plot of principal component analysis showed that a new score ("Mini GIQLI") combining only 5 questions had good correlation with the overall GIQOL score (r = 0.842). The five questions related to anxiety, fatigue, feeling unwell, loss of endurance, and feeling unfit.

CONCLUSIONS

Patients report a good score on GIQLI assessment following OAGB. The Mini GIQLI score is a quicker tool with good correlation to the full-length GIQLI score.

Renal Compression in Heart Failure: The Renal Tamponade Hypothesis

Renal dysfunction is one of the strongest predictors of outcome in heart failure. Several studies have revealed that both reduced perfusion and increased congestion (and central venous pressure) contribute to worsening renal function in heart failure. This paper proposes a novel factor in the link between cardiac and renal dysfunction: "renal tamponade" or compression of renal structures caused by the limited space for expansion. This space can be limited either by the rigid renal capsule that encloses the renal interstitial tissue or by the layer of fat around the kidneys or by the peritoneal space exerting pressure on the retroperitoneal kidneys. Renal decapsulation in animal models of heart failure and acute renal ischemia has been shown effective in alleviating pressure-related injury within the kidney itself, thus supporting this concept and making it a potentially interesting novel treatment in heart failure.

Causative Mechanisms of Childhood and Adolescent Obesity Leading to Adult Cardiometabolic Disease: A Literature Review

The past few decades have shown a worrisome increase in the prevalence of obesity and its related illnesses. This increasing burden has a noteworthy impact on overall worldwide mortality and morbidity, with significant economic implications as well. The same trend is apparent regarding pediatric obesity. This is a particularly concerning aspect when considering the well-established link between cardiovascular disease and obesity, and the fact that childhood obesity frequently leads to adult obesity. Moreover, most obese adults have a history of excess weight starting in childhood. In addition, given the cumulative character of both time and severity of exposure to obesity as a risk factor for associated diseases, the repercussions of obesity prevalence and related morbidity could be exponential in time. The purpose of this review is to outline key aspects regarding the current knowledge on childhood and adolescent obesity as a cardiometabolic risk factor, as well as the most common etiological pathways involved in the development of weight excess and associated cardiovascular and metabolic diseases.

Systematic Review of Diagnostic Sensors for Intra-Abdominal Pressure Monitoring

Intra-abdominal pressure (IAP) is defined as the steady-state pressure within the abdominal cavity. Elevated IAP has been implicated in many medical complications. This article reviews the current state-of-the-art in innovative sensors for the measurement of IAP. A systematic review was conducted on studies on the development and application of IAP sensors. Publications from 2010 to 2021 were identified by performing structured searches in databases, review articles, and major textbooks. Sixteen studies were eligible for the final systematic review. Of the 16 articles that describe the measurement of IAP, there were 5 in vitro studies (31.3%), 7 in vivo studies (43.7%), and 4 human trials (25.0%). In addition, with the advancement of wireless communication technology, an increasing number of wireless sensing systems have been developed. Among the studies in this review, five presented wireless sensing systems (31.3%) to monitor IAP. In this systematic review, we present recent developments in different types of intra-abdominal pressure sensors and discuss their inherent advantages due to their small size, remote monitoring, and multiplexing.

Anesthetic management for robotic hysterectomy in obese women

PURPOSE OF REVIEW

Obesity is a major health epidemic, with the prevalence reaching ∼40% in the United States in recent years. It is associated with increased risk of hypertension, diabetes, heart disease, stroke, obstructive sleep apnea (OSA), and gynecologic conditions requiring surgery. Those comorbidities, in addition to the physiologic changes associated with obesity, lead to increased risk of perioperative complications. The purpose of this review is to highlight the anesthetic considerations for robotic assisted hysterectomy in obese patients.

RECENT FINDINGS

In the general gynecologic population, minimally invasive surgery is associated with less postoperative fever, pain, hospital length of stay, total cost of care and an earlier return to normal function. This also applies to robotic surgery in obese patients, which is on the rise. The physiologic changes of obesity bring different anesthetic challenges, including airway management and intraoperative ventilation. Vascular access and intraoperative blood pressure monitoring can also be challenging and require modifications. Optimizing analgesia with a focus on opioid-sparing strategies is crucial due to the increased prevalence of OSA in this patient population.

SUMMARY

Anesthesia for obese patients undergoing robotic hysterectomy is challenging and must take into consideration the anatomic and physiologic changes associated with obesity.

Abdominal compartment syndrome among surgical patients

Abdominal compartment syndrome (ACS) develops when organ failure arises secondary to an increase in intraabdominal pressure. The abdominal pressure is determined by multiple factors such as blood pressure, abdominal compliance, and other factors that exert a constant pressure within the abdominal cavity. Several conditions in the critically ill may increase abdominal pressure compromising organ perfusion that may lead to renal and respiratory dysfunction. Among surgical and trauma patients, aggressive fluid resuscitation is the most commonly reported risk factor to develop ACS. Other conditions that have also been identified as risk factors are ascites, hemoperitoneum, bowel distention, and large tumors. All patients with abdominal trauma possess a higher risk of developing intra-abdominal hypertension (IAH). Certain surgical interventions are reported to have a higher risk to develop IAH such as damage control surgery, abdominal aortic aneurysm repair, and liver transplantation among others. Close monitoring of organ function and intra-abdominal pressure (IAP) allows clinicians to diagnose ACS rapidly and intervene with target-specific management to reduce IAP. Surgical decompression followed by temporary abdominal closure should be considered in all patients with signs of organ dysfunction. There is still a great need for more studies to determine the adequate timing for interventions to improve patient outcomes.

A New Device for Measuring Abdominal Wall Tension and Its Value in Screening Abdominal Infection

OBJECTIVE

This study is the largest clinical study of noninvasive Abdominal wall tension (AWT) measurement with a tensiometer to date. It also initially applies a polynomial regression equation to analyze the correlation between AWT measurement and intravesical pressure (IVP) measurement and remarkably finds interesting changes between different IVP intervals and AWT.

METHODS

Critically ill patients who were treated in the intensive care unit (ICU) of Daping Hospital, Army Medical University, from August 30, 2018, to June 30, 2020, and met the inclusion criteria were prospectively included in this study. The patients were divided into an intra-abdominal hypertension group and a non-intra-abdominal hypertension group and an abdominal infection group and no abdominal infection group. AWT and IVP were measured at 9 points on the abdominal wall on the first day after admission to the ICU. The correlations between AWTs and IVP were analyzed, and the role of AWT in the diagnosis of complications of abdominal infection and the prediction of adverse prognosis were analyzed.

RESULTS

A total of 127 patients were included. The average AWT and IVP were 2.77±0.38 N/mm and 12.31±7.01 mmHg, respectively, on the first day of admission. There was a positive correlation between AWT and IVP (correlation coefficient r = 0.706, p < 0.05). The polynomial regression model was AWT= -1.616×10-3 IVP2 +8.323×10-2 IVP+2.094. The cutoff value of the sensitivity and specificity of AWT for the diagnosis of abdominal infection was 2.57 N/mm. Furthermore, AWT = 2.57 N/mm had the best diagnostic efficiency, which was better than that of IAH and lactate.

CONCLUSION

There was a correlation between AWT and IVP. AWT measurement was helpful in the diagnosis of IAH and abdominal infection complications and can therefore serve as a new method for the clinical diagnosis of IVP and abdominal infection.

Ventricular volume, white matter alterations and outcome of major depression and their relationship to endocrine parameters - A pilot study

OBJECTIVES

Brain morphology and its relation to endocrine parameters were examined, in order to determine the link of these parameters to treatment outcome to psychopharmacological treatment in depressed patients.

METHODS

We examined the potentially predictive value of Magnetic Resonance Imaging (MRI) parameters related to mineralocorticoid receptor (MR) function on the treatment outcome of depression. 16 inpatients with a major depressive episode (MDE) were studied at baseline and 14 of them approximately six weeks later. Physiological biomarkers and 3-T-structural MRI based volume measures, using FreeSurfer 6.0 software, were determined.

RESULTS

Non-responders (<50% reduction of HAMD-21; n = 6) had a significantly smaller volume of the right anterior cingulate cortex, a significantly larger ventricle to brain ratio (VBR) and third ventricle volume, and smaller volumes of the central and central-anterior corpus callosum (CC) in comparison to responders (n = 7; all p ≤ 0.05). Correlational analysis (Spearman) demonstrated that larger ventricle volume was correlated to a worse treatment outcome, higher body mass index (BMI) and smaller CC segment volume, whereas the total CC volume was negatively correlated to the saliva aldosterone/cortisol concentration ratio (AC-ratio).

CONCLUSION

Large ventricular volume may be a predictive marker for worse treatment response to standard antidepressant treatment, potentially via compression of white matter structures. A mediating role of the previously identified markers BMI and the AC-ratio, is suggested.

An Ingestible Electronics for Continuous and Real-Time Intraabdominal Pressure Monitoring

Abdominal compartment syndrome can be treated through decompressive surgery if intraabdominal hypertension (IAH) can be detected in time. Treatment delays due to manual, conventional intravesical pressure (IVP) monitoring using a Foley catheter have been reported. In this work, we present an innovative gastrointestinal intraluminal pressure (GIP) measurement-based method to monitor and improve pressure-guided relief of intraabdominal pressure (IAP). A novel algorithm for detecting IAH in the gastrointestinal tract of a live porcine model is reported. A wireless pressure-sensing capsule (10 × 13 mm) was developed for absolute measurement. The IAP was estimated during artificial pneumoperitoneum. The pressure waveform-based measurements indicated that the wireless pressure sensor could be used to predict IAP. To enhance GIP monitoring for predicting IAH, the proposed continuous ingestible wireless electronics-based pressure waveform measurement device can be used as a complement to existing modalities. The use of the proposed pressure measurement and communication technology can help provide valuable data for digital health platforms.

Trans-esophagogastric junction pressure gradients during straight leg raise maneuver on high-resolution manometry associate with large hiatus hernias

BACKGROUND

Straight leg raise (SLR) while supine increases intra-abdominal pressure. We hypothesized that elevations in intra-abdominal pressure would transmit into the thoracic cavity if the esophagogastric junction (EGJ) was disrupted.

METHODS

Consecutive patients undergoing esophageal HRM were included if they had adequate SLR (hip flexion with knees extended for ≥ 5 seconds while supine). EGJ morphology was subtyped based on lower esophageal sphincter (LES) and crural diaphragm (CD) location (type 1: LES and CD overlap; type 2: separation of < 3 cm; type 3: separation of ≥ 3 cm). EGJ tone was assessed using EGJ contractile integral (EGJ-CI). HRM studies were analyzed according to Chicago Classification v3.0. Mean and peak intra-thoracic and abdominal pressures were measured at baseline and during SLR using on-screen software tools. Trans-EGJ gradients were compared, and pressure gradient < 1 mmHg denoted the equalization of pressures.

KEY RESULTS

Of 430 patients, 248 (57.5 ± 0.9 years, 69.4% F) completed SLR. EGJ morphology was type 1 in 122 (49.2%), type 2 in 56 (22.6%) and type 3 in 40 (16.1%). In types 1 and 2 EGJ, neither the mean nor peak trans-EGJ pressure gradient changed with SLR (P ≥ .17 for each). In contrast, in type 3 EGJ, peak pressure gradient decreased significantly following SLR (3.5 ± 1.8 mmHg vs. -8.6 ± 4.8 mmHg, P = .01). More type 3 EGJ patients equalized peak (65%) pressures across EGJ compared with types 1 and 2 (27%, P < .001).

CONCLUSIONS AND INFERENCES

The evaluation of intra-abdominal and intra-thoracic pressures with SLR during esophageal HRM can provide evidence of physiological disruption of the EGJ barrier.

Staged complex abdominal wall hernia repair in morbidly obese patients

PURPOSE

The repair of complex abdominal wall hernias in morbidly obese patients is often associated with a higher risk of complications and hernia recurrences. Improvement in obesity and its associated metabolic complications are hypothesized to improve hernia repair outcomes. This study analyzes outcomes from morbidly obese patients who underwent bariatric surgery with staged complex abdominal wall reconstruction at Creighton University Medical Center (CUMC).

METHODS

This retrospective study included morbidly obese patients with complex abdominal wall hernia, who underwent bariatric surgery with staged abdominal wall reconstruction. Data points collected included patient demographics, obesity-related co-morbidities, pre-operative BMI, EBMIL at 12 months, hernia characteristics, postoperative complications, BMI at time of hernia repair, and hernia recurrence.

RESULTS

Twelve patients with an average BMI of 48 and complex abdominal wall hernias (mean width 14.0 cm) met inclusion criteria. Seven patients (58%) had significant loss of domain. Bariatric procedures included six laparoscopic sleeve gastrectomies (LSG), three laparoscopic Roux-en-Y gastric bypasses (LRNYGB), and three revisional procedures (2 vertical band gastroplasties to LRNYGB and 1 LRNYGB revision). At 12-month follow-up, the mean excess BMI loss (EBMIL) was 64.6%. The average time to staged complex abdominal wall reconstruction was 22.3 months. Two non-elective hernia repairs were performed due to one incarceration and one strangulation. There were no recurrences after an average follow-up of 21.9 months.

CONCLUSIONS

In this study, staged mesh repair of complex abdominal wall hernias after bariatric surgery in morbidly obese patients was associated with acceptable morbidity and no hernia recurrences at approximately 1.5 year follow-up.

Recurrence types 3 years after endovenous thermal ablation in insufficient saphenofemoral junctions

OBJECTIVE

Although many studies have demonstrated that endovenous therapies have comparable efficacy to crossectomy and stripping, few studies have been published regarding the classification and recurrence patterns of varicose veins after endovenous therapy. This study attempted to provide an objective scheme for the definition and classification of recurrence. Moreover, it describes the types and rates of recurrence after endovenous thermal ablation, as well as factors associated with recurrence.

METHODS

This prospective cohort study comprised a cohort of 449 patients with saphenofemoral junction (SFJ) insufficiency who underwent endoluminal varicose vein treatment for the first time in the limb between October 2013 and January 2015. The treatments were performed by a team of three experienced phlebologists. For endovenous laser ablation, Biolitec ELVeS was used with bare, radial or radial slim fibers. Radiofrequency ablation was performed with VNUS ClosureFAST (Medtronic, Deggendorf, Germany). The patients were consecutively scheduled for 3-year follow-up examinations. Detailed ultrasound findings were collected by two experienced phlebologists who classified the observed duplex ultrasound recurrence into different recurrence types.

RESULTS

Clinically relevant recurrence was found in only 5.1% of cases. Examining only the recanalizations requiring reintervention resulted in a recurrence rate of 2.6%. However, if every new varicose vein that occurred postoperatively was considered a recurrence, the resultant recurrence rate was almost 54%. Preliminarily, we defined a recurrence as newly developed varicose veins within the region of the SFJ or along the course of the former treated vein distal to the SFJ. According to this definition, we obtained a clinically relevant recurrence rate of 5.3%, thus indicating that neovascular vessels were the largest recurrence type (57.7% within the region of the SFJ and 9.9% distal to the SFJ), followed by recanalization (8.9% within the region of the SFJ and 9.4% distal to the SFJ) and a refluxing anterior accessory saphenous vein (7.5%). We also developed a modified classification of progression to better understand recurrence after treatment of chronic venous insufficiency; the scheme included method failure (recanalization), neovascularizations, and disease progression (refluxing untreated vessels and new varicose veins occurring outside the treated region). The diameter of the treated vein (P = .001) and the clinical class according to CEAP classification (P = .008) were significant predictors of recurrence.

CONCLUSIONS

Endoluminal therapies are efficient methods for the treatment of varicose veins, which result in low recurrence rates after 3 years. Several factors influence the development of recurrence. This study provides a practice-oriented classification and description of recurrence with clinical relevance, through making distinctions among technical error, progression of the underlying disease and actual recurrence.

Acute Kidney Injury in Pregnant Patient With Pancreas-Kidney Transplant Caused by Abdominal Compartment Syndrome: A Case Presentation, Review of Literature, and Proposal of Diagnostic Approach

Rationale:

With increasing number of complex medical patients with renal transplant who get pregnant, clinicians need to be aware of abdominal compartment syndrome which may masquerade as acute renal allograft injury in pregnancy.

Presenting concerns of the patient:

A 34-year-old nulliparous Caucasian female with end-stage renal disease (ESRD) due to type 1 diabetes mellitus who received a simultaneous pancreas-kidney transplant (SPK) in 2006 and then after rejection of renal allograft another, kidney-only allograft from a donation after circulatory death became pregnant in May 2013 with dichorionic, diamniotic twins without reproductive technology, and during pregnancy, she developed two episodes of acute injury to the renal allograft.

Diagnoses:

End-stage renal disease secondary to type I diabetes, acute renal allograft injury, tacrolimus toxicity, abdominal pain.

Interventions (including prevention and lifestyle):

She received intravenous hydration, medications contributing to renal failure were held, and pain and nauseas were controlled appropriately. Abdominal compartment syndrome was managed by maintaining intravascular pressure and optimizing regional and systemic vascular perfusion by appropriate fluid balance, evacuating intraluminal contents by decompressing gastrointestinal system, and improving abdominal wall compliance by using appropriate analgesics, sedation, and patient positioning.

Outcomes:

With advancing pregnancy, the patient developed progressive abdominal pain, nausea, leg edema, and rising creatinine that were not responsive to ongoing therapies and required delivery via Cesarean section at 31 weeks of gestational age.

Lessons learned:

In the era of increasing number of pregnant renal transplant patients with multiple medical issues, we need organized approach to diagnosis of acute renal allograft injury in pregnancy and we need to consider abdominal compartment syndrome as one of the causes.

Incidence of end-stage renal disease following bariatric surgery in the Swedish Obese Subjects Study

Background

Obesity is a major public health problem leading to co-morbidities such as diabetes, hypertension and kidney failure. Bariatric surgery results in pronounced and maintained weight loss and prevention of obesity-related diseases and their complications. Most studies of bariatric surgery on kidney disease show improvements after surgery. However, long-term studies analyzing hard end-points are lacking. Here we report on the long-term effects of bariatric surgery compared to usual obesity care on incidence of end-stage renal disease (ESRD) alone and in combination with chronic kidney disease stage 4 (CKD4/ESRD).

Methods

4047 patients were included in the Swedish Obese Subjects (SOS) study. Inclusion criteria were age 37–60 years and BMI≥34 in men and BMI≥38 in women. Patients in the bariatric surgery group (N=2010) underwent banding (18%), vertical banded gastroplasty (69%) or gastric bypass (13%); controls (N=2037) received usual obesity care. In this analysis, patients were followed up for a median time of 18 years. The incidence of ESRD and CKD4 was obtained by crosschecking the SOS database with the Swedish National Patient Register.

Results

During follow-up, ESRD occurred in 13 patients in the surgery group and in 26 patients in the control group (adjusted hazard ratio (HR) = 0.27; 95% CI 0.12 – 0.60; p=0.001). The number of CKD4/ESRD events was 23 in the surgery group and 39 in the control group (adjusted HR = 0.33; 95% CI 0.18 – 0.62; p<0.001). In both analyses, bariatric surgery had a more favorable effect in patients with baseline serum insulin levels above median compared to those with lower insulin levels (interaction p=0.010). Treatment benefit of bariatric surgery was also greater in patients with macroalbuminuria at baseline compared to those without macroalbuminuria (interaction p<0.001).

Conclusions

Our study showed for the first time that bariatric surgery is associated with a long-term protection against ESRD and CKD4/ESRD.

Visceral Adiposity Predicts Severity of Acute Pancreatitis

OBJECTIVES

The aim of this study was to determine the association of visceral adiposity with severe outcomes in acute pancreatitis (AP).

METHODS

This retrospective study included consecutive patients with AP admitted to a tertiary care hospital between January 2010 and January 2015 who underwent a computed tomography scan. The visceral adipose tissue (VAT) volume was estimated using the method of Linder and colleagues. Multivariable logistic regression analysis was conducted to assess VAT as a predictor of severe AP compared with other validated predictors of severity.

RESULTS

Five hundred and seventy four patients were admitted during the study period, of which 252 had a computed tomography scan available. Patients with severe AP had a larger VAT area compared with those with mild or moderate AP (mean: 184.9 cm vs 79.9 cm, P = 0.006). Patients who developed multisystem organ failure or had acute necrotic collections had a larger VAT area than those who did not (150.6 cm vs 91.0 cm, P = 0.004 and 174.0 cm vs 91.9 cm, P = 0.003, respectively). Visceral adipose tissue area demonstrated superior discrimination of severe AP compared with other severity predictors.

CONCLUSIONS

Increased VAT area is a strong predictor of severe pancreatitis, necrosis, and multisystem organ failure.

Predicting and evaluation the severity in acute pancreatitis using a new modeling built on body mass index and intra-abdominal pressure

OBJECT

Acute pancreatitis (AP) keeps as severe medical diagnosis and treatment problem. Early evaluation for severity and risk stratification in patients with AP is very important. Some scoring system such as acute physiology and chronic health evaluation-II (APACHE-II), the computed tomography severity index (CTSI), Ranson's score and the bedside index of severity of AP (BISAP) have been used, nevertheless, there're a few shortcomings in these methods. The aim of this study was to construct a new modeling including intra-abdominal pressure (IAP) and body mass index (BMI) to evaluate the severity in AP.

METHODS

The study comprised of two independent cohorts of patients with AP, one set was used to develop modeling from Jinling hospital in the period between January 2013 and October 2016, 1073 patients were included in it; another set was used to validate modeling from the 81st hospital in the period between January 2012 and December 2016, 326 patients were included in it. The association between risk factors and severity of AP were assessed by univariable analysis; multivariable modeling was explored through stepwise selection regression. The change in IAP and BMI were combined to generate a regression equation as the new modeling. Statistical indexes were used to evaluate the value of the prediction in the new modeling.

RESULTS

Univariable analysis confirmed change in IAP and BMI to be significantly associated with severity of AP. The predict sensitivity, specificity, positive predictive value, negative predictive value and accuracy by the new modeling for severity of AP were 77.6%, 82.6%, 71.9%, 87.5% and 74.9% respectively in the developing dataset. There were significant differences between the new modeling and other scoring systems in these parameters (P < 0.05). In addition, a comparison of the area under receiver operating characteristic curves of them showed a statistically significant difference (P < 0.05). The same results could be found in the validating dataset.

CONCLUSIONS

A new modeling based on IAP and BMI is more likely to predict the severity of AP.

Morbid obesity increases risk of morbidity and reoperation in resection of benign cranial nerve neoplasms

OBJECTIVE

Obesity has been associated with increased risk for postoperative CSF leak in patients with benign cranial nerve tumors. Other measures of postoperative morbidity associated with obesity have not been well characterized.

METHODS

Patients enrolled in the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) from 2007 to 2013 with a diagnosis code of a benign neoplasm of a cranial nerve were included. The primary outcome of postoperative morbidity was analyzed as well as secondary outcomes of readmission and reoperation. The main covariate of interest was body mass index (BMI).

RESULTS

A total of 561 patients underwent surgery for a benign cranial nerve neoplasm between 2007 and 2013. Readmission data, available for 2012-2013(n=353), revealed hydrocephalus, facial nerve injury, or CSF leak requiring readmission or reoperation occurred in 0.85%, 1.42%, and 3.12%, respectively. Composite morbidity included wound complications, infection, respiratory insufficiency, transfusion requirement, stroke, venous thromboembolism, coma and cardiac arrest. On multivariable analysis patients with class I (BMI 30-34.9) and II (BMI 35-39.9) obesity showed trends towards increasing return to operating room, though not significant, but there was no trend for composite complications in class I and II obesity patients. However, class III obesity, BMI≥40, was associated with increased odds of composite morbidity (OR 4.40, 95% CI 1.24-15.88) and return to the operating room (OR 5.97, 95% CI 1.20-29.6) relative to patients with a normal BMI, 18.5-25.

CONCLUSIONS

Obesity is an independent and important risk factor for composite morbidity in resection of benign cranial nerve neoplasms, and as such, merits discussion during preoperative counseling.

The Effect of Body Mass Index on Spirometric Parameters in Children with Asthma

Aim:

Asthma and obesity represent one of the most crucial public and health problems of modern society that frequently begin in childhood and have some mutual elements of risk. Abdominal distribution of connective tissue is important determinant which brings to decrease of lungs function. Multiple influence of overweight on function of the lungs would clearly manifest over reduction of forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC).

Method:

Examining was conducted at Pediatric Clinic of University Clinical Hospital Tuzla during the year 2013/2014. Research included 60 children with diagnosed asthma who were in relation to BMI were divided in 3 groups. The first group was children with BMI ranging from 5 to 85 percentile, the second were children with 85 to 95 percentile and the third was 95 percentile. By prospective study, compared identical pulmonary variable for all three age group of asthma patients were analyzed, the children with normal body mass a well as the overweight and the obese.

Results:

At the beginning of testing, the frequency of normal spirometric findings was significantly lower in the obese group in comparison with other two observed groups (p<0,05). The only cases of mixed and restrictive disorder of ventilation were registered in the obese group of tested at the beginning of the examined (p<r0,001).

Conclusion:

When being compared the values of spirometric parameters before and after the research, the only significant difference was in the obese group, the values after tests were significantly higher, with the exception of relation FEV1/FVC, that had the same distribution of values before and after research. However, the group with normal body mass and overweight, had all the spirometric parameters with equal distribution before and after research (p>0,05 for all measurements).

Cerebrospinal fluid disturbance in overweight women after occipitocervical decompression in Chiari malformation type I

BACKGROUND

Cerebrospinal fluid disturbance (CSFD) is a well-known complication after occipitocervical decompression (OCD) in patients with Chiari malformation type I (CMI). There is scarce data focusing on preoperative patients' factors predisposing to development of CSF disturbance. The aim of this study is to evaluate a prognostic value of some patients' factors in the prediction of CSFD after OCD in CMI patients.

MATERIALS AND METHODS

We undertook a 10-year (2003-2013) retrospective study of all OCD in patients with CMI performed at Sahlgrenska IC, Sahlgrenska University Hospital, Sweden. A total of 52 consecutive patients were obtained from the operation database and we excluded one patient who was previously diagnosed with normal-pressure hydrocephalus. Data regarding preoperative age, body mass index, gender, degree of tonsillar herniation and syrinx were registered. Development of CSFD after OCD was noted.

RESULTS

Of the 51 patients reviewed, six had CSFD after OCD and were managed using a form of CSF diversion procedure. All of the patients who developed CSFD were females. They had a mean body mass index of 32.3 compared to a mean of 24.3 in patients without CSFD (p = 0.0011). There was no difference between the two groups with regard to the other examined patient factors.

CONCLUSIONS

CSF diversion was needed in six consecutive adult Chiari malformation type I patients who underwent occipitocervical decompression. All patients with postoperative CSFD were female and their mean BMI was significantly higher than patients without this complication.

Correlates of obesity-related chronic ventilatory failure

Introduction

Only a third of obese patients develop chronic ventilatory failure. This cross-sectional study assessed multiple factors potentially associated with chronic ventilatory failure.

Materials/patients and methods

Participants had a body mass index (BMI) >30 kg/m², with or without chronic ventilatory failure (awake arterial partial pressure of carbon dioxide >6 kPa or base excess (BE) ≥2 mmols/L). Factors investigated were grouped into domains: (1) obesity measures, (2) pulmonary function, (3) respiratory and non-respiratory muscle strength, (4) sleep study derivatives, (5) hypoxic and hypercapnic responses, and (6) some hormonal, nutritional and inflammatory measures.

Results

71 obese participants (52% male) were studied over 27 months, 52 (SD 9) years and BMI 47 (range 32–74) kg/m². The best univariate correlates of BE from each domain were: (1) dual-energy X-ray absorptiometry measurement of visceral fat (r=+0.50, p=0.001); (2) supine forced expiratory volume in 1 s (r=−0.40, p=0.001); (3) sniff maximum pressure (r=−0.28, p=0.02); (4) mean overnight arterial oxygen saturation (r=−0.50, p<0.001); (5) ventilatory response to 15% O₂ breathing (r=−0.28, p=0.02); and (6) vitamin D (r=−0.30, p=0.01). In multivariate analysis, only visceral fat and ventilatory response to hypoxia remained significant.

Conclusions

We have confirmed that in the obese, BMI is a poor correlate of chronic ventilatory failure, and the best independent correlates are visceral fat and hypoxic ventilatory response.

Trial registration number

NCT01380418.

The relationship between intracranial pressure and obesity: an ultrasonographic evaluation of the optic nerve

BACKGROUND

Measurements of optic nerve sheath diameter (ONSD) with noninvasive ocular ultrasonography have been shown to be accurate in determining increased intracranial pressure. Obesity is associated with chronic increases in intraabdominal pressure that could consequently result in intracranial hypertension. By utilizing ONSD ultrasonographic measurements, we compare the difference that may exist between obese and non-obese patients.

STUDY DESIGN

We prospectively collected data from patients who underwent laparoscopic procedures in the supine position between July 2013 and March 2014. Ophthalmic pathology was not present in any patient. Ultrasonographic measurement of the ONSD was obtained sagittally with a 12-MHz transducer 3 mm from its origin. The measurements were taken at 0, 15, and 30 min, and at the end of surgery.

RESULTS

There were 62 subjects, 28 females (45.2 %) and 34 males (54.8 %), with a mean age of 44.22 ± 10.44 years (range 23-66). Forty-eight percent of patients were non-obese, and 52 % of patients were obese. The mean body mass index was 30.70 ± 7.61 kg/m(2) (range 20.0-59.5). The mean ONSD of non-obese and obese patients was 4.7 and 5.5 mm at baseline (p = 0.01), 5.4 and 6.2 mm at 15 min (p = 0.01), 5.8 and 6.6 mm at 30 min (p = 0.01), and 5.1 and 5.7 mm after deflation of pneumoperitoneum (p = 0.03), respectively.

CONCLUSIONS

Utilizing a noninvasive method to measure the ONSD, a chronic increase in intracranial pressure in obese patients was demonstrated. The increase in the ONSD during laparoscopic procedures reflects a temporary increase in the intracranial pressure from baseline.

The impact of abdominal adiposity measured by sonography on the pulmonary function of pre-menopausal females

Background

The Body Mass Index (BMI) is a widely used parameter to study obesity; however it does not assess the distribution of body adiposity. Ultrasonography is a reliable method of measuring subcutaneous (SAT), visceral (VAT) and Total adipose tissue of the abdomen (TAT) to determine the influence of abdominal fat on pulmonary function by directly measuring abdominal adipose tissue.

Methods

Eighty pre-menopausal, non-smoker, sedentary females with no history of pulmonary disease were subdivided into three groups: 25 normal-weight, 28 overweight, 27 obese. Absolute and predictive spirometric values were obtained: FVC, FEV₁, FEV₁/FVC, IC, ERV.

Results

A positive correlation between increased %IC and decreased %ERV was observed with increased BMI (p < 0.02; 0.001 respectively); %FVC, %FEV₁ and %ERV decreased significantly as SAT (p = 0.01, p = 0.02; p < 0.001) and TAT (p = 0.01, p = 0.03, p < 0.001) increased, whereas VAT was negatively correlated only with %ERV (p < 0.001). Increments of 5 mm in TAT, VAT and SAT were followed by a reduction of 0.83 %, 0.81 %, 1.90 % in %FVC, respectively, as well as a reduction of 4.25 %, 4.31 % and 9.44 % in %ERV, respectively.

Conclusions

Subcutaneous abdominal adipose tissue deposition in obese females has a greater negative influence on pulmonary function than visceral adipose tissue deposition.

Disease severity and staging of obesity: a rational approach to patient selection

The increasing prevalence of obesity places ever-increasing cost demands on healthcare systems. One million individuals are eligible for bariatric surgery in the UK, and yet less than 6000 bariatric procedures are performed annually. Bariatric surgery reverses or improves almost all the medical and psychosocial co-morbidities associated with obesity. Although the BMI is a simple method to estimate adiposity at a population level, it is relatively inaccurate within an individual and provides little-to-no indication of overall health status or disease severity. Staging systems overcome the inherent limitations of BMI and allow highly informed decision-making for an individual. At a societal level, this helps to identify those most likely to gain and maximise economic benefit. This review summarises the co-morbidities associated with obesity and the evidence for their improvement following surgery. The rationale for new staging criteria and appropriate patient selection are discussed.

Impact of body mass index on cerebellar tonsil position in healthy subjects and patients with Chiari malformation

OBJECT

It is unclear if there is a relationship between Chiari malformation Type I (CM-I) and body mass index (BMI). The aim of this study was to identify the relationship between BMI and cerebellar tonsil position in a random sample of people.

METHODS

Cerebellar tonsil position in 2400 subjects from a cohort of patients undergoing MRI was measured. Three hundred patients were randomly selected from each of 8 age groups (from 0 to 80 years). A subject was then excluded if he or she had a posterior fossa mass or previous posterior fossa decompression or if height and weight information within 1 year of MRI was not recorded in the electronic medical record.

RESULTS

There were 1310 subjects (54.6%) with BMI records from within 1 year of the measured scan. Of these subjects, 534 (40.8%) were male and 776 (59.2%) were female. The average BMI of the group was 26.4 kg/m(2), and the average tonsil position was 0.87 mm above the level of the foramen magnum. There were 46 subjects (3.5%) with a tonsil position ≥ 5 mm below the level of the foramen magnum. In the group as a whole, there was no correlation (R(2) = 0.004) between BMI and cerebellar tonsil position.

CONCLUSIONS

In this examination of 1310 subjects undergoing MRI for any reason, there was no relationship between BMI and the level of the cerebellar tonsils or the diagnosis of CM-I on imaging.

The incidence of albuminuria after bariatric surgery and usual care in Swedish Obese Subjects (SOS): a prospective controlled intervention trial

BACKGROUND

Obesity is associated with increased risk of chronic kidney disease and albuminuria is a predictor of renal impairment. Bariatric surgery reduces body weight in obese subjects, but it is not known whether surgery can prevent development of albuminuria. This study aims to determine the long-term effect of bariatric surgery on the incidence of albuminuria.

SUBJECTS

The Swedish Obese Subjects study is a non-randomized, prospective, controlled study conducted at 25 public surgical departments and 480 primary health care centers in Sweden. Between 1 September 1987 and 31 January 2001, 2010 participants who underwent bariatric surgery and 2037 controls were recruited. Inclusion criteria were age 37-60 years and BMI ⩾ 34 in men and BMI ⩾ 38 in women. In this analysis, we included 1498 patients in the surgery group and 1610 controls without albuminuria at baseline. Patients in the bariatric surgery group underwent banding (18%), vertical banded gastroplasty (69%) or gastric bypass (13%); controls received usual obesity care. Date of analysis was 1 January 2011. Median follow-up was 10 years, and the rates of follow-up were 87%, 74 and 52% at 2, 10 and 15 years, respectively. The main outcome of this report is incidence of albuminuria (defined as urinary albumin excretion >30 mg per 24 h) over up to 15 years.

RESULTS

During the follow-up, albuminuria developed in 246 participants in the control group and in 126 in the bariatric surgery group, corresponding to incidence rates of 20.4 and 9.4 per 1000 person years, respectively (adjusted hazard ratio, 0.37; 95% confidence interval, 0.30-0.47; P < 0.001). The expected number of surgeries needed to prevent the development of albuminuria in one patient at 10 years was nine.

CONCLUSIONS

Bariatric surgery is associated with reduced incidence of albuminuria compared with usual obesity care.

Intraocular pressure curves of untreated glaucoma suspects and glaucoma patients in sitting and lateral decubitus positions using the goldmann applanation tonometer

PURPOSE

Evaluation of data obtained during diurnal intraocular pressure (IOP) measurements by means of the Goldmann Applanation tonometer in sitting and lateral decubitus positions.

PATIENTS AND METHODS

Retrospective cohort study of 41 consecutive untreated subjects (82 eyes) with ocular hypertension or suspicious discs. The IOP was measured by Goldmann Applanation tonometer in sitting position at 9 AM, 12 AM, 3 PM, and 6 PM; and in right lateral decubitus position around 12:15 PM.

RESULTS

In the right eye (RE) mean peak IOP was 22.19±4.68 mm Hg. In the left eye (LE) peak mean IOP was 22.19±3.8 mm Hg. In 91.5% of the eyes, the IOP increased in the lateral decubitus position. The average change in the RE was an increment of 4.22±2.67 mm Hg (P<0.001) and in the LE an increment of 3.51±3.11 (P<0.001). This increment was significantly higher in the dependent eye (i.e., lower eye) (P=0.049). Sixty-seven percent of eyes had a positional elevation of IOP between 2 and 5 mm Hg and 23.2% of eyes had IOP elevation between 6 and 12 mm Hg. In the great majority of the eyes (80.5% RE and 78% LE) the lateral decubitus IOP was greater than maximal diurnal sitting IOP.

CONCLUSIONS

The IOP in the lateral decubitus position was significantly higher than the mean maximal diurnal sitting IOP. Over 20% of the patients had an IOP increase of ≥6 mm Hg when lying down. Timely identification of patients with excessive postural elevation of IOP could affect their management and prevent visual fields loss.

Impairment of gastrointestinal quality of life in severely obese patients

AIM: To investigate the common gastro-intestinal symptoms and quality of life in severely obese subjects.

METHODS: We prospectively recruited 340 severely obese patients [mean age 30.5 ± 7.8 years; mean body mass index (BMI) 42.9 ± 6.1 kg/m²] and 340 healthy persons (mean BMI 23.1 ± 3.8 kg/m²) matched in sex, age, marriage and education. The quality of life was studied using a specific gastrointestinal quality of life index (GIQLI) questionnaire. The 36 items and four functional domains of the GIQLI were compared and analyzed between the groups. The possible correlation of GIQLI scores with specific clinical variables in severely obese patients was assessed by measuring Pearson’s coefficient of correlation.

RESULTS: The mean GIQLI score of severely obese patients was lower than the normal control group (108.5 ± 17.1 vs 123.2 ± 14.8, P < 0.01). Severely obese patients had decreased scores in the domains of general health, including physical (17.3 ± 6.0 vs 22.4 ± 3.1, P < 0.01), emotional (12.6 ± 4.3 vs 16.6 ± 3.1, P < 0.01) and social function (14.7 ± 3.9 vs 17.9 ± 2.5, P < 0.01), and in the domain of gastrointestinal symptoms (63.9 ± 6.7 vs 66.3 ± 7.2, P < 0.05). A significantly decreased score was found in nine items, and there was an increased score in one out of the 19 items in the domain of symptoms of the GIQLI questionnaire. The decreased score in the domain of symptoms was correlated with increasing glycosylated hemoglobin (HbA1c) levels.

CONCLUSION: Severe obesity resulted in a significant impairment of the quality of life and caused specific gastrointestinal symptoms compared with normal controls. The development of gastrointestinal symptoms is correlated increasing HbA1c, suggesting that a poor control of hyperglycemia might be the etiology.

Renal implications of increased intra-abdominal pressure: are the kidneys the canary for abdominal hypertension?

INTRODUCTION

Increased intra-abdominal pressure (IAP) or intra-abdominal hypertension (IAH) is a cause of organ dysfunction in critically ill patients and is independently associated with mortality. The kidneys seem to be especially vulnerable to IAH induced dysfunction and renal failure is one of the most consistently described organ dysfunctions associated with IAH. The aim of this paper is to review the historical background, awareness, definitions, pathophysiologic implications and treatment options for IAP induced renal failure.

METHODS

This review will focus on the available literature on IAH-induced renal dysfunction. A Medline and PubMed search was performed in order to find an answer to the question "What is the impact of increased IAP on renal function in the critically ill?". The resulting references were included in the current review on the basis of relevance and scientific merit.

RESULTS

Renal dysfunction in IAH is a multifactorial process. The mechanisms involved have not been clarified completely. However, decreased cardiac output, altered renal blood flow and hormonal changes have been implicated. Decompression seems to have a beneficial effect on renal dysfunction, although there are some conflicting data. This may be due to the fact that there is no consensus on indications for decompression, both in terms of IAP values and of timing. An overview of current literature is provided and some interesting leads for future research are suggested.

CONCLUSION

IAH can cause renal dysfunction. Therefore, IAP measurements should be considered in our daily practice and preventive measures should be taken to avoid (deterioration of) renal failure in patients with IAH. Decompression may have a beneficial effect in patients with established IAH and renal failure.

The influence of intra-abdominal hypertension on the central nervous system: current insights and clinical recommendations, is it all in the head?

INTRODUCTION

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome are a common occurrence in ICU patients. The deleterious effects of IAH on organ function are well known and increasingly appreciated in recent years, especially where renal and respiratory function are concerned.

METHODS

This review will focus on the available literature from the last years. A Medline and PubMed search was performed in order to find an answer to the question "What is the impact of increased IAP on neurologic function in the critically ill?"

RESULTS

The amount of data on the influence of IAH on the central nervous system is more scarce, but several animal and human studies have demonstrated a clear correlation between intra-abdominal pressure (IAP) and intracranial pressure (ICP). This correlation is probably due to transmission of the increased IAP to the thorax leading to increased intrathoracic, pleural pressure and central venous pressure, decreased venous return from the brain and increased ICP. This hypothesis is supported by the observation that the increase in ICP is abolished when a sternotomy and pleuropericardotomy are performed, and by the fact that abdominal decompression has produced good results in treating refractory intracranial hypertension (ICH) in patients with both IAH and ICH.

CONCLUSIONS

A close relationship between IAP and ICP has been observed in several animal and human studies. The clinical impact of this association is dependent on the baseline ICP and the compensatory reserve of the patient. Some studies have reported good results in treating refractory ICH by abdominal decompression in patients with concomitant IAH. Monitoring of IAP and ICP in risk patients is essential.

Clinical significance of elevated intraabdominal pressure during common conditions and procedures

INTRODUCTION

Pregnancy, obesity, peritoneal dialysis, pneumoperitoneum, prone position and application of positive end-expiratory pressure are associated with elevated intraabdominal pressure (IAP).

OBJECTIVE

To review the relation between these conditions and procedures, and intraabdominal hypertension (IAH) or abdominal compartment syndrome (ACS).

METHODS

Search of PubMed and Google Scholar and review of article bibliographies.

RESULTS AND CONCLUSION

Only obesity, peritoneal dialysis, and pneumoperitoneum are associated with symptoms related to IAH and these symptoms are reversible.

Association of increased body mass index with Chiari malformation Type I and syrinx formation in adults

Object

In this paper the authors describe an association between increased body mass index (BMI) and Chiari malformation Type I (CM-I) in adults, as well as its relationship to the development of syringomyelia.

Methods

In the period between January 2004 and December 2011, the senior author reviewed the data for all CM-I patients with or without syringomyelia and neurological deficit. Analyzed factors included clinical status (headaches and neurological signs), radiological characteristics of syringomyelia (diameter and vertical extent of syrinx), BMI, and relationship of age to BMI, syrinx diameter, and vertical extent of syrinx.

Results

Sixty consecutive adults had CM-I, 26 of whom also had syringomyelia. The mean BMI among all patients was 30.35 ± 7.65, which is Class I obesity (WHO), and was similar among patients with or without syringomyelia. Extension of the vertical syrinx was greater in overweight patients (p = 0.027) than in those with a normal body weight. Evidence of de novo syrinx formation was found in 2 patients who gained an average BMI of 10.8 points. After repeated decompression and no change in holocord syrinx width or vertical extent, a reduction in the syrinx was seen after BMI decreased 11.7 points in one individual. No correlation was found between patient age and BMI, age and vertical extension of the syrinx, and age and diameter of the syrinx.

Conclusions

An association between increased BMI and CM-I in adults was recognized. Gaining weight may influence the de novo creation of a syrinx in adults who previously had minimally symptomatic or asymptomatic CM-I, and reducing weight can improve a syrinx after unsuccessful surgical decompression. Therefore, a reduction in body weight should be recommended for all overweight and obese patients with CM-I.

Relationship between body composition and both cardiovascular risk factors and lung function in systemic sclerosis

The aims of this study were to evaluate body composition in systemic sclerosis (SSc) and to assess its association with the traditional risk factors for atherosclerosis and parameters of lung function. Eighty-six patients affected by SSc (13 men and 73 women, mean age 58.5 years, mean disease duration 10.7 years, 31 with diffuse form and 55 with limited pattern) underwent evaluation of body composition using a dual-energy X-ray (DXA) fan beam densitometer (GE Lunar iDXA) in order to assess total and regional body fat mass and fat-free mass. Clinical features, pulmonary function parameters, and the concomitant presence of the traditional cardiovascular risk factors were recorded. Android fat resulted to be higher in SSc patients with coexistence of hypercholesterolemia (P = 0.021), hypertension (P = 0.028), and overweight/obesity (P < 0.001) and positively correlated with body mass index (P < 0.001). Forced vital capacity (FVC) was inversely correlated with android fat (P = 0.034) and with the android fat/gynoid fat ratio (P = 0.013) and positively correlated with android lean (P = 0.041); the correlations were improved when FVC data were adjusted for sex, age, disease duration, and smoking habits (P = 0.010 for android fat, P = 0.010 for android fat/gynoid fat ratio, P = 0.011 for android lean). In this study, we showed that visceral abdominal fat, measured by DXA, is correlated with the main cardiovascular risk factors and lung volumes in SSc patients. Longitudinal studies are needed to evaluate if decrease of abdominal fat would improve lung function.

VENOUS INSUFFICIENCY AND THROMBOEMBOLIC DISEASE IN BARIATRIC SURGERY PATIENTS

Context Morbid obesity is associated with various co-morbidities, including chronic venous insufficiency. Bariatric surgery is the only effective treatment for morbid obesity, but with potential risks and possible complications, including venous thromboembolism. Objective To determine the prevalence of clinical and ultrasonographic signs of chronic venous insufficiency in morbid obese patients in preparation for bariatric surgery and the incidence of post-operative venous thromboembolic disease. Methods Patients on work-up for bariatric surgery of Centro Terapêutico Especializado em Fígado (CETEFI) and Pro-Gastro surgical teams of the Hospital Beneficência Portuguesa de São Paulo were included. The analysed data were pre-operative findings for venous insufficiency (CEAP - clinical, etiological, anatomical, physiopathologic - classification and venous ultrassonographic findings), type of surgery (open or laparoscopic), abdominal circumference, body mass index (BMI) and post-operative ultrassonography search for venous insufficiency and deep venous thrombosis. Results Between March 2007 and December 2009, 95 patients candidates for bariatric surgery had clinical and duplex scan evaluation of the lower limbs venous system. Of the 95 patients, 53 were submitted to the surgical procedure. There was a predominance of women (77.9%), the average age was 38.5 years, average preoperative weight 124.6 kg and average BMI of 45.5 kg/m2. Regarding obesity, 16.8% were obese, and 83.1% were morbidly obese. In relation to the venous findings, 86.3% of the patients did fit CEAP classification less than 3 and 13.7% greater than or equal to 3. Among the post-operative complications, there were four cases of wound infection. Three patients developed post-operative distal venous thrombosis (7.5%), but no one had clinically manifested pulmonary embolism. Conclusion No relation between BMI, CEAP classification and venous ultrassonographic findings were found. Although prophylaxis was used in all patients, the incidence of post-operative distal venous thrombosis was considerably high.