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Puthenpura MM, Patel V, Fam J, Katz L, Tichansky DS, Myers S. The Use of Transient Elastography Technology in the Bariatric Patient: a Review of the Literature. Obes Surg 2020; 30:5108-5116. [PMID: 32981002 DOI: 10.1007/s11695-020-05002-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/17/2022]
Abstract
Transient elastography (TE) is a non-invasive technology that demonstrates promise in assessing liver steatosis and fibrosis without the risks of traditional percutaneous liver biopsy. Many studies have examined its reliability in respect to liver biopsy, but fewer have examined using TE in obese and bariatric surgery patients. With evidence showing that bariatric surgery can lead to improvement of liver steatosis and fibrosis, TE has the potential to provide a simple avenue of hepatic assessment in patients before and after procedures. This review article investigates what is known about the reliability of TE and its implementation in obese and bariatric surgery patients.
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Affiliation(s)
- Max M Puthenpura
- Department of Surgery, Drexel University College of Medicine, 2900 W Queen Lane, Philadelphia, PA, 19129, USA.
| | - Vishal Patel
- The Center for Liver Disease, Tower Health Transplant Institute, 420 S 5th Ave, West Reading, PA, 19611, USA
| | - John Fam
- Department of Surgery, Drexel University College of Medicine, 2900 W Queen Lane, Philadelphia, PA, 19129, USA.,Tower Health Weight Loss Surgery and Wellness Center, 1220 Broadcasting Rd, Wyomissing, PA, 19610, USA
| | - Leon Katz
- Department of Surgery, Drexel University College of Medicine, 2900 W Queen Lane, Philadelphia, PA, 19129, USA.,Tower Health Weight Loss Surgery and Wellness Center, 1220 Broadcasting Rd, Wyomissing, PA, 19610, USA
| | - David S Tichansky
- Department of Surgery, Drexel University College of Medicine, 2900 W Queen Lane, Philadelphia, PA, 19129, USA.,Tower Health Weight Loss Surgery and Wellness Center, 1220 Broadcasting Rd, Wyomissing, PA, 19610, USA
| | - Stephan Myers
- Department of Surgery, Drexel University College of Medicine, 2900 W Queen Lane, Philadelphia, PA, 19129, USA.,Tower Health Weight Loss Surgery and Wellness Center, 1220 Broadcasting Rd, Wyomissing, PA, 19610, USA
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Koons K, Plotas V, S. Tichansky D, R. Kammerer M. The Safety of Elective Surgery with Concurrent Use of Immunosuppressants. ACTA ACUST UNITED AC 2017. [DOI: 10.15761/gos.1000157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sarosiek K, Pappan KL, Gandhi AV, Saxena S, Kang CY, McMahon H, Chipitsyna GI, Tichansky DS, Arafat HA. Conserved Metabolic Changes in Nondiabetic and Type 2 Diabetic Bariatric Surgery Patients: Global Metabolomic Pilot Study. J Diabetes Res 2016; 2016:3467403. [PMID: 26881244 PMCID: PMC4736952 DOI: 10.1155/2016/3467403] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/15/2015] [Accepted: 11/25/2015] [Indexed: 12/22/2022] Open
Abstract
The goal of this study was to provide insight into the mechanism by which bariatric surgical procedures led to weight loss and improvement or resolution of diabetes. Global biochemical profiling was used to evaluate changes occurring in nondiabetic and type 2 diabetic (T2D) patients experiencing either less extreme sleeve gastrectomy or a full gastric bypass. We were able to identify changes in metabolism that were affected by standard preoperation liquid weight loss diet as well as by bariatric surgery itself. Preoperation weight-loss diet was associated with a strong lipid metabolism signature largely related to the consumption of adipose reserves for energy production. Glucose usage shift away from glycolytic pyruvate production toward pentose phosphate pathway, via glucose-6-phosphate, appeared to be shared across all patients regardless of T2D status or bariatric surgery procedure. Our results suggested that bariatric surgery might promote antioxidant defense and insulin sensitivity through both increased heme synthesis and HO activity or expression. Changes in histidine and its metabolites following surgery might be an indication of altered gut microbiome ecology or liver function. This initial study provided broad understanding of how metabolism changed globally in morbidly obese nondiabetic and T2D patients following weight-loss surgery.
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Affiliation(s)
- Konrad Sarosiek
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Kirk L. Pappan
- Metabolon, Inc., Research Triangle Park, Durham, NC 27713, USA
| | - Ankit V. Gandhi
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Shivam Saxena
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Christopher Y. Kang
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Heather McMahon
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Galina I. Chipitsyna
- Department of Biomedical Sciences, University of New England, Biddeford, ME 04005, USA
- *Galina I. Chipitsyna:
| | - David S. Tichansky
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Hwyda A. Arafat
- Department of Biomedical Sciences, University of New England, Biddeford, ME 04005, USA
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Kammerer MR, Porter MM, Beekley AC, Tichansky DS. Ideal Body Weight Calculation in the Bariatric Surgical Population. J Gastrointest Surg 2015; 19:1758-62. [PMID: 26268956 DOI: 10.1007/s11605-015-2910-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 08/03/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND In bariatric surgery, ideal body weight (IBW) is used to calculate excess body weight (EBW) and percent excess weight lost (%EWL). Bariatric literature typically uses the midpoint of the medium frame from older Metropolitan Life Insurance (MetLife) tables to estimate IBW. This is neither universal nor always clinically accurate. OBJECTIVE The objective of this study was to determine the accuracy of standard IBW formulas compared to MetLife data. METHODS Weight loss data from 200 bariatric surgical patients between 2009 and 2011 was used to assess the accuracy of IBW formulas. IBWs assigned from the midpoint of the medium frame and reassigned using different gender targets were compared to standard formulas and a new formula to assess the accuracy of all formulas to both targets. RESULTS Using standard MetLife data, the mean IBW was 136 lb, the mean EBW was 153.6 lb, and the mean %EWL was 43.8 %. Using the new target baseline, the mean IBW was 137.1 lb, the mean EBW was 152.6 lb, and the mean %EWL was 44 %. Deitel and Greenstein's formula was accurate to 0.3 % of EBW using the standard method, while our new formula was accurate to 0.03 % of EBW. CONCLUSIONS Deitel and Greenstein's formula is most accurate using standard target IBW. The most accurate is our formula using the new MetLife target IBW.
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Affiliation(s)
- Michael R Kammerer
- Division of Minimally Invasive, Metabolic and Bariatric Surgery, Department of Surgery, Thomas Jefferson University, 211 South 9th Street, Suite 402, Philadelphia, PA, 19107, USA.
| | - Michelle M Porter
- Division of Minimally Invasive, Metabolic and Bariatric Surgery, Department of Surgery, Thomas Jefferson University, 211 South 9th Street, Suite 402, Philadelphia, PA, 19107, USA.
| | - Alec C Beekley
- Division of Minimally Invasive, Metabolic and Bariatric Surgery, Department of Surgery, Thomas Jefferson University, 211 South 9th Street, Suite 402, Philadelphia, PA, 19107, USA.
| | - David S Tichansky
- Division of Minimally Invasive, Metabolic and Bariatric Surgery, Department of Surgery, Thomas Jefferson University, 211 South 9th Street, Suite 402, Philadelphia, PA, 19107, USA.
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Buwen JP, Kammerer MR, Beekley AC, Tichansky DS. Laparoscopic sleeve gastrectomy: The rightful gold standard weight loss surgery procedure. Surg Obes Relat Dis 2015; 11:1383-5. [PMID: 26278194 DOI: 10.1016/j.soard.2015.06.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 06/15/2015] [Accepted: 06/16/2015] [Indexed: 01/13/2023]
Affiliation(s)
- James P Buwen
- Division of Minimally Invasive, Metabolic and Bariatric, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - Michael R Kammerer
- Division of Minimally Invasive, Metabolic and Bariatric, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alec C Beekley
- Division of Minimally Invasive, Metabolic and Bariatric, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - David S Tichansky
- Division of Minimally Invasive, Metabolic and Bariatric, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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Abstract
The obesity epidemic has far-reaching implications for the economic and health care future in the United States. Treatments that show reduction in health care costs over time should be approved and made available to as many patients as possible. It is our opinion that bariatric surgery meets this criterion. However, bariatric surgery cannot provide the impact necessary for reduction in health care and economic costs on a national scale. The obesity epidemic must be addressed by policy efforts at the local, state, and national levels. As experts on obesity, bariatric surgeons must be prepared to guide and inform these efforts.
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Affiliation(s)
- Nathan G Richards
- Department of Surgery, Thomas Jefferson University, 1100 Walnut Street, 5th floor, Philadelphia, PA 19107, USA
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Tichansky DS, Glatt AR, Madan AK, Harper J, Tokita K, Boughter JD. Decrease in sweet taste in rats after gastric bypass surgery. Surg Endosc 2010; 25:1176-81. [PMID: 20844896 DOI: 10.1007/s00464-010-1335-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 08/17/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND The literature contains evidence that Roux-en-Y gastric bypass (RYGB) surgery has an effect in humans on taste and preference for carbohydrate-rich foods. This study tested the hypothesis that RYGB affects sweet taste behavior using a rat model. METHODS Male Sprague-Dawley rats underwent either RYGB or sham surgery. Then 4 weeks after surgery, the rats were given taste-salient, brief-access lick tests with a series of sucrose concentrations. RESULTS The RYGB rats, but not the sham rats, lost weight over the 5-week postoperative period. The RYGB rats showed a significant decrease in mean licks for the highest concentration of sucrose (0.25-1.0 mol/l) but not for the low concentrations of sucrose or water. CONCLUSIONS The findings showed that RYGB surgery affected sweet taste behavior in rats, with postsurgical rats having lower sensitivity or avidity for sucrose than sham-treated control rats. This finding is similar to human reports that sweet taste and preferences for high-caloric foods are altered after bypass surgery.
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Affiliation(s)
- David S Tichansky
- Department of Surgery, Thomas Jefferson University, 1100 Walnut Street, 5th Floor, Philadelphia, PA 19107, USA.
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Fain JN, Sacks HS, Bahouth SW, Tichansky DS, Madan AK, Cheema PS. Human epicardial adipokine messenger RNAs: comparisons of their expression in substernal, subcutaneous, and omental fat. Metabolism 2010; 59:1379-86. [PMID: 20116810 DOI: 10.1016/j.metabol.2009.12.027] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 12/09/2009] [Accepted: 12/28/2009] [Indexed: 11/25/2022]
Abstract
We compared the gene expression of inflammatory and other proteins by real-time quantitative polymerase chain reaction in epicardial, substernal (mediastinal) and subcutaneous sternal, upper abdominal, and leg fat from coronary bypass patients and omental (visceral) fat from extremely obese women undergoing bariatric surgery. We hypothesized that (1) epicardial fat would exhibit higher expression of inflammatory messenger RNAs (mRNAs) than substernal and subcutaneous fat and (2) epicardial mRNAs would be similar to those in omental fat. Epicardial fat was clearly different from substernal fat because there was a far higher expression of haptoglobin, prostaglandin D(2) synthase, nerve growth factor beta, the soluble vascular endothelial growth factor receptor (FLT1), and alpha1 glycoprotein but not of inflammatory adipokines such as monocyte chemoattractant protein-1, interleukin (IL)-8, IL-1beta, tumor necrosis factor alpha, serum amyloid A, plasminogen activator inhibitor-1, or adiponectin despite underlying coronary atherosclerosis. However, the latter inflammatory adipokines as well as most other mRNAs were overexpressed in epicardial fat as compared with the subcutaneous depots except for IL-8, fatty acid binding protein 4, the angiotensin II receptor 1, IL-6, and superoxide dismutase-2. Relative to omental fat, about one third of the genes were expressed at the same levels, whereas monocyte chemoattractant protein-1, cyclooxygenase-2, plasminogen activator inhibitor-1, IL-1beta, and IL-6 were expressed at far lower levels in epicardial fat. In conclusion, epicardial fat does not appear to be a potentially more important source of inflammatory adipokines than substernal mediastinal fat. Furthermore, the expression of inflammatory cytokines such as IL-6 and IL-1beta is actually higher in omental fat from obese women without coronary atherosclerosis. The data do not support the hypothesis that most of the inflammatory adipokines are expressed at high levels in epicardial fat of humans.
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Affiliation(s)
- John N Fain
- Department of Molecular Sciences, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Abstract
The relative release in vitro of endothelin-1, zinc-alpha2-glycoprotein (ZAG), lipocalin-2, CD14, RANTES (regulated on activation, normal T cell expressed and secreted protein), lipoprotein lipase (LPL), osteoprotegerin (OPG), fatty acid-binding protein 4 (FABP-4), visfatin/PBEF/Nampt, glutathione peroxidase-3 (GPX-3), intracellular cell adhesion molecule 1 (ICAM-1), and amyloid A was examined using explants of human adipose tissue as well as the nonfat cell fractions and adipocytes from obese women. Over a 48-h incubation the majority of the release of LPL was by fat cells whereas that of lipocalin-2, RANTES, and ICAM-1 was by the nonfat cells present in human adipose tissue. In contrast appreciable amounts of OPG, amyloid A, ZAG, FABP-4, GPX-3, CD14, and visfatin/PBEF/Nampt were released by both fat cells and nonfat cells. There was an excellent correlation (r = 0.75) between the ratios of adipokine release by fat cells to nonfat cells over 48 h and the ratio of their mRNAs in fat cells to nonfat cells at the start of the incubation. The total release of ZAG, OPG, RANTES, and amyloid A by incubated adipose tissue explants from women with a fat mass of 65 kg was not different from that by women with a fat mass of 29 kg. In contrast that of ICAM-1, FABP-4, GPX-3, visfatin/PBEF/Nampt, CD14, lipocalin-2, LP, and endothelin-1 was significantly greater in tissue from women with a total fat mass of 65 kg.
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Affiliation(s)
- John N Fain
- Department of Molecular Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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Madan AK, Martinez JM, Khan KA, Tichansky DS. Endoscopic Sclerotherapy for Dilated Gastrojejunostomy After Gastric Bypass. J Laparoendosc Adv Surg Tech A 2010; 20:235-7. [DOI: 10.1089/lap.2009.0310] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Atul K. Madan
- Division of Laparoendoscopic and Bariatric Surgery, Department of Surgery, University of Miami, Miami, Florida
| | - Jose M. Martinez
- Division of Laparoendoscopic and Bariatric Surgery, Department of Surgery, University of Miami, Miami, Florida
| | - Khurram A. Khan
- Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - David S. Tichansky
- Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Fain JN, Cheema P, Madan AK, Tichansky DS. Dexamethasone and the inflammatory response in explants of human omental adipose tissue. Mol Cell Endocrinol 2010; 315:292-8. [PMID: 19853017 DOI: 10.1016/j.mce.2009.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 09/15/2009] [Accepted: 10/09/2009] [Indexed: 12/01/2022]
Abstract
Dexamethasone is a synthetic glucocorticoid that is a potent anti-inflammatory agent. The present studies examined the changes in gene expression of 64 proteins in human omental adipose tissue explants incubated for 48h both in the absence and presence of dexamethasone as well as the release of 8 of these proteins that are putative adipokines. The proteins were chosen because they are inflammatory response proteins in other cells, are key regulatory proteins or are proteins with known functions. About 50% were significantly up-regulated while about 10% were unchanged and the remaining 40% were down-regulated. Dexamethasone significantly up-regulated the expression of about 33% of the proteins but down-regulated the expression of about 12% of the proteins. We conclude that dexamethasone is a selective anti-inflammatory agent since it inhibits only about one-fourth of the proteins up-regulated during in vitro incubation of human omental adipose tissue.
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Affiliation(s)
- John N Fain
- Department of Molecular Sciences, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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12
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Fain JN, Cheema P, Tichansky DS, Madan AK. The inflammatory response seen when human omental adipose tissue explants are incubated in primary culture is not dependent upon albumin and is primarily in the nonfat cells. J Inflamm (Lond) 2010; 7:4. [PMID: 20145729 PMCID: PMC2818611 DOI: 10.1186/1476-9255-7-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Accepted: 01/21/2010] [Indexed: 12/28/2022]
Abstract
Background The present studies were designed to investigate the changes in gene expression during in vitro incubation of human visceral omental adipose tissue explants as well as fat cells and nonfat cells derived from omental fat. Methods Adipose tissue was obtained from extremely obese women undergoing bariatric surgery. Explants of the tissue as well as fat cells and the nonfat cells derived by digestion with collagenase were incubated for 20 minutes to 48 h. The expression of interleukin 1β [IL-1β], tumor necrosis factor α [TNFα], interleukin 8 [IL-8], NFκB1p50 subunit, hypoxia-inducible factor 1α [HIF1α], omentin/intelectin, and 11β-hydroxysteroid dehydrogenase 1 [11β-HSD1] mRNA were measured by qPCR as well as the release of IL-8 and TNFα. Results There was an inflammatory response at 2 h in explants of omental adipose tissue that was reduced but not abolished in the absence of albumin from the incubation buffer for IL-8, IL-1β and TNFα. There was also an inflammatory response with regard to upregulation of HIF1α and NFκB1 gene expression that was unaffected whether albumin was present or absent from the medium. In the nonfat cells derived by a 2 h collagenase digestion of omental fat there was an inflammatory response comparable but not greater than that seen in tissue. The exception was HIF1α where the marked increase in gene expression was primarily seen in intact tissue. The inflammatory response was not seen with respect to omentin/intelectin. Over a subsequent 48 h incubation there was a marked increase in IL-8 mRNA expression and IL-8 release in adipose tissue explants that was also seen to the same extent in the nonfat cells incubated in the absence of fat cells. Conclusion The marked inflammatory response seen when human omental adipose tissue is incubated in vitro is reduced but not abolished in the presence of albumin with respect to IL-1β, TNFα, IL-8, and is primarily in the nonfat cells of adipose tissue.
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Affiliation(s)
- John N Fain
- Department of Molecular Sciences, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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Madan AK, Martinez JM, Lo Menzo E, Khan KA, Tichansky DS. Omental reinforcement for intraoperative leak repairs during laparoscopic Roux-en-Y gastric bypass. Am Surg 2009; 75:839-842. [PMID: 19774958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Leaks from the gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass (LRYGB) have the potential for significant morbidity and mortality. When intraoperative leaks are discovered, we choose to perform omental reinforcement around the gastrojejunostomy and pouch after suture repair of the leaks. This study examined the hypothesis that omental reinforcement would be useful after intraoperative leaks during LRYGB. Omental reinforcement was performed on gastrojejunostomies, in which leaks were seen, created using a circular stapler during LRYGB. Data were reviewed retrospectively on these patients. There were a total of 387 patients with 32 (8.26%) patients who had a staple line dehiscence or evidence of gastric pouch or gastrojejunostomy leak intraoperatively. Leaks/dehiscences were repaired with sutures and then reinforced with omentum. None of these patient developed anastomotic leak postoperatively. Of the other 365 patients, there were four (1.1%) leaks from the gastrojejunostomy and/or gastric pouch. Omental reinforcement may be useful in decreasing the incidence of postoperative leaks when an intraoperative leak is encountered during LRYGB. However, omental reinforcement does not completely prevent a postoperative leak. Consideration of reinforcement with omentum may be given for patients in whom an intraoperative leak is noted.
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Affiliation(s)
- Atul K Madan
- Division of Laparoendoscopic and Bariatric Surgery, Daughtry Family Department of Surgery, University of Miami, Miller School of Medicine, 1475 NW 12th Avenue, Suite 4017, Miami, FL 33136, USA.
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14
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Madan AK, Martinez JM, Menzo EL, Khan KA, Tichansky DS. Omental Reinforcement for Intraoperative Leak Repairs during Laparoscopic Roux-en-Y Gastric Bypass. Am Surg 2009. [DOI: 10.1177/000313480907500917] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Leaks from the gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass (LRYGB) have the potential for significant morbidity and mortality. When intraoperative leaks are discovered, we choose to perform omental reinforcement around the gastrojejunostomy and pouch after suture repair of the leaks. This study examined the hypothesis that omental reinforcement would be useful after intraoperative leaks during LRYGB. Omental reinforcement was performed on gastrojejunostomies, in which leaks were seen, created using a circular stapler during LRYGB. Data were reviewed retrospectively on these patients. There were a total of 387 patients with 32 (8.26%) patients who had a staple line dehiscence or evidence of gastric pouch or gastrojejunostomy leak intraoperatively Leaks/dehiscences were repaired with sutures and then reinforced with omentum. None of these patient developed anastomotic leak postoperatively. Of the other 365 patients, there were four (1.1%) leaks from the gastrojejunostomy and/or gastric pouch. Omental reinforcement may be useful in decreasing the incidence of postoperative leaks when an intraoperative leak is encountered during LRYGB. However, omental reinforcement does not completely prevent a postoperative leak. Consideration of reinforcement with omentum may be given for patients in whom an intraoperative leak is noted.
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Affiliation(s)
- Atul K. Madan
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
| | - Jose M. Martinez
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
| | - Emanuele Lo Menzo
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
| | - Khurram A. Khan
- Colorado Springs Health Partners, PC, Colorado Springs, Colorado
| | - David S. Tichansky
- Division of Minimally Invasive and Bariatric Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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Ali MR, Tichansky DS, Kothari SN, McBride CL, Fernandez AZ, Sugerman HJ, Kellum JM, Wolfe LG, DeMaria EJ. Validation that a 1-year fellowship in minimally invasive and bariatric surgery can eliminate the learning curve for laparoscopic gastric bypass. Surg Endosc 2009; 24:138-44. [DOI: 10.1007/s00464-009-0550-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Revised: 03/25/2009] [Accepted: 05/01/2009] [Indexed: 10/20/2022]
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Alaedeen D, Madan AK, Ro CY, Khan KA, Martinez JM, Tichansky DS. Intraoperative endoscopy and leaks after laparoscopic Roux-en-Y gastric bypass. Am Surg 2009; 75:485-488. [PMID: 19545096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Postoperative leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) are a source of morbidity and mortality. Any intervention that would decrease leak rates after LRYGB would be useful. This investigation tested the hypothesis that postoperative leak rates are lower after LRYGB with the routine use of intraoperative endoscopy (EN). Consecutive patients who underwent LRYGB were included. Intraoperative leak testing with air and methylene blue through an orogastric tube (OG) was used in the first 200 patients. Intraoperative endoscopy was used after the first 200 patients. There were 400 patients in this study. Preoperative demographics did not differ between groups. The intraoperative leak rate of the EN group was double the OG group (8 vs 4%; P = not significant), although the difference was not statistically significant. The OG group had a postoperative leak rate of 4 per cent with a mortality rate of 1 per cent. The EN group had a postoperative leak rate of 0.5 per cent with a mortality rate of 0 per cent. The difference in leak rates was statistically significant (P < 0.04). Despite the issues of learning curve, EN demonstrates more intraoperative leaks than OG, indicating EN may be a more sensitive test than OG. Routine use of EN is associated with less postoperative leaks after LRYGB.
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Affiliation(s)
- Diya Alaedeen
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida 33136, USA
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17
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Abstract
Postoperative leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) are a source of morbidity and mortality. Any intervention that would decrease leak rates after LRYGB would be useful. This investigation tested the hypothesis that postoperative leak rates are lower after LRYGB with the routine use of intraoperative endoscopy (EN). Consecutive patients who underwent LRYGB were included. Intraoperative leak testing with air and methylene blue through an orogastric tube (OG) was used in the first 200 patients. Intraoperative endoscopy was used after the first 200 patients. There were 400 patients in this study. Preoperative demographics did not differ between groups. The intraoperative leak rate of the EN group was double the OG group (8 vs 4%; P = not significant), although the difference was not statistically significant. The OG group had a postoperative leak rate of 4 per cent with a mortality rate of 1 per cent. The EN group had a postoperative leak rate of 0.5 per cent with a mortality rate of 0 per cent. The difference in leak rates was statistically significant ( P < 0.04). Despite the issues of learning curve, EN demonstrates more intraoperative leaks than OG, indicating EN may be a more sensitive test than OG. Routine use of EN is associated with less postoperative leaks after LRYGB.
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Affiliation(s)
- Diya Alaedeen
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
- Colorado Springs Health Partners, Colorado Springs, Colorado
| | - Atul K. Madan
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
- Colorado Springs Health Partners, Colorado Springs, Colorado
| | - Charles Y. Ro
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
- Colorado Springs Health Partners, Colorado Springs, Colorado
| | - Khurram A. Khan
- Colorado Springs Health Partners, Colorado Springs, Colorado
| | - Jose M. Martinez
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
- Colorado Springs Health Partners, Colorado Springs, Colorado
| | - David S. Tichansky
- Division of Minimally Invasive and Bariatric Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
- Colorado Springs Health Partners, Colorado Springs, Colorado
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Beech BM, Madan AK, Tichansky DS. BH-202: Child feeding practices and family physical activity in patients undergoing bariatric surgery. Surg Obes Relat Dis 2009. [DOI: 10.1016/j.soard.2009.03.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tichansky DS, Taddeucci RJ, Harper J, Madan AK. V-10: Laparoscopic correction of a slipped adjustable gastric band. Surg Obes Relat Dis 2009. [DOI: 10.1016/j.soard.2009.03.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fain JN, Cheema P, Tichansky DS, Madan AK. Stimulation of human omental adipose tissue lipolysis by growth hormone plus dexamethasone. Mol Cell Endocrinol 2008; 295:101-5. [PMID: 18640775 DOI: 10.1016/j.mce.2008.05.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Revised: 05/15/2008] [Accepted: 05/22/2008] [Indexed: 12/23/2022]
Abstract
Growth hormone [GH] administration results in a reduction in adiposity of humans that is attributed to stimulation of lipolysis. We examined the effect of direct addition of human GH, in both the absence and presence of dexamethasone [Dex], as well as that of interferon beta on lipolysis by omental adipose tissue explants from obese women incubated for 48h in primary culture. There was a significant stimulation of lipolysis by GH in the presence of Dex but not by Dex or GH alone. There was also a significant further stimulation by GH in the presence of Dex of hormone-sensitive lipase, perilipin, lipoprotein lipase and beta1 adrenergic receptor mRNA. We conclude that the direct lipolytic effect of GH is accompanied by an increase in HSL mRNA in the presence of DEX, but GH also increased the mRNAs for other proteins that could explain all or part of its lipolytic action.
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Affiliation(s)
- John N Fain
- Department of Molecular Sciences, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Abstract
INTRODUCTION It seems that public perception is that physicians receive substantial payments for procedures. This investigation explores patient perception and opinion of Medicare reimbursements to surgeons related to laparoscopic surgery. Our hypothesis was that patients think the surgeon Medicare fee schedule is higher than actuality. METHODS Patients filled out an IRB exempted survey. The survey included a written description of laparoscopic gastric bypass, laparoscopic adjustable gastric band placement, laparoscopic cholecystectomy and an initial patient visit for 30 minutes. All participants were asked to give their thoughts of what Medicare currently reimburses for these procedures as well as what the payment should be. The survey also asked other questions about reimbursement related to Medicare. RESULTS There were 96 participants in the investigation with 43% of patients not filling in reimbursements for at least one procedure. Most patients (88%) looked at their bills from physicians and insurance companies carefully. For each procedure, the mean reimbursements were approximately 10 times higher than the patient perception of both the amount Medicare currently pays and the amount Medicare should pay compared to the actual fee. For the initial patient visit, the patients overestimated the payment by 158% and thought the Medicare should pay 199% of the actual fee. Most of the patients (98%) thought Medicare should pay more for more difficult cases and 85% thought Medicare should pay more if the patient visits the surgeon more times during the global period. While 32% of the patients feel Medicare pay physicians well, 91% thought that Medicare should increase fees. CONCLUSION Most of our patients overestimated what Medicare currently pays for some laparoscopic procedures. Surgeons need to do a better job in educating patients and the general public about the Medicare fee schedule.
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Affiliation(s)
- Atul K Madan
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Florida 33136, USA.
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Madan AK, Tichansky DS, Isom J, Minard G, Bee TK. Monitored anesthesia care with propofol versus surgeon-monitored sedation with benzodiazepines and narcotics for preoperative endoscopy in the morbidly obese. Obes Surg 2008; 18:545-8. [PMID: 18386111 DOI: 10.1007/s11695-007-9338-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Accepted: 10/29/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although still controversial, upper endoscopy is frequently performed before bariatric surgery. This study investigated the hypothesis that morbidly obese patients would prefer anesthesiologist-monitored sedation (AMS) compared to surgeon-monitored sedation (SMS) during preoperative endoscopy. METHODS All patients who underwent endoscopy before their bariatric surgery were given a post-procedure survey regarding their experience with the preoperative endoscopy. The survey inquired about issues during and after the procedure. We compared patients who had AMS with IV propofol versus SMS IV narcotics and benzodiazepines. RESULTS There were 100 patients (SMS=49 and AMS=51). Few patients complained of pain in the abdomen or throat during the procedure (AMS vs. SMS=2 vs. 8% and 2 vs. 10%, respectively; p=NS). More patients complained about throat pain after the procedure (AMS vs. SMS=37 vs. 45%; p=NS). More patients in the SMS group remembered the scope being placed in the mouth versus AMS (33 vs. 10%; p<0.02). More patients remembered gagging during the procedure in the SMS group versus the AMS group, but this did not reach statistical significance (24 vs. 10%; p=0.06). There was a trend that more patients in the AMS group felt they recovered in less than 1 h (53%) compared to the SMS group (37%; p=0.1). CONCLUSION Patients who undergo upper endoscopy with either AMS or SMS seem to tolerate the procedure well. The preliminary benefits seen with AMS need to be further explored. AMS should be considered for patients undergoing preoperative upper endoscopy before bariatric surgery.
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Affiliation(s)
- Atul K Madan
- Division of Laparoendoscopic and Bariatric Surgery, Department of Surgery, University of Miami, 1475 N.W. 12th Avenue Room 4017, Miami, FL 33136, USA.
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Madan AK, Harper JL, Taddeucci RJ, Tichansky DS. Goal-directed laparoscopic training leads to better laparoscopic skill acquisition. Surgery 2008; 144:345-50. [DOI: 10.1016/j.surg.2008.03.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 03/14/2008] [Indexed: 01/22/2023]
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Simone EP, Madan AK, Tichansky DS, Kuhl DA, Lee MD. Comparison of two low-molecular-weight heparin dosing regimens for patients undergoing laparoscopic bariatric surgery. Surg Endosc 2008; 22:2392-5. [PMID: 18594915 DOI: 10.1007/s00464-008-9997-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 03/14/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Venous thromboembolic events (VTE) are a morbidity and mortality concern for patients undergoing laparoscopic bariatric surgery. Although VTE prophylaxis is recommended in bariatric surgery, data with regard to monitoring and appropriate dosing of low-molecular-weight heparin are limited. Enoxaparin prophylactic doses ranging from 30 to 60 mg every 12 h have been used for this population. The authors hypothesized that higher prophylactic enoxaparin doses (60 mg) would yield more appropriate heparin antifactor Xa (anti-Xa) concentrations than the 40-mg dosage for bariatric surgery patients. METHODS Patients undergoing laparoscopic bariatric surgery by two surgeons during a 5-month period at one institution received enoxaprin 40 or 60 mg every 12 h. Anti-Xa levels were obtained 4 h after the first and third doses. Therapeutic levels were defined as 0.18 to 0.44 U/ml. Paired and unpaired t-tests and chi-square tests were used for statistical analysis as appropriate. RESULTS The first-dose mean anti-Xa concentration was 0.173 U/ml in the 40-mg group and 0.261 U/ml in the 60-mg group (p < 0.005), compared with the third-dose mean anti-Xa levels of 0.21 and 0.43 U/ml, respectively (p < 0.001). After the third dose of enoxaparin, the percentage of patients with anti-Xa concentrations who remained subtherapeutic showed a statistically significant difference: 44% in the 40-mg group versus 0% in the 60-mg group (p = 0.02). However, no supratherapeutic anti-Xa concentrations were observed in the 40-mg group, whereas 57% of the third-dose levels in the 60-mg group were supratheraputic. The highest anti-Xa level was 0.54 U/ml, but none of the patients with this level experienced bleeding events. CONCLUSIONS Enoxaparin 60-mg every 12 h was superior to a dosage of 40 mg every 12 h in achieving therapeutic anti-Xa concentrations and avoiding subtherapeutic anti-Xa levels. However, the 60-mg group had a number of supratherapeutic levels. Future studies evaluating the relationship of anti-Xa concentrations and outcomes with larger numbers of morbidly obese patients are needed.
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Affiliation(s)
- Erin P Simone
- Department of Pharmacy, Regional Medical Center at Memphis, Turner Tower Room 201, 877 Jefferson Avenue, Memphis, TN 38103, USA.
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Fain JN, Buehrer B, Bahouth SW, Tichansky DS, Madan AK. Comparison of messenger RNA distribution for 60 proteins in fat cells vs the nonfat cells of human omental adipose tissue. Metabolism 2008; 57:1005-15. [PMID: 18555844 DOI: 10.1016/j.metabol.2008.02.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 02/28/2008] [Indexed: 01/04/2023]
Abstract
The messenger RNA (mRNA) distribution of 60 proteins was examined in the 3 fractions obtained by collagenase digestion (fat cells and the nonfat cells comprising the tissue remaining after collagenase digestion [matrix] and the stromovascular cells) of omental adipose tissue obtained from morbidly obese women undergoing bariatric surgery. Fat cells were enriched by at least 3-fold as compared with nonfat cells in the mRNAs for retinol binding protein 4, angiotensinogen, adipsin, glutathione peroxidase 3, uncoupling protein 2, peroxisome proliferator-activated receptor gamma, cell death-inducing DFFA-like effector A, fat-specific protein 27, 11beta-hydroxysteroid dehydrogenase 1, glycerol channel aquaporin 7, NADPH:quinone oxidoreductase 1, cyclic adenosine monophosphate phosphodiesterase 3B, glyceraldehyde-3-phosphate dehydrogenase, insulin receptor, and amyloid A1. Fat cells were also enriched by at least 26-fold in the mRNAs for proteins involved in lipolysis such as hormone-sensitive lipase, lipoprotein lipase, adipose tissue triglyceride lipase, and FAT/CD36. The relative distribution of mRNAs in cultured preadipocytes was also compared with that of in vitro differentiated adipocytes derived from human omental adipose tissue. Cultured preadipocytes had far lower levels of the mRNAs for inflammatory proteins than the nonfat cells of omental adipose tissue. The nonfat cells were enriched by at least 5-fold in the mRNAs for proteins involved in the inflammatory response such as tumor necrosis factor alpha, interleukin lbeta, cyclooxygenase 2, interleukin 24, interleukin 6, and monocyte chemoattractant protein 1 plus the mRNAs for osteopontin, vaspin, endothelin, angiotensin II receptor 1, butyrylcholinesterase, lipocalin 2, and plasminogen activator inhibitor 1. The cells in the adipose tissue matrix were enriched at least 3-fold as compared with the isolated stromovascular cells in the mRNAs for proteins related to the inflammatory response, as well as osteopontin and endothelial nitric oxide synthase. We conclude that the mRNAs for inflammatory proteins are primarily present in the nonfat cells of human omental adipose tissue.
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Affiliation(s)
- John N Fain
- Department of Molecular Sciences, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Tichansky DS, Boughter JD, Harper J, Glatt AR, Madan AK. Gastric bypass surgery in rats produces weight loss modeling after human gastric bypass. Obes Surg 2008; 18:1246-50. [PMID: 18581193 DOI: 10.1007/s11695-008-9556-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 05/05/2008] [Indexed: 12/28/2022]
Abstract
BACKGROUND The study of the mechanisms of weight loss after bariatric surgery requires an animal model that mimics the human procedure and subsequent weight loss. A rat model eliminates the cognitive efforts associated with human weight loss and gain. METHODS A technique for gastric bypass (Roux-en-Y gastric bypass [RYGB]) was developed in Sprague-Dawley rats. A 1- to 2-cc pouch is created from the uppermost stomach using a linear stapler. A 10-cm biliopancreatic limb and 15-cm Roux limb are anastomosed side to side with running nonabsorbable suture. The gastrojejunostomy is created with a single layer of running nonabsorbable suture. Four rats underwent RYGB. Weight loss was compared to four sham rats that had a midline incision and left 60 min with an open abdomen before closure. RESULTS RYGB rats lost an average of 16.5% body weight (BW) at 1 week, 22% BW at 2 weeks, 20% BW at 3 weeks, and 11% BW at 4 weeks. The RYGB rat's weight was basically level after 4 weeks. The shams lost an average of 4% BW at 1 week, 1% BW at 2 weeks, and 0% BW at 3 weeks and gained an average of 2% at weeks. Subjectively, the RYGB rats were less interested in chow and frequently had chow left in their cage. CONCLUSION A Sprague-Dawley rat model for gastric bypass has been developed and yields approximately 11% BW loss. This will allow investigators to objectively view factors associated with weight loss without the confounding cognitive factors in humans.
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Affiliation(s)
- David S Tichansky
- Section of Minimally Invasive Surgery, Department of Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Ave., Suite 208, Memphis, TN, 38163, USA.
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Madan AK, Tichansky DS, Khan KA. Natural Orifice Transluminal Endoscopic Gastric Bypass Performed in a Cadaver. Obes Surg 2008; 18:1192-9. [DOI: 10.1007/s11695-008-9553-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Accepted: 04/30/2008] [Indexed: 01/11/2023]
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Orth WS, Madan AK, Ternovits CA, Tichansky DS. Effect of preoperative knowledge on weight loss after laparoscopic gastric bypass. Obes Surg 2008; 18:768-71. [PMID: 18470575 DOI: 10.1007/s11695-007-9317-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Accepted: 09/10/2007] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Gastric bypass surgery has been demonstrated to be an effective treatment for morbid obesity. Unfortunately, not all patients have the same weight loss after surgery. It may be that the more informed patients will have more weight loss than less informed patients. No study has investigated the relationship between initial preoperative knowledge and weight loss after laparoscopic gastric bypass surgery. METHODS All patients who underwent laparoscopic gastric bypass for a 6-month period were included in this study. Our preoperative education process includes a 21-question true/false test given at the appointment immediately before surgery. Patients repeat the test until all questions are answered correctly. We compared percentage of excess body weight loss (EBWL) between patients who correctly answered all the questions the first time (pass patients) and patients who did not correctly answer all the questions the first time (fail patients). RESULTS There were 104 patients involved in this study; although complete data were only available on 98 patients. The average preoperative body mass index was 48 kg/m(2). Forty-eight percent of patients answered all the questions correctly the first time. Follow-up ranged from 1 to 2 years on all 98 patients. Pass patients had an average of 73% EBWL, whereas fail patients had an average of 76% EBWL (p = NS). CONCLUSIONS Preoperative knowledge, assessed by a test, did not predict success after laparoscopic gastric bypass surgery. Patients who do not, at first, have full knowledge of bariatric surgery should not be discriminated against undergoing surgery if they are eventually properly educated.
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Affiliation(s)
- Whitney S Orth
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Madan AK, Khan KA, Tichansky DS. V3: Endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass. Surg Obes Relat Dis 2008. [DOI: 10.1016/j.soard.2008.03.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Tichansky DS, Madan AK, Khan KA, Orth WS. P79: Preoperative consummatory behavior assessment survey does not predict postoperative weight loss following laparoscopic gastric bypass. Surg Obes Relat Dis 2008. [DOI: 10.1016/j.soard.2008.03.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Khan KA, Madan AK, Tichansky DS, Coday M. P101: Anxiety and depression do not predict weight loss after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008. [DOI: 10.1016/j.soard.2008.03.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Tichansky DS, Taddeucci RJ, Harper J, Madan AK. Minimally invasive surgery fellows would perform a wider variety of cases in their "ideal" fellowship. Surg Endosc 2008; 22:650-4. [PMID: 17593448 DOI: 10.1007/s00464-007-9430-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND With the increase in minimally invasive surgery (MIS) fellowships, the concept of the ideal and standardized training curriculum is emerging in importance. The authors hypothesize that the procedure mix in current MIS training is different from what current MIS fellows would expect for their "ideal" fellowship. METHODS An anonymous survey of current MIS fellows examined their perceptions of the case diversity and volume they expect to perform in their fellowships as compared with an ideal fellowship. Differences between expected and ideal case volume were analyzed using Wilcoxon tests. RESULTS A total of 32 questionnaires were returned. Current MIS fellows believe their expected training will exceed the ideal volume of laparoscopic cholecystectomies (p = 0.002). They believe their expected training is equivalent to ideal training in laparoscopic gastric bypass, ventral herniorraphy, inguinal herniorraphy, antireflux procedures, appendectomy, and diagnostic endoscopy (nonsignificant difference). However, current expected training falls short of their "ideal" case volume in laparoscopic gastric banding, colectomy, common bile duct exploration, gastrectomy, esophagectomy, splenectomy, adrenalectomy, hepatectomy, nephrectomy, and pancreatectomy (p < 0.05). The current MIS fellows also expect that their thoracoscopic, therapeutic endoscopy, and robotic procedure volume will be less than "ideal" (p < 0.05). CONCLUSION In 13 of 20 procedure types, current MIS fellows expect to perform a smaller case volume than in an "ideal" fellowship. The ideal case volume in the MIS fellowship curriculum needs to be defined better.
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Affiliation(s)
- D S Tichansky
- Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science, 956 Court Avenue, Ste. G218, Memphis, TN 38163, USA.
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Abstract
Body esteem is an issue for the morbidly obese. Although the primary goal of bariatric surgery is to improve, cure, and prevent medical comorbidities, the psychological aspect of bariatric surgery is just as important. Few studies have investigated the body esteem of patients after laparoscopic gastric bypass. This investigation tested the hypothesis that body esteem improves after bariatric surgery. Preoperative and postoperative patients were asked to fill out an institutional review board-exempted survey that included the Body-Esteem Scale for Adolescents and Adults (BESAA). The subscales include Appearance, Weight, and Attribution. Postoperative patients were told to fill the BESAA as they felt currently and as they felt before surgery. They felt that they had better scores currently than before surgery. Preoperative patients had worse scores than postoperative patients. As in many medical issues, body esteem improves after bariatric surgery. When discussing its benefits, psychological aspects of body esteem should be touted as well.
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Affiliation(s)
- Atul K Madan
- Division of Laparoendoscopic and Bariatric Surgery, Department of Surgery, University of Miami Mills of Science, Miami, Florida 33136, USA.
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Madan AK, Powelson JE, Tichansky DS. Cost analysis of laparoscopic gastric bypass practice using current Medicare reimbursement and practice costs. Surg Obes Relat Dis 2008; 4:131-6. [PMID: 18294921 DOI: 10.1016/j.soard.2007.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2007] [Revised: 11/30/2007] [Accepted: 12/11/2007] [Indexed: 01/21/2023]
Abstract
BACKGROUND We performed a formal cost analysis of a hypothetical bariatric practice consisting of a surgeon, dietitian, clinical coordinator/office manager, receptionist, and certified medical assistant to determine whether a bariatric practice would have a difficult time surviving financially with the current Medicare reimbursement. METHODS The number of possible cases was calculated for the 2005 calendar year. Most of the costs and assumptions were taken from an actual bariatric practice. The malpractice insurance premium (but not physician salary and benefits) was calculated into the practice cost. RESULTS With a total of 231 days available for clinical work in 2005, 300 scheduled laparoscopic gastric bypasses could have been performed to allow for appropriate clinic time for new patient visits, postoperative visits, and annual visits. The total reimbursement from Medicare would have been $516,158, with most of the reimbursement coming from procedure fees ($407,063). The total practice cost would have been $444,592. Most of the costs were clinic staff salary and benefits ($207,065) and the malpractice premium ($55,150). The net difference of $71,566 was left to pay the salary and benefits of the bariatric surgeon. CONCLUSION The low reimbursement of Medicare for laparoscopic gastric bypass threatens the financial viability of a bariatric surgery practice. With the increasing cost of malpractice and the threatened decrease in Medicare physician reimbursement, Medicare recipients could see a decrease in the number of bariatric surgeons offering them service.
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Affiliation(s)
- Atul K Madan
- Laparoendoscopic and Bariatric Surgery Division, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida 33136, USA.
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Madan AK, Harper JL, Taddeucci RJ, Tichansky DS. 108. Goal Directed Laparoscopic Training Leads to Better Laparoscopic Skill Acquisition. J Surg Res 2008. [DOI: 10.1016/j.jss.2007.12.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Rowan BO, Kuhl DA, Lee MD, Tichansky DS, Madan AK. Anti-Xa levels in bariatric surgery patients receiving prophylactic enoxaparin. Obes Surg 2007; 18:162-6. [PMID: 18165884 DOI: 10.1007/s11695-007-9381-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Accepted: 11/21/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Limited data exist regarding efficacy and dosing of low-molecular-weight heparins, including enoxaparin, for morbidly obese patients. Prophylactic doses of 30 to 60 mg every 12 h have been described in bariatric surgery patients with appropriate anti-Xa levels reported between 0.18 and 0.6 units/mL. METHODS Fifty-two laparoscopic gastric bypass or banding patients were enrolled. Patients were divided into two groups by the dose of enoxaparin that was given: Group 1--enoxaparin 30 mg every 12 hours--and Group 2--enoxaparin 40 mg every 12 h. Anti-Xa levels were obtained 4 h after the first and third doses. Levels between 0.18-0.44 units/mL were considered appropriate. RESULTS There were 19 patients (74% female, mean body mass index [BMI] 48.4 kg/m2) in Group 1 and 33 patients (82% female, mean BMI 48.5 kg/m2) in Group 2. In Group 1, anti-Xa levels were 0.06 and 0.08 units/mL after the first and third doses, respectively. In Group 2, anti-Xa levels were 0.14 and 0.15 units/mL after first and third doses, respectively (p = NS). There was a statistically significant difference in anti-Xa levels between Group 1 first dose and Group 2 first dose (p < 0.05) and between Group 1 third dose and Group 2 third dose (p < 0.05). Percentage of appropriate anti-Xa levels at first dose differed 0% vs. 30.8% (Group 1 vs. Group 2; p = 0.01) and at third dose 9.1% vs. 41.7% (Group 1 vs. Group 2; p = 0.155). CONCLUSION When prophylactic dose enoxaparin of 30 mg every 12 h was changed to 40 mg every 12 h in bariatric surgery patients, anti-Xa levels significantly increased with prophylactic dose enoxaparin in bariatric surgery patients. The percentage of appropriate levels also increased; however, more than half of the patients receiving 40 mg every 12 hours failed to reach therapeutic levels. No levels were supratherapeutic. Dosage of 40 mg every 12 h may not be sufficient for bariatric surgery patients.
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Affiliation(s)
- Brea O Rowan
- Department of Pharmacy, Princeton Baptist Medical Center, Birmingham, AL, USA.
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Madan AK, Harper JL, Tichansky DS. Techniques of laparoscopic gastric bypass: on-line survey of American Society for Bariatric Surgery practicing surgeons. Surg Obes Relat Dis 2007; 4:166-72; discussion 172-3. [PMID: 18069071 DOI: 10.1016/j.soard.2007.08.006] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 07/12/2007] [Accepted: 08/13/2007] [Indexed: 12/24/2022]
Abstract
BACKGROUND Various techniques have been used for laparoscopic gastric bypass. This study was performed to survey American Society for Bariatric Surgery practicing surgeons on how they perform laparoscopic gastric bypass. METHODS An Internet-based survey was sent to all practicing surgeons in the American Society for Bariatric Surgery database by way of e-mail. The survey was divided into sections, including experience, pouch, limbs, gastrojejunostomy (GJ), jejunojejunostomy, and band. The survey results were collected from the Internet site after 4 months. RESULTS A total of 215 surgeons responded; 98% stated they performed laparoscopic gastric bypass. The surgeons had performed an average of 423 cases in their career and 95 cases during the past 12 months. The average pouch size was 25 cm(3) and approximately one half of the surgeons (49%) measured the pouch size by the distance for the gastroesophageal junction. Almost all surgeons (99.5%) performed Roux-en-Y and not loop GJ. The average biliopancreatic limb length was 48 cm, and the average Roux limb was 114 cm. About one half of the surgeons (46%) measured the limb length with an open grasper, and few (7%) used a suture or umbilical tape. The antecolic and antegastric approaches were the more common. The percentage of those using the circular stapler, linear stapler, and hand sewing was 43%, 41%, and 21% for the GJ technique. Most surgeons (93%) routinely tested the GJ intraoperatively. The percentage of those using staple anastomosis and hand-sewn common enterotomy, double stapling, triple stapling, and hand sewing was 53%, 36%, 13%, and 1% for the jejunojejunostomy technique. Most surgeons (94%) closed at least one mesenteric defect. Also, most surgeons (95%) did not place a band around the pouch. CONCLUSION Technical variations exist in how laparoscopic gastric bypass procedures are performed by American Society for Bariatric Surgery practicing surgeons. Additional research is needed to explore the links between the technical variations and outcomes.
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Affiliation(s)
- Atul K Madan
- Minimally Invasive Surgery Section, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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Abstract
BACKGROUND Despite comprehensive preoperative education, patients may forget important information such as potential complications. METHODS Patients who had undergone laparoscopic bariatric surgery were surveyed. All patients were asked to write down as many as possible of the potential complications. Preoperatively, patients had been given an educational book, two preoperative educational appointments, a test, and an informed consent discussion and form with clear presentation of complications which may occur. RESULTS There were 70 patients in this investigation (75% response rate), with 49 laparoscopic gastric bypass patients (bypass), 18 laparoscopic adjustable gastric banding patients (band), and 3 patients who did not indicate their procedure. Patients listed an average of 5.1 complications. Complications were grouped in 12 categories for each procedure. Percentages reported by patients (bypass vs band) were: Death 34 (69%) vs. 13 (72%), Injury to GI tract/leak 14 (29%) vs. 5 (28%), Conversion 1 (2%) vs 0 (0%), CV/pulmonary issues 11 (22%) vs. 4 (22%), Stenosis/ulcer 6 (12%) vs NA, Band erosion/migration NA vs 9 (50%), Malnutrition 24 (49%) vs, 4 (22%), GI symptoms 19 (39%) vs. 6 (33%), Infection 15 (31%) vs. 10 (56%), Weight regain/inadequate loss 5 (10%) vs. 3 (17%), Thromboembolic event 7 (14%) vs. 3 (17%), and Hemorrhage 8 (16%) vs. 0 (0%). CONCLUSIONS Many patients forget some of the serious complications after laparoscopic bariatric surgery. This may have important medicolegal consequences especially during malpractice lawsuits. These data underscore the need for continual follow-up and education in this patient population.
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Affiliation(s)
- Atul K Madan
- Minimally Invasive Surgery Section, Department of Surgery, University of Tennessee Health Science Center, Memphis 38163, USA.
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Fain JN, Nesbit AS, Sudlow FF, Cheema P, Peeples JM, Madan AK, Tichansky DS. Release in vitro of adipsin, vascular cell adhesion molecule 1, angiotensin 1-converting enzyme, and soluble tumor necrosis factor receptor 2 by human omental adipose tissue as well as by the nonfat cells and adipocytes. Metabolism 2007; 56:1583-90. [PMID: 17950111 DOI: 10.1016/j.metabol.2007.06.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2007] [Accepted: 06/06/2007] [Indexed: 01/04/2023]
Abstract
The relative release in vitro of adipsin, vascular cell adhesion molecule (VCAM) 1, angiotensin 1-converting enzyme (ACE), and soluble tumor necrosis factor alpha receptor 2 (sTNFR2) by explants of human omental and subcutaneous adipose tissue as well as the nonfat cell fractions and adipocytes from morbidly obese gastric bypass women was compared with that by tissue from obese abdominoplasty patients. Release of VCAM-1 and ACE by omental adipose tissue explants was 220% and 80% greater, respectively, over 48 hours of incubation than that by subcutaneous adipose tissue explants. However, this difference was not seen when release by adipocytes derived from omental fat was compared with that by adipocytes from subcutaneous fat. The release of adipsin and sTNFR2 by omental adipose tissue explants did not differ from that by subcutaneous tissue adipose tissue. The release of adipsin by tissue explants over 48 hours was 100-fold greater than that of VCAM-1, ACE, or sTNFR2. Most of the release of all 4 adipokines was due to the nonfat cells because adipsin release by adipocytes was only 13% of that by the nonfat cells derived from the same amount of adipose tissue, whereas ACE release by adipocytes was 7% and release of VCAM-1 as well as sTNFR2 by adipocytes was 4% or less of that by nonfat cells. The total release in vitro of ACE and sTNFR2, but not that of adipsin or VCAM-1, was enhanced in adipose tissue explants from morbidly obese women as compared with those by explants derived from obese women. We conclude that although human adipose tissue explants release appreciable amounts of adipsin and far smaller amounts of VCAM-1, ACE, and sTNFR2 in vitro, more than 87% of the release is due to the nonfat cells present in adipose tissue. Furthermore, the enhanced release of VCAM-1 and ACE seen in omental adipose tissue explants as compared with explants of subcutaneous adipose tissue is due to release by nonfat cells.
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Affiliation(s)
- John N Fain
- Department of Molecular Sciences, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Madan AK, Stoecklein HH, Ternovits CA, Tichansky DS, Phillips JC. Use of upper gastrointestinal studies after laparoscopic gastric bypass. Surg Endosc 2007; 22:275-6. [PMID: 17973166 DOI: 10.1007/s00464-007-9642-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Accepted: 09/22/2007] [Indexed: 11/29/2022]
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Fain JN, Buehrer B, Tichansky DS, Madan AK. Regulation of adiponectin release and demonstration of adiponectin mRNA as well as release by the non-fat cells of human omental adipose tissue. Int J Obes (Lond) 2007; 32:429-35. [PMID: 17895880 DOI: 10.1038/sj.ijo.0803745] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Adiponectin is an adipokine produced by adipose tissue. The present studies examined the in vitro release of adiponectin by human omental adipose tissue explants as well as the mRNA content of freshly isolated non-fat cells and adipocytes plus cultured preadipocytes and adipocytes derived from omental fat. RESULTS The release of adiponectin was reduced while that of interleukin-8 (IL-8) was enhanced in tissue explants from morbidly obese women. The release of adiponectin was also reduced by one-third in explants from morbidly obese diabetic women while that of IL-8 was unaffected by diabetes. The release of adiponectin was enhanced by insulin and by inhibition of endogenous tumor necrosis factor (TNFalpha) using etancercept. Adiponectin was released in appreciable amounts by the undigested matrix obtained by collagenase digestion of adipose tissue. The release of adiponectin by non-fat cells (matrix+SV cells) was comparable to that by the adipocytes derived from the same amount of tissue while the adiponectin mRNA content of the pooled matrix and SV cell fractions was 40% of that in intact tissue. The adiponectin mRNA content was 48-fold greater in isolated adipocytes than in non-fat cells derived from adipose tissue. In contrast, the amount of adiponectin mRNA in vitro differentiated omental adipocytes was 1 x l0(6)-fold greater than that in cultured preadipocytes while that of leptin was 3 x 10(4)-fold greater. CONCLUSION Adiponectin mRNA is present in the non-fat cells of freshly isolated adipose tissue and release by the non-fat cells derived from a gram of adipose tissue is comparable to that by adipocytes isolated from the same amount of tissue. While leptin is only released by mature adipocytes, adiponectin is released by both the non-fat cells and the fat cells derived from human omental adipose tissue.
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Affiliation(s)
- J N Fain
- Department of Molecular Sciences, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 3816, USA.
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Madan AK, Taddeucci RJ, Harper JL, Tichansky DS. Initial trocar placement and abdominal insufflation in laparoscopic bariatric surgery. J Surg Res 2007; 148:210-3. [PMID: 18262554 DOI: 10.1016/j.jss.2007.08.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 08/22/2007] [Accepted: 08/24/2007] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Initial trocar placement and abdominal insufflation in laparoscopic bariatric surgery can be challenging for the novice. One technique is the use of an optical viewing trocar without prior abdominal insufflation. This investigation tests the hypothesis that this technique can be taught to novice surgeons with good results. METHODS Patients undergoing laparoscopic bariatric surgery were included. Novice surgeons (residents/fellows) with 0-50 initial trocar placements placed the initial trocar and insufflated the abdomen in the presence of an expert surgeon (>300 initial trocar placements in morbidly obese patients). Trocar placement time was defined as the time to place the trocar into the peritoneal cavity (including infiltration of local anesthesia and incision). Insufflation time was defined as the time to insufflate the abdomen to a pressure of 10 to 15 mm Hg (including time to place tubing on trocar). Novice times were compared with expert times. RESULTS There were 81 patients (56 by expert and 25 by novice) in this study. No bowel or vessel injury during initial trocar placement was noted. No correlation was seen between times and BMI or waist/hip circumference (P = NS). Mean expert trocar placement time was shorter than the mean novice time (25 +/- 9 versus 54 +/- 27 s; P < 0.0001); although there was no difference in mean insufflation time (expert versus novice: 16 +/- 5 versus 19 +/- 10; P = NS). The mean total time to place the initial trocar and insufflate the abdomen for the novices was 72 +/- 26 s. CONCLUSIONS Initial trocar placement can be taught safely to novices. The technique using an optical viewing trocar without prior abdominal insufflation is effective and efficient in morbidly obese patients.
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Affiliation(s)
- Atul K Madan
- Minimally Invasive Surgery Section, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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Madan AK, Whitfield JD, Fain JN, Beech BM, Ternovits CA, Menachery S, Tichansky DS. Are African-Americans as successful as Caucasians after laparoscopic gastric bypass? Obes Surg 2007; 17:460-4. [PMID: 17608257 DOI: 10.1007/s11695-007-9083-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to provide weight loss comparable to open gastric bypass. It has been suggested that African-Americans (AA) are not as successful as Caucasians (CA) after bariatric surgery. Our hypothesis was that AAs are just as successful as CA after LRYGBP in terms of weight loss and comorbidity improvement. METHODS A retrospective chart review was performed on all AA and CA patients who underwent LRYGBP for a 6-month period. Success after LRYGBP [defined as (1) 25% loss of preoperative weight, (2) 50% excess weight loss (EWL), or (3) weight loss to within 50% ideal weight] was compared by ethnicity. RESULTS 102 patients were included in this study. 97 patients (30 AA patients and 67 CA patients) had at least 1-year follow-up data available. Preoperative data did not differ between both groups. There was a statistically significant difference in %EWL between AA and CA (66% vs 74%; P<0.05). However, there was no ethnic difference in the percentage of patients with successful weight loss (as defined by any of the above 3 criteria). Furthermore, there was no statistical difference between the percentages of AA and CA patients who had improved or resolved diabetes and hypertension. CONCLUSIONS LRYGBP offers good weight loss in all patients. While there may be greater %EWL in CA patients, no ethnic difference in successful weight loss exists. More importantly, co-morbidities improve or resolve equally between AA and CA patients. LRYGBP should be considered successful in AA patients.
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Affiliation(s)
- Atul K Madan
- Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center, 956 Court Ave., Room G210, Memphis, TN 38163, USA.
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Madan AK, Dickson PV, Ternovits CA, Tichansky DS, Lobe TE. Results of Teenaged Bariatric Patients Performed in an Adult Program. J Laparoendosc Adv Surg Tech A 2007; 17:473-7. [PMID: 17705730 DOI: 10.1089/lap.2006.0190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Morbid obesity is a growing epidemic among adolescents. Bariatric surgery has proven to be the only long-term effective method in treating morbidly obese adults for over a decade. The laparoscopic approach has become a popular option. This study tested the hypothesis that laparoscopic Roux-en-Y gastric bypass is a feasible option in teenaged patients with good results through an adult bariatric program. METHODS All patients under the age of 20 at the time of surgery were included in this study. Each patient had undergone a laparoscopic Roux-en-Y gastric bypass. Charts were reviewed for preoperative evaluation, operative time, complications, and length of hospital stay. Percentage of excess body weight lost (%EBWL) was calculated at the follow-up. RESULTS Of the 202 patients who underwent a laparoscopic gastric bypass procedure at our institution, 5 (2%) were teenagers. The mean age was 18 years (range, 17-19). The mean height was 69 inches (range, 61-75). Average weight was 323 lbs (range, 227-394). The mean preoperative body mass index was 48 kg/m2 (range, 44-56). All patients had medical and psychological clearance prior to surgery. Mean operative time was 150 minutes (range, 130-172). There were no complications in this subset of patients. All 5 patients were discharged on postoperative day 2. Follow-up ranged from 17.8 to 44.8 months. The mean %EBWL was 77% (range, 58%-88%). CONCLUSIONS The laparoscopic gastric bypass procedure is technically feasible in teenaged patients, with excellent results even when performed in an adult bariatric program. Long-term data will be needed to determine its role in the treatment of morbidly obese adolescents.
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Affiliation(s)
- Atul K Madan
- Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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Abstract
General surgery residency involves a mixture of 1) education of residents and 2) service by residents. The service that residents provide is not directly reimbursed in our current healthcare system by private healthcare insurance companies. This investigation characterizes the amount of reimbursement a typical resident would be able to collect if residents were allowed to collect for their services as a first assistant. The case logs of residents who graduated over 2 years from our general surgery residency program were reviewed. Data from each resident's last 2 years (postgraduate years 4 and 5) were included in this study. Relative value units (RVUs) for each Current Procedural Terminology code were reviewed. Collections were calculated by multiplying the Medicare conversion factor of $36.7856/RVU, the corresponding RVU, and a “standard” collection rate of 16 per cent for first assistants. There were 13 general surgery residents. These residents provided first assistant help with 91,473 RVUs over 2 years. A total amount of $535,380 could have been collected on first assistant fees for the last 2 years of their residency. Each resident would have been able to collect an average at least $41,414 just for first assistant operative fees. Resident assistance in the operating room provides significant savings for private healthcare insurance companies each year by reducing the need for first assistants. The data demonstrate that private insurance companies receive a considerable amount of pro bono service from residents. Changes in the financing of the current healthcare system in the United States will require educators to examine other sources ( i.e., private insurance companies) for support of graduate medication education.
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Affiliation(s)
- Atul K. Madan
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Timothy C. Fabian
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - David S. Tichansky
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Madan AK, Fabian TC, Tichansky DS. Potential financial impact of first assistant billing by surgical residents. Am Surg 2007; 73:652-7; discussion 657. [PMID: 17674935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
General surgery residency involves a mixture of 1) education of residents and 2) service by residents. The service that residents provide is not directly reimbursed in our current healthcare system by private healthcare insurance companies. This investigation characterizes the amount of reimbursement a typical resident would be able to collect if residents were allowed to collect for their services as a first assistant. The case logs of residents who graduated over 2 years from our general surgery residency program were reviewed. Data from each resident's last 2 years (post-graduate years 4 and 5) were included in this study. Relative value units (RVUs) for each Current Procedural Terminology code were reviewed. Collections were calculated by multiplying the Medicare conversion factor of $36.7856/RVU, the corresponding RVU, and a "standard" collection rate of 16 per cent for first assistants. There were 13 general surgery residents. These residents provided first assistant help with 91,473 RVUs over 2 years. A total amount of $535,380 could have been collected on first assistant fees for the last 2 years of their residency. Each resident would have been able to collect an average at least $41,414 just for first assistant operative fees. Resident assistance in the operating room provides significant savings for private healthcare insurance companies each year by reducing the need for first assistants. The data demonstrate that private insurance companies receive a considerable amount of pro bono service from residents. Changes in the financing of the current healthcare system in the United States will require educators to examine other sources (i.e., private insurance companies) for support of graduate medication education.
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Affiliation(s)
- Atul K Madan
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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Abstract
BACKGROUND The concern about internal hernias has prompted recommendations for routine closure of defects during laparoscopic Roux-en-Y gastric bypass (LRYGBP). Our belief is that not all techniques require closure of defects. We hypothesize that non-closure of defects with our particular technique would not cause a significant clinically evident internal hernia rate. METHODS All patients who were operated on between December 2002 and June 2005 were included in this study. The technique that was utilized included an antecolic antegastric gastrojejunostomy (GJ), division of the greater omentum, a long jejunojejunostomy (JJ) performed with three staple-lines, a short (< 4 cm) division of the small bowel mesentery, and placement of the JJ above the colon in the left upper quadrant. Clinical records were reviewed for reoperations. RESULTS There was a total of 300 patients, and no incidence of internal hernia. In the first 100 patients, there was 97% follow-up for 1 year or more. Four patients underwent reoperations for unexplained abdominal pain. Intraoperative findings included an adhesive band from the JJ to the colon (1), an adhesive band from the JJ to the anterior abdominal wall (1), an adhesive band 3 cm from the GJ to the anterior abdominal wall (1), and adhesions of the jejunum to the anterior abdominal wall (1). No patient had an internal hernia. CONCLUSIONS Internal hernias are not common after this particular method of LRYGBP. Before adopting routine closure of potential spaces, surgeons should consider their technique, follow-up, and incidence of internal hernias. Routine closure of these defects is not always necessary.
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Affiliation(s)
- Christopher W Finnell
- Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center Memphis, TN 38163, USA
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Madan AK, Tichansky DS, Barton GE, Taddeucci RJ. Knowledge and opinions regarding Medicare reimbursement for laparoscopic cholecystectomy. Surg Endosc 2007; 21:2091-3. [PMID: 17516117 DOI: 10.1007/s00464-007-9313-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 01/10/2007] [Accepted: 01/22/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Medicare, via its fee schedule, determines amount of payment to physicians for services for its beneficiaries. Because many private insurance companies base their payment schedule on Medicare rates, it is important for physicians to know the rates of commonly performed procedures. In addition, it seems that public perception is that physicians receive substantial payments for procedures. This investigation explores patient, student, resident, and surgeon knowledge and opinion of Medicare reimbursements for laparoscopic cholecystectomy. METHODS Patients, students, residents, and surgeons filled out an IRB-exempted survey. The survey included a written description of a laparoscopic cholecystectomy. All participants were asked to give their thoughts of what Medicare currently reimburses for a laparoscopic cholecystectomy ($622) and what they thought Medicare should reimburse for a laparoscopic cholecystectomy for our geographic area. RESULTS There were 105 participants (47 patients, 17 medical students, 33 surgical residents, and 8 attending surgeons) in the investigation. The reported mean reimbursements of what each group thought Medicare pays were patients, $9,396; students, $3,077; residents, $800; and surgeons, $711. The reported mean reimbursements of what each group thought Medicare should pay were patients, $8,067; students, $3,971; residents, $1,444; and surgeons, $1,600. The mean reimbursements were statistically different between all groups in both the amount Medicare currently pays and the amount Medicare should pay. CONCLUSION Most of our participants overestimated what Medicare currently pays for laparoscopic cholecystectomy. Even the mean amount reported in the attending surgeon group was greater than the actual payment. All groups felt Medicare should pay more than the current rate; however, only patients thought Medicare should pay less than they currently pay (probably because of the incorrect perception of the current fee schedule).
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Affiliation(s)
- Atul K Madan
- Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center, 956 Court Avenue, Suite G210, Memphis, TN 38163, USA.
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Madan AK, Harper J, Tichansky DS. 57. Surg Obes Relat Dis 2007. [DOI: 10.1016/j.soard.2007.03.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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