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Samuels JM, Albaugh VL, Yu D, Chen Y, Williams DB, Spann MD, Wang L, Flynn CR, English WJ. Sex- and operation-dependent effects on 5-year weight loss results of bariatric surgery. Surg Obes Relat Dis 2024:S1550-7289(24)00038-8. [PMID: 38462409 DOI: 10.1016/j.soard.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/19/2023] [Revised: 01/10/2024] [Accepted: 01/21/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Weight loss response after bariatric surgery is highly variable, and several demographic factors are associated with differential responses to surgery. Preclinical studies demonstrate numerous sex-specific responses to bariatric surgery, but whether these responses are also operation dependent is unknown. OBJECTIVE To examine sex-specific weight loss outcomes up to 5 years after laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). SETTING Single center, university, United States. METHODS Retrospective, observational cohort study including RYGB (n = 5057) and vertical SG (n = 2041) patients from a single, academic health center. Percentage total weight loss (TWL) over time was examined with generalized linear mixed models to determine the main and interaction effects of surgery type on weight loss by sex. RESULTS TWL demonstrated a strong sex-by-procedure interaction, with women having a significant advantage with RYGB compared with SG (adjusted difference at 5 yr: 8.0% [95% CI: 7.5-8.5]; P < .001). Men also experienced greater TWL over time with RYGB or SG, but the difference was less and clinically insignificant (adjusted difference at 5 yr: 2.9% [2.0-3.8]; P < .001; P interaction between sex and procedure type = .0001). Overall, women had greater TWL than men, and RYGB patients had greater TWL than SG patients (adjusted difference at 5 yr: 3.1% [2.4-3.2] and 6.9% [6.5-7.3], respectively; both P < .0001). Patients with diabetes lost less weight compared with those without (adjusted difference at 5 yr: 3.0% [2.7-3.2]; P < .0001). CONCLUSIONS Weight loss after bariatric surgery is sex- and procedure-dependent. There is an association suggesting a clinically insignificant difference in weight loss between RYGB and SG among male patients at both the 2- and 5-year postsurgery time points.
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Affiliation(s)
- Jason M Samuels
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Vance L Albaugh
- Metamor Institute, Pennington Biomedical Research Center at Louisiana State University, Baton Rouge, Louisiana
| | - Danxia Yu
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - You Chen
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D Brandon Williams
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew D Spann
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lei Wang
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C Robb Flynn
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wayne J English
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Wong G, Garner EM, Takkouche S, Spann MD, English WJ, Albaugh VL, Srivastava G. Combination anti‐obesity medications to effectively treat bariatric surgery weight regain at an academic obesity center. Obes Sci Pract 2023; 9:203-209. [PMID: 37287513 PMCID: PMC10242249 DOI: 10.1002/osp4.635] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/05/2022] [Indexed: 11/21/2023] Open
Abstract
AbstractBackgroundCombination anti‐obesity medications (AOMs) to treat postoperative bariatric surgery weight regain have limited data on their use in the clinical setting. Understanding the optimal treatment protocol in this cohort will maximize weight loss outcomes.MethodsA retrospective review of bariatric surgery patients (N = 44) presenting with weight regain at a single academic multidisciplinary obesity center who were prescribed AOM(s) plus intensive lifestyle modification for 12 months.ResultsAge: 28–76 years old, 93% female, mean weight 110.2 ± 20.3 kg, BMI 39.7 ± 7.4 kg/m2, presenting 5.2 ± 1.6 years post‐bariatric surgery [27 (61.4%), 14 (31.8%), and 3 (6.8%) laparoscopic Roux‐en‐Y gastric bypass (RYGB), laparoscopic vertical sleeve gastrectomy (VSG), and open RYGB, respectively], with 15.1 ± 11.1 kg mean weight gain from nadir. Mean weight loss after medical intervention at 3‐, 6‐, and 12‐month time points was 4.4 ± 4.6 kg, 7.3 ± 7.0 kg, and 10.7 ± 9.2 kg, respectively. At 12 months, individuals prescribed 3 or more AOMs lost more weight than those prescribed one (−14.5 ± 9.0 kg vs. −4.9 ± 5.7 kg, p < 0.05) irrespective of age, gender, number of comorbidities, initial weight or BMI, type of surgery, or GLP1 use. RYGB patients lost less weight overall (7.4% vs. 14.8% VSG respectively; p < 0.05).ConclusionsCombination AOMs may be needed to achieve optimal weight loss results to treat post‐operative weight regain.
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Affiliation(s)
- Gunther Wong
- Department of Medicine Division of Diabetes, Endocrinology & Metabolism Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt Weight Loss Center Vanderbilt University Medical Center Nashville Tennessee USA
| | - Erica M. Garner
- Department of Medicine Division of Diabetes, Endocrinology & Metabolism Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt Weight Loss Center Vanderbilt University Medical Center Nashville Tennessee USA
| | - Sahar Takkouche
- Department of Medicine Division of Diabetes, Endocrinology & Metabolism Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt Weight Loss Center Vanderbilt University Medical Center Nashville Tennessee USA
| | - Matthew D. Spann
- Vanderbilt Weight Loss Center Vanderbilt University Medical Center Nashville Tennessee USA
- Department of Surgery Vanderbilt University School of Medicine Nashville Tennessee USA
| | - Wayne J. English
- Vanderbilt Weight Loss Center Vanderbilt University Medical Center Nashville Tennessee USA
- Department of Surgery Vanderbilt University School of Medicine Nashville Tennessee USA
| | - Vance L. Albaugh
- Metamor Institute Pennington Biomedical Research Center Baton Rouge Louisiana USA
| | - Gitanjali Srivastava
- Department of Medicine Division of Diabetes, Endocrinology & Metabolism Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt Weight Loss Center Vanderbilt University Medical Center Nashville Tennessee USA
- Department of Surgery Vanderbilt University School of Medicine Nashville Tennessee USA
- Department of Pediatrics Vanderbilt University School of Medicine Nashville Tennessee USA
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Hawkins AT, Ueland T, Aher C, Geiger TM, Spann MD, Horst SN, Schafer IV, Ye F, Fan R, Sharp KW. Shared Decision-Making in General Surgery: Prospective Comparison of Telemedicine vs In-Person Visits. J Am Coll Surg 2023; 236:762-771. [PMID: 36728391 DOI: 10.1097/xcs.0000000000000538] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has accelerated a shift toward virtual telemedicine appointments with surgeons. While this form of healthcare delivery has potential benefits for both patients and surgeons, the quality of these interactions remains largely unstudied. We hypothesize that telemedicine visits are associated with lower quality of shared decision-making. STUDY DESIGN We performed a mixed-methods, prospective, observational cohort trial. All patients presenting for a first-time visit at general surgery clinics between May 2021 and June 2022 were included. Patients were categorized by type of visit: in-person vs telemedicine. The primary outcome was the level of shared decision-making as captured by top box scores of the CollaboRATE measure. Secondary outcomes included quality of shared decision-making as captured by the 9-item Shared Decision-Making Questionnaire and satisfaction with consultation survey. An adjusted analysis was performed accounting for potential confounders. A qualitative analysis of open-ended questions for both patients and practitioners was performed. RESULTS During a 13-month study period, 387 patients were enrolled, of which 301 (77.8%) underwent in-person visits and 86 (22.2%) underwent telemedicine visits. The groups were similar in age, sex, employment, education, and generic quality-of-life scores. In an adjusted analysis, a visit type of telemedicine was not associated with either the CollaboRATE top box score (odds ratio 1.27; 95% CI 0.74 to 2.20) or 9-item Shared Decision-Making Questionnaire (β -0.60; p = 0.76). Similarly, there was no difference in other outcomes. Themes from qualitative patient and surgeon responses included physical presence, time investment, appropriateness for visit purpose, technical difficulties, and communication quality. CONCLUSIONS In this large, prospective study, there does not appear to be a difference in quality of shared decision making in patients undergoing in-person vs telemedicine appointments.
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Affiliation(s)
- Alexander T Hawkins
- Section of Colon and Rectal Surgery (Hawkins, Ueland, Geiger, Schafer), Vanderbilt University Medical Center, Nashville, TN
| | - Thomas Ueland
- Section of Colon and Rectal Surgery (Hawkins, Ueland, Geiger, Schafer), Vanderbilt University Medical Center, Nashville, TN
| | - Chetan Aher
- From the Division of General Surgery (Aher, Spann, Sharp), Vanderbilt University Medical Center, Nashville, TN
| | - Timothy M Geiger
- Section of Colon and Rectal Surgery (Hawkins, Ueland, Geiger, Schafer), Vanderbilt University Medical Center, Nashville, TN
| | - Matthew D Spann
- From the Division of General Surgery (Aher, Spann, Sharp), Vanderbilt University Medical Center, Nashville, TN
| | - Sara N Horst
- Departments of Gastroenterology, Hepatology, and Nutrition (Horst), Vanderbilt University Medical Center, Nashville, TN
| | - Isabella V Schafer
- Section of Colon and Rectal Surgery (Hawkins, Ueland, Geiger, Schafer), Vanderbilt University Medical Center, Nashville, TN
| | - Fei Ye
- Biostatistics (Ye, Fan), Vanderbilt University Medical Center, Nashville, TN
| | - Run Fan
- Biostatistics (Ye, Fan), Vanderbilt University Medical Center, Nashville, TN
| | - Kenneth W Sharp
- From the Division of General Surgery (Aher, Spann, Sharp), Vanderbilt University Medical Center, Nashville, TN
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Flynn CR, Tamboli RA, Antoun J, Sidani RM, Williams B, Spann MD, English WJ, Welch EB, Sundaresan S, Abumrad NN. Caloric Restriction and Weight Loss Are Primary Factors in the Early Tissue-Specific Metabolic Changes After Bariatric Surgery. Diabetes Care 2022; 45:1914-1916. [PMID: 35724307 PMCID: PMC9346980 DOI: 10.2337/dc22-0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/03/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate changes in insulin sensitivity, hormone secretion, and hepatic steatosis immediately after caloric restriction, vertical sleeve gastrectomy (VSG), and Roux-en-Y gastric bypass (RYGB). RESEARCH DESIGN AND METHODS Obese subjects were assessed for 1) insulin sensitivity with hyperinsulinemic-euglycemic clamp with glucose tracer infusion, 2) adipokine concentrations with serum and subcutaneous adipose interstitial fluid sampling, and 3) hepatic fat content with MRI before and 7-10 days after VSG, RYGB, or supervised caloric restriction. RESULTS Each group exhibited an ∼5% total body weight loss, accompanied by similar improvements in hepatic glucose production and hepatic, skeletal muscle, and adipose tissue insulin sensitivity. Leptin concentrations in plasma and adipose interstitial fluid were equally decreased, and reductions in hepatic fat were similar. CONCLUSIONS The improvements in insulin sensitivity and adipokine secretion observed early after bariatric surgery are replicated by equivalent caloric restriction and weight loss.
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Affiliation(s)
- Charles Robb Flynn
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Robyn A Tamboli
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Joseph Antoun
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Reem M Sidani
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Brandon Williams
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew D Spann
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Wayne J English
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - E Brian Welch
- Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Sinju Sundaresan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Naji N Abumrad
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
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Abel SA, English WJ, Duke MC, Williams DB, Aher CV, Broucek JR, Spann MD. Benefits of Adjuvant Medical Weight Loss Intervention in Setting of Weight Regain and Inadequate Weight Loss After Weight Loss Surgery. Am Surg 2022:31348221078957. [PMID: 35317659 DOI: 10.1177/00031348221078957] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Currently, there is no nationally accepted protocol for addressing weight regain or inadequate weight loss after MBS. OBJECTIVES To devise, implement, and evaluate a protocol targeting weight regain or inadequate weight loss in MBS patients at our institution. SETTING Vanderbilt University Medical Center, Nashville, TN, United States. METHODS Patients at least 6 months following primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) who achieved or were trending toward <50% excess body weight loss or who regained ≥10% of their lowest postoperative weight, were identified and referred for medical weight loss (MWL) intervention. Exclusion criteria were body mass index (BMI) ≤ 27 kg/m2, treatment with adjustable gastric banding, and conversion from SG to RYGB. RESULTS 2274 patients who were >6 months out from surgery were evaluated over 12 months. 93 patients (86% female) met criteria for inclusion. 69 (74%) patients agreed to intervention and were followed for an average of 165 days (SD 106.89 days), demonstrating a mean weight change of -5.11 kg (SD 6.86 kg), and BMI change of -1.81 kg/m2 (SD 2.37 kg/m2). Patients who spent <90 days in a MWL program demonstrated less average weight loss (1.75 kg vs 6.48 kg) (P = .0042), and less change in BMI (-.63 kg/m2 vs -2.29 kg/m2) (P = .0037) when compared to patients who spent >90 days in the MWL intervention. CONCLUSIONS This study identifies criteria for intervention in patients suffering weight regain or inadequate weight loss after MBS and demonstrates that standardized identification and referral for treatment results in modest weight loss.
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Affiliation(s)
- Stuart A Abel
- Division of Surgery, RinggoldID:12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wayne J English
- Division of Surgery, RinggoldID:12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meredith C Duke
- Division of Surgery, RinggoldID:12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - D Brandon Williams
- Division of Surgery, RinggoldID:12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chetan V Aher
- Division of Surgery, RinggoldID:12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph R Broucek
- Division of Surgery, RinggoldID:12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D Spann
- Division of Surgery, RinggoldID:12328Vanderbilt University Medical Center, Nashville, TN, USA
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Kent D, Stanley J, Aurora RN, Levine CG, Gottlieb DJ, Spann MD, Torre CA, Green K, Harrod CG. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2021; 17:2507-2531. [PMID: 34351849 DOI: 10.5664/jcsm.9594] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation. METHODS The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations. RESULTS The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), oxygen desaturation index (ODI), increase in lowest oxygen saturation (LSAT), sleep quality, and improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI, and increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, ODI, and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggest that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.
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Affiliation(s)
- David Kent
- Vanderbilt University Medical Center, Nashville, TN
| | | | - R Nisha Aurora
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Daniel J Gottlieb
- VA Boston Healthcare System, Brigham and Women's Hospital, Boston, MA
| | | | - Carlos A Torre
- University of Miami, Miller School of Medicine, Miami FL
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Kent D, Stanley J, Aurora RN, Levine C, Gottlieb DJ, Spann MD, Torre CA, Green K, Harrod CG. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2021; 17:2499-2505. [PMID: 34351848 DOI: 10.5664/jcsm.9592] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction This guideline establishes clinical practice recommendations for referring adults with obstructive sleep apnea (OSA) for surgical consultation. Methods The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine, otolaryngology, and bariatric surgery to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using the GRADE process. The task force evaluated the relevant literature and the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations. Recommendations The following recommendations are intended as a guide for clinicians who treat adults with OSA. Each recommendations statement is assigned a strength ("Strong" or "Conditional"). A "Strong" recommendation (i.e., "We recommend…") is one that clinicians should follow under most circumstances. A "Conditional" recommendation is one that requires that the clinician use clinical knowledge and experience, and strongly consider the patient's values and preferences to determine the best course of action. 1. We recommend that clinicians discuss referral to a sleep surgeon with adults with OSA and BMI<40 who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. (STRONG) 2. We recommend that clinicians discuss referral to a bariatric surgeon with adults with OSA and obesity (class II/III, BMI ≥35) who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. (STRONG) 3. We suggest that clinicians discuss referral to a sleep surgeon with adults with OSA, BMI<40, and persistent inadequate PAP adherence due to pressure-related side effects as part of a patient-oriented discussion of adjunctive or alternative treatment options. (CONDITIONAL) 4. We suggest clinicians recommend PAP as initial therapy for adults with OSA and a major upper airway anatomic abnormality prior to consideration of referral for upper airway surgery. (CONDITIONAL).
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Affiliation(s)
- David Kent
- Vanderbilt University Medical Center, Nashville, TN
| | | | - R Nisha Aurora
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Corinna Levine
- University of Miami, Miller School of Medicine, Miami FL
| | - Daniel J Gottlieb
- VA Boston Healthcare System, Brigham and Women's Hospital, Boston, MA
| | | | - Carlos A Torre
- University of Miami, Miller School of Medicine, Miami FL
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Albaugh VL, Williams DB, Aher CV, Spann MD, English WJ. Prevalence of thiamine deficiency is significant in patients undergoing primary bariatric surgery. Surg Obes Relat Dis 2020; 17:653-658. [PMID: 33478908 DOI: 10.1016/j.soard.2020.11.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/02/2020] [Revised: 09/20/2020] [Accepted: 11/26/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients undergoing metabolic and bariatric surgery are prone to developing micronutrient deficiencies, necessitating life-long nutritional supplementation and monitoring. Historically, these deficiencies were thought to be driven by postsurgical changes in absorption. Recent data, though, have demonstrated that obesity alone is also associated with micronutrient deficiencies. Thiamine deficiency, in particular, can lead to permanent neurologic deficits. OBJECTIVE Identify thiamine deficiency prevalence within the preoperative metabolic and bariatric surgery patient population. SETTING Single institution academic medical center. METHODS A retrospective review of deidentified data was examined that included whole blood thiamine measured from consecutive patients from April 2018 to June 2019 (n = 346). Cohort characteristics were assessed including age, operation, preoperative weight, and race/ethnicity. The majority of the cohort were women (83%) with an average age of 44.9 years. Racial representation included White/Caucasian (73%) and Black (21%), while operations included Roux-en-Y gastric bypass (58%), sleeve gastrectomy (31%), and revisions (10%). RESULTS Thiamine concentration was normally distributed with a mean of 144 nM. Overall, 3.5% of patients had thiamine concentrations below the lower limit of normal of <70 nM, while 35 additional patients (14%) were at risk for thiamine deficiency with concentrations <100 nM. On the average, these patients were of similar age and were all undergoing primary procedures (50% gastric bypass, 50% sleeve gastrectomy). Regression methods demonstrated that patients with thiamine deficiency tended to be females with higher body mass index, even after controlling for sex, height, and preoperative weight. After covariate adjustment, male sex and increasing height were both associated with higher thiamine concentration. CONCLUSION Previously quoted rates of thiamine deficiency in the preoperative patient are variable, but we describe a significant number of patients with, or at risk of, thiamine deficiency. Male sex and increasing height are likely associated with increased skeletal muscle mass, which is enriched with thiamine. Routine thiamine measurement, either preoperatively or at the time of surgery, is warranted given its limited stores within the body and potential catastrophic complications associated with acute or chronic deficiency.
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Affiliation(s)
- Vance L Albaugh
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D Brandon Williams
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chetan V Aher
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew D Spann
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wayne J English
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee.
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Spann MD, Aher CV. Standardized Approach to Perioperative Thromboembolic Chemoprophylaxis Surrounding Bariatric and Metabolic Surgery. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.197] [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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Matevish LE, Hawkins AT, Bethurum AJ, Aher CV, English WJ, Williams DB, Spann MD. Change in Total Body Water as a Metric for Predicting Need for Outpatient Intravenous Fluids in Postoperative Bariatric Patients. Am Surg 2020; 86:1169-1174. [PMID: 32862663 DOI: 10.1177/0003134820945271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dehydration drives a significant proportion of readmissions following bariatric surgery. Routinely performed body composition testing and total body water (TBW) calculations may present a novel method for diagnosing dehydration for outpatient intervention. We sought to determine if a change in TBW from preoperative baseline could help identify bariatric patients requiring outpatient intravenous fluid (IVF) administration for dehydration. METHODS The VUMC Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was retroactively queried for all patients undergoing bariatric surgery at an accredited bariatric surgery center from January 1, 2017 to May 31, 2018. Body composition test results presurgery and postsurgery were extracted from the electronic health record. Change in TBW was compared between patients requiring outpatient IVF and those who did not use multivariable logistic regression. RESULTS 583 patients underwent surgery over the study period (388 laparoscopic Roux-en-Y gastric bypass, 195 sleeve). 62 (10.6%) required outpatient fluid administration for dehydration. After multivariable analysis, patients with an increased hospital length of stay at index operation were more likely to require outpatient IVF (odds ratio [OR] 1.65, 95% CI 1.22-2.2). Preexisting diabetes diagnosis was protective (OR 0.35, 95% CI 0.16-0.74). Neither 1-week nor 1-month change in TBW from preoperative baseline was significantly different between patients receiving outpatient IVF and those who did not. CONCLUSION Increased hospital length of stay predicts patients at risk of postoperative dehydration requiring IVF administration. Body composition testing and TBW were not useful in distinguishing between populations. Further research is needed to examine the efficacy of outpatient IVF in preventing hospital readmissions for dehydration.
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Affiliation(s)
- Lauren E Matevish
- 5718 Department of Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander T Hawkins
- 5718 Department of Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alva J Bethurum
- 5718 Department of Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chetan V Aher
- 5718 Department of Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wayne J English
- 5718 Department of Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - D Brandon Williams
- 5718 Department of Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D Spann
- 5718 Department of Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Spann MD, Harrison NJ, English WJ, Bolduc AR, Aher CV, Williams DB, Hawkins AT. Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass. Am Surg 2020; 86:250-255. [PMID: 32223806] [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: 06/10/2023]
Abstract
Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repair in regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m² at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.
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Affiliation(s)
- Matthew D Spann
- From the *Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Noah J Harrison
- †Vanderbilt University School of Medicine, Nashville, Tennessee; and
| | - Wayne J English
- From the *Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aaron R Bolduc
- From the *Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chetan V Aher
- From the *Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D Brandon Williams
- From the *Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander T Hawkins
- ‡Department of Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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12
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Spann MD, Harrison NJ, English WJ, Bolduc AR, Aher CV, Williams DB, Hawkins AT. Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass. Am Surg 2020. [DOI: 10.1177/000313482008600336] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repairin regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m2at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.
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Affiliation(s)
- Matthew D. Spann
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Noah J. Harrison
- Vanderbilt University School of Medicine, Nashville, Tennessee; and
| | - Wayne J. English
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aaron R. Bolduc
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chetan V. Aher
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D. Brandon Williams
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander T. Hawkins
- Department of Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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13
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Abstract
Cardiovascular disease (CVD) is the world’s leading cause of mortality and obesity is a well-recognized risk factor of CVD. Early detection and management of CVD is critical to reduce CVD risk. Especially in patients suffering from obesity with obesity-related CVD risk factors such as hypertension (HTN), dyslipidemia, and diabetes mellitus (DM). A substantial and sustained decrease in body weight after metabolic and bariatric surgery is associated with a significant reduction of cardiovascular risk factors. This article reviews CVD risk models, mechanisms of CVD risk associated with obesity, and overall CVD risk reduction between different metabolic and bariatric procedures.
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Affiliation(s)
- Wayne J English
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D Spann
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chetan V Aher
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - D Brandon Williams
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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14
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Sullivan S, Swain J, Woodman G, Edmundowicz S, Hassanein T, Shayani V, Fang JC, Noar M, Eid G, English WJ, Tariq N, Larsen M, Jonnalagadda SS, Riff DS, Ponce J, Early D, Volckmann E, Ibele AR, Spann MD, Krishnan K, Bucobo JC, Pryor A. Randomized sham-controlled trial of the 6-month swallowable gas-filled intragastric balloon system for weight loss. Surg Obes Relat Dis 2018; 14:1876-1889. [PMID: 30545596 DOI: 10.1016/j.soard.2018.09.486] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [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: 05/09/2018] [Revised: 09/14/2018] [Accepted: 09/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Obesity is a significant health problem and additional therapies are needed to improve obesity treatment. OBJECTIVE Determine the efficacy and safety of a 6-month swallowable gas-filled intragastric balloon system for weight loss. SETTING Fifteen academic and private practice centers in the United States. METHODS This was a double-blind, randomized sham-controlled trial of the swallowable gas-filled intragastric balloon system plus lifestyle therapy compared with lifestyle therapy alone for weight loss at 6 months in participants aged 22 to 60 years with body mass index 30 to 40 kg/m2, across 15 sites in the United States. The following endpoints were included: difference in percent total weight loss in treatment group versus control group was >2.1%, and a responder rate of >35% in the treatment group. RESULTS Three hundred eighty-seven patients swallowed at least 1 capsule. Of participants, 93.3% completed all 24 weeks of blinded study testing. Nonserious adverse events occurred in 91.1% of patients, but only .4% were severe. One bleeding ulcer and 1 balloon deflation occurred. In analysis of patients who completed treatment, the treatment and control groups achieved 7.1 ± 5.0% and 3.6 ± 5.1% total weight loss, respectively, and a mean difference of 3.5% (P = .0085). Total weight loss in treatment and control groups were 7.1 ± 5.3 and 3.6 ± 5.1 kg (P < .0001), and body mass index change in the treatment and control groups were 2.5 ± 1.8 and 1.3 ± 1.8 kg/m2 (P < .0001), respectively. The responder rate in the treatment group was 66.7% (P < .0001). Weight loss maintenance in the treatment group was 88.5% at 48 weeks. CONCLUSIONS Treatment with lifestyle therapy and the 6-month swallowable gas-filled intragastric balloon system was safe and resulted in twice as much weight loss compared with a sham control, with high weight loss maintenance at 48 weeks.
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Affiliation(s)
- Shelby Sullivan
- Washington University School of Medicine, St. Louis, Missouri; University of Colorado School of Medicine, Aurora, Colorado.
| | - James Swain
- HonorHealth Research Institute, Scottsdale, Arizona
| | | | - Steven Edmundowicz
- Washington University School of Medicine, St. Louis, Missouri; University of Colorado School of Medicine, Aurora, Colorado
| | | | - Vafa Shayani
- Bariatric Institute of Greater Chicago, Bolingbrook, Illinois
| | - John C Fang
- University of Utah Hospital, Salt Lake City, Utah
| | - Mark Noar
- Endoscopy Microsurgery Associates, Townson, Maryland
| | - George Eid
- Alleghany Singer Research at West Penn, Pittsburgh, Pennsylvania
| | | | - Nabil Tariq
- Houston Methodist Research Institute, Houston, Texas
| | | | | | | | - Jaime Ponce
- Chattanooga Bariatrics, Chattanooga, Tennessee
| | - Dayna Early
- Washington University School of Medicine, St. Louis, Missouri
| | | | - Anna R Ibele
- University of Utah Hospital, Salt Lake City, Utah
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15
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King AB, Spann MD, Jablonski P, Wanderer JP, Sandberg WS, McEvoy MD. An enhanced recovery program for bariatric surgical patients significantly reduces perioperative opioid consumption and postoperative nausea. Surg Obes Relat Dis 2018; 14:849-856. [PMID: 29555468 DOI: 10.1016/j.soard.2018.02.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/05/2018] [Accepted: 02/04/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients frequently remain in the hospital after bariatric surgery due to pain, nausea, and inability to tolerate oral intake. Enhanced recovery after surgery (ERAS) concepts address these perioperative complications and therefore improve length of stay for bariatric surgery patients. OBJECTIVES To determine if ERAS concepts increase the proportion of patients discharged on postoperative day 1. Secondary objectives included mean length of stay, perioperative opioid use, emergency department visits, and readmissions. SETTING A large metropolitan university tertiary hospital. METHODS A quantitative before and after study was conducted for patients undergoing bariatric surgical patients. Data were collected surrounding length of stay, perioperative opioid consumption, antiemetic therapy requirements postoperatively, multimodal analgesia compliance, emergency department visits, and hospital readmission rates. Wilcoxon rank-sum and χ2 test were used to compare continuous and categorical variables, respectively. A secondary analysis was performed using Aligned Rank Transformation and Cochran-Mantel-Haenszel χ2 tests to account for an increase in sleeve gastrectomies in the intervention group. RESULTS The 2 groups had clinically similar baseline characteristics. Comparison group (N = 366) and ERAS group (N = 715) patients underwent a primary bariatric surgery procedure. There was an increase in the number of patients undergoing a laparoscopic sleeve gastrectomy in the intervention group. After accounting for this increase, the percentage of patients discharged on postoperative day 1 was unchanged (79.8% non-ERAS versus 83.1% ERAS, P = .52). ERAS length of stay was statistically significantly lower for gastric bypass (P<.001) and robotic gastric bypass (P = .01). Perioperative opioid consumption was reduced (41.0 versus 16.2 morphine equivalents, P<0.001), and fewer ERAS patients required postoperative antiemetics (68.8% versus 46.2%, P<.001). Emergency department visits at 7 days were reduced (6.0% versus 3.2%, P = .04), but hospital readmission rates were unchanged. CONCLUSIONS Implementing ERAS did not reduce the percentage of patients discharged on postoperative day 1 in a bariatric surgery program with historically low length of stay, but it led to significant reductions in perioperative opioid use, decreases in postoperative nausea, and early emergency room visits.
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Affiliation(s)
- Adam B King
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew D Spann
- Department of Surgical Science, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patrick Jablonski
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Spann MD, Aher CV, English WJ, Williams DB. Endoscopic management of erosion after banded bariatric procedures. Surg Obes Relat Dis 2017; 13:1875-1879. [PMID: 28870760 DOI: 10.1016/j.soard.2017.07.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 05/10/2017] [Revised: 06/29/2017] [Accepted: 07/17/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prosthetic materials wrapped around a portion of the stomach have been used to provide gastric restriction in bariatric surgery for many years. Intraluminal erosion of adjustable and nonadjustable gastric bands typically occurs many years after placement and results in various symptoms. Endoscopic management of gastric band erosion has been described and allows for optimal patient outcomes. OBJECTIVES We will describe our methods and experience with endoscopic management of intraluminal gastric band erosions after bariatric procedures. SETTING University hospital in the United States. METHODS A retrospective review of our bariatric surgery database identified patients undergoing removal of gastric bands. A chart review was then undertaken to confirm erosion of prosthetic material into the gastrointestinal tract. Baseline characteristics, operative reports, and follow-up data were analyzed. RESULTS Sixteen patients were identified with an eroded gastric band: 11 after banded gastric bypass, 3 after laparoscopic adjustable gastric band (LAGB), and 2 after vertical banded gastroplasty. All patients were successfully treated with endoscopic removal of the prosthetic materials using either endoscopic scissors or ligation of the banding material with off-label use of a mechanical lithotripter device. Complications included a postoperative gastrointestinal bleed requiring repeat endoscopy, 1 patient with asymptomatic pneumoperitoneum requiring observation, and 1 with seroma at the site of LAGB port removal. CONCLUSIONS Endoscopic management of intraluminal prosthetic erosion after gastric banded bariatric procedures can be safe and effective and should be considered when treating this complication. Erosion of the prosthetic materials inside the gastric lumen allows for potential endoscopic removal without free intraabdominal perforation. Endoscopic devices designed for dividing eroded LAGBs may help standardize and increase utilization of this approach.
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Affiliation(s)
- Matthew D Spann
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Chetan V Aher
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wayne J English
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D Brandon Williams
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
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Spann MD, Idrees K. Management of duodenal carcinoid tumors in the setting of morbid obesity. Surg Obes Relat Dis 2017; 13:1635-1637. [PMID: 28624533 PMCID: PMC10175039 DOI: 10.1016/j.soard.2017.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 05/17/2017] [Accepted: 05/17/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Matthew D Spann
- Department of Surgery, Vanderbilt Center for Surgical Weight Loss, Nashville, Tennessee.
| | - Kamran Idrees
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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18
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Abstract
The use of methamphetamine (MA) as a recreational drug has increased exponentially in recent years, resulting in an emergence of clandestine laboratories. Consequently, the frequency with which burn centers across the country are admitting patients injured as a consequence of the volatile manufacturing process of MA is increasing. This study focused on comparing outcomes between burn patients injured secondary to MA laboratory explosions and patients sustaining burns from other mechanisms. All patients identified to have suffered burns secondary to MA laboratory explosions between 1998 and 2004 were included in this study. These patients were compared with those who did not experience such burns during this same time period. In total, 19 patients were identified as having been burned in MA laboratory explosions. These patients had a larger component of third-degree burns (24.8% vs 13.5%; P < .05) as well as TBSA burned (28.4% vs 20.7%; P < .05). In addition, patients using MA had an increased incidence of inhalation injury (31.2% vs 6.1%; P < .05). They also exhibited a significantly increased frequency of complications, such as nosocomial pneumonia, respiratory failure, and sepsis. Overall, the rate of mortality was significantly increased in patients using MA (26.3% vs 8.5%; P < .05); however, no significant difference was observed after adjustment for age, burn size, and inhalation injury. MA burn patients have larger burn size, incidence of inhalation injury, and increased morbidity when compared with non-MA burn patients.
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Affiliation(s)
- Matthew D Spann
- Center for Injury Sciences, University of Alabama at Birmingham, Alabama 35294-0016, USA
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