Panel report: best practices for the surgical treatment of obesity

BACKGROUND

Bariatric surgery is a rapidly growing field. Advances in surgical technologies and techniques have raised concerns about patient safety. Bariatric surgeons and programs are under increased scrutiny from regulatory agencies, insurers, and public health officials to provide high quality and safe care for bariatric patients at all phases of care.

METHODS

During the 2009 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on patient safety and best practices in bariatric surgery. The following article is a summary of this panel presentation.

RESULTS AND CONCLUSIONS

Weight loss surgery is a field that is evolving and adapting to multiple external pressures. Safety concerns along with increasing public scrutiny have led to a systematic approach to defining best practices, creating standards of care, and identifying mechanisms to ensure that patients consistently receive the best and most effective care possible. In many ways, bariatric surgery and multidisciplinary bariatric surgery programs may serve as a model for other programs and surgical specialties in the near future.

Laparoscopic gastric banding in a kidney-pancreas transplant recipient with new onset type II diabetes mellitus associated with morbid obesity

Combined kidney-pancreas transplantation is the treatment of choice for end-stage diabetic nephropathy. Post-transplant weight gain increases the risk for post-transplant complications and death owing to cardiovascular events. Gastric banding is an established treatment for moderate morbid obesity. We report on a patient who experienced significant weight gain and developed type II diabetes mellitus following successful kidney-pancreas transplantation. He underwent laparoscopic gastric banding and initially had good weight loss. However, lack of compliance with dietary guidelines led to transient failure of weight loss therapy. With further adjustment of the gastric band good weight loss was achieved.

[The use of volunteers to support family carers of dementia patients: results of a prospective longitudinal study investigating expectations towards and experience with training and professional support]

Caring for a dementia patient in the family often turns out to be a full-time job for family carers. So home visitors-for example volunteers spending time with the patient and thus offering some respite to the family-may be a very important aspect of stabilizing home care. This study investigates the expectations of volunteers concerning their training and their future voluntary work, as well as their visiting experiences, and their reasons for stopping the voluntary work. A total of 40 volunteers were interviewed three times over a 18 month period. The interviews were based on interview guidelines and were problem-centered. The interviewees' replies were subject to a summarizing qualitative content analysis. Of the study participants 85% were women, 48% had previously been family carers themselves, and 50% had previous experience of other voluntary work. Their wish "to do something useful" and "to learn more about dementia" were the main reasons for participation in voluntary work. The interviewed persons tend to learn most about communicating with dementia patients through case studies and practical exercises. Work pressures or restarting employment were the most common reasons to stop the voluntary work. Only if the volunteers are supported by professionals--particularly in the form of a contact person who is always available when problems occur--can this type of respite for family carers be maintained.

Laparoscopic bariatric surgery

Laparoscopy has meant profound changes for the field of bariatric surgery. Bariatric operations, which are technically difficult because of the patient population, were not performed laparoscopically until the last 5 years of the 20th century. The years 1998 to 2003, herein defined as the Bariatric Revolution, saw profound changes in the way bariartric surgery was practiced. Major changes in patient education, public awareness, patient enthusiasm, popularity of the surgery, and academic acceptance of bariatric surgery occurred during this time. This led to such a massive increase in procedures performed that there was a reactionary movement by insurers to deny coverage for these procedures. Limitation of access to care and other important socioeconomic issues are now being debated and confronted in the bariatric arena. Recommendations for the field are suggested. The outcomes of these controversies will potentially have a profound impact on all of surgery.

The SAGES Bariatric Surgery Outcome Initiative

BACKGROUND

The recent initiative for identifying centers of excellence in bariatric surgery calls for documentation of surgical outcomes. The SAGES Outcomes Initiative is a national database introduced in 1999 as a method for surgeons to accumulate and compare their data with summary national data. A bariatric-specific dataset was established later in 2001. The aim of this study was to compare the outcomes of bariatric surgery from the Society of American Gastrointestinal Endoscopic Surgeons' (SAGES) bariatric database with data derived from a national administrative database of academic centers.

METHODS

Between 2001 and 2004, 24 surgeons with 1,954 patients participated in the SAGES Bariatric Outcome Initiative, and 97 institutions with 42,847 patients participated in the University HealthSystem Consortium (UHC) database. Only 7 of the 24 surgeons participating in the SAGES Bariatric Outcome Initiative submitted more than 50 cases. The main outcome measures included demographics, comorbidities, type of bariatric procedure, operative time, length of hospital stay, short- and long-term complications, mortality, and weight loss.

RESULTS

Both datasets were comparable for gender. Roux-en-Y gastric bypass had been performed for 88% of the patients in the SAGES database and 96% of the patients in the UHC database. Associated comorbidities were similar between the two groups except for a higher rate of hyperlipidemia for the patients in the SAGES database. The SAGES database contains more bariatric-specific information such as body mass index, operative time, blood loss, bariatric-specific complications, long-term complications, and weight loss data than the UHC database. According to the available data, no statistically significant differences exist between the two datasets in terms of perioperative complications and mortality.

CONCLUSIONS

The SAGES Bariatric Outcome Initiative provides valuable bariatric-specific data not currently available in an administrative database that may be useful for benchmarking purposes. However, this database is currently underutilized.

Optimal management of the morbidly obese patient SAGES appropriateness conference statement

BACKGROUND

Obesity is a growing health problem that contributes to numerous life-threatening or disabling disorders, including coronary artery disease, hypertension, type 2 diabetes mellitus, hyperlipidemia, degenerative joint disease, and obstructive sleep apnea. Significant weight reduction in the morbidly obese improves or reverses associated illness and benefits well-being. The purpose of the SAGES Appropriateness Conference was to summarize the state of the art for open and laparoscopic operations for the morbidly obese.

METHODS

The English literature comparing bariatric procedures was reviewed and grouped by level of evidence by three surgeons (BS, LV, and CC). From more than 1,500 articles, all conference participants were provided with reprints and table summaries of no less than 50 selected manuscripts. Ten experts were requested to present reviews and make evidence-based arguments for and against the open and laparoscopic approaches in written format. An expert panel of six surgeons, including an ethicist and patient, commented on implications of data presented. The finalized statement was e-mailed to all participants for approval and comment.

RESULTS

Consensus statements were achieved on various aspects of morbid obesity, including indications for surgery, resolution of comorbid illnesses with significant weight loss, and the importance of committed bariatric program. Our panel of experts agreed, in general, to the advantages of laparoscopic approaches compared to open operations in skilled hands.

CONCLUSIONS

Laparoscopic Roux-en-Y gastric bypass (RYGB) affords improved short-term recovery compared to open gastric bypass. Laparoscopic adjustable banding can be performed with lower average mortality than either RYGB or any of the malabsorptive operations, and it produces variable degrees of short-term weight loss. Prospective randomized trials are needed to compare gastric bypass, malabsorptive, and restrictive procedures.

Near-infrared reflectance spectroscopy enables the fast and accurate prediction of the essential amino acid contents in soy, rapeseed meal, sunflower meal, peas, fishmeal, meat meal products, and poultry meal

Near-infrared reflectance spectroscopy (NIRS) calibrations were developed to enable the accurate and fast prediction of the total contents of methionine, cystine, lysine, threonine, tryptophan, and other essential amino acids, protein, and moisture in the most important protein-rich feed ingredients. More than 1000 samples of global origin collected over four years were analyzed on amino acids following the official methods of the United States and the European Union. Detailed data and graphics are given to characterize the obtained calibration equations. NIRS was validated with independent samples for soy and meat meal products and compared to the amino acid predictions using linear crude protein regressions. With a few exceptions, validation showed that 85-98% of the amino acid variance in the samples could be explained using NIRS. NIRS predictions compared to reference results agree excellently, with relative mean deviations below 5%. Especially for meat and poultry meals, NIRS can predict amino acids much better than crude protein regressions. By enabling the amino acid analysis of many samples to be completed in a short time, NIRS can improve the accuracy of feed formulation and thus the quality and production costs of mixed feeds.

Visual discrimination task improvement: A multi-step process occurring during sleep

Performance on a visual discrimination task shows long-term improvement after a single training session. When tested within 24 hr of training, improvement was not observed unless subjects obtained at least 6 hr of posttraining sleep prior to retesting, in which case improvement was proportional to the amount of sleep in excess of 6 hr. For subjects averaging 8 hr of sleep, overnight improvement was proportional to the amount of slow wave sleep (SWS) in the first quarter of the night, as well as the amount of rapid eye movement sleep (REM) in the last quarter. REM during the intervening 4 hr did not appear to contribute to improvement. A two-step process, modeling throughput as the product of the amount of early SWS and late REM, accounts for 80 percent of intersubject variance. These results suggest that, in the case of this visual discrimination task, both SWS and REM are required to consolidate experience-dependent neuronal changes into a form that supports improved task performance.

Development of an IR tunable diode laser absorption spectrometer for trace humidity measurements at atmospheric pressure

The development of a laser diode absorption spectrometer that uses a strong water vapor absorption at 1393 nm is reported. Three spectroscopic techniques were compared in approximately 0.4 m of laboratory air, namely, frequency modulation, wavelength modulation, and two-tone frequency modulation spectroscopy. The first two techniques use a single-frequency modulation at 9.2 GHz and 1 kHz, respectively, generated either by a phase modulator operating at 9.2 GHz or injection current modulation at 1 kHz. The two-tone method requires modulation at two frequencies, in this case 9.19 and 9.21 GHz. It is shown that the two-tone method should provide the highest sensitivity for a trace moisture detection system.

Intraoperative and laparoscopic ultrasound

Intraoperative ultrasound, whether during celiotomy or laparoscopy, plays an important role in assisting the surgeon in directing appropriate therapy for intra-abdominal diseases, particularly primary or metastatic malignancies involving the liver and primary malignancies of the pancreas and upper gastrointestinal tract. It is the most sensitive imaging technique for detecting small intraparenchymal lesions of the liver, pancreas, and other solid organs. Owing to its increased sensitivity over all commonly used preoperative imaging studies, it is responsible for changing the intraoperative treatment plan of these tumors in a significant percentage of cases. This is particularly true with respect to resectability. In the era of laparoscopic surgery, it replaces the surgeon's inability to palpate the liver and other organs during surgery. As surgeons use a laparoscopic approach with increasing frequency to treat intra-abdominal disease, they will have an increasing need to master the use of intraoperative ultrasound in order to render optimal care to their patients.

Effect of teacher questions on the reading comprehension of deaf children

We examined the effect of comprehension questions that require analysis, synthesis, and evaluation on the reading comprehension of deaf children. The subjects were six deaf children ranging in age from 10 years, months to 12 years, 5 months. They were divided into four reading groups for the study. Quantitative analysis of the children's responses to comprehension questions indicated that the children could analyze, synthesize, and evaluate narrative text and their ability to do so did not need to be supported by answering questions related to story details. Qualitative analysis indicated that the children had some difficulty with seven reading tasks: locating pertinent information, applying relevant and accurate background knowledge, expressing themselves unambiguously, understanding the intent of the question, not relying too heavily or too little on background knowledge, considering consequential details, and providing sufficient answers.

A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy. Laparoscopic Appendectomy Study Group

BACKGROUND

While the advantages of laparoscopic cholecystectomy are clear, the benefits of laparoscopic appendectomy (LA) are more subtle. We conducted a randomized clinical trial to evaluate whether LA is deserving of more widespread clinical application than it has yet received.

MATERIALS AND METHODS

Two hundred fifty-three patients with a preoperative diagnosis of acute appendicitis were randomized into three groups. LA with an endoscopic linear stapler (LAS) (U.S. Surgical Corp., Norwalk, Connecticut) was performed on 78 patients, LA with catgut ligatures (LAL) on 89, and open appendectomy (OA) on 86. LA was performed with a three-trocar technique. OA was accomplished through a right lower-quadrant transverse incision. Data with normal distributions were analyzed by analysis of variance. Nonparametric data were analyzed with either the Kruskal-Wallis H test or Fisher's exact test.

RESULTS

The mean operative times for the procedures were 66 +/- 24 minutes (LAS), 68 +/- 25 minutes (LAL), and 58 +/- 27 minutes (OA). The relative brevity of OA compared to LAS and LAL was statistically significant (P < 0.01). Conversion to open procedures was approximately as frequent in the LAS group (n = 5) and the LAL (n = 6). One OA, 2 LAS, and 11 LAL patients experienced vomiting postoperatively (P < 0.05). Two intra-abdominal abscesses occurred in LAS, 4 in LAL, and 0 in OA patients (P = NS). Wound infections were more common following OA (n = 11) than LAL (n = 4) or LAS (n = 0) (P < 0.05, < 0.001). The mean length of postoperative hospital stay was 2.16 +/- 3.2 days (LAS), 2.98 +/- 2.7 days (LAL), and 2.83 +/- 1.6 (OA) (P < 0.05 OA versus LAS). The number of days patients required pain medications overall was not different between groups, but a subgroup analysis of 134 patients who rated their postoperative pain on a visual analogue scale revealed a significantly lower mean level among patients undergoing LA (LAS and LAL) versus OA (P < 0.001). Patients undergoing LA resumed regular activities sooner than those undergoing OA (9 +/- 9 days versus 14 +/- 11 days, P < 0.001). Rates of readmission to the hospital were similar for all procedures.

CONCLUSIONS

Laparoscopic appendectomy appears to have distinct advantages over open appendectomy. The laparoscopic procedures produced less pain and allowed more rapid return to full activities, and LAS required shorter hospital stays. The only disadvantages to the laparoscopic approach were slightly increased operative time for both procedures, and increased emesis following LAL.

Completion gastrectomy for refractory gastroparesis following surgery for peptic ulcer disease. Long-term follow-up with subjective and objective parameters

We recently have shown that 50% of patients with preoperative gastric outlet obstruction go on to develop chronic nonmechanical gastric stasis after surgery and require further operations in attempts to relieve their symptoms. In the present study we report our experience with completion gastrectomy (CG), offered to a subgroup of this population who failed to respond to both available and experimental medical therapy with prokinetic agents. Manometric studies of the small bowel were performed on three of these patients using a semiconductor solid recording probe to assess the motility of efferent jejunal limbs. There were seven females and one male (N = 8) with a mean age of 45 years. All had persistent symptoms of abdominal pain, bloating, nausea, vomiting, early satiety, decreased appetite, and weight loss dating back to the time of surgery. Gastric stasis was documented by delayed gastric emptying of a radionuclide solid meal (chicken liver labeled with technetium-99m sulfur colloid) with a mean retention of 86 +/- 6.2% (less than 60% being normal) in the setting of an upper endoscopy showing stomal patency. The mean duration of symptoms was 31.6 +/- 15.7 months (range 6-60) since the last surgery. The number of previous gastric operations was a mean of 2.3 per patient. Five of eight patients had undergone a Roux-en-Y procedure as the last operation while the other three had a Billroth II. Surgery consisted of a 90% or complete resection of the remaining stomach and a jejunal-esophageal anastomosis. In some cases the Roux-en-Y limb was lengthened to greater than 45 cm if needed.(ABSTRACT TRUNCATED AT 250 WORDS)

Relation of left ventricular mass to geometry of the proximal coronary arteries in the dog

Proximal epicardial coronary artery luminal diameters were measured from silicone casts formed in situ in freshly excised hearts under a constant pressure of 100 mm Hg. Twenty-five coronary arteries from 15 normal dogs and 22 coronary arteries in 13 dogs with either chronic pressure or volume overload hypertrophy were studied. Mean left ventricular (LV) body weight ratios were 4.75 +/- 1.01 g/kg in the normal dogs, 8.4 +/- 1.7 g/kg in the pressure-overload dogs, and 6.2 +/- 0.6 g/kg in the volume-overload dogs. The cross-sectional area of the left circumflex (LC) coronary artery was determined at 11 branch sites. The ratio of the area of the branches to the area of the parent vessel was 1.095 +/- 0.105, indicating that the cross-sectional area after a branch point increased. A poor correlation existed between LV mass and coronary artery diameter in both normal and hypertrophy groups for the LC (r = 0.44), the left anterior descending (LAD) (r = 0.63), and the combined LC and LAD (r = 0.52). The mean cross-sectional area of the combined LC and LAD was 0.12 cm2 in the normal group and 0.15 cm2 in the hypertrophy group; this increase was not statistically significant (p = 0.13). When the mean cross-sectional area of the combined vessels was adjusted for heart weight, there was a decrease in the cross-sectional area/100 g of myocardium in the hypertrophy group compared with the control group. These data demonstrate that coronary artery luminal diameter in the dog does not increase commensurately with the increase in mass associated with myocardial hypertrophy.

Differing uptake of emulsion triglyceride by the fed and fasted rat liver

The recycling perfusion of a fasted rat liver with an apoprotein E-enriched synthetic triglyceride emulsion revealed a significantly greater hepatic uptake of both the apoprotein and the triglyceride than did the liver of a chow-fed animal. This greater hepatic triglyceride uptake by the perfused fasted liver in comparison to the fed was also noted for emulsions containing no added apoprotein or supplemented with both the E and CIII-1 proteins. However, no difference in the uptake of the triglyceride emulsion was seen for the fed and fasted livers when evaluated by a nonrecycling single pass perfusion. The isolated hepatocyte plasma membranes from fasted rats failed to demonstrate enhanced binding of apoprotein or lipid when compared to those from fed animals. If the residual E loaded triglyceride emulsion was recovered from the recycling perfusates of fed and fasted livers and evaluated in a non-recycling single-pass system, the emulsion from the fasted perfusion was cleared as facilely as previously, whereas that from the fed was less actively cleared. The emulsions retrieved from the perfusion of the fed liver contained significantly more protein than did the fasted; in particular apo C. This apparent alteration of emulsion apoproteins by the fed liver possibly results in a less active hepatic retrieval and may be important in downregulating the entry of lipoprotein triglyceride in the postabsorptive liver.

[A computer-controlled monitoring and therapy system for shock compensation in severe burns (author's transl)]

A computer-controlled control loop for the automatic diagnosis of shock and infusion therapy is reported. External information (off-line) and vital parameters measured with serial devices (on-line) are used by the computer for the automatic control of infusion pumps. By this method the critical shock phase could be prevented in five seriously burned patients. The construction of the system also permits its use in other shock conditions.