Primary care provider management of patients with obesity at an integrated health network: A survey of practices, views, and knowledge

BACKGROUND

Obesity is a serious health problem that affects a wide range of patients and disease processes.

OBJECTIVE

The purpose of this study is to evaluate perceptions, knowledge, and practice habits of primary care providers (PCPs) regarding the care of patients with obesity, including barriers to effective care and their experience with bariatric surgery in our integrated health network.

SETTING

Integrated health network.

METHODS

A 16-question survey was distributed electronically to 160 PCPs at our integrated health network. Results were analyzed to identify attitudes, knowledge, practice habits, and bariatric surgery referral patterns while treating patients with obesity.

RESULTS

Among 160 PCPs, 45 (28.1%) responded. Specialty, sex, patient population, insurance accepted, and practice years of PCPs were reported. Most PCPs reported "always" calculating patient body mass index (88.9%) with only 13.3% "always" discussing the body mass index results. Respondents most frequently prescribed diet and exercise to patients with obesity and rarely prescribed medications, with bariatric surgery referrals falling between the two. PCPs viewed management of obesity as the responsibility of the patient (97.6%) and the PCP (100%). Ninety-three percent felt obesity is a common diagnosis in their practice, but no one correctly identified the prevalence of obesity in our region. Respondents demonstrated adequate knowledge regarding medical consequences of obesity. A majority was able to identify the correct eligibility criteria for bariatric surgery, as well specific medical problems that can improve or be eliminated postoperatively. While 61.9% of respondents were aware of free weight loss and bariatric informational sessions offered, 28.6% reported that they were unfamiliar with existing bariatric surgeons. One respondent was not aware of any bariatric surgery performed. Some PCPs reported prior negative experiences with post-bariatric surgery patients, and thus were hesitant to refer additional patients.

CONCLUSIONS

PCPs report discussing an obesity diagnosis with patients but are not always using body mass index in that discussion. They most often prescribe lifestyle modification as treatment for patients, which they believe to be most effective to treat obesity. However, they report only one third of their patients are motivated to lose weight. Additionally, they demonstrate appropriate knowledge of indications and benefits of bariatric surgery. A majority of the PCPs is aware of weight loss informational sessions and bariatric services provided within our integrated health network, but almost one third were unable to identify a surgeon, a possible target for improved relationships. Barriers to care include patient motivation and insurance coverage.

Clinical trial demonstrates exercise following bariatric surgery improves insulin sensitivity

BACKGROUND

Roux-en-Y gastric bypass (RYGB) surgery causes profound weight loss and improves insulin sensitivity (S(I)) in obese patients. Regular exercise can also improve S(I) in obese individuals; however, it is unknown whether exercise and RYGB surgery-induced weight loss would additively improve S(I) and other cardiometabolic factors.

METHODS

We conducted a single-blind, prospective, randomized trial with 128 men and women who recently underwent RYGB surgery (within 1-3 months). Participants were randomized to either a 6-month semi-supervised moderate exercise protocol (EX, n = 66) or a health education control (CON; n = 62) intervention. Main outcomes measured included S(I) and glucose effectiveness (S(G)), which were determined from an intravenous glucose tolerance test and minimal modeling. Secondary outcomes measured were cardiorespiratory fitness (VO2 peak) and body composition. Data were analyzed using an intention-to-treat (ITT) and per-protocol (PP) approach to assess the efficacy of the exercise intervention (>120 min of exercise/week).

RESULTS

119 (93%) participants completed the interventions, 95% for CON and 91% for EX. There was a significant decrease in body weight and fat mass for both groups (P < 0.001 for time effect). S(I) improved in both groups following the intervention (ITT: CON vs. EX; +1.64 vs. +2.24 min⁻¹/μU/ml, P = 0.18 for Δ, P < 0.001 for time effect). A PP analysis revealed that exercise produced an additive S(I) improvement (PP: CON vs. EX; +1.57 vs. +2.69 min⁻¹/μU/ml, P = 0.019) above that of surgery. Exercise also improved S(G) (ITT: CON vs. EX; +0.0023 vs. +0.0063 min⁻¹, P = 0.009) compared with the CON group. Exercise improved cardiorespiratory fitness (VO2 peak) compared with the CON group.

CONCLUSION

Moderate exercise following RYGB surgery provides additional improvements in S(I), S(G), and cardiorespiratory fitness compared with a sedentary lifestyle during similar weight loss.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT00692367.

FUNDING

This study was funded by the NIH/National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK078192) and an NIH/National Center for Research Resources/Clinical and Translational Science Award (UL1 RR024153).

StomaphyX vs a sham procedure for revisional surgery to reduce regained weight in Roux-en-Y gastric bypass patients : a randomized clinical trial

IMPORTANCE

Revisional laparoscopic surgery after Roux-en-Y gastric bypass (RYGB) has been linked to substantial complications and morbidity.

OBJECTIVE

To investigate the safety and effectiveness of endoscopic gastric plication with the StomaphyX device vs a sham procedure for revisional surgery in RYGB patients to reduce regained weight.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, single-center, randomized, single-blinded study from July 2009 through February 2011, evaluating revisional surgery using StomaphyX was conducted in patients with initial weight loss after RYGB performed at least 2 years earlier. We planned for 120 patients to be randomized 2:1 to multiple full-thickness plications within the gastric pouch and stoma using the StomaphyX device with SerosFuse fasteners or a sham endoscopic procedure and followed up for 1 year. The primary efficacy end point was reduction in pre-RYGB excess weight by 15% or more excess body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) loss and BMI less than 35 at 12 months after the procedure. Adverse events were recorded.

RESULTS

Enrollment was closed prematurely because preliminary results indicated failure to achieve the primary efficacy end point in at least 50% of StomaphyX-treated patients. One-year follow-up was completed by 45 patients treated with StomaphyX and 29 patients in the sham treatment group. Primary efficacy outcome was achieved by 22.2% (10) with StomaphyX vs 3.4% (1) with the sham procedure (P < .01). Patients undergoing StomaphyX treatment experienced significantly greater reduction in weight and BMI at 3, 6, and 12 months (P ≤ .05). There was one causally related adverse event with StomaphyX, that required laparoscopic exploration and repair.

CONCLUSIONS AND RELEVANCE

StomaphyX treatment failed to achieve the primary efficacy target and resulted in early termination of the study.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00939055.

Pre- to postoperative changes in physical activity: report from the longitudinal assessment of bariatric surgery-2 (LABS-2)

BACKGROUND

Numerous studies have reported that bariatric surgery patients report more physical activity (PA) after surgery than before; however, the quality of the PA assessment has been questionable.

METHODS

The longitudinal assessment of bariatric surgery-2 is a 10-center longitudinal study of adults undergoing bariatric surgery. Of 2458 participants, 455 were given an activity monitor, which records the steps per minute, and an exercise diary before and 1 year after surgery. The mean number of steps/d, active min/d, and high-cadence min/wk were calculated for 310 participants who wore the monitor ≥10 hr/d for ≥3 days at both evaluations. Pre- and postoperative PA were compared for differences using the Wilcoxon signed-rank test. Generalized estimating equations were used to identify independent preoperative predictors of postoperative PA.

RESULTS

PA increased significantly (P < .0001) from before to after surgery for all PA measures. The median values before and after surgery were 7563 and 8788 steps/d, 309 and 340 active min/d, and 72 and 112 high-cadence min/wk, respectively. However, depending on the PA measure, 24-29% of participants were ≥5% less active postoperatively than preoperatively. Controlling for surgical procedure, gender, age, and body mass index, more PA preoperatively independently predicted for more PA postoperatively (P < .0001, for all PA measures). Less pain, not having asthma, and the self-report of increasing PA as a weight loss strategy preoperatively also independently predicted for more high-cadence min/wk postoperatively (P < .05).

CONCLUSIONS

The majority of adults increase their PA level after bariatric surgery. However, most remain insufficiently active, and some become less active. Increasing PA, addressing pain, and treating asthma before surgery might have a positive effect on postoperative PA.

Walking capacity of bariatric surgery candidates

BACKGROUND

This study characterizes the walking limitations of bariatric surgery candidates by age and body mass index (BMI) and determines factors independently associated with walking capacity. The setting was multi-institutional at research university hospitals in the United States.

METHODS

Participants of the Longitudinal Assessment of Bariatric Surgery study (n=2458; age 18-78 yr, BMI 33-94 kg/m(2)) attended a preoperative research visit. Their walking capacity was measured by self-report and the 400 m Long Distance Corridor Walk (LDCW).

RESULTS

Almost two thirds (64%) of subjects reported limitations with walking several blocks, 48% had an objectively defined mobility deficit, and 16% reported at least some walking aid use. In multivariate analysis, BMI, older age, lower income, and greater bodily pain were independently associated (P < .05) with walking aid use, physical discomfort during the LDCW, an inability to complete the LDCW, and a slower time to complete the LDCW. Female gender, Hispanic ethnicity (but not race), greater heart rate at rest, a history of smoking, several co-morbidities (history of stroke, ischemic heart disease, diabetes, asthma, sleep apnea, venous edema with ulcerations), and depressive symptoms were also independently related (P < .05) to at least one measure of reduced walking capacity.

CONCLUSIONS

Walking limitations are common in bariatric surgery candidates, even among the least severely obese and youngest patients. Physical activity counseling must be tailored to individuals' abilities. Although several factors identified in the present study (eg, BMI, age, pain, co-morbidities) should be considered, directly assessing the patient's walking capacity will facilitate appropriate goal setting.

Long-term outcomes of laparoscopic Roux-en-Y gastric bypass in US veterans

BACKGROUND

The objective of this study is to evaluate the long-term outcomes following laparoscopic Roux-en-Y gastric bypass (LREYGB) in veteran patients. The VA bariatric population differs from its counterpart in the private sector by the predominance of a male population, a higher percentage of patients from a lower socioeconomic background, a higher mean age, and a higher rate of obesity-related comorbidities.

METHODS

A retrospective review with prospectively collected data was used to analyze postoperative changes of comorbidities and percent of excess weight loss (% EWL) in consecutive patients who underwent LREYGB between August 2003 and September 2006.

RESULTS

Among 70 patients, 73% were men with a mean age of 52 years (29-66 years). Average preoperative weight and body mass index were 310 lbs (224-397 lbs) and 46 kg/m(2) (36-60 kg/m(2)), respectively. The incidence of major and minor complications was 1.4% and 15.7%, respectively. There were no mortalities. Follow-up (f/u) was possible in all patients. At a mean f/u rate of 39 months, % EWL was 56%. At 1, 3, and 5 years, % EWL was 61%, 53%, and 59%, respectively. Thirty-five patients (50%) had type 2 diabetes mellitus (T2DM). Glycosylated hemoglobin concentrations returned to normal levels in 91% of patients and improved in an additional 6% of T2DM cases. Only 7% of patients are still maintained on antidiabetic medications. In patients with more than 1 year f/u, most other comorbidities were improved or resolved.

CONCLUSIONS

Long-term f/u of LREYGB in veteran patients demonstrated significant and durable weight loss (56% EWL) with marked improvements in comorbidities especially T2DM.

Laparoscopic colorectal surgery is safe in the high-risk patient: a NSQIP risk-adjusted analysis

BACKGROUND

Laparoscopic colectomy was considered initially to be contraindicated in patients at high risk for operative morbidity and mortality. We hypothesized that this procedure is safe to perform in high-risk patients, stratifying this risk using National VA Surgical Quality Improvement Program (NSQIP) algorithms.

METHODS

A case-matched, comparative study was performed for high-risk veteran patients who underwent colectomy during the period October 2002-September 2004. Consecutive patients undergoing laparoscopic colectomy were matched to patients who underwent open colectomy during the same period for age, body mass index (BMI), procedure, and NSQIP-predicted risk. The groups were compared for risk-stratified, 30-day morbidity/mortality, length of stay (LOS), and operating time.

RESULTS

Forty-five patients (23 laparoscopic and 22 open cases) were defined as at high risk for complications (predicted complication >0.15). The rate of major complications was significantly less in the laparoscopic group. There were 4 (18%) cases of postoperative respiratory failure in the open group and none in the laparoscopic group. There was no surgically related mortality in the laparoscopic group, compared with 2 deaths in the open group (P = .5). Median LOS was less in the laparoscopic group (5 days) compared with open (8 days) (P = .001). There were no significant differences in operating time or the number of minor complications.

CONCLUSIONS

Our results suggest that the laparoscopic approach to colorectal diseases is safe in the population of patients at high risk for operative morbidity and mortality. Rather, this approach may represent a safer alternative to open access.

Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy

BACKGROUND

Longstanding morbid obesity can be associated with severe cardiomyopathy. However, the safety and efficacy of bariatric surgery in patients with severe cardiomyopathy has not been studied, and the effect of surgical weight loss on postoperative cardiac function is also unknown. In addition, morbidly obese patients have significantly increased mortality associated with cardiac transplantation, often precluding them from becoming recipients.

METHODS

A retrospective study of patients with a left ventricular ejection fraction < or =35% who underwent bariatric surgery (1998-2005) was performed. Short-term morbidity/mortality, length of stay, excess weight loss, pre- and postoperative left ventricular ejection fraction, and New York Heart Association (NYHA) functional class were assessed.

RESULTS

A total of 14 patients (10 men and 4 women) with a mean preoperative body mass index of 50.8 +/- 2.04 kg/m(2) underwent bariatric surgery (10 underwent laparoscopic Roux-en-Y gastric bypass, 1 open Roux-en-Y gastric bypass, 2 sleeve gastrectomy, and 1 laparoscopic gastric banding). The complications were pulmonary edema in 1, hypotension in 1, and transient renal insufficiency in 2. The median length of stay was 3.0 days (range 2-9). The mean excess weight loss at 6 months was 50.4%, with a decrease in the mean body mass index from 50.8 +/- 2.04 kg/m(2) to 36.8 +/- 1.72 kg/m(2). The mean left ventricular ejection fraction at 6 months had significantly improved from 23% +/- 2% to 32% +/- 4% (P = .04), correlating with improved functional capacity, as measured by the NYHA classification. Preoperatively, 2 patients (14%) had an NYHA classification of IV, 6 (43%) a classification of III, and 6 (43%) a classification of II. At 6 months postoperatively, no patient had an NYHA classification of IV, 2 (14%) had a classification of III, and 12 (86%) an NYHA classification of II. Two patients had undergone cardiac transplant evaluations preoperatively and underwent successful transplantation after weight loss.

CONCLUSION

The results of our study have shown that bariatric surgery for patients with cardiomyopathy is feasible and effective. Surgically induced weight loss results in both subjective and objective improvement in cardiac function. In addition, surgical weight loss can provide a bridge to transplantation in patients who were prohibited secondary to their morbid obesity.

Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass

PURPOSE

Many women with polycystic ovarian syndrome (PCOS) are overweight. This study investigated the impact of weight loss surgery on the clinical manifestations of this disorder in morbidly obese women with PCOS-a major risk factor for the development of heart disease, stroke, and type II diabetes.

METHODS

We reviewed the outcomes of women diagnosed with PCOS who had undergone weight loss surgery at the University of Pittsburgh between July 1997 and November 2001. We evaluated the changes in menstrual cycles, hirsutism, infertility, and type II diabetes.

RESULTS

A total of 24 women with PCOS were included in the study. Their mean age was 34 +/- 9.7 years. The mean preoperative body weight was 306 +/- 44 lb, with a body mass index of 50 +/- 7.5. All patients were oligomenorrheic. Of the 24 patients, 23 were hirsute. All women underwent elective laparoscopic gastric bypass surgery. The mean follow-up period was 27.5 +/- 16 months. The mean excess weight loss at 1 year of follow-up was 56.7% +/- 21.2%. All women resumed normal menstrual cycles after a mean of 3.4 +/- 2.1 months postoperatively. Of the 23 women with hirsutism, 12 (52%) had complete resolution at a mean follow-up of 8 +/- 2.3 months, 6 (25%) had moderate resolution at a mean of 21 +/- 18 months, and 3 had minimal resolution at 34 +/- 14 months. Two women reported no change in their hirsutism at 32 +/- 7 months. Five women were able to conceive after surgery without the use of clomiphene.

CONCLUSION

Gastric bypass surgery and its consequent weight loss results in significant improvement of multiple clinical problems related to PCOS.

Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass

OBJECTIVES

A precipitating factor for marginal ulcer formation after Roux-en-Y gastric bypass may be the prolonged irritation by foreign material, such as nonabsorbable suture at the gastrojejunostomy. This study examines the incidence of marginal ulcers before and after a change was made from using nonabsorbable suture to using absorbable suture for the inner layer of the anastomosis.

METHODS

A total of 3285 laparoscopic Roux-en-Y gastric bypass operations were performed during a 5-year period. The gastrojejunostomy technique was modified in August 2002. Those patients who developed a marginal ulcer postoperatively were identified, and their charts were retrospectively analyzed for the operative technique, patient age, history of previous gastric surgery, presence of preoperative diabetes, coronary artery disease, or peptic ulcer disease, and use of nonsteroidal anti-inflammatory medications or tobacco.

RESULTS

The incidence of marginal ulceration after Roux-en-Y gastric bypass decreased significantly from 2.6% (28/1095) with the use of nonabsorbable suture to 1.3% (29/2190) after the change to absorbable suture for the inner layer of the gastrojejunal anastomosis (P < .001). The incidence of visible suture adjacent to the ulcer on endoscopy was also significantly reduced (64.3% vs 3.4%; P < .001). When the results were corrected for length of follow-up, the difference in the incidence of ulcers occurring within 1 year of surgery remained significant between the two groups (P = .002). There were no other significant differences in the factors analyzed.

CONCLUSIONS

The use of nonabsorbable sutures for the inner layer of the gastrojejunal anastomosis is associated with an increased incidence of marginal ulcers, and the adoption of absorbable suture material has reduced this incidence.

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons

BACKGROUND

This study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons.

METHODS

From October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants.

RESULTS

Responses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10-150 cases) are needed for a claim of proficiency.

CONCLUSION

Laparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery.

A novel technique for fascial fixation of laparoscopic adjustable gastric band ports

Access port dislodgement after laparoscopic adjustable gastric banding is a recurring problem that often requires operative revision. Securing the port to the abdominal wall fascia in the traditional way with standard instruments is challenging in obese patients due to a thick abdominal wall. Therefore, we have devised a novel and simple technique for access port fixation using the EndoStitch device.

Laparoscopic repair of umbilical hernias in conjunction with other laparoscopic procedures

BACKGROUND

This study evaluates the feasibility of laparoscopic transfascial suture repair of umbilical hernias when combined with another laparoscopic procedure that potentially contaminates the peritoneal cavity.

METHOD

From August 1997 to November 2001, 32 patients underwent laparoscopic umbilical suture repair in association with another laparoscopic procedure. The repair was performed with the Carter-Thomason suture passer.

RESULTS

Of the 32, 26 patients with more than 1-year follow-up were included in the study. The mean diameter of the umbilical hernia defect was 1.67 cm (range, 0.5 to 3). At a mean follow-up of 34 months (range, 12 to 60), there were only 2 recurrences (7.7%) both of which happened in patients with hernia defects larger than 2 cm in diameter. Apart from 2 wound infections, no other complications occurred.

CONCLUSION

Laparoscopic suture repair of umbilical hernias with the suture passer method is effective and durable even when combined with other laparoscopic procedures that potentially contaminate the peritoneal cavity with bile or enteric contents.

Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and the metabolic syndrome

OBJECTIVE

To evaluate the effects of surgical weight loss on fatty liver disease in severely obese patients.

SUMMARY BACKGROUND DATA

Nonalcoholic fatty liver disease (NAFLD), a spectrum that extends to liver fibrosis and cirrhosis, is rising at an alarming rate. This increase is occurring in conjunction with the rise of severe obesity and is probably mediated in part by metabolic syndrome (MS). Surgical weight loss operations, probably by reversing MS, have been shown to result in improvement in liver histology.

METHODS

Patients who underwent laparoscopic surgical weight loss operations from March 1999 through August 2004, and who agreed to have an intraoperative liver biopsy followed by at least one postoperative liver biopsy, were included.

RESULTS

There were 70 patients who were eligible. All patients underwent laparoscopic operations, the majority being laparoscopic Roux-en-Y gastric bypass. The mean excess body weight loss at time of second biopsy was 59% +/- 22% and the time interval between biopsies was 15 +/- 9 months. There was a reduction in prevalence of metabolic syndrome, from 70% to 14% (P < 0.001), and a marked improvement in liver steatosis (from 88% to 8%), inflammation (from 23% to 2%), and fibrosis (from 31% to 13%; all P < 0.001). Inflammation and fibrosis resolved in 37% and 20% of patients, respectively, corresponding to improvement of 82% (P < 0.001) in grade and 39% (P < 0.001) in stage of liver disease.

CONCLUSION

Surgical weight loss results in significant improvement of liver morphology in severely obese patients. These beneficial changes may be associated with a significant reduction in the prevalence of the metabolic syndrome.

Application of a Trocar Wound Closure System Designed for Laparoscopic Procedures in Morbidly Obese Patients

Herniation into the trocar-site is a relatively common complication of laparoscopic surgery, and represents a serious cause of morbidity because of the potential to develop into a Richter's hernia. The risk of trocar-site herniation is greater in obese and bariatric patients, because of the larger preperitoneal space and elevated intra-abdominal pressure; thus, fascial closure alone is not adequate. Full-thickness trocar-wound closure can prevent this complication. However, hand suturing and some port-closure devices can be difficult to use in this patient group. We report on the use of a specialized trocar wound closure system designed for use on obese and bariatric patients. In this report, we describe use of the system in the case of a 34-year-old Caucasian female who underwent a laparoscopic Roux-en-Y gastric bypass procedure.

The impact of laparoscopy on bariatric surgery

The rising popularity of bariatric surgery over the past several years is attributable in part to the development of laparoscopic bariatric surgery. Morbidly obese patients have associated comorbid conditions that may predispose them to postoperative morbidity. The laparoscopic approach to bariatric surgery offers a minimally invasive option that reduces the physiologic stress and provides clinical benefits, as compared with the open approach. This review summarizes the impact of laparoscopic surgery on bariatric surgery, the various risk factors that could potentially predispose morbidly obese patients to postoperative morbidity, the fundamental differences between laparoscopic and open bariatric surgery, and the physiology of reduced tissue injury associated with laparoscopic bariatric surgery.

Results of laparoscopic gastric bypass in patients with cirrhosis

BACKGROUND

The safety and efficacy of bariatric surgery in patients with cirrhosis has not been well studied.

METHODS

A retrospective review was conducted of patients with cirrhosis who underwent weight-loss surgery at a single institution.

RESULTS

Out of a total of 2119 patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), 30 patients (1.4%) with cirrhosis were identified. When compared with the entire cohort, patients with cirrhosis were significantly more prone to be heavier (BMI 53 vs 48), older in years (age 50 vs 45), more likely to be male (RR=1.3), and have a higher incidence of diabetes (70% vs 21%) and hypertension (67% vs 21%), P<0.05. The diagnosis of cirrhosis was made intra-operatively in 90% of patients. There were no perioperative deaths, conversions to laparotomy, or liver-related complications. Early complications occurred in 9 patients and included anastomotic leak (1), acute tubular necrosis (4), prolonged intubation (2), ileus (1), and blood transfusion (2). Mean length of hospital stay was 4 days (2-18). There was one late unrelated death and one patient with prolonged nausea and protein malnutrition. The average follow-up time was 16 months (1-48). For patients >12 months postoperatively (n=15), the average percent excess weight loss was 63+/-15%.

CONCLUSION

Laparoscopic RYGBP in the cirrhotic patient has an acceptable complication rate and achieves satisfactory early weight loss. Patients tend to be heavier, older, male and more likely to have diabetes and hypertension. Long-term studies are necessary to examine how weight loss impacts established cirrhosis.

Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred

BACKGROUND

There is no consensus regarding the optimal treatment of ventral hernias in patients who present for weight loss surgery.

METHODS

Medical records of consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y (LRYGB) gastric bypass with a secondary diagnosis of ventral hernia were reviewed. Only patients who were beyond 6 months of follow-up were included.

RESULTS

The study population was 85 patients. There were three groups of patients according to the method of repair: primary repair (59), small intestine submucosa (SIS) (12), and deferred treatment (14). Average follow-up was 26 months. There was a 22% recurrence in the primary repair group. There were no recurrences in the SIS group. Five of the patients in the deferred treatment group (37.5%) presented with small bowel obstruction due to incarceration.

CONCLUSION

Biomaterial mesh (SIS) repair of ventral hernias concomitant with LRYGB resulted in the most favorable outcome albeit having short follow-up. Concomitant primary repair is associated with a high rate of recurrence. All incarcerated ventral hernias should be repaired concomitant with LRYGB, as deferment may result in small bowel obstruction.

Medium-term follow-up confirms the safety and durability of laparoscopic ventral hernia repair with PTFE

BACKGROUND

Ventral abdominal wall hernias are common lesions and may be associated with life-threatening complications. The application of laparoscopic principles to the treatment of ventral hernias has reduced recurrence rates from a range of 25% to 52% to a range of 3.4% to 9%. In this study, we review our experience and assess the clinical outcome of patients who have undergone laparoscopic repair of ventral hernias.

METHODS

We reviewed the outcome of 79 patients with more than 1 year of follow-up who underwent laparoscopic ventral hernia repair between March 1996 and December 2001. Patient demographics, hernia characteristics, operative parameters, and clinical outcomes were evaluated.

RESULTS

Of the 79 patients, 37 were males. Mean age was 55.8 years (range 28-81). Sixty-eight patients had incisional hernias, including 17 with recurrent hernias. Eleven patients had primary ventral hernias. The mean defect size was 103 cm(2) (range 4-510); incarceration was present in 22 patients (27.8%), and multiple (Swiss-cheese) defects in 20 (25.3%). Laparoscopic expanded polytetrafluoroethylene mesh repair by the modified Rives-Stoppa technique was completed in 78 (98.7%). One conversion occurred because of bowel injury. The mean operating time was 110 minutes (range 45-210) and mean hospital stay was 1.7 days (range 0-20), with 46 patients (58.2%) being discharged within 24 hours of surgery. Complications included seroma formation (3), chronic pain (3), prolonged ileus (1), hematoma formation (1), and missed bowel injury (1) for a complication rate of (11.4%). There were no deaths. After a follow-up of up to 6 years (a mean of 34 months), there were 4 recurrences (5%).

CONCLUSION

The laparoscopic repair of ventral hernias is safe, effective, and durable with minimal morbidity. It is particularly successful in patients with recurrent lesions. The laparoscopic approach to ventral hernia repair should be considered the standard of care.

Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus

OBJECTIVE

To evaluate pre- and postoperative clinical parameters associated with improvement of diabetes up to 4 years after laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients with type 2 diabetes mellitus (T2DM).

SUMMARY BACKGROUND DATA

The surgical treatment of morbid obesity leads to dramatic improvement in the comorbidity status of most patients with T2DM. However, little is known concerning what preoperative clinical factors are associated with postoperative long-term improvement in diabetes in the morbidly obese patient with diabetes. METHODS We evaluated pre- and postoperative data, including demographics, duration of diabetes, metabolic parameters, and clinical outcomes, in all patients with impaired fasting glucose (IFG) and type T2DM undergoing LRYGBP from July 1997 to May 2002.

RESULTS

During this 5-year period, 1160 patients underwent LRYGBP and 240 (21%) had IFG or T2DM. Follow up was possible in 191 of 240 patients (80%). There were 144 females (75%) with a mean preoperative age of 48 years (range, 26-67 years). After surgery, weight and body mass index decreased from 308 lbs and 50.1 kg/m2 to 211 lbs and 34 kg/m2 for a mean weight loss of 97 lbs and mean excess weight loss of 60%. Fasting plasma glucose and glycosylated hemoglobin concentrations returned to normal levels (83%) or markedly improved (17%) in all patients. A significant reduction in use of oral antidiabetic agents (80%) and insulin (79%) followed surgical treatment. Patients with the shortest duration (<5 years), the mildest form of T2DM (diet controlled), and the greatest weight loss after surgery were most likely to achieve complete resolution of T2DM.

CONCLUSION

LRYGBP resulted in significant weight loss (60% percent of excess body weight loss) and resolution (83%) of T2DM. Patients with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery, suggesting that early surgical intervention is warranted to increase the likelihood of rendering patients euglycemic.

Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus

OBJECTIVE

To evaluate pre- and postoperative clinical parameters associated with improvement of diabetes up to 4 years after laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients with type 2 diabetes mellitus (T2DM).

SUMMARY BACKGROUND DATA

The surgical treatment of morbid obesity leads to dramatic improvement in the comorbidity status of most patients with T2DM. However, little is known concerning what preoperative clinical factors are associated with postoperative long-term improvement in diabetes in the morbidly obese patient with diabetes. METHODS We evaluated pre- and postoperative data, including demographics, duration of diabetes, metabolic parameters, and clinical outcomes, in all patients with impaired fasting glucose (IFG) and type T2DM undergoing LRYGBP from July 1997 to May 2002.

RESULTS

During this 5-year period, 1160 patients underwent LRYGBP and 240 (21%) had IFG or T2DM. Follow up was possible in 191 of 240 patients (80%). There were 144 females (75%) with a mean preoperative age of 48 years (range, 26-67 years). After surgery, weight and body mass index decreased from 308 lbs and 50.1 kg/m2 to 211 lbs and 34 kg/m2 for a mean weight loss of 97 lbs and mean excess weight loss of 60%. Fasting plasma glucose and glycosylated hemoglobin concentrations returned to normal levels (83%) or markedly improved (17%) in all patients. A significant reduction in use of oral antidiabetic agents (80%) and insulin (79%) followed surgical treatment. Patients with the shortest duration (<5 years), the mildest form of T2DM (diet controlled), and the greatest weight loss after surgery were most likely to achieve complete resolution of T2DM.

CONCLUSION

LRYGBP resulted in significant weight loss (60% percent of excess body weight loss) and resolution (83%) of T2DM. Patients with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery, suggesting that early surgical intervention is warranted to increase the likelihood of rendering patients euglycemic.

Laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents

BACKGROUND/PURPOSE

Obesity has contributed significantly to morbidity and premature deaths in the adolescent population. Because many patients do not respond to dietary modification, exercise regimens, or pharmacologic treatment, weight reduction surgery has become a viable alternative, although the morbidity of conventional gastric bypass has tempered enthusiasm for this approach. Experience with the laparoscopic approach has not been reported previously. The authors examined the outcome of adolescents undergoing laparoscopic Roux-En-Y gastric bypass (lap RYGB).

METHODS

Medical records of patients less than 20 years of age (n = 4; 3 girls, 1 boy) who had undergone lap RYGB for morbid obesity were reviewed. All patients met National Institute of Health criteria for bariatric surgery. Outcome variables examined included weight; body mass index (BMI); hospital length of stay (LOS); comorbid conditions; and tolerance of a regular diet. Mean time to follow-up was 17 months.

RESULTS

All procedures were completed laparoscopically. There were no complications. The average LOS was 2 days. Patients with greater than 20-month follow-up lost an average of 87% of their excess body weight and had nearly complete resolution of comorbidities (including hypertriglyceridemia, hypercholesterolemia, asthma, and gastroesophageal reflux disease).

CONCLUSION

Laparoscopic gastric bypass is a safe alternative in morbidly obese adolescents who have not responded to medical therapy.

Contralateral internal jugular vein interposition for salvage of a functioning arteriovenous fistula

Outflow obstruction in patients with hemodialysis access can cause venous hypertension and jeopardize the patency of the access site. Numerous surgical procedures have been described to decompress an occluded subclavian vein. In this report, we describe the use of the contralateral internal jugular vein as a bypass conduit to decompress an occluded brachiocephalic vein in a patient whose dialysis was dependent on this vein access.