Alexander P. Nagle

Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery.

INTRODUCTION: The increased incidence of morbid obesity has resulted in an increase of bariatric surgical procedures. Obstructive sleep apnea (OSA) is a commonly encountered comorbidity in morbidly obese patients. Sedatives, analgesics, and anesthetics alter airway tone, and airway obstruction and death have been reported in patients with OSA after minimal doses of sedatives and anesthetics, yet there is a lack of consensus regarding the care of these patients. In this study, we sought to determine whether obese patients with polysomnography-confirmed diagnosis of OSA were at significantly greater risk for postoperative hypoxemic episodes in the first 24 h after laparoscopic bariatric surgery than morbidly obese patients without a diagnosis of OSA. METHODS: Adult subjects (Body Mass Index, 35–75 kg/m2) scheduled to undergo laparoscopic bariatric surgery were studied. A finger pulse oximetry probe was placed preoperatively and oxygen saturation (Spo2) was recorded continuously. All subjects underwent preoperative polysomnography testing within 4 wk of surgery. Anesthetic management was standardized, using propofol for induction and desflurane and remifentanil for maintenance of anesthesia. Patient-controlled analgesia programmed to deliver morphine, 1 mg. every 10 minutes, was used for pain management postoperatively. Hypoxemic episodes were scored as Spo2 >4% below the polysomnography study baseline and lasting for more than 10 s. RESULTS: Eight men and 32 women were enrolled and 1 subject had incomplete data. Thirty-one of the 40 subjects had polysomnography-confirmed OSA. Eight subjects used home continuous positive airway pressure devices nightly, and six of these used their device postoperatively. Preoperatively, subjects with OSA had lower nadir Spo2 during the polysomnography study and a larger number had an apnea/hypopnea index >10 episodes per hour compared with the non-OSA group. In the first 24 h postoperatively, there was no difference in the median Spo2 with and without oxygen therapy, between OSA and non-OSA groups.The number of episodes of oxygen desaturation >4% below the polysomnography study baseline value and the mean number of desaturation episodes per hour did not differ between the groups. CONCLUSIONS: In morbidly obese subjects, in the first 24 h after laparoscopic bariatric surgery, OSA does not seem to increase the risk of postoperative hypoxemia. Our data confirm that morbidly obese subjects, with or without OSA, experience frequent oxygen desaturation episodes postoperatively, despite supplemental oxygen therapy suggesting that perioperative management strategies in morbidly obese patients undergoing laparoscopic bariatric surgery should include measures to prevent postoperative hypoxemia.

A single institution's experience with single incision cholecystectomy compared to standard laparoscopic cholecystectomy

BACKGROUND The advent of single incision laparoscopic surgery has brought renewed attention to cholecystectomy due to the promise of improved cosmesis and less parietal trauma. Small series have demonstrated the feasibility of single incision laparoscopic cholecystectomy (LC). Our series adds to the literature by demonstrating a variety of ancillary techniques that may be employed to perform single incision LC safely, and compares our early experience with that of our standard LC. METHODS We performed a retrospective chart review of patients who underwent single incision LC between February 2008 and April 2009. These patients were compared with an equal number of randomly selected patients undergoing LC during the same period. We identified 25 attempted single incision LC, which were included in our analysis. RESULTS Single incision LC was successfully performed in 21 patients, with only 4 patients requiring conversion to LC. No patients in either group had acute cholecystitis. The critical view of safety was documented in 20 of 21 patients undergoing a successful single incision LC compared with all patients undergoing LC. Operative time was significantly longer in the single incision group. Complications were minor and comparable between the 2 groups. In 9 patients (43%), a suture passer helped to retract the gallbladder. In 8 patients (38%), 1 or 2 Prolene sutures placed by means of a Keith needle helped to retract the gallbladder over the liver and/or helped to retract the infundibulum. In 2 patients, ≥1 supplemental 5-mm port was utilized. In 5 patients (24%), no supplementary retraction was necessary. CONCLUSION Single incision LC is technically more challenging than LC, but can be performed safely by experienced laparoscopic surgeons with results comparable with LC.

High failure rate of the laparoscopic-adjustable gastric band as a primary bariatric procedure

BACKGROUND Determinants of success of a bariatric procedure are many but paramount is the ability to durably produce significant and reliable weight loss. We sought to determine the primary success of the laparoscopic adjustable gastric band (LAGB) by defining failure as clinical weight loss failure with an intact band (excess weight loss [EWL]<20%) or band removal (terminal removal or conversion to a secondary bariatric procedure). METHODS A retrospective chart review was performed on patients who underwent an LAGB as a primary bariatric procedure between January 2003 and December 2007. Data collected included body mass index (BMI), weight, postoperative follow-up length, EWL, and adjustment number, as well as complications of the LAGB. RESULTS Sixteen of 120 patients had the band removed. Nine were terminally removed for unmanageable symptoms, and 7 were converted to an alternative bariatric procedure. The average follow-up for the 104 patients with an intact band was 4.8 years. The average EWL for successful intact bands was 44.9±19.4%; however, an additional 35.6% of patients had an EWL<20%. Patients with an EWL<20% had a significantly higher preoperative BMI and fewer band adjustments. In total, 44% of patients had band failure because of clinical weight loss failure (31%) or eventual band removal (13%). CONCLUSION This study finds that the LAGB failed as a primary bariatric procedure for 44% of patients because of either inadequate weight loss or adequate weight loss with unmanageable symptoms. This suggests that the LAGB should be abandoned as a primary bariatric procedure for the majority of morbidly obese patients because of its high failure rate.

Impact of a structured skills laboratory curriculum on surgery residents' intraoperative decision-making and technical skills.

Background This project sought to study the effectiveness of a curriculum to enhance the intraoperative clinical judgment and procedural skill of surgical residents. Method A multiinstitutional, prospective, randomized study was performed. A cognitive task analysis of laparoscopic cholecystectomy (LC) was conducted on which instructional activities and measurement instruments were designed. Residents were randomly assigned to a control or intervention group. Subjects took written pre- and posttests examining procedure-related judgment and knowledge. The intervention group participated in a three-session curriculum emphasizing LC critical decisions and error prevention. All subjects were evaluated performing the procedure on a cadaveric model. Scores from written and practical exams were compared using independent-sample and paired Student t tests. Results Written examination scores increased for both groups. The intervention group scored significantly higher (P < .05) on the written posttest than the control group. There were no differences between groups on the practical examination. Reliability coefficients for the written examination ranged from .65 to .75. Reliability coefficients for the oral exam, technical skill, and error items on the porcine practical exam were .83, .90, and .53. Conclusions The curriculum resulted in enhanced performance on a written exam designed to assess intraoperative judgment, but no differences in technical skills, showing important implications for future skills lab curriculum formats.

Single access laparoscopic splenectomy.

This report suggests that single-access laparoscopic splenectomy may be an opportunity to further refine minimally invasive approaches for general surgical disease.

Revisional bariatric surgery at a single institution.

BACKGROUND Bariatric surgery, although safe, can have long-term complications that require revision. Our series illustrates the spectrum of primary procedures, indications for surgery, and strategies for revision. METHODS The study was a retrospective chart review. Sixty-three patients were identified. Of specific interest were complications and percentage of excess weight loss (EWL) during the follow-up period. RESULTS Eighteen patients had a previous vertical banded gastroplasty (VBG), 26 had a Roux-en-Y gastric bypass (RYGB), 18 had a laparoscopic adjustable gastric banding (LAGB), and 1 had a jejunal-ileal bypass. All VBG patients were revised to RYGB. Seventeen RYGB patients were revised with RYGB. Eight LAGB patients were revised with RYGB. Eight RYGB patients had placement of LAGB. Two LAGB patients were revised with LAGB because of a slipped band. Eight LAGB patients had the band removed. The morbidity rate was 30% with a major morbidity rate of 11%. There were 2 leaks, neither required reoperation. Other major complications included 3 pneumonias, 2 reoperations, and 2 intra-abdominal abscesses. There were no mortalities. In the 15 patients who had conversion of VBG to RYGB, the mean EWL was 50%, with 60% of patients achieving more than 50% EWL. In the 10 patients who had revision of their RYGB, the mean EWL was 51%, with 60% of patients achieving more than 50%. In the 6 patients who had revision of LAGB to RYGB, the mean EWL was 39%, with 33% of patients achieving more than 50% EWL. In the 8 patients who had LAGB after RYGB the mean EWL was -2%, with 0% of patients achieving more than 50%. CONCLUSIONS Revisional surgery is effective, although complication rates are higher than primary bariatric surgery. The type of initial and revisional procedure affects EWL.

General surgery training without laparoscopic surgery fellows: The impact on residents and patients

BACKGROUND To evaluate resident case volume after discontinuation of a laparoscopic surgery fellowship, and to examine disparities in patient care over the same time period. METHODS Resident case logs were compared for a 2-year period before and 1 year after discontinuing the fellowship, using a 2-sample t test. Databases for bariatric and esophageal surgery were reviewed to compare operative time, length of stay (LOS), and complication rate by resident or fellow over the same time period using a 2-sample t test. RESULTS Increases were seen in senior resident advanced laparoscopic (Mean Fellow Year = 21 operations vs Non Fellow Year = 61, P < 0.01), esophageal (1 vs 11, P < .01) and bariatric volume (9 vs 36, P < .01). Junior resident laparoscopic volume increased (P < 0.05). No difference in LOS or complication rate was seen with resident vs fellow assistant. Operative time was greater for gastric bypass with resident assistant (152 ± 51 minutes vs 138 ± 53, P < .05). CONCLUSION Discontinuing a laparoscopic fellowship significantly increases resident case volume in laparoscopic surgery. Operative time for complex operations may increase in the absence of a fellow. Other patient outcomes are not affected by this change.

Surgical management of obesity

Bariatric surgery has undergone significant change in the past several decades. There are now several attractive surgical options for the management of clinically severe obesity (body mass index > 40 kg/m2). Gastric restrictive procedures predominate and have been performed with acceptable complication rates. Long-term weight loss is frequently > 50% excess weight with amelioration of obesity-related illnesses. Laparoscopic approaches are increasingly popular. Patient selection and appropriate follow-up remain challenging aspects of patient care. In summary, bariatric surgery is a reliable option for the surgical management of clinically severe obese patients.Read more and get great! Thats what the book enPDFd surgical management of obesity will give for every reader to read this book. This is an on-line book provided in this website. Even this book becomes a choice of someone to read, many in the world also loves it so much. As what we talk, when you read more every page of this surgical management of obesity, what you will obtain is something great.

Bariatric Surgery—A Surgeon's Perspective

The prevalence of obesity has increased steadily during the past several decades, and this has become an important public health concern. More than one third of the population of the United States is considered obese, and approximately 15 million (5%) Americans now have a body mass index (BMI) !40 (1). Obesity has been linked to numerous chronic health conditions, including hypertension, hyperlipidemia, sleep apnea, type 2 diabetes mellitus, and heart disease (2). Obesity-associated conditions significantly increase hospital length of stay and overall health care costs and markedly decrease life expectancy (3). Furthermore, there are many quality-oflife and adverse psychosocial aspects associated with obesity (4). Bariatric surgery currently appears to be the only effective treatment for severe obesity and its associated comorbidities. In addition, evidence is accumulating that bariatric surgery provides a survival benefit for patients with morbid obesity. Two recent cohort studies have showed that bariatric surgery compared with medical management reduced long-term mortality in patients with morbid obesity (5,6). After adjustment for population characteristics, the decrease in mortality rates in the two studies amounted to 29% (95% confidence interval 8% to 46%) and 40% (95% confidence interval 33% to 55%), respectively.

Assessment of contraceptive needs in women undergoing bariatric surgery

OBJECTIVE To evaluate documentation of contraception and counseling in women planning to undergo bariatric surgery. STUDY DESIGN Chart review of 1012 women ages 18-45years presenting for bariatric surgery evaluation. Data on socio-demographic variables, documented contraceptive method, preconception counseling, gynecology referrals and postoperative pregnancies were collected. RESULTS The charts of only 272 women (26.9%) contained documentation of a contraceptive method; the most common was oral contraceptives (n=132, 48.5%). Sixteen pregnancies were identified in the first 18months postoperatively. CONCLUSIONS Currently, the documentation of contraceptive counseling is lacking in clinical practice. Measures to enhance provider and patient awareness of these issues will improve patient care. IMPLICATIONS Pregnancy planning and documentation of perioperative contraceptive use in women undergoing bariatric surgery are suboptimal, placing these women at risk of unintended pregnancies. Future research should delineate the best practices in contraceptive provision in this high-risk population of women.