Ali Ardestani

Band revision versus Roux-en-Y gastric bypass conversion as salvage operation after laparoscopic adjustable gastric banding

BACKGROUND With the increasing popularity of laparoscopic adjustable banding (LAGB), reoperations to treat band complications have become increasingly more common. Few studies, however, have documented the outcomes of such revisional procedures. The purpose of the present study was to compare the different reoperative approaches after LAGB placement. The present study was conducted at a tertiary referral academic medical center in the United States. METHODS We reviewed our bariatric database to identify patients who had undergone LAGB from 2004 to 2007 and had undergone either revision of their original band or conversion to Roux-en-Y gastric bypass. RESULTS Of the 66 patients who met our inclusion criteria, 47 (71.2%) had undergone revision and 19 (28.8%) conversion. The patient demographics were similar between the 2 groups. The interval to revision or conversion was 22 and 28 months, respectively. Band slippage was the most common surgical indication in the revision group, and inadequate weight loss was the most common in the conversion group. Although patients in the revision group had experienced good weight loss before their reoperation, the conversion group had not. However, the conversion group experienced good weight loss after their reoperation, with an average excess body weight loss of 48%. CONCLUSION Patients who have experienced successful weight loss with LAGB and experience band complications will have satisfactory outcomes with band revision, maintaining their excess body weight loss. These data suggest that patients with inadequate weight loss after LAGB can do well after conversion to Roux-en-Y gastric bypass.

Insulin cessation and diabetes remission after bariatric surgery in adults with insulin-treated type 2 diabetes.

OBJECTIVE The impact of bariatric surgeries on insulin-treated type 2 diabetes (I-T2D) in the general population is largely undocumented. We assessed changes in insulin treatment after bariatric surgery in a large cohort of I-T2D patients, comparing Roux-en-Y gastric bypass surgery (RYGB) with laparoscopic adjustable gastric banding (LAGB), controlling for differences in weight loss between procedures. RESEARCH DESIGN AND METHODS Of 113,638 adult surgical patients in the Bariatric Outcomes Longitudinal Database (BOLD), 10% had I-T2D. Analysis was restricted to 5,225 patients with I-T2D and at least 1 year of postoperative follow-up. Regression models were used to identify factors that predict cessation of insulin therapy. To control for differences in weight loss patterns between RYGB and LAGB, a case-matched analysis was also performed. RESULTS Of I-T2D patients who underwent RYGB (n = 3,318), 62% were off insulin at 12 months compared with 34% (n = 1,907) after LAGB (P < 0.001). Regression analysis indicated that RYGB strongly predicted insulin cessation at both 1 and 12 months postoperatively. In the case-matched analysis at 3 months, the proportion of insulin cessation was significantly higher in the RYGB group than in the LAGB group (P = 0.03), and the diabetes remission rate was higher at all time points after this surgery. RYGB was a weight-independent predictor of insulin therapy cessation early after surgery, whereas insulin cessation after LAGB was linked to weight loss. CONCLUSIONS I-T2D patients have a greater probability of stopping insulin after RYGB than after LAGB (62% vs. 34%, respectively, at 1 year), with weight-independent effects in the early months after surgery. These findings support RYGB as the procedure of choice for reversing I-T2D.

Resection or reduction? The dilemma of managing retrograde intussusception after Roux-en-Y gastric bypass.

BACKGROUND Retrograde intussusception (RI) at the jejunojejunostomy can occur after Roux-en-Y gastric bypass (RYGB). Although this complication is rare, it has been encountered more frequently as the number of bariatric procedures have increased. Little data is available to assist surgeons with the optimal management of this condition. Our objectives were to identify the risk factors for RI after RYGB and report on outcomes after surgical intervention at a tertiary academic surgical unit. METHODS We used our prospective longitudinal institutional bariatric surgical database to identify patients with post-RYGB RI from 1996 to 2011. RESULTS We identified 28 post-RYGB RI cases. The median interval between RYGB and RI was 52 months, and the median percentage of excess weight loss was 75%. Patients presented with acute symptoms in 36% of the cases. All patients underwent surgical exploration, including resection and revision of the jejunojejunostomy (46%) or operative reduction with or without enteropexy (54%). Those undergoing resection had a longer hospital stay but similar 30-day complication rates. At a median follow-up of 9 months, only 1 recurrence was documented. CONCLUSIONS RI is a rare and late complication of RYGB and typically occurs after significant weight loss. In the presence of ischemia or nonreducible RI, resection and revision of the jejunojejunostomy is recommended. In less acute patients, laparoscopic management with reduction and/or enteropexy offers a reduced hospital length of stay while maintaining equivalent morbidity and low recurrence compared with resection.

Hiatal hernia repair and gastroesophageal reflux disease in gastric banding patients: Analysis of a national database

BACKGROUND Hiatal hernia (HH) is a risk factor for complications after laparoscopic adjustable gastric banding (LAGB), with recommendation to repair these at the time of LAGB placement. We reviewed the characteristics and outcomes of bariatric patients undergoing HH repair during LAGB. The aim of this study was to determine the prevalence of HH repair in LAGB patients and its potential effect on outcomes. METHODS Using the Bariatric Outcomes Longitudinal Database, we identified patients who had hiatal hernia repair at the time of their LAGB (HHR group) and compared them to other LAGB patients without a HH repair (NonHHR group). RESULTS Of 41,611 patients who underwent LAGB during 2007-2010, 8120 (19.5%) had HH repair (HHR), adding only 4 minutes to the operating time, without an increase in blood transfusion, length of stay, or band-related complications. Preoperatively, the HHR cohort had a higher incidence of gastroesophageal reflux disease (GERD) compared with nonHHR (49% versus 40%, respectively; P<.001) with a higher GERD score (1.13 versus .88, respectively; P<.001). Of those with GERD, similar percentage of patients in the HHR and nonHHR groups experienced improvement 1-year after surgery (53% versus 52%, respectively, P = .4), with similar GERD scores at this time point. CONCLUSION HH are repaired in one fifth of LAGB patients, with a surprisingly minimal increase in operative times and no change in length of stay, morbidity, or mortality. In patients with GERD, HH repair had minimal effect on postoperative improvements in reflux symptoms. These findings suggest that many of the repairs may involve small hernias with unclear clinical effect.

Assessing the effectiveness of surgical skills laboratories: a national survey.

Introduction Surgical skills laboratories have gained widespread use in surgery residency training. Although the availability of simulators and skills laboratories has expanded, little is known about their use and effect on residency training. Methods An online survey consisting of 18 questions was distributed to all members of the Association of Program Directors in Surgery. The survey addressed surgical skills laboratory funding, types of simulators, curricula, tools for evaluation, and opinions on successful implementation of a skills laboratory. Statistical analysis was performed on data obtained from completed surveys. Results A total of 248 programs were invited to respond to the survey, and 81 responses were obtained (33% response rate). Among programs that responded, most mandate time for residents to use their skills laboratory (76%), and most offer a formal curriculum (63%). Few programs require demonstrated proficiency before participating in the operating room (16%), and only 55% of responders believed that their resident’s overall intraoperative technical skills had improved since the implementation of their skills laboratory. Respondents believed that interns derive the most benefit from their skills laboratory when compared with all other years of surgical training (P < 0.001). Faculty participation was most commonly considered as the most important factor for successful implementation of a surgical skills laboratory, regardless of program characteristics. Conclusions Among surgical residency programs that responded to the survey, most programs schedule time for residents to use a skills laboratory, and most use a curriculum. Those surveyed report that interns derive the most benefit, whereas chief residents derive the least. They also believe that faculty participation is the most important aspect to successful implementation of a skills laboratory.

RxSem: A rule based semantic integration method for medical informatics

Obesity and its related co-morbidities are chronic diseases with significant associated healthcare cost. Although many procedures, diets and medications have been introduced to induce weight loss, Bariatric surgery has been established as the most effective therapy for morbid obesity. However, the outcome of such surgeries is unpredictable. Bariatric Surgery Information Systems (BSIS) can be used to improve the prediction of the outcome. In this paper we will present a robust rule based semantic data integration method (RxSem) for solving the data preparation and combination problems associated with Medical Data (MD) for BSIS. RxSem enables the integration of clinical data from disparate sources by resolving canonical inconsistencies and semantic non-homogeneities. We will present ReSem using an illustrative example and share our observations regarding the difficulties and stumbling points encountered in data preparation and integration in this domain. We present solutions to some of the most pressing problems. Although we concentrate on BSIS, our observations and solutions are general and apply to a vast array of health and medical information systems.

The impact of lipomatous tumors on type 2 diabetes: are adipose-derived tumors metabolically active?

BACKGROUND The metabolic and immunologic properties of adipose tissue are linked to the pathogenesis of type 2 diabetes mellitus. Lipomatous tumors, such as liposarcomas, are rare but can reach significant size. We hypothesized that some lipomatous tumors are metabolically active and can alter systemic glucose homeostasis. METHODS We performed a retrospective study of patients who underwent resection of a lipomatous tumor at a tertiary cancer referral center (2004-2015). We divided patients into nondiabetics, well-controlled diabetics (hemoglobin A1c [HbA1c] < 7), and poorly controlled diabetics (HbA1c ≥ 7). We compared patient demographics, tumor characteristics, and measures of glycemic control among these groups before and after tumor resection. RESULTS We reviewed 217 operations for lipomatous tumors. No differences were observed in tumor characteristics in patients with and without diabetes. However, tumor characteristics differed significantly between the well-controlled and poorly controlled diabetics groups. Patients with poorly controlled diabetes had larger tumors that were more likely to be malignant, retroperitoneal, and well-differentiated. Tumor resection had no detectable impact on diabetes, as assessed by HbA1c, and requirement for diabetic medications. CONCLUSIONS Poorly controlled diabetes was linked to the presence of large, malignant, and retroperitoneal lipomatous tumors. However, in limited follow-up, no detectable impact of tumor resection was apparent on glycemic control. These data suggest that most lipomatous tumors do not exert a clinically relevant impact on glucose homeostasis.

Gastroesophageal Reflux Disease and Hiatal Hernia in Bariatric Procedures

Gastroesophageal reflux disease (GERD) and hiatal hernia (HH) are common problems more frequently found in the obese. Growing experience indicates that bariatric surgery can lead to significant weight loss and, in many cases, improvement in GERD. Laparoscopic Roux-en-Y gastric bypass in particular is a highly effective therapy for GERD and can be safely performed in conjunction with repair of an HH. Laparoscopic sleeve gastrectomy (LSG) has rapidly become the most commonly performed bariatric procedure; however, one major drawback of LSG is the potential for development of GERD postoperatively. The indications for LSG in the setting of GERD and HH remain incompletely defined. This chapter highlights aspects of evaluation and management of the obese pre- or postop bariatric surgery patient with GERD and/or HH, including areas of controversy.

Sharing personal genetic information: the impact of privacy concern and awareness of benefit

Purpose Human genomic research (HGR) demands very large pools of data to generate meaningful inference. Yet, the sharing of one’s genetic data for research is a voluntary act. The collection of data sufficient to fuel rapid advancement is contingent on individuals’ willingness to share. Privacy risks associated with sharing this unique and intensely personal data are significant. Genetic data are an unambiguous identifier. Public linkage of donor to their genetic data could reveal predisposition to diseases, behaviors, paternity, heredity, intelligence, etc. The purpose of this paper is to understand individuals’ willingness to volunteer their private information in this high-risk/high-reward context. Design/methodology/approach The authors collect survey data from 273 respondents and use structural equation modeling techniques to analyze responses. Findings The authors find statistical support for our theorization. They find that while heightened awareness of the benefits and risks of sharing correlates with increased privacy concerns, the net impact is an increase in intention to share. Social implications The findings suggest that prescriptive awareness might be an effective tool with which policy-makers can gain the sufficient voluntary participation from individuals necessary to drive large-scale medical research. Originality/value This study contributes a theoretically and empirically informed model which demonstrates the impact of awareness and privacy concern on individuals’ willingness to share their genetic data for large-scale HGR. It helps inform a rising class of data sufficiency problems related to large-scale medical research.