Atul K. Madan

Vitamin and Trace Mineral Levels after Laparoscopic Gastric Bypass

Background: Nutritional deficiencies are a concern after any bariatric surgery procedure. Restriction of oral intake and/or decreased absorption may cause vitamin abnormalities. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. An investigation was undertaken to examine preoperative and short-term (1-year) postoperative levels of vitamins/trace minerals in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: Serum preoperative and postoperative vitamin/trace element levels of LRYGBP patients were recorded in a retrospective chart review (n = 100). Unavailable and undrawn levels were not included in the results. Results: Preoperative and 1-year postoperative percentage of abnormal levels were: vitamin A 11% and 17%, vitamin B12 13% and 3%, vitamin D-25 40% and 21%, zinc 30% and 36%, iron 16% and 6%, ferritin 9% and 3%, selenium 58% and 3%, and folate 6% and 11%. Conclusions: Abnormal vitamin and trace mineral values are common both preoperatively and postoperatively in a bariatric surgery patient population. Routine evaluation of serum levels should be performed in this specific patient population.

TNFα release by the nonfat cells of human adipose tissue

OBJECTIVE: The primary aim was to investigate the relative importance of the adipocytes vs the nonfat cells present in human adipose tissue with respect to release of immunoreactive tumor necrosis factor-α (TNFα). The second aim was to examine the correlation between body mass index (BMI) and the subsequent release of adiponectin and TNFα by explants of human subcutaneous and visceral adipose tissue incubated in primary culture for 48 h.RESULTS: We found that the maximal release of TNFα was seen during the first 4 h of a 48-h incubation by explants of human adipose tissue in primary culture. Over 95% of the TNFα released to the medium by human adipose tissue explants over a 4-h incubation came from the nonfat cells present in the adipose tissue. The release of TNFα by the nonfat cells released during collagenase digestion was slightly higher than that by the cells present in the adipose tissue matrix after collagenase digestion. TNFα release by the combined matrix and isolated nonfat cells was greater than that by explants of tissue indicating some upregulation induced by collagenase digestion. Immunoreactive TNFα disappeared from the medium with a half-time of approximately 10 h. There was a positive correlation coefficient of 0.79 between TNFα release by tissue explants and the BMI of the fat donors as well as a correlation of 0.52 between BMI and release by adipocytes. TNFα release negatively correlated [−0.60] with adiponectin release by adipose tissue. The release of TNFα was far less than that of adiponectin or IL-6, and less than that of plasminogen activator inhibitor-1, hepatocyte growth factor, or leptin over a 4-h incubation of human adipose tissue explants. TNFα release over 4 h was enhanced by lipopolysaccharide and inhibited by a cyclooxygenase-2 inhibitor.CONCLUSION: The release of TNFα by adipose tissue of obese humans is primarily due to the nonfat cells present in adipose tissue. TNFα is a short-lived adipokine whose release by human adipose tissue in primary culture correlates with the BMI of the fat donors.

Identification of omentin mRNA in human epicardial adipose tissue: comparison to omentin in subcutaneous, internal mammary artery periadventitial and visceral abdominal depots.

Objective:The purpose of this study was to determine the relative distribution of omentin and visfatin mRNA in human epicardial, peri-internal mammary, upper thoracic, upper abdominal and leg vein subcutaneous adipose tissue as well as the distribution of omentin in the nonfat cells and adipocytes of human omental adipose tissue.Background:Omentin is found in human omentum but not subcutaneous fat. Omentin and visfatin are considered markers of visceral abdominal fat.Research design and methods:The mRNA content of omentin and visfatin was measured by qRT-PCR analysis of fat samples removed from humans undergoing cardiac or bariatric surgery.Results:Omentin mRNA in internal mammary fat was 3.5%, that in the upper thoracic subcutaneous fat was 4.7% while that in the other subcutaneous fat depots was less than 1% of omentin in epicardial fat. The distribution of visfatin mRNA did not vary between the five depots. Omentin mRNA was preferentially expressed in the nonfat cells of omental adipose tissue since the omentin mRNA content of isolated adipocytes was 9% of that in nonfat cells, and similar results were seen for visfatin. The amount of omentin mRNA in differentiated adipocytes was 0.3% and that of visfatin 4% of that in nonfat cells. The amount of omentin mRNA in preadipocytes was virtually undetectable while that of visfatin was 3% of that in freshly isolated nonfat cells from omental adipose tissue.Conclusion:Omentin mRNA is predominantly found in epicardial and omental human fat whereas visfatin mRNA is found to the same extent in epicardial, subcutaneous and omental fat.

Alcohol and drug use in victims of life-threatening trauma.

OBJECTIVE Alcohol and drug use has been implicated as a contributing factor to all types of trauma. This investigation seeks to determine the prevalence of alcohol and drug use in patients who are victims of life-threatening injuries and the association of alcohol and drug use with intentional trauma. METHODS The Medical Center of Louisiana at New Orleans (Charity Campus) trauma registry was used to identify patients sustaining life-threatening injuries that presented to our American College of Surgeons Level 1 trauma center over a 6-month period. Serum ethanol levels and urine toxicology were assessed at initial presentation for all patients. RESULTS A total of 557 patients were evaluated. Seventy percent (n = 319) of tested patients (n = 450) had positive serum ethanol and/or urine toxicology results. Male gender (75% vs. 55%; p < 0.001) was associated with positive screens; ethnicity was not. No difference in hospital days or mortality was seen between positive and negative screens. Victims of intentional trauma showed a higher percent of positive screens (80% vs. 63%; p < 0.005). CONCLUSION These data suggest that alcohol and drug use is associated with life-threatening injury, especially intentional injury. Prevention of substance abuse is essential for the prevention of trauma.

Esophageal Doppler ultrasound monitor versus pulmonary artery catheter in the hemodynamic management of critically ill surgical patients.

BACKGROUND The pulmonary artery (PA) catheter has been used to determine hemodynamic indices; however, it has recently been criticized. This study was undertaken to evaluate an esophageal Doppler monitor (EDM) as a possible replacement for PA catheter in critically ill, mechanically ventilated patients. METHODS EDM and PA catheters were placed in patients in the surgical intensive care units (n = 14, 118 matched sets of data). PA catheter and EDM measurements, including corrected flow time (FTc,) a measure of preload, were obtained. Pearson correlation (r) was analyzed to compare PA catheter and EDM measurements, and a nonlinear regression model was used to describe Starling Relationships. RESULTS Cardiac output correlated between EDM and PA catheter (r = 0.6; p < 0.001). FTc correlated more strongly with cardiac output than did pulmonary capillary wedge pressure. (FTc: r2 = 0.27; p < 0.001; cardiac output: r2 = 0.04; p = 0.06). CONCLUSION Corrected flow time is a better indicator of preload than pulmonary capillary wedge pressures. EDM seems to be at least as useful as PA catheter in managing the hemodynamic status of critically ill surgical patients.

Support Group Meeting Attendance is Associated with Better Weight Loss

BackgroundSupport group meetings (SGM) are assumed to be an integral part of success after bariatric surgery. This investigation studies the effect of SGM on weight loss as well as factors associated with attendance of SGM. It is our hypothesis that patients who attend SGM (ASGM) lose more weight than those patients who do not attend SGM (NASGM).MethodsPostoperative bariatric patients completed a questionnaire regarding their opinions of SGM. Change in body mass index (BMI) was computed for each patient. The patients were then divided into two groups: ASGM and NASGM for data comparison.ResultsThere were 46 patients in the investigation. Patients in the NASGM group tended to feel that SGM are not needed after bariatric surgery compared to the ASGM group (5.29 vs. 7.06; p = 0.07). Patients in the NASGM group tended to feel that they would lose the same amount of weight with or without attending SGM compared to the ASGM group (5.67 vs. 7.38; p = 0.07). There were no differences in distance to clinic nor in time to clinic between both groups. Gastric bypass patients in the ASGM group had a statistically significantly higher percent decrease in BMI than the patients in the NASGM group (42% vs. 32%; p < 0.03).ConclusionPatients in the ASGM group lose more weight than patients in the NASGM group. The importance of attending SGM should be incorporated in preoperative patient counseling and encouraged during postoperative follow-up visits.

Comparison of messenger RNA distribution for 60 proteins in fat cells vs the nonfat cells of human omental adipose tissue

The messenger RNA (mRNA) distribution of 60 proteins was examined in the 3 fractions obtained by collagenase digestion (fat cells and the nonfat cells comprising the tissue remaining after collagenase digestion [matrix] and the stromovascular cells) of omental adipose tissue obtained from morbidly obese women undergoing bariatric surgery. Fat cells were enriched by at least 3-fold as compared with nonfat cells in the mRNAs for retinol binding protein 4, angiotensinogen, adipsin, glutathione peroxidase 3, uncoupling protein 2, peroxisome proliferator-activated receptor gamma, cell death-inducing DFFA-like effector A, fat-specific protein 27, 11beta-hydroxysteroid dehydrogenase 1, glycerol channel aquaporin 7, NADPH:quinone oxidoreductase 1, cyclic adenosine monophosphate phosphodiesterase 3B, glyceraldehyde-3-phosphate dehydrogenase, insulin receptor, and amyloid A1. Fat cells were also enriched by at least 26-fold in the mRNAs for proteins involved in lipolysis such as hormone-sensitive lipase, lipoprotein lipase, adipose tissue triglyceride lipase, and FAT/CD36. The relative distribution of mRNAs in cultured preadipocytes was also compared with that of in vitro differentiated adipocytes derived from human omental adipose tissue. Cultured preadipocytes had far lower levels of the mRNAs for inflammatory proteins than the nonfat cells of omental adipose tissue. The nonfat cells were enriched by at least 5-fold in the mRNAs for proteins involved in the inflammatory response such as tumor necrosis factor alpha, interleukin lbeta, cyclooxygenase 2, interleukin 24, interleukin 6, and monocyte chemoattractant protein 1 plus the mRNAs for osteopontin, vaspin, endothelin, angiotensin II receptor 1, butyrylcholinesterase, lipocalin 2, and plasminogen activator inhibitor 1. The cells in the adipose tissue matrix were enriched at least 3-fold as compared with the isolated stromovascular cells in the mRNAs for proteins related to the inflammatory response, as well as osteopontin and endothelial nitric oxide synthase. We conclude that the mRNAs for inflammatory proteins are primarily present in the nonfat cells of human omental adipose tissue.

Minimally invasive surgery for achalasia: a 10-year experience ☆

Minimally invasive esophagomyotomy for achalasia has become the preferred surgical treatment; the employment of a concomitant fundoplication with the myotomy is controversial. Here we report a retrospective analysis of 53 patients with achalasia treated with laparoscopic Heller myotomy; fundoplication was used in all patients except one, and 48 of the fundoplications were complete (floppy Nissen). There were no deaths or reoperations, and minor complications occurred in three patients. Good-to-excellent long-term results were obtained in 92% of the subjects (median follow-up 3 years). Two cases (4%) of persistent postoperative dysphagia were documented, one of which was treated with dilatation. Postoperative reflux occurred in five patients, four of whom did not receive a complete fundoplication; these patients were well controlled with medical therapy. We suggest that esophageal achalasia may be successfully treated with laparoscopic Heller myotomy and floppy Nissen fundoplication with an acceptable rate of postoperative dysphagia.

Laparoscopic Roux-en-Y Gastric Bypass is Safe and Feasible after Orthotopic Liver Transplantation

Liver transplantation has become a life-saving procedure for patients with end-stage liver disease. Since obesity is rampant in our society, it is not surprising that patients with a liver transplant suffer from obesity as well. In addition, Roux-en-Y gastric bypass (RYGBP) is a life-saving procedure for patients suffering from morbid obesity. However, a liver transplant is an extensive and invasive abdominal procedure. Further operations after orthotopic liver transplantation may be challenging. With increasing surgeon experience and technical advancements in laparoscopic equipment, previous abdominal surgery is no longer a contraindication to utilize the laparoscopic approach for RYGBP. In fact, herein, we describe the first laparoscopic RYGBP after orthotopic liver transplantation in the world literature.

Prospective randomized controlled trial of laparoscopic trainers for basic laparoscopic skills acquisition

BackgroundLaparoscopic surgery requires a different set of skills than traditional open surgery. The acquisition of basic laparoscopic skills may help novices when learning laparoscopic procedures. This study tested the hypothesis that the combination of virtual reality and box trainers leads to better basic laparoscopic skill acquisition than either method alone or no training.MethodsA randomized control trial involving preclinical medical students with no prior operative experience was performed. The students were grouped according to four training methods: virtual reality training, inanimate box training, a combination of both, and no training (control). The pre- and posttraining scores for four skills in the porcine laboratory were the metrics chosen for this study.ResultsA total of 65 students participated in this study. There were no differences among any of the pretraining scores (p > 0.05). The posttraining times differed between the four groups. Post hoc analyses showed statistically significant differences (p < 0.05) between the participants trained with both trainers and the control subjects.ConclusionsOur data demonstrate that the combination of virtual reality training and inanimate box training leads to better laparoscopic skill acquisition than either training method alone or no training at all. Optimal preclinical laparoscopic training should incorporate both virtual reality trainers and inanimate box trainers.