Beth A. Ryder

Pre‐ to Postoperative Physical Activity Changes in Bariatric Surgery Patients: Self Report vs. Objective Measures

Bariatric surgery patients report significant pre‐ to postoperative increases in physical activity (PA). However, it is unclear whether objective measures would corroborate these changes. The present study compared self‐reported and accelerometer‐based estimates of changes in moderate‐to‐vigorous intensity PA (MVPA) from pre‐ (pre‐op) to 6 months postsurgery (post‐op). Twenty bariatric surgery (65% laparoscopic‐adjustable gastric banding, 35% gastric bypass) patients (46.2 ± 9.8 years, 88% female, pre‐op BMI = 50.8 ± 9.7 kg/m2) wore RT3 accelerometers as an objective measure of MVPA and completed the Paffenbarger Physical Activity Questionnaire (PPAQ) as a subjective measure before and 6 months after bariatric surgery. Time (min/week) spent in MVPA was calculated for the PPAQ and RT3 (≥1‐min and ≥10‐min bouts) at pre‐op and post‐op. Self‐reported MVPA increased fivefold from pre‐op to post‐op (44.6 ± 80.8 to 212.3 ± 212.4 min/week; P < 0.005). By contrast, the RT3 showed nonsignificant decreases in MVPA for both ≥1‐min (186.0 ± 169.0 to 151.2 ± 118.3 min/week) and ≥10‐min (41.3 ± 109.3 to 39.8 ± 71.3 min/week) bouts. At pre‐op, the percentage of participants who accumulated ≥150‐min/week of MVPA in bouts ≥10‐min according to the PPAQ and RT3 was identical (10%). However, at post‐op, 55% of participants reported compliance with the recommendation compared to 5% based on RT3 measurement (P = 0.002). Objectively‐measured changes in MVPA from pre‐op to 6 months post‐op appear to be much smaller than self‐reported changes. Further research involving larger samples is needed to confirm these findings and to determine whether self‐report and objective PA measures are differentially associated with surgical weight loss outcomes.

Objective quantification of physical activity in bariatric surgery candidates and normal-weight controls

BACKGROUND Physical activity (PA) is an important component of weight loss programs and should be encouraged for severely obese patients undergoing bariatric surgery. However, few studies have determined the amount and intensity of activities undertaken preoperatively by bariatric surgery patients using objective measures. METHODS Using RT3 tri-axial accelerometers, the present study compared 38 bariatric surgery candidates and 20 normal weight controls on activity counts/hr; the number of minutes daily spent in moderate-to-vigorous intensity PA (MVPA) and vigorous intensity PA; and the level of compliance with national recommendations to accumulate 150 min/wk of MVPA in bouts of > or = 10 minutes. RESULTS Surgery candidates, compared with controls, recorded significantly (P <.01) fewer activity counts/hr (13,799 +/- 3758 counts/hr versus 19,462 +/- 4259 counts/hr) and spent fewer minutes per day engaged in MVPA (26.4 +/- 23.0 min/d versus 52.4 +/- 24.7 min/d) and vigorous PA (1.2 +/- 3.4 min/d vs 11.8 +/- 9.0 min/d). More than two thirds (68%) of the surgery candidates versus 13% of the normal weight controls did not accumulate any MVPA in bouts of > or = 10 minutes and only 4.5% of obese patients met the weekly MVPA recommendation versus 40% of the controls. CONCLUSION The results of our study have shown that bariatric surgery candidates have low PA levels and rarely engage in PA bouts of sufficient duration and intensity to maintain and improve health. Additional research is needed to determine how best to increase PA in bariatric surgery candidates.

Decreasing the incidence of prolonged air leak after right upper lobectomy with the anterior fissureless technique

OBJECTIVE For major pulmonary resections, the incidence of prolonged air leak may be highest after right upper lobectomy. Dissection through an incomplete minor fissure for pulmonary artery exposure may contribute to air leak. We evaluate the efficacy of the anterior fissureless technique in decreasing the incidence of prolonged air leak after right upper lobectomy. METHODS Twenty-seven consecutive patients had right upper lobectomy by the classic technique of fissure dissection for pulmonary artery exposure (group A). The next 66 patients had right upper lobectomy by the anterior fissureless technique (group B). RESULTS During the period of group A, we observed a higher incidence of prolonged air leak [22.2% (6/27) vs 6.5% (3/46), P = .049] and an increase in hospitalization days (mean 14.8 vs 8.7 days, P = .021) after right upper lobectomy as compared with all other lobar resections. Comparing the 2 techniques for right upper lobectomy (group A vs group B), there was no difference in patient characteristics, operative characteristics, morbidity, or mortality. However, there was a difference in the time to air leak cessation (log-rank P = .002), incidence of prolonged air leak [22.2% (6/27) vs 7.6% (5/66), P = .047], days with chest tube (mean 9.7 vs 6.6 days, P = .044), and days in hospital (mean 14.8 vs 8.2 days, P = .001) favoring group B. No other factors predicted prolonged air leak after right upper lobectomy. CONCLUSIONS The anterior fissureless technique decreases the duration of air leak, incidence of prolonged air leak, days with chest tube, and days in hospital without any noted disadvantages. This technique should be considered when performing right upper lobectomy.

Exercise improves quality of life in bariatric surgery candidates: Results from the Bari-Active trial

To examine the impact of a pre‐bariatric surgery physical activity intervention (PAI), designed to increase bout‐related (≥10 min) moderate to vigorous PA (MVPA), on health‐related quality of life (HRQoL).

Leukocyte-depleted blood transfusion is associated with decreased survival in resected early-stage lung cancer

OBJECTIVES Blood transfusion has been shown to have deleterious effect on lung cancer survival, but little data are available that assess whether leukocyte-depleted (LD) blood has a similar adverse effect. Our institution has been using LD red cells since 2001. We sought to determine whether LD blood has an effect on survival after resection of early-stage lung cancer. METHODS From a prospective database, we evaluated all patients with pathologic stage I non-small cell lung cancer. Patients receiving LD blood were compared with those receiving no transfusion. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis by Cox regression was used to identify independent risk factors affecting survival. RESULTS From 2001 to 2009, 361 patients were evaluated; 63 received LD red cell cell transfusion and 298 received no transfusion. Median follow-up was 48 months. Disease-free survival (P < .001) and overall survival (P < .001) were worse in patients receiving LD blood. Stratifying for stage, disease-free survival continued to be worse with transfusion for stage IA (P = .002) and IB (P = .002). Similarly, overall survival continued to be worse with transfusion for stage IA (P < .001) and IB (P < .001). For disease-free and overall survival, univariate analysis revealed increased age, male gender, anemia, transfusion, and higher stage to be adverse factors, with transfusion and higher stage continuing to be significant adverse factors after multivariate analysis. CONCLUSIONS Our data suggest that transfusion of LD blood is associated with a worse disease-free and overall survival in patients with resected stage I non-small cell lung cancer.

Treatment of postpneumonectomy empyema with debridement followed by continuous antibiotic irrigation.

BACKGROUND The goal of this study was to determine the efficacy of treating postpneumonectomy empyema (PPE) with debridement followed by continuous antibiotic irrigation for pneumonectomy space sterilization. STUDY DESIGN All patients presenting with PPE were evaluated. Patients with bronchopleural fistula (BPF) underwent thoracotomy for fistula closure and debridement. Patients without BPF underwent video-assisted thoracic surgery debridement. All patients then underwent intraoperative placement of an 8-F irrigation catheter and a 36-F drainage catheter. Two weeks of continuous antibiotic irrigation, as determined by cultures, were followed by collection of chest cultures on 3 consecutive days. If cultures returned negative, antibiotic was instilled into the chest and all catheters were removed. If cultures were positive, another 2 weeks of irrigation were reinitiated, adjusting the antimicrobial agent based on culture results. This regimen was repeated until three consecutive negative cultures were obtained. RESULTS Over a 5-year period, 8 consecutive patients with PPE were evaluated. Two had BPF. Mean age was 56 years. Median time to empyema after pneumonectomy was 20 days (range 12 to 497 days). Mean irrigation duration was 40 days (range 18 to 72 days) and mean followup was 580 days (range 75 to 1,666 days). There was no treatment-associated morbidity or mortality. No patients experienced empyema recurrence during followup. CONCLUSIONS PPE can be successfully treated with thoracic debridement followed by continuous antibiotic irrigation. This method avoids the morbidity of rib resection or thoracic cavity reduction procedures. Closure of BPF, if present, is a prerequisite. Debridement can be performed by video-assisted thoracic surgery in patients without fistula.

Image display in endoscopic surgery

— Advances in the technology of optical displays have changed the way surgeons are able to manage different illnesses. Minimally invasive surgery encompasses a wide range of endoscopic procedures, whereby the body cavity (abdomen, thorax, gastrointestinal tract, and joint spaces) is accessed through small incisions and the use of telescopes and fine, long instruments. These techniques have rapidly gained in popularity during the last decades, as patients are experiencing less discomfort after surgery. Visualization of the operative field requires optimal image capture, processing, and display. The introduction of charge-coupled devices has enabled surgeons to view the operative field on a video monitor, allowing ever-more-complex operations to be performed endoscopically. However, limitations include loss of 3-D perception and tactile sense, poor ergonomics, often suboptimal positioning of image display and image quality that is too dependent on outside influences. These limitations, and possible solutions, are addressed, as is the “ideal” display system for endoscopic surgery.

Thoracoscopic Approach for the Treatment of Postpneumonectomy Syndrome

Postpneumonectomy syndrome develops after pneumonectomy when excessive mediastinal shifting leads to compression of the contralateral main bronchus. This case report describes a total thoracoscopic approach for the treatment of postpneumonectomy syndrome.

Changes in enjoyment, self-efficacy, and motivation during a randomized trial to promote habitual physical activity adoption in bariatric surgery patients

BACKGROUND The Bari-Active trial found that a physical activity (PA) intervention (PAI), versus standard presurgical care control (SC), produced significant increases in daily bout-related moderate-to-vigorous PA (MVPA, in≥10-min bouts) preoperatively. The present study examined whether PAI also produces superior improvements in psychological and/or motivational processes that may be important for PA adoption. OBJECTIVES Compare PAI and SC on baseline to postintervention changes in PA-related enjoyment, self-efficacy, and motivations, and examine whether greater bout-related MVPA changes are associated with greater improvements in these variables. SETTING University hospital, United States. METHODS Participants (87% female; body mass index = 45.0±6.5 kg/m(2)) were randomly assigned to 6 weeks of PAI (n = 40) or SC (n = 35). PAI received weekly counseling sessions to increase daily walking exercise. At baseline and postintervention, both groups completed 7-day objective PA monitoring and questionnaires to evaluate changes in bout-related MVPA and PA enjoyment, self-efficacy, and motivation. RESULTS Retention was 84% at postintervention. Intent-to-treat analyses showed that PAI on average reported more favorable changes than SC in PA enjoyment, self-efficacy, amotivation (i.e., lack of PA motivation), and identified and intrinsic regulations (i.e., more autonomous PA motivations; P<.01). In PAI completers (n = 33), changes in bout-related MVPA and psychological/motivational variables were unrelated. CONCLUSION PAI produced greater improvements in PA-related enjoyment, self-efficacy, and motivations than SC. The lack of association between objectively measured PA changes and psychological/motivational processes highlights the need for future research to identify which processes are most important for PA adoption and maintenance in bariatric surgery patients, and to determine whether the method used to measure PA affects the pattern of association.

Comparative Effectiveness and Safety of Bariatric Procedures in Medicare-Eligible Patients: A Systematic Review

Importance The prevalence of obesity in patients older than 65 years is increasing. A substantial number of beneficiaries covered by Medicare meet eligibility criteria for bariatric procedures. Objective To assess the comparative effectiveness and safety of bariatric procedures in the Medicare-eligible population. Evidence Review This systematic review was conducted according to the PRISMA guidelines. Articles were identified through searches of PubMed, Embase, CINAHL, PsycINFO, Cochrane Central Trials Registry, Cochrane Database of Systematic Reviews, and scientific information packages from manufacturers, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and US Food and Drug Administration drugs and devices portals from January 1, 2000, to June 31, 2017. Randomized and nonrandomized comparative studies that evaluated bariatric procedures in the Medicare-eligible population were eligible. Six researchers extracted data on design, interventions, outcomes, and study quality. Findings were synthesized qualitatively; a planned meta-analysis was not undertaken owing to clinical heterogeneity. Findings A total of 11 455 citations were screened for eligibility. Of those, 16 met the eligibility criteria. Compared with no surgery or conventional weight-loss treatment, bariatric surgery results in greater weight loss. Overall mortality after 30 days is lower among bariatric patients (hazard ratio, HR, 0.50; 95% CI, 0.31-0.79, in the study with the longest follow-up of 5.9 years), although, based on 1 study, mortality within 30 days of surgery was higher than in nonsurgically treated controls (1.55% vs 0.53%; P < .001). Bariatric surgery is associated with lower risk of cardiovascular disease (HR, 0.59; 95% CI, 0.44-0.79 in the largest study comparison) and with improvements in respiratory, musculoskeletal, metabolic, and renal outcomes (increase in estimated glomerular filtration rate, 9.84; 95% CI, 8.05-11.62 mL/min/1.73m2). Compared with sleeve gastrectomy (SG) and adjustable gastric banding (AGB), Roux-en-Y gastric bypass (RYGB) appears to be associated with greater weight loss (percent excess weight loss, 23.8% [95% CI, 16.2%-31.4%] at the longest follow-up of 4 years) but the 3 procedures have similar associations with most non–weight loss outcomes. Overall postoperative complications are not statistically significantly different between RYGB and SG, although major and/or serious complications are more common after RYGB. However, these associations are susceptible to at least moderate risk of confounding, selection, or measurement biases. Conclusions and Relevance In the Medicare population, there is low to moderate strength of evidence that bariatric surgery as a weight loss treatment improves non–weight loss outcomes. Well-designed comparative studies are needed to credibly determine the treatment effects for bariatric procedures in this patient population.