David S. Tichansky

Multivariate Analysis of Risk Factors for Death Following Gastric Bypass for Treatment of Morbid Obesity

Objective:To identify the factors that increase mortality for either open or laparoscopic Roux-en-Y gastric bypass. Summary Background Data:Perioperative mortality is the most feared outcome of bariatric surgery, reported to occur in between 0.5% and 1.5% of patients. Methods:The bariatric database at Virginia Commonwealth University was queried for patients who had undergone either an open gastric bypass (O-GBP) or a laparoscopic gastric bypass (L-GBP). A multivariate logistic regression analysis to identify factors related to perioperative mortality was performed. Factors examined included age, gender, body mass index, preoperative weight, hypertension, diabetes mellitus, sleep apnea, obesity hypoventilation syndrome, venous stasis ulcers, intestinal leak, small bowel obstruction, and pulmonary embolus. Results:Since 1992, more than 2000 patients had either an O-GBP (n = 1431) or a L-GBP (n = 580). Of the O-GBP, 547 patients had a proximal GBP (P-GBP) and 884 superobese (body mass index > 50 kg/m2) patients had a long-limb GBP (LL-GBP). The differences in patient demographics, complications, and perioperative mortality rates between L-GBP and O-GBP and P-GBP and LL-GBP patients were examined. Overall, the independent risk factors associated with perioperative death included leak, pulmonary embolus, preoperative weight, and hypertension. Conclusions:The risk factors for perioperative death can be separated into patient characteristics and complications. The access method, open versus laparoscopic, was not independently predictive of death, but the operation type, proximal versus long limb, was predictive. The data do not suggest that superobese patients should not undergo surgery, as they are high risk for early death due to their body weight and comorbidities without surgery. Surgery should not be reserved as a desperate last measure for weight loss.

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.

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.

Strictureplasty for Crohn's disease

PURPOSE: The objective of this study was to analyze patient outcome after strictureplasty for management of intestinal stricture caused by Crohns disease based on differences in surgical procedures. METHODS: A MEDLINE search was performed using a medical subject heading analysis for strictureplasty in Crohns disease. Meta-analysis of multiple variables for outcome was performed using random-effects models. RESULTS: Five hundred six patients underwent 1,825 strictureplasties for Crohns disease with minimal morbidity and zero mortality. Ninety percent of strictures were less than 10 cm in length. Approximately 85 percent of these procedures used the Heineke-Mikulicz technique and 13 percent used Finney strictureplasty. Forty-four percent of procedures included concurrent bowel resection. Recurrence rate of Crohns disease after strictureplasty was increased in patients with longer study duration after surgery (P=0.04), who showed symptoms of active disease (P=0.02), who experienced preoperative weight loss (P=0.02), or who received the Heineke-Mikulicz procedure (P=0.008). The proportion of patients requiring additional surgery was increased with longer study duration (P=0.006), with properative weight loss (P=0.001), or with the Heineke-Mikulicz procedure (P=0.005). The proportion of patients requiring additional surgery was decreased when a Finney strictureplasty was used (P=0.008) as compared with those treated by the Heineke-Mikulicz procedure. CONCLUSION: Although the Heineke-Mikulicz technique is most often used for Crohns strictureplasty, outcome analysis revealed the Finney strictureplasty may reduce the reoperation rate.

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.

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.

Risk of Second Cancers in Patients with Colorectal Carcinoids

INTRODUCTION: It is often stated that patients with colorectal carcinoid tumors have an increased risk of developing other malignancies. However, this risk has not been conclusively documented. A comprehensive evaluation is needed to more thoroughly assess the risk of second cancers in patients with colorectal carcinoids. METHODS: A search of the National Cancer Institute Surveillance, Epidemiology, and End Result database from 1973 to 1996 revealed 2,086 patients with colorectal carcinoids. This subset of patients was examined for occurrence of second cancers. The observed incidence of cancer for each site was compared with the expected incidence based on the gender-adjusted and age-adjusted cancer rates in the remaining Surveillance, Epidemiology, and End Result file. A Poisson distribution probability was used to determine the significance of these comparisons. RESULTS: Patients with colorectal carcinoids had an increased rate of cancer in the colon and rectum (P < 0.001), small bowel (P < 0.001), esophagus/stomach (P = 0.02), lung/bronchus (P < 0.001), urinary tract (P = 0.005), and prostate (P < 0.001), when compared with a control population. Most of the gastrointestinal tract cancers were synchronous cancers, whereas lesions outside the gastrointestinal tract were most commonly metachronous tumors. CONCLUSIONS: A significantly increased risk of synchronous colorectal, small-bowel, gastric, and esophageal cancers and metachronous lung, prostate, and urinary tract neoplasms is clearly demonstrated. After the diagnosis of colorectal carcinoid tumors, patients should undergo appropriate screening and surveillance for cancer at these sites.

Human epicardial adipokine messenger RNAs: comparisons of their expression in substernal, subcutaneous, and omental fat

We compared the gene expression of inflammatory and other proteins by real-time quantitative polymerase chain reaction in epicardial, substernal (mediastinal) and subcutaneous sternal, upper abdominal, and leg fat from coronary bypass patients and omental (visceral) fat from extremely obese women undergoing bariatric surgery. We hypothesized that (1) epicardial fat would exhibit higher expression of inflammatory messenger RNAs (mRNAs) than substernal and subcutaneous fat and (2) epicardial mRNAs would be similar to those in omental fat. Epicardial fat was clearly different from substernal fat because there was a far higher expression of haptoglobin, prostaglandin D(2) synthase, nerve growth factor beta, the soluble vascular endothelial growth factor receptor (FLT1), and alpha1 glycoprotein but not of inflammatory adipokines such as monocyte chemoattractant protein-1, interleukin (IL)-8, IL-1beta, tumor necrosis factor alpha, serum amyloid A, plasminogen activator inhibitor-1, or adiponectin despite underlying coronary atherosclerosis. However, the latter inflammatory adipokines as well as most other mRNAs were overexpressed in epicardial fat as compared with the subcutaneous depots except for IL-8, fatty acid binding protein 4, the angiotensin II receptor 1, IL-6, and superoxide dismutase-2. Relative to omental fat, about one third of the genes were expressed at the same levels, whereas monocyte chemoattractant protein-1, cyclooxygenase-2, plasminogen activator inhibitor-1, IL-1beta, and IL-6 were expressed at far lower levels in epicardial fat. In conclusion, epicardial fat does not appear to be a potentially more important source of inflammatory adipokines than substernal mediastinal fat. Furthermore, the expression of inflammatory cytokines such as IL-6 and IL-1beta is actually higher in omental fat from obese women without coronary atherosclerosis. The data do not support the hypothesis that most of the inflammatory adipokines are expressed at high levels in epicardial fat of humans.

Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass

BackgroundThe utility of routine upper gastrointestinal (UGI) studies after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a matter of great debate. Because the morbidity and mortality rates associated with an unrecognized postoperative leak are high after LRYGB, diagnosis of a postoperative leak earlier would be of benefit. Clinical signs, however, may predict the diagnosis of a postoperative leak more often. This study explored the hypothesis that UGI studies are more predictive than clinical signs for the early diagnosis of a postoperative leak after LRYGB.MethodsAll patients who underwent LRYGB at the authors’ institution were included in this study. Charts were reviewed to examine immediate clinical signs (heart rate, temperature, and white blood cell count within the first 24 h), UGI studies, and clinical course. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of clinical signs and UGI studies were calculated.ResultsThis study included 245 patients with a 3% rate of leak. The positive and negative predictive value of UGI studies were 67% and 99%, respectively. Only an elevated white blood count had a better predictive value (100% for negative predictive value). The efficiency of UGI studies (98%) was better than that of heart rate (83%), white blood count (8%), or temperature (95%).ConclusionsAccording to our data, UGI studies are the most predictive of an early leak diagnosis. Clinical signs alone may not be as useful in predicting leaks early after laparoscopic gastric bypasses. Routine early postoperative UGI studies are a reasonable approach to predicting leaks after LRYGB.