Heena P. Santry

Pregnancy and fertility following bariatric surgery: a systematic review.

CONTEXTnUse of bariatric surgery has increased dramatically during the past 10 years, particularly among women of reproductive age.nnnOBJECTIVESnTo estimate bariatric surgery rates among women aged 18 to 45 years and to assess the published literature on pregnancy outcomes and fertility after surgery.nnnEVIDENCE ACQUISITIONnSearch of the Nationwide Inpatient Sample (1998-2005) and multiple electronic databases (Medline, EMBASE, Controlled Clinical Trials Register Database, and the Cochrane Database of Reviews of Effectiveness) to identify articles published between 1985 and February 2008 on bariatric surgery among women of reproductive age. Search terms included bariatric procedures, fertility, contraception, pregnancy, and nutritional deficiencies. Information was abstracted about study design, fertility, and nutritional, neonatal, and pregnancy outcomes after surgery.nnnEVIDENCE SYNTHESISnOf 260 screened articles, 75 were included. Women aged 18 to 45 years accounted for 49% of all patients undergoing bariatric surgery (>50,000 cases annually for the 3 most recent years). Three matched cohort studies showed lower maternal complication rates after bariatric surgery than in obese women without bariatric surgery, or rates approaching those of nonobese controls. In 1 matched cohort study that compared maternal complication rates in women after laparoscopic adjustable gastric band surgery with obese women without surgery, rates of gestational diabetes (0% vs 22.1%, P < .05) and preeclampsia (0% vs 3.1%, P < .05) were lower in the bariatric surgery group. Findings were supported by 13 other bariatric cohort studies. Neonatal outcomes were similar or better after surgery compared with obese women without laparoscopic adjustable gastric band surgery (7.7% vs 7.1% for premature delivery; 7.7% vs 10.6% for low birth weight, P < .05; 7.7% vs 14.6% for macrosomia, P < .05). No differences in neonatal outcomes were found after gastric bypass compared with nonobese controls (26.3%-26.9% vs 22.4%-20.2% for premature delivery, P = not reported [1 study] and P = .43 [1 study]; 7.7% vs 9.0% for low birth weight, P = not reported [1 study]; and 0% vs 2.6%-4.3% for macrosomia, P = not reported [1 study] and P = .28 [1 study]). Findings were supported by 10 other studies. Studies regarding nutrition, fertility, cesarean delivery, and contraception were limited.nnnCONCLUSIONnRates of many adverse maternal and neonatal outcomes may be lower in women who become pregnant after having had bariatric surgery compared with rates in pregnant women who are obese; however, further data are needed from rigorously designed studies.

Predictors of Patient Selection in Bariatric Surgery

Objective:To identify sociodemographic and clinical predictors of patient selection in bariatric surgery. Summary Background Data:Population-based studies suggest that bariatric surgery patients are disproportionately privately insured, middle-aged white women. It is uncertain whether such disparities are due to surgeon decisions to operate, differences among morbidly obese individuals in access to surgery, or patients’ personal preferences regarding surgical treatment. Methods:We conducted a national survey of 1343 U.S. bariatric surgeons. The questionnaire contained clinical vignettes generated using a balanced fractional factorial design. For each of 3 hypothetical patients unique in age, race, gender, body mass index (BMI), comorbidities, social support, functional status, and insurance, respondents were asked if they would operate. Logistic regression was used to determine the odds of selection for each characteristic while controlling for the other 7 characteristics. Subset analyses were also performed using combinations of BMI and comorbidities. Results:A total of 62.5% of eligible surgeons responded (n = 820). Patient race did not influence surgeon decisions to operate. Hypothetical patient age, BMI, and social support were most influential. In the subgroup of patients who did not meet current NIH BMI and comorbidity criteria for bariatric surgery, male sex (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.14–0.76) was associated with decreased odds of selection. Overall, younger age (OR, 0.09; 95% CI, 0.07–0.11), older age (OR, 0.70; 95% CI, 0.56–0.90), limited functional status (OR, 0.66; 95% CI, 0.52–0.82), poor social support (OR, 0.37; 95% CI, 0.30–0.47), self-pay (OR, 0.72; 95% CI, 0.57–0.91), and public insurance (OR, 0.54; 95% CI, 0.43–0.67) were associated with decreased odds of selection. BMI and comorbidity criteria influenced the magnitude of these effects. Conclusions:Patient race did not play a role in surgeon decisions to operate. Further research should examine the roles of unequal access to bariatric surgery and differing socio-cultural perceptions of morbid obesity on racial disparities. The influence of patient age, gender, insurance status, social support, and functional status on decisions to operate was mitigated by BMI and comorbidities. Policy-makers currently debating BMI and comorbidity criteria for bariatric surgery should also consider guidelines pertaining to these sociodemographic issues that influence patient selection in bariatric surgery.

Vitamin D deficiency in preoperative bariatric surgery patients

BACKGROUNDnObese patients are at risk of hypovitaminosis D. This is particularly concerning for those considering bariatric surgery because of the risk of postoperative nutritional deficiency. We hypothesized that it is necessary to screen for vitamin D deficiency preoperatively and conducted a study to identify the patterns of vitamin D deficiency among prospective bariatric surgery patients.nnnMETHODSnA retrospective analysis of available preoperative laboratory values was conducted for all consecutive patients (n = 312) scheduled to undergo bariatric surgery from January 2004 to October 2006.nnnRESULTSnOf the 312 patients, 179 (57.4%) were deficient in vitamin D preoperatively (25-hydroxyvitamin D < or =20 ng/mL). The average body mass index was 52.3 kg/m2 and the average age was 42.4 years. Of the 139 black patients evaluated, 109 (78.4%) were vitamin D deficient; of the 156 white patients evaluated, 57 (36.5%) were vitamin D deficient; and of the 14 Hispanic patients evaluated, 11 (78.6%) were vitamin D deficient. We also evaluated serum red blood cell folate, vitamin B(12), and free retinol vitamin A levels preoperatively. Of the 312 patients, 39 (12.5%) were vitamin A deficient and 11 (3.5%) were vitamin B(12) deficient. No patient had a red blood cell folate deficiency. Patients with hypovitaminosis D were also checked for secondary hyperparathyroidism; 42 patients (23.5%) fit the criteria (parathyroid hormone levels >75 pg/mL). Many patients with low vitamin D levels were being considered for the duodenal switch procedure.nnnCONCLUSIONnThe results of our study have shown that prospective bariatric surgery patients, particularly candidates for highly malabsorptive procedures, should be screened for hypovitaminosis D preoperatively. Our findings also showed that blacks are particularly at risk of vitamin D deficiency.

Surgeon Volume and Elective Resection for Colon Cancer: An Analysis of Outcomes and Use of Laparoscopy

BACKGROUNDnSurgeon volume may be an important predictor of quality and cost outcomes. We evaluated the association between surgeon volume and quality and cost of surgical care in patients with colon cancer.nnnSTUDY DESIGNnWe performed a retrospective study of patients who underwent resection for colon cancer, using data from the University HealthSystem Consortium from 2008 to 2011. Outcomes evaluated included use of laparoscopy, ICU admission, postoperative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized according to high (HVS), medium (MVS), and low (LVS) average annual volumes.nnnRESULTSnA total of 17,749 patients were included in this study. The average age of the cohort was 65 years and 51% of patients were female. After adjustment for potential confounders, compared with LVS, HVS and MVS were more likely to use laparoscopy (HVS, odds ratio [OR] 1.27, 95% CI 1.15, 1.39; MVS, OR 1.16 95% CI 1.65, 1.26). Postoperative complications were significantly lower in patients operated on by HVS than LVS (OR 0.77 95% CI 0.76, 0.91). The HVS patients were less likely to require reoperation than those in the LVS group (OR 0.70, 95% CI 0.53, 0.92) Total direct costs were

The use of multidisciplinary teams to evaluate bariatric surgery patients: results from a national survey in the U.S.A.

927 (95% CI -

Use of Cholecystostomy Tubes in the Management of Patients with Primary Diagnosis of Acute Cholecystitis

1,567 to -

Centre volume and resource consumption in liver transplantation.

287) lower in the HVS group compared with the LVS group.nnnCONCLUSIONSnHigher quality, lower cost care was achieved by HVS in patients undergoing surgery for colon cancer. An assessment of differences in processes of care by surgeon volume may help further define the mechanism for this observed association.

Interhospital transfers of acute care surgery patients: should care for nontraumatic surgical emergencies be regionalized?

Background: The degree to which U.S. bariatric surgeons use multidisciplinary methods to evaluate patients is unknown. Methods: We conducted a national survey of practising bariatric surgeons, mailed in 3 waves from September-December 2004, to describe and determine predictors of surgeons approach to the multidisciplinary evaluation of prospective bariatric surgery patients. Multivariate analyses were performed to determine patterns and predictors of multidisciplinary methods. Results: The response rate was 62% (813/1,312). Although 95% of respondents reported using a multidisciplinary team, only 53% had a general physician, nutritionist, and mental health specialist (NIH-recommended team). Just 47% mandated primary care, nutrition, and mental health evaluations (NIH-recommended evaluations). Practice type, size, and location as well as membership in the American Society for Bariatric Surgery did not influence these outcomes. General surgery board certification reduced the odds of having an NIH-recommended team (OR = 0.56, 95%CI 0.35-0.92). Practicing bariatric surgery for >8 years decreased the odds of reported multidisciplinary team use (OR = 0.29, 95%CI 0.10-0.82) and requiring NIH-recommended evaluations (OR = 0.36, 95%CI 0.24-0.53). Medium volume surgeons had increased odds of reporting use of a team (OR = 2.96, 95%CI 1.22-7.18) and decreased odds of requiring NIH-recommended evaluations (OR = 0.65, 95%CI 0.44-0.92). Conclusion: Inconsistent and unpredictable patterns of multidisciplinary methods were found. Further research should explore the impact of different methods on outcomes. New policies should detail a minimum standard for the multidisciplinary evaluation of bariatric surgery patients. Health professionals across disciplines are needed to assist surgeons in evaluating prospective bariatric surgery patients.

Not Just Full of Hot Air: Hyperbaric Oxygen Therapy Increases Survival in Cases of Necrotizing Soft Tissue Infections

BACKGROUNDnManagement of patients with severe acute cholecystitis (AC) remains controversial. In settings where laparoscopic cholecystectomy (LC) can be technically challenging or medical risks are exceedingly high, surgeons can choose between different options, including LC conversion to open cholecystectomy or surgical cholecystostomy tube (CCT) placement, or initial percutaneous CCT. We reviewed our experience treating complicated AC with CCT at a tertiary-care academic medical center.nnnSTUDY DESIGNnAll adult patients (n = 185) admitted with a primary diagnosis of AC and who received CCT from 2002 to 2010 were identified retrospectively through billing and diagnosis codes.nnnRESULTSnMean patient age was 71 years and 80% had ≥1 comorbidity (mean 2.6). Seventy-eight percent of CCTs were percutaneous CCT placement and 22% were surgical CCT placement. Median length of stay from CCT insertion to discharge was 4 days. The majority (57%) of patients eventually underwent cholecystectomy performed by 20 different surgeons in a median of 63 days post-CCT (range 3 to 1,055 days); of these, 86% underwent LC and 13% underwent open conversion or open cholecystectomy. In the radiology and surgical group, 50% and 80% underwent subsequent cholecystectomy, respectively, at a median of 63 and 60 days post-CCT. Whether surgical or percutaneous CCT placement, approximately the same proportion of patients (85% to 86%) underwent LC as definitive treatment.nnnCONCLUSIONSnThis 9-year experience shows that use of CCT in complicated AC can be a desirable alternative to open cholecystectomy that allows most patients to subsequently undergo LC. Additional studies are underway to determine the differences in cost, training paradigms, and quality of life in this increasingly high-risk surgical population.

Contemporary trends in necrotizing soft-tissue infections in the United States

BACKGROUNDnUsing SRTR/UNOS data, it has previously been shown that increased liver transplant centre volume improves graft and patient survival. In the current era of health care reform and pay for performance, the effects of centre volume on quality, utilization and cost are unknown.nnnMETHODSnUsing the UHC database (2009-2010), 63 liver transplant centres were identified that were organized into tertiles based on annual centre case volume and stratified by severity of illness (SOI). Utilization endpoints included hospital and intensive care unit (ICU) length of stay (LOS), cost and in-hospital mortality.nnnRESULTSnIn all, 5130 transplants were identified. Mortality was improved at high volume centres (HVC) vs. low volume centres (LVC), 2.9 vs. 3.4%, respectively. HVC had a lower median LOS than LVC (9 vs. 10 days, P < 0.0001), shorter median ICU stay than LVC and medium volume centres (MVC) (2 vs. 3 and 3 days, respectively, P < 0.0001) and lower direct costs than LVC and MVC (