Janak A. Parikh

Is social support associated with greater weight loss after bariatric surgery?: a systematic review

Social support may be associated with increased weight loss after bariatric surgery. The objective of this article is to determine impact of post‐operative support groups and other forms of social support on weight loss after bariatric surgery. MEDLINE search (1988–2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened studies, 10 reported on social support and weight loss outcomes. Five studies reported on support groups and five studies reported on other forms of social support (such as perceived family support or number of confidants) and degree of post‐operative weight loss (total n = 735 patients). All studies found a positive association between post‐operative support groups and weight loss. One study found a positive association between marital status (being single) and weight loss, while three studies found a non‐significant positive trend and one study was inconclusive. Support group attendance after bariatric surgery is associated with greater post‐operative weight loss. Further research is necessary to determine the impact of other forms of social support. These factors should be addressed in prospective studies of weight loss following bariatric surgery, as they may represent ways to improve post‐operative outcomes.

Developing Quality Indicators for Elderly Surgical Patients

Objective:To develop process-based quality indicators to improve perioperative care for elderly surgical patients. Background:The population is aging and expanding, and physicians must continue to optimize elderly surgical care to meet the anticipated increase in surgical services. We sought to develop process-based quality indicators applicable to virtually all disciplines of surgery to identify necessary and meaningful ways to improve surgical care and outcomes in the elderly. Methods:We identified candidate perioperative quality indicators for elderly patients undergoing ambulatory, or major elective or nonelective inpatient surgery through structured interviews with thought leaders and systematic reviews of the literature. An expert panel of physicians in surgery, geriatrics, anesthesia, critical care, internal, and rehabilitation medicine formally rated the indicators using a modification of the RAND/UCLA Appropriateness Methodology. Results:Ninety-one of 96 candidate indicators were rated as valid. They were categorized into 8 domains: comorbidity assessment, elderly issues, medication use, patient-provider discussions, intraoperative care, postoperative management, discharge planning, and ambulatory surgery. Of note, 71 (78%) of the indicators rated as valid address processes of care not routinely performed in younger surgical populations. Conclusions:Attention to the quality of care in elderly patients is of great importance due to the increasing numbers of elderly undergoing surgery. This project used a validated methodology to identify and rate process measures to achieve high quality perioperative care for elderly surgical patients.

Does weight loss immediately before bariatric surgery improve outcomes: a systematic review

BACKGROUND Preoperative weight loss before bariatric surgery has been proposed as a predictive factor for improved patient compliance and the degree of excess weight loss achieved after surgery. In the present study, we sought to determine the effect of preoperative weight loss on postoperative outcomes. METHODS A search of MEDLINE was completed to identify the patient factors associated with weight loss after bariatric surgery. Of the 909 screened reports, 15 had reported on preoperative weight loss and the degree of postoperative weight loss achieved. A meta-analysis was performed that compared the postoperative weight loss and perioperative outcomes in patients who had lost weight preoperatively compared to those who had not. RESULTS Of the 15 articles (n = 3404 patients) identified, 5 found a positive effect of preoperative weight loss on postoperative weight loss, 2 found a positive short-term effect that was not sustained long term, 5 did not find an effect difference, and 1 found a negative effect. A meta-analysis revealed a significant increase in the 1-year postoperative weight loss (mean difference of 5% EWL, 95% confidence interval 2.68-7.32) for patients who had lost weight preoperatively. A meta-analysis of other outcomes revealed a decreased operative time for patients who had lost weight preoperatively (mean difference 23.3 minutes, 95% confidence interval 13.8-32.8). CONCLUSION Preoperative weight loss before bariatric surgery appears to be associated with greater weight loss postoperatively and might help to identify patients who would have better compliance after surgery.

Indications for performing carpal tunnel surgery: clinical quality measures.

Background: Rates of carpal tunnel surgery vary for unclear reasons. In this study, the authors developed measures determining when surgery is necessary (benefits exceed risks), inappropriate (risks outweigh benefits), or optional. Methods: Measures were developed using a modified-Delphi panel. Clinical scenarios were defined incorporating symptom severity, symptom duration, clinical probability of carpal tunnel syndrome, electrodiagnostic testing, and nonoperative treatment response. A multidisciplinary panel of 11 carpal tunnel syndrome experts rated appropriateness of surgery for each scenario on a scale ranging from 1 to 9 scale (7 to 9, surgery is necessary; 1 to 3, surgery is inappropriate). Results: Of 90 scenarios (36 for mild, 36 for moderate, and 18 for severe symptoms), panelists judged carpal tunnel surgery as necessary for 16, inappropriate for 37, and optional for 37 scenarios. For mild symptoms, surgery is generally necessary when clinical probability of carpal tunnel syndrome is high, there is a positive electrodiagnostic test, and there has been unsuccessful nonoperative treatment. For moderate symptoms, surgery is generally necessary with a positive electrodiagnostic test involving two or more of the following: high clinical probability, unsuccessful nonoperative treatment, and symptoms lasting longer than 12 months. Surgery is generally inappropriate for mild to moderate symptoms involving two or more of the following: low clinical probability, no electrodiagnostic confirmation, and nonoperative treatment not attempted. For severe symptoms, surgery is generally necessary with a positive electrodiagnostic test or unsuccessful nonoperative treatment. Conclusions: These are the first formal measures assessing appropriateness of carpal tunnel surgery. Applying these measures can identify underuse (failure to provide necessary care) and overuse (providing inappropriate care), giving insight into variations in receipt of this procedure.

Acute small bowel perforation after wireless capsule endoscopy in a patient with Crohn's disease: a case report

IntroductionWireless capsule endoscopy is an important tool for minimally invasive evaluation of the small bowel, allowing improved diagnostic yield with low complication rates relative to traditional modalities. Recently however, reports on small bowel perforation after wireless capsule endoscopy have surfaced. Here we present the first case of acute small bowel perforation in a middle-aged male in the United States.Case presentationA 58-year-old male with a presumed quiescent history of Crohns Disease presented to the Emergency Department in a septic state 48 hours after a wireless capsule endoscopy procedure complaining of abdominal pain, distension, and frequent emesis. A computed tomography scan of the abdomen was suggestive of small bowel perforation and ischemic enteritis. The patient was adequately resuscitated and taken to the operating room for an ileocecectomy and extensive resection of the small bowel. Pathology of the resected specimen revealed an ileal stricture and associated necrotizing ileitis, and a perforation just proximal to the stricture.ConclusionWireless capsule endoscopy remains the preferred endoscopic imaging method of the small bowel. This case illustrates the importance of appropriate patient selection and evaluation of functional patency of the small bowel prior to wireless capsule endoscopy, especially with the growing role of this procedure in the evaluation of inflammatory bowel disease.

Patient behaviors associated with weight regain after laparoscopic gastric bypass

SUMMARY BACKGROUND Patients undergoing gastric bypass lose substantial weight, but 20% regain weight starting at 2 years after surgery. Our objective was to identify behavioral predictors of weight regain after laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS We retrospectively surveyed 197 patients for factors predictive of weight regain (≥15% from lowest weight to weight at survey completion). Consecutive patients who had bariatric surgery from 1/2003 through 12/2008 were identified from an existing database. Response rate was 76%, with 150 patients completing the survey. RESULTS Follow-up after LRYGB was 45.0 ± 12.7 months, 22% of patients had weight regain. After controlling for age, gender, and follow-up time, factors associated with weight regain included low physical activity (odds ratio (OR) 6.92, P = 0.010), low self-esteem (OR 6.86, P = 0.008), and Eating Inventory Disinhibition (OR 1.30, P = 0.029). CONCLUSIONS Physical activity, self-esteem, and maladaptive eating may be associated with weight regain after LRYGB. These factors should be addressed in prospective studies of weight loss following bariatric surgery, as they may identify patients at risk for weight regain who may benefit from tailored interventions.

Secondary Analyses of Large Population-Based Data Sets: Issues of Quality, Standards, and Understanding

Nathan and Pawlik have written an important commentary regarding secondary analyses of large population-based data sets1 for this issue of the Annals of Surgical Oncology. The commentary highlights not only some of the important issues that investigators need to address when performing such studies, but also some of the issues that the reder needs to understand when evaluating these types of studies. Each of the issues raised by the authors is important and could be the focus of a detailed dissertation; we would like to build on their commentary and discuss five items/ideas as the field moves forward.