Louis Flancbaum

A health status assessment of the impact of weight loss following Roux-en-Y gastric bypass for clinically severe obesity

BACKGROUNDnThe field of medical outcomes emphasizes effects of medical treatments on quality of life as seen from the patients perspective. The increasing incidence of obesity has had tremendous impact on the physical, psychological, social, and economic health of our nation with important longterm implications for the development of future social and health care policies. This study evaluated the effects of clinically severe obesity on overall health status measured in a standardized fashion and the impact of durable weight loss achieved through surgical intervention.nnnSTUDY DESIGNnPatients scheduled for Roux-en-Y gastric bypass for treatment of obesity were prospectively evaluated. At the preoperative visit, each patient completed Short Form 36 (SF-36). Postoperatively, patients were again asked to complete SF-36, in person or through a telephone interview at an interim point (3 to 12 months) and after their weight had reached a plateau (>18 months).nnnRESULTSnThe mean body mass index (BMI) was 51+/-10 kg/m2 preoperatively (range 38 to 85 kg/m2). Mean BMI was 45+/-10 kg/m2 (range 33 to 78 kg/m2) at the interim point and 35+/-8 kg/m2 (range 28 to 55 kg/m2) at plateau. The weight change for the group was from 306+/-8 lb (138+/-4 kg) preoperatively to 211+/-55 lb (96+/-25 kg) at the plateau, with the average percent of excess body weight lost being 63+/-23% at the plateau. Preoperatively, patients with clinically severe obesity scored significantly lower than the normal population in all areas except Role Activities (Emotional Factors). At the plateau period, patients demonstrated significant improvement in limitations in all areas compared with preoperative values and scores were the same as (Physical Activities, Role Activities [Physical Factors], General Mental Health, General Health Perceptions), or significantly better than (Social Functioning, Role Activities [Emotional Factors], Bodily Pain, Vitality), the national normal population.nnnCONCLUSIONnClinically severe obesity is a chronic disabling disease that results in significantly decreased health status in seven of the eight areas measured by SF-36. This disability resolves with successful weight reduction. In some areas, function even surpasses the national normal population. Surgical treatment of clinically severe obesity has a profoundly positive impact on patients perception of their health status.

Changes in patients' taste acuity after Roux-en-Y gastric bypass for clinically severe obesity.

OBJECTIVEnPatients who have undergone Roux-en-Y gastric bypass (RYGB) for clinically severe obesity often report an aversion to sweet foods and meat. This study was designed to determine whether changes in taste acuity occur after RYGB.nnnDESIGNnThis prospective, repeated measures trial evaluated acuity for sweet (sucrose) and bitter (urea) tastes, zinc status, and reported changes in taste perceptions in patients undergoing RYGB for weight reduction.nnnSUBJECTSnTaste acuity and serum zinc level were measured in 14 subjects, 6 men and 8 women (mean preoperative body mass index [calculated as kg/m2] = 60.8 +/- 11.8 and mean age = 38.4 +/- 6 years), before surgery and 6 and 12 weeks after surgery. Inquiries regarding taste preferences were made at each postoperative visit with specific reference to sweets and meat. Serum zinc level was measured at the same visit. A noncontrolled comparison group of 4 subjects who were consuming a very-low-calorie diet also underwent taste acuity testing at similar intervals.nnnMAIN OUTCOME MEASURESnThe main outcome measures were recognition taste thresholds, serum zinc levels, and taste preference changes.nnnSTATISTICAL ANALYSISnAnalysis of variance with repeated measures over time, Pearson correlation coefficients, and post hoc analysis of variance were used to analyze data.nnnRESULTSnMean recognition thresholds for sucrose were 0.047 +/- 0.03 mol/L preoperatively and fell significantly to 0.024 +/- 0.01 and 0.019 +/- 0.01 mol/L at 6 and 12 weeks postoperatively, respectively. Overall, there were no significant differences in taste thresholds for urea over time; a significant difference was noted, however, in the pattern of change for urea between patients who reported an aversion to meats and those who did not. Zinc concentrations did not change during the study.nnnAPPLICATION/CONCLUSIONSnAt 6 weeks postoperatively, all patients reported that foods tasted sweeter, and they modified food selection accordingly. Six patients reported an aversion to meats associated with increased nausea and vomiting. Acuity for sweet and bitter tastes may need to be considered when planning dietary modifications for patients undergoing RYGB.

A prospective randomized trial of preoperative “optimization” of cardiac function in patients undergoing elective peripheral vascular surgery

BACKGROUNDnPrevious investigations have suggested that preoperative invasive hemodynamic monitoring with optimization of cardiovascular function may favorably affect the outcome among patients undergoing peripheral vascular surgery. The purpose of this study was to evaluate the effect of preoperative optimization of hemodynamic parameters on outcome in patients undergoing aortic reconstruction (AR) or limb salvage procedures (LSP) in a randomized, prospective clinical trial.nnnMETHODSnAll 72 patients who consented to participate in this study were admitted to the intensive care unit at least 12 hours before operation for placement of a pulmonary artery catheter (PAC). Patients who were randomized to the treatment group (n = 32) were optimized by adjusting their hemoglobin concentration, oxygen saturation (SaO2), cardiac output, or afterload until the mixed venous O2 saturation (SvO2) was at least 65%. The control group (n = 40) underwent placement of a PAC and had oxygen transport parameters measured without any attempt to optimize SvO2.nnnRESULTSnThere were no significant differences between the treatment and control groups with respect to age, gender, type of operation, initial Acute Physiology and Chronic Health Evaluation (APACHE) II score, SvO2, pulmonary artery occlusion pressure, or cardiac index. All treatment patients achieved an SvO2 of at least 65% before operation. Comparing the treatment and control groups, postoperative cardiovascular complications occurred in 25% versus 27%, intraoperative complications in 28% versus 20%, and death in 9% versus 5%, respectively. None of these differences was statistically significant as a whole or within the subgroups undergoing AR or LSP.nnnCONCLUSIONSnThese data suggest that preoperative optimization of cardiovascular function by using achievement of SvO2 above 65% as the end point does not result in any reduction of intraoperative or perioperative cardiac complications in patients undergoing PVS. Further studies with alternative assessments and manipulation of different cardiopulmonary parameters may yield additional information.

Changes in measured resting energy expenditure after Roux-en-Y gastric bypass for clinically severe obesity☆

BACKGROUNDnRoux-en-Y gastric bypass (RYGB) results in sustained weight loss and amelioration of comorbid conditions in patients with clinically severe obesity. The mechanism of weight loss after RYGB is not well defined. The objective of this study was to document the changes in measured resting energy expenditure (MREE) over time in patients with clinically severe obesity after RYGB.nnnMETHODSnWe prospectively studied MREE in 70 patients (11 male, 59 female; body mass index [BMI], 40 to 80 kg/m2) treated by RYGB. MREE was measured by indirect calorimetry before operation and at 6 weeks and 3, 6, 12, 18, and 24 months after operation. Patients were stratified to hypometabolic ([HM] MREE less than 85% of Harris-Benedict [HB] predicted; n = 22) or normal metabolic rate ([NM] MREE +/- 15% HB predicted; n = 48) before operation; mean BMIs were HM, 53.4 +/- 11.0 kg/m2; NM, 51.4 +/- 9.8 kg/m2; p = not significant. MREE, weight loss, percent excess body weight loss (EWL), and energy intake were determined at each time point.nnnRESULTSnOverall, MREE was significantly less than HB-predicted REE before operation (90 +/- 28%), but rose to become equal to the HB-predicted REE by 6 weeks (96 +/- 15%) and remained so. When stratified by initial metabolic rate, MREE increased significantly in the HM patients by 6 weeks, from 1329 +/- 604 kcal/day (55% of HB predicted) to 1882 +/- 398 kcal/day (88% of HB predicted) (p < 0.001), and MREE remained normal (2332 +/- 484 kcal/day to 2029 +/- 410 kcal/day) in the NM patients. Percent EWL was similar in both groups at each time. Energy intake was 2603 +/- 982 kcal/day before operation and fell to 815 +/- 196 kcal/day at 3 months, 969 +/- 241 kcal/day at 6 months, 1095 +/- 307 kcal/day at 12 months, 1259 +/- 466 kcal/day at 18 months, and 1373 +/- 620 kcal/day at 24 months, and was similar between the groups at each time point. Percent HB-predicted REE increased significantly after operation despite a significant decrease in energy intake.nnnCONCLUSIONSnRYGB is associated with significant changes in MREE over time. In NM patients MREE fell over time consistent with weight loss but remained normal, whereas patients who were hypometabolic exhibited increases in MREE toward normal. These changes in MREE occurred despite reduced energy intake comparable to a very low calorie diet. This paradoxical effect on MREE may contribute to the enhanced weight loss associated with RYGB.

Prevalence of Co-morbidities in Obese Patients before Bariatric Surgery: Effect of Race

Background: We evaluated the prevalence of co-morbidities, in particular diabetes, in a diverse population of morbidly obese patients who underwent gastric bypass surgery at our institution in New York City. Methods: A retrospective study of 300 patients who had bariatric surgery between January 2001 and April 2002 was conducted. Results: 57% of the patients had at least one metabolic complication, 30% had diabetes, 38% hypertension and 35% dyslipidemia. Our population was ethnically diverse, with 40% Hispanic, 34% Caucasian, 25% African-American and 1% Asian. There was no difference in the prevalence of diabetes among races. However, Caucasians had the highest prevalence of hyperlipidemia, and the Hispanic patients were the least hypertensive. Among patients with diabetes, one-third were undiagnosed and 50% untreated. Similarly, 45% of the hypertensive patients and 51% of those with hyperlipidemia remained undiagnosed. Men had more co-morbidities than women. Conclusion: These results suggest a high prevalence of co-morbid conditions in severely obese patients undergoing bariatric surgery. Age, ethnicity and gender influence the type of co-morbid conditions. More research is needed to understand why diabetes and other metabolic complications remain undiagnosed and untreated in a large number of these high risk patients.

The Effect of Catheter Type and Site on Infection Rates in Total Parenteral Nutrition Patients

Infections pose a major problem in patients receiving total parenteral nutrition. Controversy continues concerning the effect of catheter type (triple-, double-, single-lumen, or pulmonary artery), insertion site (subclavian, internal jugular, or femoral vein), and the incidence of catheter-related infections. We retrospectively studied multi-lumen catheter use for total parenteral nutrition over a 6-month period in 192 patients, a total of 3334 catheter days. Nonintensive care unit catheters were inserted by the Nutrition Support Service, and intensive care unit catheters were inserted by the intensive care unit staff. All catheters were cared for using Nutrition Support Service protocols, with multi-lumen catheters changed every 7 to 10 days and pulmonary artery catheters changed every 4 days. Infections were determined by semiquantitative cultures (> 15 colonies/plate). The incidence of infections for triple-lumen catheters was 5 (subclavian), 17 (internal jugular), and 36% (femoral) respectively; total infection rate for triple-lumen catheters was 10%. Infection rates for pulmonary artery catheters were 4 (subclavian), and 6% internal (jugular site), respectively, the overall infection rate was 5%. There were no differences in infection rates at any site based on catheter type; however, when triple-lumen catheter sites were compared, the differences were significant (p < .001 vs subclavian, chi 2). Catheter duration was 7.8 days (subclavian),, 7.3 days (internal jugular), and 4.6 (femoral) days. These data suggest that the use of multi-lumen catheters for total parenteral nutrition is safe, that there is a benefit associated with the subclavian route, and that the femoral site should be avoided.

Hepatic portal venous gas identified by computed tomography in a patient with blunt abdominal trauma : a case report

An abdominal computed tomographic (CT) scan in a middle-aged man injured in a high-speed motor vehicle accident demonstrated the presence of portal venous gas. Findings on initial peritoneal lavage were entirely negative. Exploratory celiotomy performed because of increasing abdominal pain and leukocytosis revealed gangrene of the cecum. This report illustrates the importance of the finding of portal venous gas on CT scan in patients with blunt abdominal trauma.

Survival of critically ill surgical patients discharged to extended care facilities.

Abstract Background: Rates of discharge of surgical ICU (SICU) patients to extended care facilities (ECF) increase as SICU length of stay (LOS) increases. Increased SICU LOS and APACHE II scores have been related to increased hospital mortality. This study evaluated factors influencing ECF survival after SICU patient discharge. Study Design: We did a longitudinal followup study of patients admitted to our tertiary care SICU during a 2-year period who were eventually discharged to ECF. Demographic data, SICU admission APACHE II score, and LOS data were obtained prospectively. Patient followup was obtained 2 years after discharge by telephone interviews with patients themselves or next of kin to ascertain current status or date of demise. Results: Of 1,799 SICU patients admitted during the study period, 160 patients (9%) were discharged to an ECF. Telephone followup was obtained from 150 patients (94%). Mean length of followup was 21 months after hospital discharge (range 7 to 34 months), mean patient age 64 years (range 16 to 96 years), mean SICU admission APACHE II score 13 (range 2 to 29), and mean SICU LOS 11 days (range 1 to 146 days). At followup, 45% of patients had died, 37% had been discharged home, and 18% still resided in an ECF or hospital. Elderly patients (above age 65) had significantly worse 1-year (p Conclusions: Outcomes of ECF discharge after SICU admission is poor, with nearly 50% 2-year mortality. ECF mortality seems significantly higher for the elderly, with patients undergoing otolaryngologic procedures being at highest risk. Severity of illness at the time of SICU admission and SICU LOS does not seem to influence ECF outcomes.

Preoperative intensive care unit admission and hemodynamic monitoring in patients scheduled for major elective noncardiac surgery: A retrospective review of 95 patients

OBJECTIVEnTo review experience with preoperative intensive care unit (ICU) admission and hemodynamic monitoring to determine which patients benefited and how.nnnDESIGNnRetrospective review over 32-month period (1991 to 1994).nnnSETTINGnSurgical ICU of a university teaching hospital.nnnPARTICIPANTSnNinety-five patients admitted to the surgical ICU before a major elective noncardiac, nonthoracic surgical procedure.nnnINTERVENTIONSnAll patients underwent hemodynamic monitoring with a pulmonary artery catheter (PAC). Interventions were made at the discretion of the ICU attending and attending surgeon, based on a general algorithm. Patients were categorized based on history or hemodynamics. The historic classification was as follows: group I, patients with cardiac disease documented by history and cardiac imaging, n = 37; group II, patients with cardiac disease documented by history, but not cardiac imaging, n = 24; group III, patients without documented cardiac disease, but with other significant medical problems, n = 34. Hemodynamic classification considered patients to have subnormal parameters if the cardiac index was < 2.5 L/min/m2, the mixed venous oxygen saturation was < 65%, or the oxygen delivery index was < 350 mL/min/m2 (n = 45), and normal parameters if greater than these (n = 50).nnnMAIN RESULTSnThere were no differences in APACHE II scores. Group I patients had greater Goldman Cardiac Risk Indices than group III patients (7.4 +/- 4.8 v 5.0 +/- 3.0). Patients in group I had a significantly greater incidence of subnormal initial hemodynamic values (63%) than patients in group II (47%) or group III (32%). The incidence of postoperative cardiovascular complications among groups was not different. Fifty patients (52%) had normal hemodynamics initially; two (4%) developed postoperative cardiovascular complications compared with 10 patients (22%) of the 45 with subnormal initial hemodynamic values. Of these 45 patients, 24 (52%) had their hemodynamic parameters corrected preoperatively with crystalloids, packed red blood cells, inotropes, and/or afterload reduction. Two of these 24 patients (8%) experienced postoperative cardiovascular complications, compared with 8 of the remaining 21 patients who had no attempt to normalize their hemodynamic values preoperatively other than maintaining a normal pulmonary artery occlusion pressure.nnnCONCLUSIONSnPatients who had normal initial preoperative hemodynamic parameters or abnormal initial parameters that were normalized preoperatively experienced significantly fewer perioperative cardiovascular complications than those with abnormal initial values that were not normalized preoperatively. These results suggest that there may be benefit to the practice of preoperative ICU admission, hemodynamic monitoring with a PAC, and optimization of cardiac function in selected patients undergoing major elective noncardiac surgery. Further studies are needed to better delineate the most appropriate patient populations and effective therapeutic protocol.

Original Scientific ArticlesSurvival of critically ill surgical patients discharged to extended care facilities1

Abstract Background: Rates of discharge of surgical ICU (SICU) patients to extended care facilities (ECF) increase as SICU length of stay (LOS) increases. Increased SICU LOS and APACHE II scores have been related to increased hospital mortality. This study evaluated factors influencing ECF survival after SICU patient discharge. Study Design: We did a longitudinal followup study of patients admitted to our tertiary care SICU during a 2-year period who were eventually discharged to ECF. Demographic data, SICU admission APACHE II score, and LOS data were obtained prospectively. Patient followup was obtained 2 years after discharge by telephone interviews with patients themselves or next of kin to ascertain current status or date of demise. Results: Of 1,799 SICU patients admitted during the study period, 160 patients (9%) were discharged to an ECF. Telephone followup was obtained from 150 patients (94%). Mean length of followup was 21 months after hospital discharge (range 7 to 34 months), mean patient age 64 years (range 16 to 96 years), mean SICU admission APACHE II score 13 (range 2 to 29), and mean SICU LOS 11 days (range 1 to 146 days). At followup, 45% of patients had died, 37% had been discharged home, and 18% still resided in an ECF or hospital. Elderly patients (above age 65) had significantly worse 1-year (p Conclusions: Outcomes of ECF discharge after SICU admission is poor, with nearly 50% 2-year mortality. ECF mortality seems significantly higher for the elderly, with patients undergoing otolaryngologic procedures being at highest risk. Severity of illness at the time of SICU admission and SICU LOS does not seem to influence ECF outcomes.