Marcelo W. Hinojosa

Association of Hypertension, Diabetes, Dyslipidemia, and Metabolic Syndrome with Obesity: Findings from the National Health and Nutrition Examination Survey, 1999 to 2004

BACKGROUND Hypertension, diabetes, and dyslipidemia are common conditions associated with obesity. This study provides current estimates of the prevalence of hypertension, diabetes, dyslipidemia, and metabolic syndrome according to the severity of obesity in men and women participating in the 1999 to 2004 National Health and Nutrition Examination Survey (NHANES). STUDY DESIGN Data from a representative sample of 13,745 US men and women who participated in the NHANES between 1999 and 2004 were reviewed. Overweight and obesity classes 1, 2, and 3 were defined as a body mass index of 25.0 to 29.9, 30.0 to 34.9, 35.0 to 39.9, and> or =40.0 kg/m(2), respectively. Metabolic syndrome was defined according to the 2004 National Heart, Lung and Blood Institute/American Heart Association conference proceedings. RESULTS With increasing overweight and obesity class, there is an increase in the prevalence of hypertension (18.1% for normal weight to 52.3% for obesity class 3), diabetes (2.4% for normal weight to 14.2% for obesity class 3), dyslipidemia (8.9% for normal weight to 19.0% for obesity class 3), and metabolic syndrome (13.6% for normal weight to 39.2% for obesity class 3). With normal weight individuals as a reference, individuals with obesity class 3 had an adjusted odds ratio of 4.8 (95% CI 3.8 to 5.9) for hypertension, 5.1 (95% CI 3.7 to 7.0) for diabetes, 2.2 (95% CI 1.7 to 2.4) for dyslipidemia, and 2.0 (95% CI 1.4 to 2.8) for metabolic syndrome. CONCLUSIONS The prevalence of hypertension, diabetes, dyslipidemia, and metabolic syndrome substantially increases with increasing body mass index. These findings have important public health implications for the prevention and treatments (surgical and nonsurgical) of obesity.

Single-Laparoscopic Incision Transabdominal Surgery Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy has recently been added to the list of appropriate weight loss operations presently performed by bariatric surgeons. The sleeve gastrectomy is routinely performed using five and up to seven laparoscopic trocars with enlargement of one of the trocar sites for extraction of the gastric specimen. We describe a case of laparoscopic sleeve gastrectomy performed through a single laparoscopic incision.

Minimally Invasive Esophagectomy : Lessons Learned From 104 Operations

Objectives:To review the outcomes of 104 consecutive minimally invasive esophagectomy (MIE) procedures for the treatment of benign and malignant esophageal disease. Summary Background Data:Although minimally invasive surgical approaches to esophagectomy have been reported since 1992, MIE is still considered investigational at most institutions. Methods:This prospective study evaluates 104 MIE procedures performed between August 1998 and September 2007. Main outcome measures include operative techniques, operative times, blood loss, length of stay, conversion rates, morbidities, and mortalities. Results:Indications for surgery were esophageal cancer (n = 80), Barrett esophagus with high-grade dysplasia (n = 6), recalcitrant stricture (n = 8), gastrointestinal stromal tumor (n = 3), and gastric cardia cancer (n = 7). Surgical approaches included thoracoscopic/laparoscopic esophagectomy with a cervical anastomosis (n = 47), minimally invasive Ivor Lewis esophagectomy (n = 51), laparoscopic hand-assisted blunt transhiatal esophagectomy (n = 5), and laparoscopic proximal gastrectomy (n = 1). There were 77 males. The mean age was 65 years. Three patients (2.9%) required conversion to a laparotomy. The median ICU and hospital stays were 2 and 8 days, respectively. Major complications occurred in 12.5% of patients and minor complications in 15.4% of patients. The incidence of leak was 9.6% and of anastomotic stricture was 26%. The 30-day mortality was 1.9% with an in-hospital mortality of 2.9%. The mean number of lymph nodes retrieved was 13.8. Conclusions:Minimally invasive esophagectomy is feasible with a low conversion rate, acceptable morbidity, and low mortality. Our preferred operative approach is the laparoscopic\thoracoscopic Ivor Lewis resection, which provides a tension-free intrathoracic anastomosis.

Laparoscopic surgery is associated with a lower incidence of venous thromboembolism compared with open surgery.

Background:Although laparoscopy now plays a major role in most general surgical procedures, little is known about the relative risk of venous thromboembolism (VTE) after laparoscopic compared with open procedures. Objective:To compare the incidence of VTE after laparoscopic and open surgery over a 5-year period. Patients and Interventions:Clinical data of patients who underwent open or laparoscopic appendectomy, cholecystectomy, antireflux surgery, and gastric bypass between 2002 and 2006 were obtained from the University HealthSystem Consortium Clinical Database. The principal outcome measure was the incidence of venous thrombosis or pulmonary embolism occurring during the initial hospitalization after laparoscopic and open surgery. Results:During the 60-month period, a total of 138,595 patients underwent 1 of the 4 selected procedures. Overall, the incidence of VTE was significantly higher in open cases (271 of 46,105, 0.59%) compared with laparoscopic cases (259 of 92,490, 0.28%, P < 0.01). Our finding persists even when the groups were stratified according to level of severity of illness. The odds ratio (OR) for VTE in open procedures compared with laparoscopic procedures was 1.8 [95% confidence interval (CI) 1.3–2.5]. On subset analysis of individual procedures, patients with minor/moderate severity of illness level who underwent open cholecystectomy, antireflux surgery, and gastric bypass had a greater risk for developing perioperative VTE than patients who underwent laparoscopic cholecystectomy (OR: 2.0; 95% CI: 1.2–3.3; P < 0.01), antireflux surgery (OR: 24.7; 95% CI: 2.6–580.9; P < 0.01), and gastric bypass (OR: 3.4; 95% CI: 1.8–6.5; P < 0.01). Conclusions:Within the context of this large administrative clinical data set, the frequency of perioperative VTE is lower after laparoscopic compared with open surgery. The findings of this study can provide a basis to help surgeons estimate the risk of VTE and implement appropriate prophylaxis for patients undergoing laparoscopic surgical procedures.

Tumor subsite location within the colon is prognostic for survival after colon cancer diagnosis.

PURPOSE: Proximal colon cancers are more likely to present with advanced stage than distal cancers; however, previous reports conflict regarding the independent prognostic significance of tumor location on survival. We examined survival by colon cancer subsite location by use of data from the California Cancer Registry. METHODS: An analysis of colon cancer cases from 1994 to 2004 was conducted, with follow-up through 2006. Colon subsite location was defined as proximal colon (cecum, ascending colon, hepatic flexure), transverse colon, descending colon (splenic flexure, descending colon), and sigmoid colon. Subsite-specific survival analyses were conducted with use of the Kaplan-Meier method and Cox proportional hazards ratios. RESULTS: A total of 82,926 colon cancer cases were identified, including 40,078 proximal (48%), 8,023 transverse (10%), 8,657 descending (10%), and 26,168 sigmoid cancers (32%). A larger proportion of sigmoid cancers (30.5%) presented as Stage I compared with proximal (18.5%), transverse (16.8%), or descending colon cancers (20.1%). Proximal cancers had the greater proportion with high tumor grade (27%), and had a greater mean number of lymph nodes examined. There were no differences in treatment rendered when each colon subsite was stratified by stage. After adjustment for stage, grade, treatment, lymph node examination, and other relevant clinical variables, sigmoid cancers had decreased colorectal cancer-specific mortality compared with proximal tumors (hazards ratio = 0.88; 95% confidence interval, 0.85–0.92). CONCLUSIONS: In this analysis, sigmoid colon cancers were observed to have earlier stage, lower tumor grade, and independently decreased colorectal cancer-specific mortality compared with proximal tumors.

Hepatic artery pseudoaneurysm : A report of seven cases and a review of the literature

PurposeTo analyze seven cases of hepatic artery pseudoaneurysm (HAP) encountered at our hospital and review the relevant literature.MethodsWe searched the computerized medical record database from January 1, 1996, to September 1, 2003, to identify all cases of HAP, which we then reviewed in detail, examining etiology, findings, laboratory data, therapeutic intervention, complications, and outcome. We then compared these findings with those reported in the literature.ResultsThere were five cases of HAP among 18 015 trauma and surgical admissions to the University of California Irvine Medical Center, representing an incidence of 0.03%. There were an additional two cases of HAP among 200 orthotopic liver transplants (OLT). The five HAPs not associated with OLT were preceded by blunt abdominal trauma, liver biopsy, pancreatic pseudocyst, and polyarteritis nodosa, in one patient each, and there was no apparent cause in one patient. Two patients were treated by ligation, and the patients with post-OLT HAP underwent resection and replacement with saphenous bypass grafts. Successful embolization was performed in the other three patients.ConclusionHepatic artery pseudoaneurysm is a rare but dangerous complication of both acute surgical and chronic injury to the hepatic artery. However, early diagnosis and intervention can result in an excellent long-term outcome.

A Single-Port Technique for Laparoscopic Extended Stapled Appendectomy

background data. Natural orifice translumenal endoscopic surgery (NOTES) has become an exciting area of surgical development. Significant limitations to this surgical concept include lack of surgical expertise and appropriate flexible instrumentation. An alternative and competing technology to NOTES is single-incision laparoscopic surgery. Methods. This study describes a patient in whom a laparoscopic surgical technique for appendectomy used incisions that were all placed within the umbilicus. Results. The operative time was 40 minutes. There were no intraoperative complications. The patient did well postoperatively and was discharged on postoperative day 1. There were no perioperative complications at 1-month follow-up. Conclusion. Appendectomy performed through laparoscopic incisions placed within the umbilicus was technically feasible and safe. Development of advanced flexible instrumentation and visualization platform may facilitate this new operative approach.

Correlations between intra-abdominal pressure and obesity-related co-morbidities

BACKGROUND Obesity is associated with chronic increases in intra-abdominal pressure (IAP). The aim of the present study was to examine the correlation between the IAP and the number of obesity-related co-morbidities. METHODS A total of 63 morbidly obese patients who were undergoing bariatric surgery had their IAP measured intraoperatively while in a supine position and under general anesthesia. The IAP readings were obtained through an indwelling urinary bladder catheter. The correlation of obesity-related co-morbidities, including systemic hypertension, type 2 diabetes mellitus, gastroesophageal reflux disease, urinary stress incontinence, lower extremity edema, obstructive sleep apnea, and abdominal wall hernia, and the level of IAP were examined using a stepwise regression analysis model. RESULTS Of the 62 patients, 57 were women. The mean age was 44 + or - 11 years, and the body mass index was 49 + or - 10 kg/m(2). Of the 62 patients, 48 (77%) had an elevated IAP (> or = 9 cm H(2)O). A significant and positive correlation was found between the IAP level and the number of obesity-related co-morbidities (Pearsons r = .8; P <.05). Stepwise logistic regression analysis revealed that systemic hypertension, American Society of Anesthesiologists score, and body mass index were predictors of elevated IAP. A normal IAP appeared to offer a protective effect against systemic hypertension. CONCLUSION In this cohort of mainly obese women, the baseline IAP of morbidly obese patients was abnormally elevated. A greater IAP correlated with the presence of a greater number of obesity-related co-morbid conditions. Systemic hypertension was significantly associated with an elevated IAP. Chronic increases in IAP might, in part, be responsible for the pathogenesis of systemic hypertension in the morbidly obese.

Laparoscopy should be the approach of choice for acute appendicitis in the morbidly obese

BACKGROUND The current study compared the outcome of morbidly obese patients undergoing laparoscopic versus open appendectomy. METHODS We obtained data from the University HealthSystem Consortium (UHC) database on 1,943 morbidly obese patients who underwent appendectomy for acute or perforated appendicitis between 2002 and 2007. RESULTS Compared to open appendectomy, laparoscopic appendectomy was associated with a shorter length of stay (3 vs 4 days) and a lower overall complication rate (9% vs 17%). Most notably, a lower rate of wound infection was noted (1% vs 3%). Within a subset analysis of morbidly obese patients who underwent appendectomy for perforated appendicitis, there was a higher overall complication rate (27% vs 18%) and cost (

Change in Pain and Physical Function Following Bariatric Surgery for Severe Obesity.

16,600 vs