Masha Livhits

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.

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.

Basal Rather Than Induced Heme Oxygenase-1 Levels Are Crucial in the Antioxidant Cytoprotection

Heme oxygenase-1 (HO-1) overexpression protects against tissue injury in many inflammatory processes, including ischemia/reperfusion injury (IRI). This study evaluated whether genetically decreased HO-1 levels affected susceptibility to liver IRI. Partial warm ischemia was produced in hepatic lobes for 90 min followed by 6 h of reperfusion in heterozygous HO-1 knockout (HO-1+/−) and HO-1+/+ wild-type (WT) mice. HO-1+/− mice demonstrated reduced HO-1 mRNA/protein levels at baseline and postreperfusion. This corresponded with increased hepatocellular damage in HO-1+/− mice, compared with WT. HO-1+/− mice revealed enhanced neutrophil infiltration and proinflammatory cytokine (TNF-α, IL-6, and IFN-γ) induction, as well as an increase of intrahepatic apoptotic TUNEL+ cells with enhanced expression of proapoptotic genes (Bax/cleaved caspase-3). We used cobalt protoporphyrin (CoPP) treatment to evaluate the effect of increased baseline HO-1 levels in both WT and HO-1+/− mice. CoPP treatment increased HO-1 expression in both animal groups, which correlated with a lower degree of hepatic damage. However, HO-1 mRNA/protein levels were still lower in HO-1+/− mice, which failed to achieve the degree of antioxidant hepatoprotection seen in CoPP-treated WT. Although the baseline and postreperfusion HO-1 levels correlated with the degree of protection, the HO-1 fold induction correlated instead with the degree of damage. Thus, basal HO-1 levels are more critical than the ability to up-regulate HO-1 in response to the IRI and may also predict the success of pharmacologically induced cytoprotection. This model provides an opportunity to further our understanding of HO-1 in stress defense mechanisms and design new regimens to prevent IRI.

Risk of surgery following recent myocardial infarction.

Objective: We aimed to assess the impact of recent myocardial infarction (MI) on outcomes after subsequent surgery in the contemporary clinical setting. Background: Prior work shows that a history of a recent MI is a risk factor for complications following noncardiac surgery. However, this data does not reflect current advances in clinical management. Methods: Using the California Patient Discharge Database, we retrospectively analyzed patients undergoing hip surgery, cholecystectomy, colectomy, elective abdominal aortic aneurysm repair, and lower extremity amputation from 1999 to 2004 (n = 563,842). Postoperative 30-day MI rate, 30-day mortality, and 1-year mortality were compared for patients with and without a recent MI using univariate analyses and multivariate logistic regression. Relative risks (RR) with 95% confidence intervals were estimated using bootstrapping with 1000 repetitions. Results: Postoperative MI rate for the recent MI cohort decreased substantially as the length of time from MI to operation increased (0–30 days = 32.8%, 31–60 days = 18.7%, 61–90 days = 8.4%, and 91–180 days = 5.9%), as did 30-day mortality (0–30 days = 14.2%, 31–60 days = 11.5%, 61–90 days = 10.5%, and 91–180 days = 9.9%). MI within 30 days of an operation was associated with a higher risk of postoperative MI (RR range = 9.98–44.29 for the 5 procedures), 30-day mortality (RR range, 1.83–3.84), and 1-year mortality (RR range, 1.56–3.14). Conclusions: A recent MI remains a significant risk factor for postoperative MI and mortality following surgery. Strategies such as delaying elective operations for at least 8 weeks and medical optimization should be considered.

Coronary revascularization after myocardial infarction can reduce risks of noncardiac surgery.

BACKGROUND Recent studies suggest that preoperative coronary revascularization overall does not improve outcomes after noncardiac surgery. It is not known whether this holds true for high-risk patients with a history of recent MI. Our objective was to determine whether preoperative revascularization improves outcomes after noncardiac surgery in patients with a recent MI. STUDY DESIGN Using the California Patient Discharge Database, we retrospectively analyzed patients with a recent MI who underwent hip surgery, cholecystectomy, bowel resection, elective abdominal aortic aneurysm repair, and lower extremity amputation from 1999 to 2004 (n = 16,478). Postoperative 30-day reinfarction and 30-day and 1-year mortality were compared for patients who underwent preoperative revascularization (percutaneous transluminal coronary angioplasty, coronary stenting, or coronary artery bypass graft) and those who were not revascularized using univariate analyses and multivariate logistic regression. Relative risks with 95% confidence intervals were estimated using bootstrapping with 1,000 repetitions. RESULTS Patients with a recent MI who were revascularized before surgery had an approximately 50% decreased rate of reinfarction (5.1% versus 10.0%; p < 0.001) and 30-day (5.2% versus 11.3%; p < 0.001) and 1-year mortality (18.3% versus 35.8%; p < 0.001) compared with those who were not. Stenting within 1 month of surgery was associated with a trend toward increased reinfarction (relative risk: 1.36; 95% CI, 0.96-1.97), and coronary artery bypass graft was associated with a decreased risk (relative risk: 0.70; 95% CI, 0.55-0.95). CONCLUSIONS This large sample representing real world practice suggests that patients with a recent MI can benefit from preoperative revascularization. Coronary artery bypass graft can improve outcomes more than stenting, especially when surgery is necessary within 1 month of revascularization, but additional prospective studies are indicated.

Surgery is associated with improved survival for adrenocortical cancer, even in metastatic disease

BACKGROUND Adrenocortical carcinoma (ACC) is a rare but lethal tumor. Predictors of survival include earlier stage at presentation and complete operative resection. We assessed effect of treatment and demographic variables on survival. METHODS ACC cases were abstracted from the California Cancer Registry and Office of Statewide Health Planning and Development (1999-2008). Predictors included patient demographics, comorbidities, tumor size, stage, and treatment (none, surgery, chemotherapy and/or radiation [CRT], and surgery plus CRT). RESULTS We studied 367 patients with median tumor size of 10 cm. At presentation, 37% had localized, 17% had regional, and 46% had metastatic disease. Median survival was 1.7 years (7.4 years local, 2.6 years regional, and 0.3 years metastatic, P < .0001). One-year and 5-year survival was: 92%/62% (local); 73%/39% (regional); and 24%/7% (metastatic). Increased age (hazard ratio [HR] 1.16) and Cushings syndrome (HR 1.66) worsened survival (P < .05). Low socioeconomic status worsened survival in local and regional disease (P < .05). In multivariable regression, both surgery (regional HR 0.13; metastatic HR 0.52) and surgery plus CRT (regional HR 0.15; metastatic HR 0.31) improved survival compared with no treatment (P < .02). CONCLUSION In ACC, surgery is associated with improved survival, even in metastatic disease. Surgery should be considered for select patients as part of multimodality treatment.

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.

Clinical Factors Influencing the Performance of Gene Expression Classifier Testing in Indeterminate Thyroid Nodules

BACKGROUND Molecular diagnostic testing is increasingly used in the management of indeterminate thyroid nodules. Limited data exist regarding the influence of clinical factors on gene expression classifier (GEC) test performance. This study examined the positive and negative predictive value of GEC as stratified by nodule size. METHODS A prospectively maintained pathology database from a single tertiary referral center was queried from 2012 to 2015 for indeterminate thyroid nodules that underwent GEC testing. Nodule size, patient demographics, Bethesda classification, and Hürthle cell-predominant nodules (HCNs) were evaluated as predictors of GEC performance. RESULTS Two hundred and thirty-one patients with 245 indeterminate nodules were examined. Assuming all nodules to be benign unless proven malignant on histopathology, the sensitivity and specificity of GEC testing were 95.2% and 60.1%, respectively. The malignancy rate among resected nodules was 25.3%. The positive predictive value was consistent across nodule sizes: 45.5% for nodules <1 cm, 42.9% for nodules 1-1.9 cm, 36.0% for nodules 2-2.9 cm, 54.2% for nodules 3-3.9 cm, and 50.0% for nodules ≥4 cm. The negative predictive value ranged from 93.3% to 100% and was not affected by nodule size. HCNs had a high rate of GEC suspicious results (77.4% vs. 50.5% for nodules without Hürthle cell predominance, p < 0.01), though this did not correspond to a difference in the rate of malignancy (25.8% vs. 25.3%). CONCLUSIONS Nodule size did not affect GEC test performance in the present cohort. GEC benign results remain reliable in large nodules. GEC suspicious nodules >3 cm carry a similar risk of malignancy compared to smaller nodules, and do not warrant more aggressive treatment. GEC testing has limited clinical utility for HCNs due to the high rate of false-positive results.

Factors Associated With Discordance Between Preoperative Parathyroid 4-Dimensional Computed Tomographic Scans and Intraoperative Findings During Parathyroidectomy

Importance Parathyroid 4-dimensional computed tomographic scans (4D-CTs) have emerged as an accurate and cost-effective initial localization study for patients with primary hyperparathyroidism. However, potential limitations and factors affecting the accuracy of preoperative 4D-CTs remain poorly defined. Objectives To characterize factors associated with missed parathyroid lesions on preoperative 4D-CTs and to investigate patterns of commonly observed errors. Design, Setting, and Participants A prospectively accrued patient database was analyzed from September 1, 2011, through October 31, 2016. The study was performed in a tertiary referral center. Consecutive patients with primary hyperparathyroidism undergoing preoperative 4D-CTs and subsequent parathyroidectomy were included in the study. Main Outcomes and Measures Discordance between preoperative 4D-CTs and intraoperative findings in the number and location of abnormal parathyroid lesions. Results Of 411 patients studied (mean [SD] age, 59 [14] years; 325 [79.1%] female), 123 (29.9%) had discordance between preoperative 4D-CTs and intraoperative findings. Among the 411 patients, 75 (18.2%) had major discordance, including incorrectly localized adenoma on the contralateral side of the neck, missed double adenoma, and absence of any abnormal lesion detected on 4D-CTs. Compared with concordant cases, discordant cases had higher frequencies of multigland disease (66.7% [82 of 123] vs 24.3% [70 of 288], P < .001) and multinodular goiter or thyroid nodule (40.7% [50 of 123] vs 29.2% [84 of 288], P = .02). Missed parathyroid lesions were smaller (mean [SD], 0.86 [0.29] vs 1.24 [0.50] cm; P < .001) and were more likely to be in the inferior position (65.4% [87 of 133] vs 38.1% [177 of 465], P < .001). Parathyroid lesion size of 10 mm or less (odds ratio [OR], 4.37; 95% CI, 2.24-8.54), multigland disease (OR, 7.63; 95% CI, 3.49-16.69), multinodular goiter or thyroid nodule (OR, 1.82; 95% CI, 1.01-3.28), and parathyroid lesion in the inferior position (OR, 6.82; 95% CI, 3.10-14.99) were independently associated with discordant 4D-CT results. Conclusions and Relevance Multigland disease was most strongly associated with discordance between preoperative 4D-CTs and intraoperative findings, followed by parathyroid lesion in the inferior position and parathyroid lesion size of 10 mm or less. Awareness of these potential pitfalls may allow surgeons to better leverage this new localization technique in preoperative planning and intraoperative troubleshooting.

Gene Expression Classifier vs Targeted Next-Generation Sequencing in the Management of Indeterminate Thyroid Nodules

Context Molecular testing has reduced the need for diagnostic hemithyroidectomy for indeterminate thyroid nodules. No studies have directly compared molecular testing techniques. Objective Compare the diagnostic performance of Afirma Gene Expression Classifier (GEC) with that of ThyroSeq v2 next-generation sequencing assay. Design Parallel randomized trial, monthly block randomization of patients with Bethesda III/IV cytology to GEC or ThyroSeq v2. Setting University of California, Los Angeles. Participants Patients who underwent thyroid biopsy (April 2016 to June 2017). Intervention Testing with GEC or ThyroSeq v2. Main Outcome Measure Molecular test performance. Results Of 1372 thyroid nodules, 176 (13%) had indeterminate cytology and 149 of 157 eligible indeterminate nodules (95%) were included in the study. Of nodules tested with GEC, 49% were suspicious, 43% were benign, and 9% were insufficient. Of nodules tested with ThyroSeq v2, 19% were mutation positive, 77% were mutation negative, and 4% were insufficient. The specificities of GEC and ThyroSeq v2 were 66% and 91%, respectively (P = 0.002); the positive predictive values of GEC and ThyroSeq v2 were 39% and 57%, respectively. Diagnostic hemithyroidectomy was avoided in 28 patients tested with GEC (39%) and 49 patients tested with ThyroSeq v2 (62%). Surveillance ultrasonography was available for 46 nodules (45 remained stable). Conclusions ThyroSeq v2 had higher specificity than Afirma GEC and allowed more patients to avoid surgery. Long-term surveillance is necessary to assess the false-negative rate of these particular molecular tests. Further studies are required for comparison with other available molecular diagnostics and for newer tests as they are developed.