Megan Baker

Preoperative hemoglobin A1c and postoperative glucose control in outcomes after gastric bypass for obesity

BACKGROUND Hemoglobin A1c (HbA1c) is a reliable marker for long-term glycemic control in obese diabetic patients. Roux-en-Y gastric bypass improves HbA1c levels over time. However, it is not clear whether the preoperative HbA1c level is a predictor of the outcome in these patients. Our objectives were to understand the predictive capacity of the preoperative HbA1c level in gastric bypass patients at a single university-based Bariatric Center of Excellence. METHODS We performed a retrospective review of 468 charts from 2006 to 2009 of patients who had undergone Roux-en-Y gastric bypass. Using their preoperative HbA1c status, the patients were categorized and the postoperative outcomes compared. RESULTS Of the 468 patients reviewed, 310 (66.2%) had a HbA1c of <6.5% (group 1), 92 (19.4%) had a HbA1c of 6.5-7.9% (group 2), and 66 (14.1%) had a HbA1c level of >8.0% (group 3). No difference was found among the 3 groups in baseline body mass index, race, procedure type, length of stay, hospital cost, and smoking status. Groups 2 and 3 were associated with older age, male gender, and higher baseline creatinine. Groups 2 and 3 also had a proportionally greater inpatient postoperative blood glucose level. An elevated postoperative glucose level was independently associated with wound infection (P = .008) and acute renal failure (P = .04). Also, group 3 experienced worse outcomes, including less weight loss at 18 months and fewer diabetic remissions. Over time, however, the vast majority in all groups achieved excellent chronic glycemic control, with HbA1c <6.5% after Roux-en-Y gastric bypass. CONCLUSION Poor preoperative glycemic control is associated with worse glucose level control postoperatively, fewer diabetic remissions, and less weight loss. An elevated mean postoperative glucose level is independently associated with increased morbidity.

Outcomes in Women Treated With MammoSite Brachytherapy or Whole Breast Irradiation Stratified by ASTRO Accelerated Partial Breast Irradiation Consensus Statement Groups

PURPOSE The American Society for Radiation Oncology published a Consensus Statement for accelerated partial breast irradiation identifying three groups: Suitable, Cautionary, and Unsuitable. The objective of this study was to compare oncologic outcomes in women treated with MammoSite brachytherapy (MB) vs. whole breast irradiation (WBI) after stratification into Statement groups. METHODS Eligible women had invasive carcinoma or ductal carcinoma in situ (DCIS) ≤ 3 cm, and ≤ 3 lymph nodes positive. Women were stratified by radiation modality and Statement groups. Survival analysis methods including Kaplan-Meier estimation, Cox regression, and competing risks analysis were used to assess overall survival (OS), disease-free survival (DFS), time to local failure (TTLF), and tumor bed failure (TBF). RESULTS A total of 459 (183 MB and 276 WBI) patients were treated from 2002 to 2009. After a median follow-up of 45 months, we found no statistical differences by stratification group or radiation modality with regard to OS and DFS. At 4 years TTLF or TBF were not statistically different between the cohorts. Univariate analysis in the MB cohort revealed that nodal positivity (pN1 vs. pN0) was related to TTLF (hazard ratio 6.39, p = 0.02). There was a suggestion that DCIS histology had an increased risk of failure when compared with invasive ductal carcinoma (hazard ratio 3.57, p = 0.06). CONCLUSIONS MB and WBI patients stratified by Statement groups seem to combine women who will have similar outcomes regardless of radiation modality. Although outcomes were similar, we remain guarded in overinterpretation of these preliminary results until further analysis and long-term follow-up data become available. Caution should be used in treating women with DCIS or pN1 disease with MB.

The molecular detection of micrometastatic breast cancer

BACKGROUND The rapid evolution of molecular technology and novel markers provides the opportunity to establish a more effective means to detect micrometastatic breast cancer. Given the controversies concerning application and clinical relevance, this review critically evaluates the current status of these molecular staging technologies. DATA SOURCES Breast cancer literature addressing (1). molecular detection methodologies (immunohistochemistry, reverse transcriptase polymerase chain reaction, and microarray analysis); (2). specific tissue applications such as lymph nodes, bone marrow aspirate, and peripheral blood; (3). expert commentary concerning the clinical applications and pitfalls of these technologies; and (4). recent data from our molecular diagnostics laboratory. CONCLUSIONS Molecular detection technologies such as reverse transcriptase polymerase chain reaction and microarray analyses are being developed that will likely have future application as cancer diagnostics. Further work is needed to establish assays that are validated by prospective clinical studies. Early identification of clinically relevant disease could lead to new treatment or staging approaches for breast cancer.

Gastrointestinal bleeding after gastric bypass surgery: nuisance or catastrophe?

BACKGROUND Bleeding in the early postoperative period after gastric bypass surgery is a rare complication reported in 1-4% of cases. In most cases, the bleeding will be self-limited, resolving after discontinuation of anticoagulation for deep venous thrombosis prophylaxis. Occasionally, however, bleeding can be problematic, resulting in significant postoperative morbidity or even mortality. The purpose of the present study was to review cases of early postoperative gastrointestinal bleeding after gastric bypass to identify possible risk factors and examine outcomes. METHODS A prospective weight loss surgery patient database was reviewed to examine the cases occurring from January 2005 to July 2008. Patients with early postoperative bleeding were identified. The demographics and co-morbidities were compared between those with and without postoperative bleeding. The outcomes of interest included the transfusion requirement, postoperative morbidity, need for reoperation, length of hospital stay, intensive care unit admission, and 30-day mortality. RESULTS A total of 776 patients had undergone gastric bypass during the study period. Of these, 26 (3.3%) were identified with early postoperative bleeding. No significant differences were found in the demographics between the patients with early postoperative bleed and those without. Of the patients with early postoperative bleeding, the most common presenting sign or symptom was tachycardia (46%) followed by melena (32%) and hematemesis (18%). The transfusion requirement range was 0-11 U (average 3.2 U/patient). Of the 26 patients, 4 (15%) required intensive care unit admission and 8 (31%) required reoperation. Four gastrointestinal leaks, one stomal ulceration, and one gastrogastric fistula were identified in the early postoperative bleeding group. One patient (3.8%) in the early postoperative bleeding group died. Compared with nonbleeding patients, those with early postoperative bleeding had a significantly longer hospital stay (4.8 versus 3, P <.0001) and greater mortality rate (7.1% versus .9%, P <.01). CONCLUSION Postoperative bleeding is a significant complication after gastric bypass surgery. Although in many cases, the bleeding will be self-limited, it can result in additional notable complications. In the present study, postoperative bleeding contributed to significantly longer hospital stays and resulted in 1 death. A patient with bleeding after gastric bypass should raise due concern, with attention to the potential attendant complications.

Venous Congestion of the Breast Mimicking Inflammatory Breast Cancer: Case Report and Review of Literature

Abstract:  Unilateral breast edema can be worrisome for inflammatory breast cancer. We review the literature and present a clinical case of a patient presenting with features concerning for inflammatory breast cancer, but in fact were the result of dialysis access related venous congestion of the breast.

Primary Sarcoid of the Breast with Incidental Malignancy

Breast sarcoidosis is rare and usually presents in patients with known sarcoid involving other organ systems. In the breast, sarcoidosis may mimic malignancy which must be excluded by core biopsy. We report a very unusual case of primary breast sarcoidosis with incidentally discovered breast carcinoma. The roles of mammography, ultrasound, and MRI in the diagnosis as well as other potential differential diagnosis are discussed.

Surgical Treatment of Obesity

Once an obese patient has failed attempts at diet modification, physical activity, pharmacologic treatment, and possibly even complementary and alternative therapies, the next step is to consider surgical management. Treatment plans must be customized for individual patients and should involve evaluation by the primary care provider, a dietician, psychologist, and surgeon. Then depending on the individuals needs, comorbidities, and candidacy, a specific surgical intervention may be necessary. These procedures are restrictive, malabsorptive, and a combination of both. Each procedure has its own short-term and long-term complications and must be monitored for the rest of the individuals life.

Successful use of biweekly gemcitabine plus nab-paclitaxel in two male patients with stage iv breast cancer: case reports and review of the literature.

Male breast cancer is a rare disease. As a consequence, male breast cancer is often recognized later, and most patients present at an advanced clinical stage. We report the cases of two men with stage IV hormone receptor positive breast cancer who had both received at different times both systemic endocrine therapy with an aromatase inhibitor and gemcitabine as well as nab-paclitaxel-based combination chemotherapy. Although the aromatase inhibitors such as anastrozole, exemestane, and letrozole are very active in postmenopausal women with hormone receptor positive breast cancer, their efficacy in male breast cancer has not been demonstrated in phase II or III trials. Moreover, Gemcitabine and nab-paclitaxel every 14 days, with or without bevacizumab, are an active combination in male metastatic breast cancer and should be considered as an option in patients with extensive visceral metastases or hormone refractory disease.

Perioperative Glucose Control in the Gastric Bypass Population: How Well Do We Do, How Well Do We Think We Do, and is it Predictable

Background: Bariatric patients are prone to insulin resistance and Postoperative Hyperglycemia (PH), which adversely affects postoperative care. Clinicians may underestimate PH on surgical wards. We aimed to characterize inpatient Blood Glucose (BG) control and identify predictors of PH after RYGB. Methods: From a single University-based center, a retrospective review of 431 patients undergoing RYGB was performed. Postoperative inpatient BG control and diabetic therapy were characterized. Attending bariatric surgeons and surgical house staff were surveyed regarding inpatient BG management. BG management was compared, and predictors of PH were identified. Results: PH (BG>180 mg/dL) was common particularly in patients with HbA1C>6.5%. From the observed sample, the mean postoperative BG was 133.5 ± 2.6 mg/dL, 167.0 ± 6.0 mg/dL, and 190.9 ± 9.2 mg/dL for each increasing HbA1c class, while physician perceived mean postoperative BG was 116.5 ± 7.9 mg/dL (p 180 mg/dL) was predicted with a sensitivity of 42%, a specificity of 95%, a PPV of 60%, NPV of 90% and an overall accuracy of 87%. Conclusions: The incidence of PH is common after RYGB and may be overestimated, while mean postoperative BG may be underestimated. Postoperative hypoglycemia is rare and overestimated. Preoperative HbA1c and nonfasting BG help identify patients at greatest risk PH.

IH-101: Preoperative vitamin D status in potential bariatric surgery patients

Abstract Background: Vitamin D deficiency has been described in a variety of population groups. Specifically, the vitamin D status in pre-operative bariatric patients is a growing concern in the field of weight reduction surgery, where gastric bypass may exacerbate a preexisting deficiency or insufficiency. Objectives: The purpose of this study was to determine the vitamin D status in pre-operative bariatric patients and to compare results according to race, gender, Body Mass Index, and age. Setting: Medical University of South Carolina, Charleston, South Carolina. Methods: Our study cohort included 235 morbidly obese adult patients who presented for bariatric surgery. Serum levels of 25-hydroxy vitamin D were tested and categorized as insufficient (20–80 nmol/L or 8–32 ng/mL), deficient (15–20 nmol/L or 6–8 ng/mL), or severely deficient (  60 in kg/m2), age groups ( 65), race (black or ...