Monica Sethi

Long-term outcomes after biliopancreatic diversion with and without duodenal switch: 2-, 5-, and 10-year data

BACKGROUND There are minimal long-term data on biliopancreatic diversion (BPD) with or without duodenal switch (BPD/DS). OBJECTIVES To investigate the long-term weight loss, co-morbidity remission, complications, and quality of life after BPD and BPD/DS. SETTING An academic, university hospital in the United States. METHODS We conducted a retrospective review of patients who underwent BPD or BPD/DS between 1999 and 2011. Outcomes included weight loss measures at 2, 5, and 10-15 years postoperatively; co-morbidity remission; long-term complications; nutritional deficiencies; and patient satisfaction. RESULTS One hundred patients underwent BPD (34%) or BPD/DS (64%). Mean preoperative body mass index (BMI) was 50.2 kg/m2. Mean follow up was 8.2 years (range: 1-15 yr) with 72% of eligible patients in active follow up at 10-15 years postoperatively. Excess weight loss (EWL) was 65.1% at 2 years, 63.8% at 5 years, and 67.9% at 10-15 years. Approximately 10% higher %EWL was achieved for those with preoperative BMI<50 kg/m2 versus≥50 kg/m2 and patients who underwent BPD/DS versus BPD. Although co-morbidities improved, 37% of patients developed long-term complications requiring surgery. There were no 30-day mortalities; however, there was one mortality from severe malnutrition. Nutritional deficiencies in fat-soluble vitamins, anemia, and secondary hyperparathyroidism were common. Overall, 94% of patients reported satisfaction with their choice of surgery. CONCLUSION This clinical experience supports the long-term positive safety profile and efficacy of BPD and BPD/DS at a single U.S. center. Higher levels of excess weight loss are achieved by patients with a lower preoperative BMI and BPD/DS. Although nutritional deficiencies and postoperative complications are common, patient satisfaction remains high.

Bicycle helmets are highly protective against traumatic brain injury within a dense urban setting.

BACKGROUND New York City (NYC) has made significant roadway infrastructure improvements, initiated a bicycle share program, and enacted Vision Zero, an action plan to reduce traffic deaths and serious injuries. The objective of this study was to examine whether bicycle helmets offer a protective advantage against traumatic brain injury (TBI) within a contemporary dense urban setting with a commitment to road safety. METHODS A prospective observational study of injured bicyclists presenting to a Level I trauma centre was performed. All bicyclists arriving within 24 h of injury were included. Data were collected between February, 2012 and August, 2014 and included demographics, imaging studies (e.g. computed tomography (CT)), injury patterns, and outcomes including Glasgow Coma Scale (GCS) and Injury Severity Score. RESULTS Of 699 patients, 273 (39.1%) were wearing helmets at the time of injury. Helmeted bicyclists were more likely to have a GCS of 15 (96.3% [95% Confidence Interval (CI), 93.3-98.2] vs. 87.6 [95% CI, 84.1-90.6]) at presentation. Helmeted bicyclists underwent fewer head CTs (40.3% [95% CI, 34.4-46.4] vs. 52.8% [95% CI, 48.0-57.6]) and were less likely to sustain intracranial injury (6.3% [95% CI, 2.6-12.5] vs. 19.7% [14.7-25.6]), including skull fracture (0.9% [95% CI, 0.0-4.9] vs. 15.3% [95% CI, 10.8-20.7]) and subdural hematoma (0.0% [95% CI, 0.0-3.2] vs. 8.1% [95% CI, 4.9-12.5]). Helmeted bicyclists were significantly less likely to sustain significant TBI, i.e. Head AIS ≥3 (2.6% [95% CI: 0.7-4.5] vs.10.6% [7.6-12.5]). Four patients underwent craniotomy while three died; all were un-helmeted. A multivariable logistic regression model showed that helmeted bicyclists were 72% less likely to sustain TBI compared with un-helmeted bicyclists (Adjusted Odds Ratio 0.28, 95% CI 0.12-0.61). CONCLUSIONS Despite substantial road safety measures in NYC, the protective impact of simple bicycle helmets in the event of a crash remains significant. A re-assessment of helmet laws for urban bicyclists is advisable to most effectively translate Vision Zero from a political action plan to public safety reality.

Alcohol use by urban bicyclists is associated with more severe injury, greater hospital resource use, and higher mortality.

Alcohol use is a risk factor for severe injury in pedestrians struck by motor vehicles. Our objective was to investigate alcohol use by bicyclists and its effects on riding behaviors, medical management, injury severity, and mortality within a congested urban setting. A hospital-based, observational study of injured bicyclists presenting to a Level I regional trauma center in New York City was conducted. Data were collected prospectively from 2012 to 2014 by interviewing all bicyclists presenting within 24 h of injury and supplemented with medical record review. Variables included demographic characteristics, scene-related data, Glasgow Coma Scale (GCS), computed tomography (CT) scans, and clinical outcomes. Alcohol use at the time of injury was determined by history or blood alcohol level (BAL) >0.01 g/dL. Of 689 bicyclists, 585 (84.9%) were male with a mean age of 35.2. One hundred four (15.1%) bicyclists had consumed alcohol prior to injury. Alcohol use was inversely associated with helmet use (16.5% [9.9-25.1] vs. 43.2% [39.1-47.3]). Alcohol-consuming bicyclists were more likely to fall from their bicycles (42.0% [32.2-52.3] vs. 24.2% [20.8-27.9]) and less likely to be injured by collision with a motor vehicle (52.0% [41.7-62.1] vs. 67.5% [63.5-71.3]). 80% of alcohol-consuming bicyclists underwent CT imaging at presentation compared with 51.5% of non-users. Mortality was higher among injured bicyclists who had used alcohol (2.9% [0.6-8.2] vs. 0.0% [0.0-0.6]). Adjusted multivariable analysis revealed that alcohol use was independently associated with more severe injury (Adjusted Odds Ratio 2.27, p = 0.001, 95% Confidence Interval 1.40-3.68). Within a dense urban environment, alcohol use by bicyclists was associated with more severe injury, greater hospital resource use, and higher mortality. As bicycling continues to increase in popularity internationally, it is important to heighten awareness about the risks and consequences of bicycling while under the influence of alcohol.

The Effect of Sharrows, Painted Bicycle Lanes and Physically Protected Paths on the Severity of Bicycle Injuries Caused by Motor Vehicles

We conducted individual and ecologic analyses of prospectively collected data from 839 injured bicyclists who collided with motorized vehicles and presented to Bellevue Hospital, an urban Level-1 trauma center in New York City, from December 2008 to August 2014. Variables included demographics, scene information, rider behaviors, bicycle route availability, and whether the collision occurred before the road segment was converted to a bicycle route. We used negative binomial modeling to assess the risk of injury occurrence following bicycle path or lane implementation. We dichotomized U.S. National Trauma Data Bank Injury Severity Scores (ISS) into none/mild (0–8) versus moderate, severe, or critical (>8) and used adjusted multivariable logistic regression to model the association of ISS with collision proximity to sharrows (i.e., bicycle lanes designated for sharing with cars), painted bicycle lanes, or physically protected paths. Negative binomial modeling of monthly counts, while adjusting for pedestrian activity, revealed that physically protected paths were associated with 23% fewer injuries. Painted bicycle lanes reduced injury risk by nearly 90% (IDR 0.09, 95% CI 0.02–0.33). Holding all else equal, compared to no bicycle route, a bicycle injury nearby sharrows was nearly twice as likely to be moderate, severe, or critical (adjusted odds ratio 1.94; 95% confidence interval (CI) 0.91–4.15). Painted bicycle lanes and physically protected paths were 1.52 (95% CI 0.85–2.71) and 1.66 (95% CI 0.85–3.22) times as likely to be associated with more than mild injury respectively.

Enteric Leaks After Sleeve Gastrectomy: Prevention and Management

Laparoscopic sleeve gastrectomy (LSG) is safe and effective for the treatment of morbid obesity. Leaks after LSG are rare (~1–3 %) but can result in significant morbidity. Utilizing bougie ≥40Fr may decrease leak rate without affecting overall weight loss up to 36 months postoperatively. For patients who develop leak after LSG, nutritional support and source control are cornerstones of management, including laparoscopic drainage and washout and feeding jejunostomy tube, if necessary. Most leaks resolve with endoscopic stenting. In rare cases, surgery (resection with Roux-en-Y esophagojejunostomy or placement of Roux limb to the fistula) is required for definitive management.

Drawing the Curtain Back on Injured Commercial Bicyclists

OBJECTIVES We determined the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating New York Citys (NYCs) central business district. METHODS Our study involved a secondary analysis of prospectively collected data from a level 1 regional trauma center in 2008 to 2014 of bicyclists struck by motor vehicles. We performed univariable and multivariable logistic regression analyses. RESULTS Of 819 injured bicyclists, 284 (34.7%) were working. Commercial bicyclists included 24.4% to 45.1% of injured bicyclists annually. Injured commercial bicyclists were more likely Latino (56.7%; 95% confidence interval [CI] = 50.7, 62.8 vs 22.7%; 95% CI = 19.2, 26.5). Commercial bicyclists were less likely to be distracted by electronic devices (5.0%; 95% CI = 2.7, 8.2 vs 12.7%; 95% CI = 9.9, 15.9) or to have consumed alcohol (0.7%; 95% CI = 0.9, 2.5 vs 9.5%; 95% CI = 7.2, 12.3). Commercial and noncommercial bicyclists did not differ in helmet use (38.4%; 95% CI = 32.7, 44.4 vs 30.8%; 95% CI = 26.9, 34.9). Injury severity scores were less severe in commercial bicyclists (odds ratio = 0.412; 95% CI = 0.235, 0.723). CONCLUSIONS Commercial bicyclists represent a unique cohort of vulnerable roadway users. In NYC, minorities, especially Latinos, should be targeted for safety education programs.

Clinical Efficacy of a Medically Supervised Low-Calorie Diet Program versus a Conventional Carbohydrate-Restricted Diet

Objective: To determine the effectiveness of a 6 month intensive medical intervention (IMI) with caloric restriction and high-protein meal replacements versus a conventional carbohydrate-restricted (CCR) diet. Methods: This is an observational study designed to determine weight outcomes at 6, 12, 18 and 24 months after completing the IMI or CCR treatment. Patients were also required to participate in at least 5 miles of walking and 240 minutes of overall exercise per week. The primary outcome was percent body weight loss (BWL). Results: A total of 604 patients with obesity or overweight were studied. Sixty-seven percent were in the IMI group, versus 33% in the CCR group. Initial BMI was similar in both groups (36.4 kg/m2 (SD=7.7) vs. 36.0 kg/m2 (SD=7.8), p=0.608). At 6 months, the IMI group had superior body weight loss (11.9% (SD=7.4) vs. 6.0% (SD=6.1), p<0.0001). However, the IMI group had greater weight regain than the CCR group, resulting in similar weight loss at two years (7.1% (SD=10.2) vs. 8.1% (SD=6.3), p=0.735). An adjusted analysis of outcomes averaged across 2 years demonstrated 2.8% greater BWL among the IMI group. Blood pressure significantly improved in both groups (p<0.001). Males (OR=1.77, 95% CI=(1.10,2.84), p=0.019) and patients with BMI ≥ 35 kg/m2 (OR=3.32, 95% CI=(1.95, 5.65), p<0.0001) were more likely to achieve weight loss success with the IMI. Conclusion: An Intensive Medical Intervention (IMI) characterized by high-protein meal replacements and caloric restriction can be highly effective in reducing body weight, even at two years post-intervention. This type of intervention should be strongly considered among obese patients who do not qualify for bariatric surgery, those with contraindications to weight loss medications, or those in need of weight loss prior to a medical procedure.

Mo1678 30-Day Readmission After Laparoscopic Sleeve Gastrectomy - A Predictable Event?

Corrosive injuries to the upper gastrointestinal tract is one of the difficult problems to treat. It resultsin major morbidity and mortality. Corrosives are substances which corrode and destroy tissues through direct chemical reaction. The strictures can present with various severity in pharynx, oesophagus and stomach. Isolated gastric strictures are less observed. Although corrosive substances can reach rapidly from oesophagus onto the stomach, they get stagnant in the prepyloric region because of pyloric spasm. The stricture may involve antrum, body and the pyloroduodenal area or diffusely the entire stomach depending upon the rapidity of spread of the ingested corrosive substance. We have classified the gastric strictures so as to optimize the treatment options based on the subtype. We herewith formulate a newworking classification. Treatment options according to the classified subtypes are also suggested to optimize the outcome. Data: 48 patients of isolated gastric stricture were included in this study. We had 20 patients with Type I; 12 underwent arcade preserving antrectomy, 14 had Bilroth Type I and 6 had Bilroth Type II restoration. We had one Type IIA; managed by strictureplasty. Four Type IIB; managed with pylorus preserving antrectomy. We had three Type III; treated by circumferential sleeve resection and gastrogastrostomy. We had five Type IV; managed with total gastrectomy. We had one Type V; managed by limited oesophagogastrectomy. We had three Type VI; managed by gastrojejunostomy as these patients had first part duodenal involvement. We had eleven Type VII; called as gastrocele; managed with antrectomy and colon pullup in five, gastrojejunostomy and colon pullup in three and antrectomy and retrograde dilatation in two. One patient died due to massive aspiration prior to treatment. There were acceptable morbidiy and two mortality in this series. Our new working formulation will form the basis of care in patients with gastric corrosive strictures.