Peter N. Benotti

Small Intestinal Perforation and Necrotizing Fasciitis After Abdominal Liposuction

Liposuction, the most common aesthetic procedure performed in the United States, is not without risk, but the overall complication rate in the literature varies from less than 1% to 9.3%. A 55-year-old woman who had undergone abdominal liposuction with bilateral breast augmentation was hospitalized in a state of profound septic shock. A diagnosis of necrotizing fasciitis was made on the basis of findings that included abdominal skin discoloration, subcutaneous emphysema, and air in the subcutaneous plane seen on abdominal computed tomography (CT) scan. During the operative procedure for abdominal wall debridement, extensive necrosis of abdominal wall fascia with leakage of bilious fluid from defects in the rectus sheath was found. Subsequent peritoneal cavity exploration showed two perforations in the mid ileum with gross peritoneal cavity contamination.

Feasibility and Impact of an Evidence-Based Program for Gastric Bypass Surgery

BACKGROUND Health care in the United States is expensive and quality is variable. The aim of this study was to investigate whether our integrated health system, composed of academic hospitals, a practice plan, and a managed care payer, could reliably implement an evidence-based program for gastric bypass surgery. A secondary aim was to evaluate the impact of the program on clinical outcomes. STUDY DESIGN A standardized program for delivery of clinical best-practice elements for patients undergoing initial open or laparoscopic Roux-en-Y gastric bypass was implemented in 2008. Best-practice elements were embedded into the workflow. The best-practice elements were refined after reviewing failures observed during the early implementation period. The study period was divided into 3 groups: group α = year preceding program implementation (control), group β = first year of implementation (unreliable), and group Ω = 2nd to 4th years of implementation (reliable). Outcomes data were collected for all patients who had undergone Roux-en-Y gastric bypass between May 2008 and April 2012 and were compared with a control group from the preceding year using multiple logistic regression analysis. RESULTS Two thousand and sixty-one patients were studied, with no significant demographic differences between study groups. Best-practice elements delivery was 40% in group β, but was >90% for group Ω (p < 0.001). Length of stay for group α was 3.5 days and improved to 2.2 days (p < 0.001) for group Ω. Complications and readmission rates improved considerably with reliable delivery of best-practice elements. CONCLUSIONS Standardization of evidence-based care delivery for Roux-en-Y gastric bypass was feasible and reliable delivery of this pathway improved clinical outcomes.

Gastric Bypass Surgery Produces a Durable Reduction in Cardiovascular Disease Risk Factors and Reduces the Long‐Term Risks of Congestive Heart Failure

Background Obesity and its association with reduced life expectancy are well established, with cardiovascular disease as one of the major causes of fatality. Metabolic surgery is a powerful intervention for severe obesity, resulting in improvement in comorbid diseases and in cardiovascular risk factors. This study investigates the relationship between metabolic surgery and long‐term cardiovascular events. Methods and Results A cohort of Roux‐en‐Y gastric bypass surgery (RYGB) patients was tightly matched by age, body mass index, sex, Framingham Risk Score, smoking history, use of antihypertension medication, diabetes mellitus status, and calendar year with a concurrent cohort of nonoperated control patients. The primary study end points of major cardiovascular events (myocardial infarction, stroke, and congestive heart failure) were evaluated using Cox regression. Secondary end points of longitudinal cardiovascular risk factors were evaluated using repeated‐measures regression. The RYGB and matched controls (N=1724 in each cohort) were followed for up to 12 years after surgery (overall median of 6.3 years). Kaplan–Meier analysis revealed a statistically significant reduction in incident major composite cardiovascular events (P=0.017) and congestive heart failure (0.0077) for the RYGB cohort. Adjusted Cox regression models confirmed the reductions in severe composite cardiovascular events in the RYGB cohort (hazard ratio=0.58, 95% CI=0.42–0.82). Improvements of cardiovascular risk factors (eg, 10‐year cardiovascular risk score, total cholesterol, high‐density lipoprotein, systolic blood pressure, and diabetes mellitus) were observed within the RYGB cohort after surgery. Conclusions Gastric bypass is associated with a reduced risk of major cardiovascular events and the development of congestive heart failure.

A Novel Technique for Wound Protector Deployment and Efficient Specimen Extraction Following Laparoscopic Sleeve Gastrectomy

Challenges of specimen extraction during laparoscopic sleeve gastrectomy and other resectional laparoscopic procedures can often be proven to be time consuming and frustrating, and the risk of wound infection and port site tumor implantation increases. In this paper, we discuss our experience with an efficient approach to specimen extraction utilizing a novel technique for deployment of a very small self-expanding wound protector through a 12- or 15-mm port. We also report our observations with regard to the learning curve of this technique and the influence of BMI to retractor insertion times and specimen extraction times during laparoscopic sleeve gastrectomy.

Metabolic Complications, Nutritional Deficiencies, and Medication Management Following Metabolic Surgery

Metabolic surgery has emerged as the preferred sustainable treatment for the disease of obesity and its formidable health comorbidities. This evolution has resulted from major advances in surgical quality care including minimally invasive techniques and the introduction of accredited multidisciplinary centers of excellence. Multidisciplinary care including obesity medicine specialists, certified bariatric nurses, dietitians, and behavioral medicine professionals has improved perioperative care and helped to identify many early and late metabolic as well as nutritional complications of these procedures.

Patient Education and Informed Consent

The long-term success of bariatric surgery is dependent on patient motivation and the capability of patients to make changes in lifestyle and eating behavior. Bariatric surgery is not curative, but a simple change in gastrointestinal anatomy, which facilitates limitation of calories. The variable results of individual patient weight loss accomplishment and the 10–25 % of patients who struggle with weight loss and weight maintenance are largely a reflection of the inability of patients to successfully change lifestyle and eating behavior. This offers opportunities in patient education and patient selection as more is learned about behavioral and lifestyle factors that may interfere with weight loss success after bariatric surgery. The process of patient-centered informed consent is designed to provide the patient with details of those individual factors, which argue for and against bariatric surgery. The communication of this important information in a manner which patients can comprehend is essential as is the confirmation that the patient does understand the information. Patient education and the informed consent process are complicated by inadequate health literacy skill, a common problem in patients with extreme obesity. Enhanced communication strategies and teaching techniques including audiovisual and multimedia interventions, extended patient discussions, and feedback techniques will help in addressing health literacy issues.

Comprehensive Medical Evaluation

The initial medical evaluation, which is conducted by a medical provider with familiarity with all obesity-related comorbid conditions that contribute to surgical risk, establishes the focus for the comprehensive medical evaluation. Extreme obesity is commonly associated with significant abnormalities in critical organ function, which are usually related to the extent and duration of obesity. The degree of obesity-related organ dysfunction must be carefully evaluated in order to complete a patient-centered risk assessment. Patients with significant cardio-pulmonary impairment should be evaluated for obese cardiomyopathy, pulmonary hypertension, obesity hypoventilation, severe sleep apnea, and thromboembolism risk. The comprehensive medical evaluation includes those specialty consultations and medical tests necessary to establish patient-centered health risks of extreme obesity and risks of bariatric surgery.

Anesthesia Considerations in Bariatric Surgery

The increasing popularity of surgical interventions for weight loss has been a major stimulus for major advances in anesthesia management of patients with extreme obesity. These advances have resulted in safer anesthetic management for patients with extreme obesity in all surgical specialties. Patients with extreme obesity present unique challenges for anesthesiologists in relation to enhanced pulmonary and airway risks, increased risks of postoperative hypoxemia and hypercarbia, glycemic control, and strategies for narcotic-sparing pain control. This chapter summarizes the important anesthesia developments and current challenges in the management of bariatric surgery patients. Best practice recommendations for bariatric surgery patients are reviewed as well as current important areas of needed study.

Nutrition II: Minerals

The gastrointestinal anatomic changes associated with bariatric surgical procedures result in altered absorptive capability for minerals such as Iron, Zinc, and Copper, which are normally absorbed in the duodenum. Mineral deficiencies are now being recognized with increasing frequency in patients following bariatric surgery. For prevention and management of deficiency, specialized nutritional follow-up by individuals familiar with the assessment of mineral nutrition and the recognition of deficiency states is an essential component of multidisciplinary management. Improved protocols for nutritional follow-up are essential for improving the value of bariatric surgery and expanding patient access to this treatment.

Diagnostic Endoscopy: Perioperative

The evolution of bariatric surgery has been a major factor in the return of endoscopy to the scope of practice and training in general surgery. Endoscopy is an essential specialty component of bariatric surgery programs. Interventional endoscopy is now emerging as a treatment option in the nonoperative management of complications of bariatric surgery. This chapter reviews current indications, controversies, and best practice recommendations regarding endoscopy in the perioperative period.