Ross L. McMahon

Binge eating, Quality of life and physical activity improve after Roux-en-Y gastric bypass for morbid obesity

Background: Severe obesity has been associated with disordered eating, impaired quality of life (QoL), and decreased physical activity.This study examines changes in these variables 6 months after Roux-en-Y gastric bypass (RYGBP). Methods: 40 morbidly obese patients were evaluated at baseline and at 6 months after RYGBP on the following measures: Binge Eating Scale, Three Factor Eating Questionnaire, Impact of Weight on Quality of Life-Lite (IWQoL-Lite), and the Baseline Questionnaire of Activity. Results: 6 months after RYGBP, weight loss averaged 26.7%, and scores on measures of disordered eating, weight-related QoL, and physical activity showed statistically significant improvement from baseline. At the time of follow-up, 100% of participants achieved a score on the Binge Eating Scale that indicated no binge eating problems, and weight-related QoL scores approached those obtained by a reference sample of community volunteers. There were also improvements in the level of self-reported physical activity and television watching behavior. Conclusions: RYGBP resulted in significant improvements in disordered eating, weight-related QoL, and physical activity in addition to weight loss.

The STEDMAN project: biophysical, biochemical and metabolic effects of a behavioral weight loss intervention during weight loss, maintenance, and regain.

The Study of the Effects of Diet on Metabolism and Nutrition (STEDMAN) Project uses comprehensive metabolic profiling to probe biochemical mechanisms of weight loss in humans. Measurements at baseline, 2 and 4 weeks, 6 and 12 months included diet, body composition, metabolic rate, hormones, and 80 intermediary metabolites measured by mass spectrometry. In 27 obese adults in a behavioral weight loss intervention, median weight decreased 13.9 lb over the first 6 months, then reverted towards baseline by 12 months. Insulin resistance (HOMA) was partially ameliorated in the first 6 months and showed sustained improvement at 12 months despite weight regain. Ghrelin increased with weight loss and reverted to baseline, whereas leptin and PYY fell at 6 months and remained persistently low. NPY levels did not change. Factors possibly contributing to sustained improvement in insulin sensitivity despite weight regain include adiponectin (increased by 12 months), IGF-1 (increased during weight loss and continued to increase during weight regain), and visceral fat (fell at 6 months but did not change thereafter). We observed a persistent reduction in free fatty acids, branched chain amino acids, and related metabolites that may contribute to improved insulin action. These findings provide evidence for sustained benefits of weight loss in obese humans and insights into mechanisms.

VersaStep™ trocar hernia rate in unclosed fascial defects in bariatric patients

ObjectiveUse of the VersaStepTM trocar system (US Surgical, Norwalk, CT) has the perceived advantage of minimal trocar-related hernias in patients undergoing Roux-en-Y gastric bypass surgery (RYGB). We performed a retrospective review of our last 747 consecutive operative procedures using these trocars.Methods and proceduresThe patient population was 747 consecutive patients who underwent laparoscopic RYGB at Duke University Health System Weight Loss Surgery Center from January 2002 through April 2005. A total of 3735 radially expanded trocar sites were used. VersaStepTM trocars were used in all cases. The port configuration included one supraumbilical Hasson port, two 12-mm ports, and three 5-mm ports. The Hasson port was closed with a figure-of-eight number 1 Polysorb suture. All other trocar sites had no fascial closure. Intestinal anastomoses were created with a linear stapler in all of the laparoscopic cases, with hand suturing of the residual enterotomy. The fascial incisions were therefore not extended to accommodate an EEA stapler. The charts were reviewed for occurrence of subsequent trocar site hernias.ResultsThere were no hernias at any of the VersaStepTM trocar sites—an incidence of 0%. There were nine incisional hernias at the Hasson port site which later required surgical repair—an incidence of 1.20%.ConclusionsThere were no hernias detected at any of the 1494 12-mm or 2241 5-mm VersaStepTM trocar sites, despite lack of suture closure. At the Hasson port site, there was a hernia incidence of 1.20%. In the bariatric RYGB population, routine suture closure of the fascia or muscle is not necessary when using radially expanding VersaStepTM trocars.

Laparoscopic antireflux surgery in the lung transplant population

Background: Lung transplantation has emerged as a viable therapeutic option for patients with a variety of end-stage pulmonary diseases. As immediate posttransplant surgical outcomes have improved, the greatest limitation of lung transplantation remains chronic allograft dysfunction. Gastroesophageal reflux disease (GERD) with resultant aspiration has been implicated as a potential contributing factor in allograft dysfunction. GERD is prevalent in end-stage lung disease patients, and it is even more common in patients after transplantation. We report here on the safety of laparoscopic fundoplication surgery for the treatment of GERD in lung transplant patients. Methods: Eighteen of the 298 lung transplants performed at Duke University Medical Center underwent antireflux surgery for documented severe GERD. The safety and benefit of laparoscopic fundoplications in this population was evaluated. Results: The antireflux surgeries included 13 laparoscopic Nissen fundoplications, four laparoscopic Toupets, and one open Nissen (converted secondary to extensive adhesions). Two of the 18 patients reported recurrence of symptoms (11%), and two others reported minor GI complaints postoperatively (nausea, bloating). There were no deaths from the antireflux surgery. After fundoplication surgery, 12 of the 18 patients showed measured improvement in pulmonary function (67%). Conclusions: GERD occurs commonly in the posttransplant lung population. Laparoscopic fundoplication surgery, when indicated, can be done safely with minimal morbidity and mortality. In addition to the resolution of reflux symptoms, improvement in pulmonary function may be seen in this population after fundoplication. Lung transplant patients with severe GERD should be strongly considered for antireflux surgery.

A canine model of gastroesophageal reflux disease (GERD).

Background: Although a variety of antireflux procedures and medications are used to treat gastroesophageal reflux disease (GERD), reliable large-animal models of GERD that can be used to objectively compare the efficacy of these treatments are lacking. Methods: Esophageal manometry and 24-h gastroesophageal pH monitoring with event data were performed in 18 mongrel dogs with a cervical esophagopexy. We then calculated a modified DeMeester score: The Duke Canine reflux score (DCR). Thereafter, the animals underwent a 4-cm anterior distal esophageal myotomy, incision of the left diaphragmatic crus, and intrathoracic gastric cardiopexy. Postoperative 24-h pH and manometry were obtained 2 weeks later. Results: The postoperative 24-h pH results showed a significant increase in the mean DCR score (5.9 ± 4.5 vs 84.9 ± 56.1, p < 0.0002), and manometry indicated a significant decrease in mean lower esophageal sphincter (LES) pressure (7.1 ± 2.9 vs 3.2 ± 2.5 mmHg, p < 0.0001). Conclusion: This technique reliably creates a canine model of GERD.

A review of laparoscopy for non-obstetric-related surgery during pregnancy.

PURPOSE Similar to the general population, parturients (and their fetuses) could benefit from the reduced manipulation associated with laparoscopy. The purpose of this article is to review the current state of knowledge (both clinical and experimental) with respect to the fetal effects of maternal laparoscopy for non-obstetric-related surgery during pregnancy. METHODS Human and experimental animal results are examined, and we present preliminary data from our own laboratory. CONCLUSIONS Future experiments are proposed to further develop and refine standards of care for general surgeons and obstetricians who are presented with gravid females in abdominal distress.

Laparoscopic Repair of a Morgagni Hernia Presenting with Syncope in an 85-Year-Old Woman: Case Report and Update of the Literature

An 85-year-old woman was transferred from her local hospital for cardiac evaluation after presenting with repeated episodes of syncope during bowel movements. A thorough evaluation revealed no cardiac abnormalities but did reveal a Morgagni hernia with transverse colon in the mediastinum. She underwent laparoscopic reduction of the colon and repair of the hernia with mesh and had a rapid and uneventful recovery.

Laparoscopy and the internet. A surgeon survey.

BackgroundThe Internet has become an important new tool for the delivery and acquisition of medical information.MethodsA 13-item questionnaire designed to collect information on the attitudes and practices of surgeons regarding the use of the Internet as a medical resource was posted on the World Wide Web and also sent via e-mail.ResultsOver a 2-month period, 459 surgeons were enrolled in this study. Most of the respondents were identified as male surgeons (96%) between the ages of 31 and 50 years (79.25%). They accessed the Internet mainly from their homes (67.10%) and offices (17%) using 56 Kbps (34.86%) and 33.6 Kbps (21.79%) modems. These participants indicated that they use the Internet to expand their knowledge of general surgery (78.87%), learn more about technologies related to the practice of surgery (74.51%), access the Medline medical database (73.20%), and locate other resources for academic purposes (68%). Approximately half of them said that they favored the use of robotic assist devices in the operating room (53%), and most supported the use of technology for telementoring purposes (78%). Almost 80% professed an interest in video streaming technology applied to surgical education.ConclusionsThis study showed that the Internet is a useful and powerful real-time survey tool that can help us to assess the impact of the World Wide Web and related technologies on surgical education and practice. However, the respondents in this study belong to a biased group that is already familiar with the Internet and computer technology and thus may not be representative of the surgical community as a whole.

Celecoxib (Celebrex) increases canine lower esophageal sphincter pressure

BACKGROUND Prostaglandins inhibit the contraction of gastrointestinal smooth muscle and may decrease lower esophageal sphincter tone. The purpose of this study was to determine whether the cyclooxygenase-2 inhibitor celecoxib (Celebrex) could increase lower esophageal pressure (without affecting gastric emptying) compared to placebo and cisapride (Prepulsid), a compound previously used to treat reflux disease. MATERIALS AND METHODS Six mongrel dogs were assigned to receive celecoxib, cisapride, and placebo using a randomized cross-over design with a 1-week washout period between treatments. Prior to dosing, each dog underwent an esophagopexy to provide access to the esophagus and stomach. On the fourth day of dosing, sphincter tone was measured in awake unsedated dogs using radial manometry. In a different set of six dogs, liquid and solid gastric emptying rates were scintigraphically determined. RESULTS Celecoxib significantly increased mean and average maximum lower esophageal pressures compared to placebo without affecting the gastric emptying rate. The magnitudes of these increases were similar to that produced by cisapride. CONCLUSIONS Celecoxib had a positive effect on canine lower esophageal sphincter tone. This finding, combined with the drugs low incidence of gastrointestinal toxicity, suggests that celecoxib may warrant consideration and investigation as a pharmacotherapy for human reflux disease.

746 The Effect of Concurrent Esophageal Pathology on Bariatric Surgical Planning

In the presence of esophageal pathology, there is risk of worse outcomes after laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG). This study reviewed how an esophageal workup affected a bariatric operative plan in patients with concurrent esophageal pathology. We retrospectively reviewed patients planning bariatric surgery referred with significant reflux, dysphagia, and hiatal hernia (>3 cm) to determine how and why a thorough esophageal workup changed a bariatric operative plan. We identified 79 patients for analysis from 2009 to 2013. In 10/41 patients (24.3 %) planning LAGB and 5/9 patients planning SG (55.5 %), a Roux was preferred because of severe symptoms of reflux and aspiration, dysphagia, manometric abnormalities (aperistaltic or hypoperistaltic esophagus with low mean wave amplitudes), large hiatal hernia (>5 cm), and/or presence of Barrett’s esophagus. Patients without these characteristics had a decreased risk of foregut symptoms after surgery. We recommend a thorough esophageal workup in bariatric patients with known preoperative esophageal pathology. The operative plan might need to be changed to a Roux to prevent adverse outcomes including dysphagia, severe reflux, or suboptimal weight loss. An esophageal workup may improve surgical decision making and improve patient outcomes.