Ruth R. Leeth

Impact of Obesity on Resource Utilization for General Surgical Procedures

Objective:To determine the impact of the obesity epidemic on workload for general surgeons. Summary Background Data:In 2001, the prevalence of obesity in the United States reached 26%, more than double the rate in 1990. This study focuses on the impact of obesity on surgical practice and resource utilization. Methods:A retrospective analysis was done on patients undergoing cholecystectomy, unilateral mastectomy, and colectomy from January 2000 to December 2003 at a tertiary care center. The main outcome variables were operative time (OT), length of stay (LOS), and complications. The key independent variable was body mass index. We analyzed the association of obesity status with OT, LOS, and complications for each surgery, using multivariate regression models controlling for surgeon time-invariant characteristics. Results:There were 623 cholecystectomies, 322 unilateral mastectomies, and 430 colectomies suitable for analysis from 2000 to 2003. Multivariable regression analyses indicated that obese patients had statistically significantly longer OT (P < 0.01) but not longer LOS (P > 0.05) or more complications (P > 0.05). Compared with a normal-weight patient, an obese patient had an additional 5.19 (95% confidence interval [CI], 0.15–10.24), 23.67 (95% CI, 14.38–32.96), and 21.42 (95% CI, 9.54–33.30) minutes of OT with respect to cholecystectomy, unilateral mastectomy, and colectomy. These estimates were robust in sensitivity analyses. Conclusions:Obesity significantly increased OT for each procedure studied. These data have implications for health policy and surgical resource utilization. We suggest that a CPT modifier to appropriately reimburse surgeons caring for obese patients be considered.

Breast Milk-Derived Antigen-Specific CD8+ T Cells: An Extralymphoid Effector Memory Cell Population in Humans

Although mouse studies have demonstrated the presence of an effector memory population in nonlymphoid tissues, the phenotype of human CD8+ T cells present in such compartments has not been characterized. Because of the relatively large number of CD8+ T cells present in breast milk, we were able to characterize the phenotype of this cell population in HIV-infected and uninfected lactating women. CMV, influenza virus, EBV, and HIV-specific CD8+ T cells as measured by the IFN-γ ELISPOT and MHC class I tetramer staining were all present at greater frequencies in breast milk as compared with blood. Furthermore, a greater percentage of the breast milk CD8+ T cells expressed the intestinal homing receptor, CD103, and the mucosal homing receptor CCR9. Breast milk T cells were predominantly CD45RO+HLADR+ and expressed low levels of CD45RA, CD62L, and CCR7 consistent with an effector memory population. Conversely, T cells derived from blood were mainly characterized as central memory cells (CCR7+CD62L+). These results demonstrate a population of extralymphoid CD8+ T cells with an effector memory phenotype in humans, which could contribute to enhanced local virologic control and the relative lack of HIV transmission via this route.

Influence of complications and extent of weight loss on quality of life after laparoscopic Roux-en-Y gastric bypass

IntroductionObesity decreases health-related quality of life, but bariatric surgery improves it. This study evaluates the effect of laparoscopic Roux-en-Y gastric bypass, postoperative complications, and percentage of excess body weight loss on quality of life.MethodsSF-36v.1 questionnaires were administered preoperative (n = 505), 1 year (n = 237) and 2 years (n = 106) following laparoscopic Roux-en-Y gastric bypass. Analysis was performed using Student’s t-test and multiple logistic regression analysis. Complications were defined as requiring additional intervention or hospitalization. SF-36 responses were normalized to 1998 US norms.ResultsBariatric patients scored significantly lower on all scales compared to the normal population. Health-related quality of life notably improves after surgery. At 1 year, scores not only improved from baseline, but were higher than those of the non-obese reference population regardless of complications. Compared to patients at 2 years without complications, patients experiencing complications reported decreased scores, but scores remained higher than preoperative scores in five scales. At 1 and 2 years, ≤50% excess body weight loss decreased scores; however, scores were significantly improved from baseline.ConclusionsHealth-related quality of life in bariatric patients is worse than in controls, but it improves 1 and 2 years after laparoscopic Roux-en-Y gastric bypass. Complications or ≤50% excess body weight loss slightly decreases this improvement.

Outcomes of cholecystectomy after endoscopic sphincterotomy for choledocholithiasis

Laparoscopic cholecystectomy (LC) for treatment of symptomatic common bile duct stones (CBDS) after endoscopic sphincterotomy (ES) is associated with increased conversion and complications compared with other indications. We examined factors associated with conversion and complications of LC after ES. A retrospective study of 32 patients undergoing ES for CBDS followed by cholecystectomy was undertaken. Surgical outcomes for this group were compared with a control population of 499 LCs for all other indications. Factors associated with open cholecystectomy and complications in the ES group were analyzed. Patients undergoing LC preceded by ES had a significantly higher complication (odds ratio [OR] = 7.97; 95% CI, 2.84–22.5) and conversion rate (OR = 3.45; 95% CI, 1.56–7.66) compared with LC for all other indications. Pre-ES serum bilirubin greater than 5 mg/dL was predictive of conversion (positive predictive value = 63%, P < 0.005). Patients with symptomatic CBDS that undergo LC after ES have higher complication and conversion rates than patients undergoing LC without ES. Pre-ES serum bilirubin is useful in identifying patients who may not have a successful laparoscopic approach at cholecystectomy.