Scott F. Gallagher

Gastric Bypass is an Effective Treatment for Obstructive Sleep Apnea in Patients with Clinically Significant Obesity

Background: We have demonstrated that obstructive sleep apnea (OSA) is prevalent in 60% of patients undergoing bariatric surgery. A study was conducted to determine whether weight loss following bariatric surgery ameliorates OSA. Methods: All 100 consecutive patients with symptoms of OSA were prospectively evaluated by polysomnography before gastric bypass. Preoperative and postoperative scores of Epworth Sleepiness Scale (ESS), Respiratory Disturbance Index (RDI), and other parameters of sleep quality were compared using t-test. Results: Preoperative RDI was 40±4 (normal 5 events/hour, n=100). 13 patients had no OSA, 29 had mild OSA, while the remaining 58 patients were treated preoperatively for moderate-severe OSA. At a median of 6 months follow-up, BMI and ESS scores improved (38±1 vs 54±1 kg/m2, 6±1 vs 12±0.1, P<0.001, postoperatively vs preoperatively). To date, 11 patients have completed postoperative polysomnography (3-21 months) after losing weight (BMI 40±2 vs 62±3 kg/m2, P<0.001).There was significant improvement in ESS (3±1 vs 14±2), minimum O2 saturation (SpO2 86±2 vs 77±5), sleep efficiency (85±2% vs 65±5%), all P<0.001, postop vs preop; and RDI (56±13 vs 23±7, P=0.041). Regression analysis demonstrated no correlation between preoperative BMI, ESS score and the severity of OSA; and no correlation between % excess body weight loss and postoperative RDI. Conclusion: Weight loss following gastric bypass results in profound improvement in OSA. The severity of apnea cannot be reliably predicted by preoperative BMI and ESS; therefore, patients with symptoms of OSA should undergo polysomnography.

Anastomotic leaks after laparoscopic gastric bypass.

The gastrojejunostomy may be the most technically challenging step when performing laparoscopic Roux-en-Y gastric bypass. Patients who develop anastomotic leaks have increased morbidity and mortality rates. Difficulty in diagnosis is related to nonspecific systemic symptoms and limitations in most radiological studies. Our aim is to evaluate the incidence, etiology, diagnosis, management, and prevention of anastomotic leaks occurring in patients undergoing laparoscopic Roux-en-Y gastric bypass.

Male breast carcinoma: correlation of ER, PR, Ki-67, Her2-Neu, and p53 with treatment and survival, a study of 65 cases.

Male breast cancer is rare, and experience of it in any single institution is limited. Our current understanding regarding its biology, natural history, and treatment strategies has been extrapolated from its female counterpart. The aim of this study is to evaluate the expression patterns of estrogen receptor (ER), progesterone receptor (PR), MiB1 (Ki67), Her-2/neu (c-erbB2), and p53 and to correlate them with the prognosis, presentation, staging, management, and survival/outcome in male breast carcinoma identified through the Veterans Administration nationwide cancer registry. Sixty-five cases of male breast cancer were reviewed for classification. Tumor blocks were requested from each institution for immunohistochemical staining and evaluation of ER, PR, p53, Her2-neu, and MiB1. Seventeen age- and disease-matched male veteran patients with breast gynecomastia were used as controls. Traditional prognostic data were collected for comparison with female breast cancers (i.e., age, lymph node status, clinical staging, tumor size, histological grade, and disease-free and overall survival). Male breast carcinoma had worse disease-free survival than controls (P = .03). The clinical stage regardless of tumor size or lymph node metastasis was the single most significant prognostic factor (P < .0001). ER-positive patients appeared to have a better survival than did ER-negative patients (P = .03, univariate; P not significant in multivariate) and did not benefit from treatment with tamoxifen (P = .0027, univariate; P = .42, multivariate). MiB1 and PR expressions did not correlate with treatment or survival, and p53 was associated with shorter disease free survival (P = .07, univariate; P = .047, multivariate). Stage for stage, Her2-neu was associated with shorter disease-free survival (P < .0001) and correlated with positive lymph nodes (P = .08). Surgery alone versus surgery with adjuvant treatments (chemotherapy, radiotherapy, tamoxifen, or combination) did not show any survival difference. Adjuvant therapy seemed to be associated with worse outcome. In the Veterans Administration hospital setting, the clinical stage and the expressions of p53 and Her2-neu in male breast carcinoma may be prognostically useful markers in guiding future treatment in prospective studies, whereas ER, PR, and MiB1 expressions are of limited value.

The importance of routine liver biopsy in diagnosing Nonalcoholic Steatohepatitis in bariatric patients

Background: Nonalcoholic Steatohepatitis (NASH) commonly occurs in obese patients and predisposes to cirrhosis. Prevalence of NASH in bariatric patients is unknown. Our aim was to determine the role of routine liver biopsy in managing bariatric patients. Methods: Prospective data on patients undergoing Roux-en-Y gastric bypass (RYGBP) was analyzed. One pathologist graded all liver biopsies as mild, moderate or severe steatohepatitis. NASH was defined as steatohepatitis without alcoholic or viral hepatitis. Consecutive liver biopsies were compared to those liver biopsies selected because of grossly fatty livers. Results: 242 patients underwent open and laparoscopic RYGBP from 1998-2001. Routine liver biopsies (68 consecutive patients) and selective liver biopsies (additional 86/174, 49%) were obtained. Findings of cirrhosis on frozen section changed the operation from a distal to a proximal RYGBP. The two groups were similar in age, gender, and BMI. The group with the routine liver biopsies showed a statistically significant larger preponderance of NASH (37% vs 32%). Both groups had a similar prevalence of cirrhosis. Neither BMI nor liver enzymes predicted the presence or severity of NASH. Conclusions: Routine liver biopsy documented significant liver abnormalities in a larger group of patients compared with selective liver biopsies, thereby suggesting that liver appearance is not predictive of NASH. Liver biopsy remains the gold-standard for diagnosing NASH. We recommend routine liver biopsy during bariatric operations to determine the prevalence and natural history of NASH, which will have important implications in directing future therapeutics for obese patients with NASH and for patients undergoing bariatric procedures.

The Impact of Bariatric Surgery on the Veterans Administration Healthcare System: A Cost Analysis

Background: The economic burden of caring for veterans with clinically severe obesity and its comorbidities is straining the Veterans Administration (VA) healthcare system. The authors determined the cost of Roux-en-Y Gastric Bypass (RYGBP) in the VAs single-payor healthcare system. Methods:The records of all 25 patients who underwent RYGBP from May 1999 to October 2001 were reviewed. All obesity-related health-care costs including hospitalizations as well as outpatient visits, medications and home health devices were calculated for 12 months before and after the RYGBP. Results: Age was 52±2 yr and preoperative BMI was 52±2 kg/m2; ASA score was III (21 patients) and II (4 patients). Mean follow-up was 18 months.Total cost of care for these patients preoperatively was

Current management of adrenal tumors

10,778±2,460/patient (outpatient visits=

Postoperative Hypoxemia: Common, Undetected, and Unsuspected After Bariatric Surgery

5,476±682, hospital admissions=

Kupffer cell-derived fas ligand plays a role in liver injury and hepatocyte death

12,221±6,062, and home health devices=

A state-wide review of contemporary outcomes of gastric bypass in Florida : Does provider volume impact outcomes?

1,383±349). Postoperative length of stay was 8±0.5 days. Cost of the gastric bypass was

Effect of staple height on gastrojejunostomy during laparoscopic gastric bypass: a multicenter prospective randomized trial

8,976±497/pt (OR fixed cost=