Tara Mokhtari

Mammography before and after bariatric surgery

BACKGROUND Morbidly obese women are at increased risk for breast cancer, and the majority of surgical weight-loss patients are older than 40 years old. OBJECTIVE The purpose of the present study was to determine the technical and interpretive changes in mammography following bariatric surgery. SETTING Accredited Academic Hospital. METHODS Two breast-imaging radiologists reviewed screening mammograms performed on 10 morbidly obese women undergoing bariatric surgery both pre- and postoperatively. American College of Radiology Breast Imaging Reporting and Data System (ACR BI-RADS) density, imaging quality measurements, compression force, breast thickness, pectoral nipple line (PNL) length, and x-ray beam kilovoltage (kVp) and miliamperes per second (mAs) were recorded. RESULTS The average patient age was 56 years old, with mean age at menarche of 13 years old; 70% of patients were postmenopausal (average age 49 years at menopause) and 50% had a family history of breast cancer. There was a significant reduction in both BMI (-13.2 kg/m2, P<.01) and waist circumference (-32.0 cm, P<.01) following bariatric surgery. There was a significant reduction in breast thickness (-23.8 mm), reduction in PNL length (-1.9 cm), reduction in kVp (-1.2), and reduction in mAs (-16.7) even though there was no compression force change in pre- and postoperative mammograms detected. All breast densities were fatty or scattered though there were more scattered and fewer fatty images after surgery (P = .002). CONCLUSION Morbidly obese women can undergo quality mammograms before and after bariatric surgery; however, weight loss after bariatric surgery leads to only slightly denser mammograms. Furthermore, weight loss reduces mammographic radiation doses.

Heterogeneity of weight loss after gastric bypass, sleeve gastrectomy, and adjustable gastric banding

Background: Laparoscopic Roux‐en‐Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding all lead to substantial weight loss in obese patients. Long‐term weight loss can be highly variable beyond 1‐year postsurgery. This study examines and compares the frequency distribution of weight loss and lack of treatment effect rates after laparoscopic Roux‐en‐Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding. Methods: A total of 1,331 consecutive patients at a single academic institution were reviewed from a prospectively collected database. Preoperative data collected included demographics, body mass index, and percent excess weight loss. Postoperative BMI and %EWL were collected at 12, 24, and 36 months. Percent excess weight loss was analyzed by the percentiles of excess weight lost, and the distribution of percent excess weight loss was evaluated in 10% increments. Lack of a successful treatment effect was defined as <25% excess weight loss. Results: Of the 1,331 patients, 72.4% (963) underwent laparoscopic Roux‐en‐Y gastric bypass, 18.3% (243) laparoscopic sleeve gastrectomy, and 9.4%(125) laparoscopic adjustable gastric banding. Mean percent excess weight loss was greatest for laparoscopic Roux‐en‐Y gastric bypass, followed by laparoscopic sleeve gastrectomy, and then by laparoscopic adjustable gastric banding at every time point: at 2 years mean percent excess weight loss was 77.9± 24.4 for laparoscopic Roux‐en‐Y gastric bypass, 50.8 ± 25.8 for laparoscopic sleeve gastrectomy, and 40.8± 25.9 for laparoscopic adjustable gastric banding (P < .0001). The rates of a successful treatment effect s for laparoscopic Roux‐en‐Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding were 0.9%, 5.2%, and 24.3% at 1 year; 0.3%, 11.1%, and 26.0% at 2 years; and 1.0%, 25.3%, and 30.2% at 3 years. At 1 year, the odds ratio of lack of a successful treatment effect of laparoscopic sleeve gastrectomy versus laparoscopic Roux‐en‐Y gastric bypass was 6.305 (2.125–19.08; P = .0004), the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic Roux‐en‐Y gastric bypass was 36.552 (15.64–95.71; P < .0001), and the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic sleeve gastrectomy was 5.791 (2.519–14.599; P < .0001). At 2 years, the odds ratio for laparoscopic sleeve gastrectomy versus laparoscopic Roux‐en‐Y gastric bypass increased to 70.7 (9.4–531.7; P < .0001), the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic Roux‐en‐Y gastric bypass increased to 128.1 (16.8–974.3; P < .0001), and the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic sleeve gastrectomy decreased to 1.8 (0.9–3.6; P = .09). Conclusion: This study emphasizes the existing variability in weight loss across bariatric procedures as well as in the lack of a treatment effect for each procedure. Although laparoscopic adjustable gastric banding has the greatest rate of a lack of a successful treatment effect, the rate remained stable over 3 years postoperatively. Laparoscopic sleeve gastrectomy showed a doubling in the rate of a lack of a successful treatment effect every year reaching 25% at year 3. The rates for lack of a successful treatment effect for laparoscopic Roux‐en‐Y gastric bypass remained stable at about 1% for the first 3 years postoperatively.

In reference to Spontaneous middle cranial fossa cerebrospinal fluid otorrhea in adults

We read with interest the recent article by Rao and Redleaf. The authors present their experience managing the clinical course of spontaneous cerebrospinal fluid (CSF) otorrhea and point to sometimes accepting the role of nonoperative management of this condition. Although Rao and Redleaf report only one patient in their cohort who presented with meningitis, and none developed meningitis during the study period, previous studies of spontaneous CSF otorrhea have described a higher proportion of meningitis. In our experience with spontaneous CSF leaks of the temporal bone, 28% of patients presented with recurrent meningitis. Therefore, the rate of meningitis may be higher than that encountered in the authors’ cohort. Furthermore, although patients with CSF otorrhea can potentially survive for many years without complications, they continue to be at risk of developing meningitis during this time period. Streptococcus pneumoniae is the most common bacterial pathogen causing adult meningitis and carries significant morbidity and mortality. The fatality rate for pneumococcal meningitis is estimated at 30%, with up to 14% to 24% of adult survivors developing hearing loss. Death is not a rare outcome of bacterial meningitis. Although close follow-up and observation may be appropriate to detect the onset of meningitis in patients who absolutely refuse surgery, we are of the opinion that the risk of developing meningitis is significant and should not be underestimated when weighing the risks and benefits of surgical intervention. Patients need to be informed of the possible complications of meningitis, including the risk of death, when making the decision to forego treatment of a CSF leak. The authors also discuss the dehiscence of dura in patients with chronic mastoiditis and cholesteatoma. Although we have observed a number of patients with dehiscent dura in the presence of disease, we have also treated a number of patients with intracranial empyemas and abscesses from those diseases. A brief review of the literature reveals that intracranial infection continues to occur not infrequently in the developing world in the absence of treatment. The decision to proceed without surgical intervention in the case of spontaneous CSF otorrhea must be made with extreme caution and only after significant patient counseling. We believe that meningitis poses a considerable risk that should not be underestimated, and we urge caution in nonoperative management of spontaneous CSF leak and dehiscent dura in cholesteatoma patients.