William H. Chapman

Perioperative safety in the longitudinal assessment of bariatric surgery.

BACKGROUND To improve decision making in the treatment of extreme obesity, the risks of bariatric surgical procedures require further characterization. METHODS We performed a prospective, multicenter, observational study of 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical sites in the United States from 2005 through 2007. A composite end point of 30-day major adverse outcomes (including death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and failure to be discharged from the hospital) was evaluated among patients undergoing first-time bariatric surgery. RESULTS There were 4776 patients who had a first-time bariatric procedure (mean age, 44.5 years; 21.1% men; 10.9% nonwhite; median body-mass index [the weight in kilograms divided by the square of the height in meters], 46.5). More than half had at least two coexisting conditions. A Roux-en-Y gastric bypass was performed in 3412 patients (with 87.2% of the procedures performed laparoscopically), and laparoscopic adjustable gastric banding was performed in 1198 patients; 166 patients underwent other procedures and were not included in the analysis. The 30-day rate of death among patients who underwent a Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding was 0.3%; a total of 4.3% of patients had at least one major adverse outcome. A history of deep-vein thrombosis or pulmonary embolus, a diagnosis of obstructive sleep apnea, and impaired functional status were each independently associated with an increased risk of the composite end point. Extreme values of body-mass index were significantly associated with an increased risk of the composite end point, whereas age, sex, race, ethnic group, and other coexisting conditions were not. CONCLUSIONS The overall risk of death and other adverse outcomes after bariatric surgery was low and varied considerably according to patient characteristics. In helping patients make appropriate choices, short-term safety should be considered in conjunction with both the long-term effects of bariatric surgery and the risks associated with being extremely obese. (ClinicalTrials.gov number, NCT00433810.)

Video-assisted minimally invasive mitral valve surgery

OBJECTIVE This study was done to determine the potential benefits of minimally invasive mitral surgery performed with intraoperative video assistance. METHODS From May 1996 until March 1997, a minithoracotomy and video assistance were used in 31 consecutive patients undergoing mitral repair (n = 20) and replacement (n = 11). Their ages ranged from 18 to 77 years (59 +/- 2.6 years; mean +/- standard error of the mean). Ejection fractions were 35% to 62% (55% +/- 1.5%). Operations were done with either antegrade/retrograde (n = 10) or antegrade (n = 19) cold blood cardioplegia and a new transthoracic crossclamp or with ventricular fibrillation (n = 2). Peripheral arterial cannulation (n = 28) and pump-assisted right atrial drainage (n = 26) were used most often. RESULTS No hospital deaths occurred, but the 30-day mortality was 3.2%. Complications included deep venous thrombosis and a phrenic nerve palsy in one patient each. No patient had a stroke or required reoperation for bleeding. Postoperative echocardiography showed excellent valve function in all but one patient. Cardiopulmonary bypass and arrest times averaged 183 +/- 7.2 and 136 +/- 5.5 minutes, respectively. Compared with 100 patients having conventional mitral valve operations, these patients had significantly shorter hospitalization times (8.6 +/- 0.5 vs 5.1 +/- 0.9 days, p = 0.05). Moreover, 81% of the later cohort were discharged between day 3 and 5 (3.6 +/- 0.2 days). Hospital charges (decreases 27%, p = 0.05) and costs (decreases 34%, p < 0.05) were less than in conventional operations. Patient follow-up suggested minimal perioperative pain and rapid recovery. CONCLUSIONS Early results suggest that video-assisted minimally invasive mitral operations can be done safely. These methods may benefit patients through less morbidity, earlier discharge, and lower cost.

Robotic Surgical Training in an Academic Institution

ObjectiveTo detail robotic procedure development and clinical applications for mitral valve, biliary, and gastric reflux operations, and to implement a multispecialty robotic surgery training curriculum for both surgeons and surgical teams. Summary Background DataRemote, accurate telemanipulation of intracavitary instruments by general and cardiac surgeons is now possible. Complex technologic advancements in surgical robotics require well-designed training programs. Moreover, efficient robotic surgical procedures must be developed methodically and safely implemented clinically. MethodsAdvanced training on robotic systems provides surgeon confidence when operating in tiny intracavitary spaces. Three-dimensional vision and articulated instrument control are essential. The authors’ two da Vinci robotic systems have been dedicated to procedure development, clinical surgery, and training of surgical specialists. Their center has been the first United States site to train surgeons formally in clinical robotics. ResultsEstablished surgeons and residents have been trained using a defined robotic surgical educational curriculum. Also, 30 multispecialty teams have been trained in robotic mechanics and electronics. Initially, robotic procedures were developed experimentally and are described. In the past year the authors have performed 52 robotic-assisted clinical operations: 18 mitral valve repairs, 20 cholecystectomies, and 14 Nissen fundoplications. These respective operations required 108, 28, and 73 minutes of robotic telemanipulation to complete. Procedure times for the last half of the abdominal operations decreased significantly, as did the knot-tying time in mitral operations. There have been no deaths and few complications. One mitral patient had postoperative bleeding. ConclusionRobotic surgery can be performed safely with excellent results. The authors have developed an effective curriculum for training teams in robotic surgery. After training, surgeons have applied these methods effectively and safely.

Early experience with telemanipulative robot-assisted laparoscopic cholecystectomy using da Vinci.

In the past decade, robot-assisted surgery has become increasingly used to assist in minimally invasive surgical procedures. In this article we review the evolution of robotic devices, from the first use of an industrial robot for stereotactic biopsies to pioneering work with robots used for hip and prostate surgery, to the development of robotic guidance systems that enabled solo endoscopic surgery, to telemanipulative surgery with master-servant computer-enhanced robotic devices. In addition, we review our early experience with da Vinci Robotic Surgical Systems (Intuitive Surgical, Inc., Mountain View, CA, U.S.A.), which we used to perform robot-assisted laparoscopic cholecystectomies.

Skeletal muscle lipid oxidation and obesity: influence of weight loss and exercise

Obesity is associated with a decrement in the ability of skeletal muscle to oxidize lipid. The purpose of this investigation was to determine whether clinical interventions (weight loss, exercise training) could reverse the impairment in fatty acid oxidation (FAO) evident in extremely obese individuals. FAO was assessed by incubating skeletal muscle homogenates with [1-(14)C]palmitate and measuring (14)CO(2) production. Weight loss was studied using both cross-sectional and longitudinal designs. Muscle FAO in extremely obese women who had lost weight (decrease in body mass of approximately 50 kg) was compared with extremely obese and lean individuals (BMI of 22.8 +/- 1.2, 50.7 +/- 3.9, and 36.5 +/- 3.5 kg/m(2) for lean, obese, and obese after weight loss, respectively). There was no difference in muscle FAO between the extremely obese and weight loss groups, and FAO was depressed (-45%; P < or = 0.05) compared with the lean subjects. Muscle FAO also did not change in extremely obese women (n = 8) before and 1 yr after a 55-kg weight loss. In contrast, 10 consecutive days of exercise training increased (P < or = 0.05) FAO in the skeletal muscle of lean (+1.7-fold), obese (+1.8-fold), and previously extremely obese subjects after weight loss (+2.6-fold). mRNA content for PDK4, CPT I, and PGC-1alpha corresponded with FAO in that there were no changes with weight loss and an increase with physical activity. These data indicate that a defect in the ability to oxidize lipid in skeletal muscle is evident with obesity, which is corrected with exercise training but persists after weight loss.

Mechanism for Improved Insulin Sensitivity after Gastric Bypass Surgery

CONTEXT Surgical treatments of obesity have been shown to induce rapid and prolonged improvements in insulin sensitivity. OBJECTIVE The aim of the study was to investigate the effects of gastric bypass surgery and the mechanisms that explain the improvement in insulin sensitivity. DESIGN We performed a cross-sectional, nonrandomized, controlled study. SETTING This study was conducted jointly between the Departments of Exercise Science and Physiology at East Carolina University in Greenville, North Carolina. SUBJECTS Subjects were recruited into four groups: 1) lean [body mass index (BMI) < 25 kg/m(2); n = 93]; 2) weight-matched (BMI = 25 to 35 kg/m(2); n = 310); 3) morbidly obese (BMI > 35 kg/m(2); n = 43); and 4) postsurgery patients (BMI approximately 30 kg/m(2); n = 40). Postsurgery patients were weight stable 1 yr after surgery. MAIN OUTCOME MEASURES Whole-body insulin sensitivity, muscle glucose transport, and muscle insulin signaling were assessed. RESULTS Postsurgery subjects had insulin sensitivity index values that were similar to the lean and higher than morbidly obese and weight-matched control subjects. Glucose transport was higher in the postsurgery vs. morbidly obese and weight-matched groups. IRS1-pSer(312) in the postsurgery group was lower than morbidly obese and weight-matched groups. Inhibitor kappaBalpha was higher in the postsurgery vs. the morbidly obese and weight-matched controls, indicating reduced inhibitor of kappaB kinase beta activity. CONCLUSIONS Insulin sensitivity and glucose transport are greater in the postsurgery patients than predicted from the weight-matched group, suggesting that improved insulin sensitivity after bypass is due to something other than, or in addition to, weight loss. Improved insulin sensitivity is related to reduced inhibitor of kappaB kinase beta activity and enhanced insulin signaling in muscle.

Baseline characteristics of participants in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study

Baseline characteristics of participants in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study Steven H. Belle, Ph.D., M.Sc.Hyg.*, Paul D. Berk, M.D., William H. Chapman, M.D., Nicholas J. Christian, Ph.D., Anita P. Courcoulas, M.D., M.P.H., F.A.C.S., Greg F. Dakin, M.D., David R. Flum, M.D., M.P.H., F.A.C.S., Mary Horlick, M.D., Wendy C. King, Ph.D., Carol A. McCloskey, M.D., James E. Mitchell, M.D., Emma J. Patterson, M.D., John R. Pender, M.D., Kristine J. Steffen, Pharm.D., Ph.D., Richard C. Thirlby, M.D., Bruce M. Wolfe, M.D., F.A.C.S., Susan Z. Yanovski, M.D., for The LABS Consortium University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania Columbia University Medical Center, New York, New York East Carolina University, Greenville, North Carolina University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Weill Cornell University Medical Center, New York, New York University of Washington, Seattle, Washington National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland Neuropsychiatric Research Institute, Fargo, North Dakota Legacy Good Samaritan Hospital, Portland, Oregon Virginia Mason Medical Center, Seattle, Washington Oregon Health and Science University, Portland, Oregon Received January 23, 2013; accepted January 29, 2013

Robotic-assisted Adrenalectomy for Adrenal Incidentaloma: Case and Review of the Technique

An incidental left adrenal mass was found in a patient during an evaluation for mediastinal widening. The patient had no symptoms attributable to adrenal excess. Preoperative biochemical screening was negative for a functioning medullary or cortical adrenal tumor. Surgical resection was successfully completed with the assistance of the da Vinci robotic system. Pathology demonstrated a rare adrenal oncocytoma.

The Relationship of BMI with Demographic and Clinical Characteristics in the Longitudinal Assessment of Bariatric Surgery (LABS)

BACKGROUND The relationship between body mass index (BMI) and demographic/clinical characteristics of patients undergoing bariatric surgery is poorly characterized. BMI is often used to characterize patient risk in bariatric surgery. However, its relationship with other risk factors has not been well characterized. METHODS The Longitudinal Assessment of Bariatric Surgery-1 was a study of the 30-day outcomes in patients undergoing bariatric procedures at 10 clinical centers in the United States. The sample for this study included participants with a BMI > or =40 kg/m(2) and no history of undergoing a bariatric procedure from March 1, 2005 to March 26, 2007. This analysis examined the relationships between BMI strata and several demographic/clinical characteristics. RESULTS Of 2559 patients (23% male, 10% black, 9% age > or =60 yr) with a BMI of > or =40 kg/m(2), 29% had a BMI of 50 to <60 kg/m(2) and 12% a BMI of > or =60 kg/m(2). The percentage of men and blacks increased with greater BMI category and the percentage of older patients (age > or =60 yr) decreased. Patients with a greater BMI were more likely to have a history of several co-morbid conditions (hypertension, diabetes, congestive heart failure, asthma, poor functional status, sleep apnea, pulmonary hypertension, venous thromboembolism, or venous edema with ulcerations) than were patients with a BMI of 40-50 kg/m(2) after adjusting for age, race, sex, and ethnicity. CONCLUSION A greater BMI was associated with several patient characteristics that have been linked to less weight loss, more adverse outcomes, and increased healthcare use in previous studies. Outcomes analyses should consider the potential for the confounding of BMI with demographic and clinical characteristics.

Computer-Assisted Laparoscopic Splenectomy with the da Vinci™ Surgical Robot

Laparoscopic splenectomy has become the standard of care for the surgical treatment of idiopathic thrombocytopenic purpura (ITP). The minimally invasive approach to splenic disorders such as ITP clearly results in the same benefits to the patients as have been demonstrated with the laparoscopic cholecystectomy techniques. New technologies in minimally invasive surgery have resulted in the development of robotic devises that assist the surgeon during the procedures. Robotic surgery is in its infancy at this point in time. Herein, we report a splenectomy performed with the assistance of the da Vinci surgical robot. With advancement of technology, robotic systems will play an integral role in future minimally invasive surgery.