Xuan-Mai T. Nguyen

A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs.

Background:Gastric bypass and adjustable gastric banding are the 2 most commonly performed bariatric procedures for the treatment of morbid obesity. The aim of this study was to compare the outcomes, quality of life, and costs of laparoscopic gastric bypass versus laparoscopic gastric banding. Study Design:Between 2002 and 2007, 250 patients with a body mass index of 35 to 60 kg/m2 were randomly assigned to gastric bypass or gastric banding. After exclusion, 111 patients underwent gastric bypass and 86 patients underwent gastric banding. Outcome measures included demographic data, operative time, blood loss, length of hospital stay, morbidity, mortality, early and late reoperation rate, weight loss, changes in quality of life, and cost. Treatment failure was defined as losing less than 20% of excess weight or conversion to another bariatric operation for failure of weight loss. Results:There were no deaths at 90 days in either group. The mean body mass index was higher in the gastric bypass group (47.5 vs. 45.5 kg/m2, respectively, P < 0.01) while the mean age was higher in the gastric band group (45 vs. 41 years, respectively, P < 0.01). Compared with gastric banding, operative blood loss was higher and the mean operative time and length of stay were longer in the gastric bypass group. The 30-day complication rate was higher after gastric bypass (21.6% vs. 7.0% for gastric band); however, there were no life-threatening complications such as leaks or sepsis. The most frequent late complication in the gastric bypass group was stricture (14.3%). The 1-year mortality was 0.9% for the gastric bypass group and 0% for the gastric band group. The percent of excess weight loss at 4 years was higher in the gastric bypass group (68 ± 19% vs. 45 ± 28%, respectively, P < 0.05). Treatment failure occurred in 16.7% of the patients who underwent gastric banding and in 0% of those who underwent gastric bypass, with male gender being a predictive factor for poor weight loss after gastric banding. At 1-year postsurgery, quality of life improved in both groups to that of US norms. The total cost was higher for gastric bypass as compared with gastric banding procedure (

Trends in Use of Bariatric Surgery, 2003−2008

12,310 vs.

Association of obesity with risk of coronary heart disease: findings from the National Health and Nutrition Examination Survey, 1999-2006.

10,766, respectively, P < 0.01). Conclusions:Laparoscopic gastric bypass and gastric banding are both safe and effective approaches for the treatment of morbid obesity. Gastric bypass resulted in better weight loss at medium- and long-term follow-up but was associated with more perioperative and late complications and a higher 30-day readmission rate. There was a wide variation in weight loss after gastric banding with a small proportion of patients considered as treatment failure, and male gender was a predictive factor for poor weight loss.

The Impact of Select Chronic Diseases on Outcomes after Trauma: A Study from the National Trauma Data Bank

BACKGROUND During the past decade, the field of bariatric surgery has changed dramatically. This study was intended to determine trends in the use of bariatric surgery in the United States. Data used were from the Nationwide Inpatient Sample from 2003 through 2008. STUDY DESIGN We used ICD-9 diagnosis and procedural codes to identify all hospitalizations during which a bariatric procedure was performed for the treatment of morbid obesity between 2003 and 2008. Data were reviewed for patient characteristics, annual number of bariatric procedures, and proportion of laparoscopic cases. US Census data were used to calculate the population-based annual rate of bariatric surgery per 100,000 adults. The number of surgeons performing bariatric surgery was estimated by the number of members in the American Society for Metabolic and Bariatric Surgery. RESULTS For the period between 2003 and 2008, the number of bariatric operations peaked in 2004 at 135,985 cases and plateaued at 124,838 cases in 2008. The annual rate of bariatric operations peaked at 63.9 procedures per 100,000 adults in 2004 and decreased to 54.2 procedures in 2008. The proportion of laparoscopic bariatric operations increased from 20.1% in 2003 to 90.2% in 2008. The number of bariatric surgeons with membership in the American Society for Metabolic and Bariatric Surgery increased from 931 to 1,819 during the 6 years studied. The in-hospital mortality rate decreased from 0.21% in 2003 to 0.10% in 2008. CONCLUSIONS In the United States, the number of bariatric operations peaked in 2004 and plateaued thereafter. Use of the laparoscopic approach to bariatric surgery has increased to >90% of bariatric operations. In-hospital mortality continually decreased throughout the 6-year period.

Strategic Laparoscopic Surgery for Improved Cosmesis in General and Bariatric Surgery: Analysis of Initial 127 Cases

BACKGROUND Obesity is a well-known risk factor for the development of coronary heart disease (CHD). The aim of the present study was to examine the differences in the 10-year CHD risk with increasing severity of obesity in men and women participating in the latest National Health and Nutrition Examination Survey. METHODS Data from a representative sample of 12,500 U.S. participants in the National Health and Nutrition Examination Survey from 1999 to 2006 were reviewed. The Framingham risk score was calculated for men and women according to a body mass index (BMI) of <25.0, 25.0-29.9, 30.0-34.9, and ≥ 35.0 kg/m(2). RESULTS The prevalence of those with hypertension increased with an increasing BMI, from 24% for a BMI <25.0 kg/m(2) to 54% for a BMI of ≥ 35.0 kg/m(2). The prevalence of an abnormal total cholesterol level (>200 mg/dL) increased from 40% for a BMI <25.0 kg/m(2) to 48% for a BMI of ≥ 35.0 kg/m(2). The 10-year CHD risk for men increased from 3.1% for a BMI <25.0 kg/m(2) to a peak of 5.6% for a BMI of 30.0-34.9 kg/m(2). The 10-year CHD risk for women increased from .8% for a BMI <25.0 kg/m(2) to a peak of 1.5% for a BMI of ≥ 35.0 kg/m(2). Both diabetes and hypertension were independent risk factors for an increasing CHD risk. CONCLUSIONS The 10-year CHD risk, calculated using the Framingham risk score, substantially increased with an increasing BMI. An important implication from our findings is the need to implement surgical and medical approaches to weight reduction to reduce the effect of morbidity and mortality from CHD on the U.S. healthcare system.

Inhibition of intraluminal pancreatic enzymes with nafamostat mesilate improves clinical outcomes after hemorrhagic shock in swine

BACKGROUND Data regarding pre-existing comorbidities is often poorly recorded in trauma registries, and reports of their impact on outcomes are conflicting. Additionally, many previous reports, when conducting data analysis, do not reliably account for differences in case and control cohorts. Our objective was to identify a subset of patients with reliable comorbidity and complication data in the National Trauma Data Bank (NTDB) in order to determine the impact of select chronic organ system dysfunction on morbidity and mortality using case-control methodology. STUDY DESIGN We analyzed a refined dataset from NTDB 7.1 (2002 to 2006) containing admissions to Level 1 and 2 trauma centers, which specified using chart abstraction to document comorbidities and complications. Patients with a history of cirrhosis, dialysis, HIV, and warfarin therapy were compared with a 2:1 case-matched control group. Data regarding age; Injury Severity Score (ISS); ventilator, ICU, and hospital lengths of stay; complications; and mortality were obtained. Pearsons chi-square, Fishers exact test, and the t-test were used to compare demographics and outcomes of each comorbidity group. A p value < 0.05 was considered significant. RESULTS After case-control matching, pre-existing cirrhosis, dialysis, and warfarin therapy were found to be risk factors for both complications and mortality; HIV/AIDS was found to be a risk factor only for complications. CONCLUSIONS Chronic hepatic failure, end-stage renal disease, immunodeficiency, and acquired coagulopathy are associated with higher resource use, complication rates, and mortality in a refined subset of NTDB patients.

Alcohol Consumption and Risk of Coronary Artery Disease (from the Million Veteran Program)

OBJECTIVE Strategic laparoscopic surgery for improved cosmesis (SLIC) is a less invasive surgical approach than conventional laparoscopic surgery. The aim of this study was to examine the feasibility and safety of SLIC for general and bariatric surgical operations. Additionally, we compared the outcomes of laparoscopic sleeve gastrectomy with those performed by the SLIC technique. SUBJECTS AND METHODS In an academic medical center, from April 2008 to December 2010, 127 patients underwent SLIC procedures: 38 SLIC cholecystectomy, 56 SLIC gastric banding, 26 SLIC sleeve gastrectomy, 1 SLIC gastrojejunostomy, and 6 SLIC appendectomy. SLIC sleeve gastrectomy was initially performed through a single 4.0-cm supraumbilical incision with extraction of the gastric specimen through the same incision. The technique evolved to laparoscopic incisions that were all placed within the umbilicus and suprapubic region. RESULTS There were no 30-day or in-hospital mortalities or 30-day re-admissions or re-operations. For SLIC cholecystectomy, gastric banding, appendectomy, and gastrojejunostomy, conversion to conventional laparoscopy occurred in 5.3%, 5.4%, 0%, and 0%, respectively; there were no major or minor postoperative complications. For SLIC sleeve gastrectomy, there were no significant differences in mean operative time and length of hospital stay compared with laparoscopic sleeve gastrectomy; 1 (3.8%) of 26 SLIC patients required conversion to five-port laparoscopy. There were no major complications. Minor complications occurred in 7.7% in the SLIC sleeve group versus 8.3% in the laparoscopic sleeve group. CONCLUSIONS SLIC in general and bariatric operations is technically feasible, safe, and associated with a low rate of conversion to conventional laparoscopy. Compared with laparoscopic sleeve gastrectomy, SLIC sleeve gastrectomy can be performed without a prolonged operative time with comparable perioperative outcomes.

DASH Score and Subsequent Risk of Coronary Artery Disease: The Findings From Million Veteran Program

BACKGROUND Recent studies suggest that intraluminal pancreatic enzymes play a major role in the initiation of the inflammatory cascade by the gut after hemorrhagic shock. Previous animal models have shown that the inhibition of enteral pancreatic enzymes with a serine protease inhibitor, nafamostat mesilate (NM), decreases leukocyte activation and transfusion requirements after hemorrhagic shock. The objective of this study was to determine whether enteroclysis with NM would improve the clinical outcomes in swine after hemorrhagic shock and intestinal hypoperfusion. METHODS Thirty-three male Yucatan minipigs weighing 25 kg to 30 kg underwent a controlled hemorrhage of 25 mL/kg with mesenteric clamp for further gut ischemia. Animals were allocated to three groups: (1) shock only (n = 15), (2) shock + enteroclysis with 100 mL/kg GoLYTELY (GL) as a carrier (n = 11), and (3) shock + enteroclysis with GL + 0.37 mmol/L NM (GL+NM, n = 7). Animals were resuscitated, recovered from anesthesia, observed for 3 days, and graded on a daily 4-point clinical scoring system. A score of 0 indicated a moribund state or early death, and a score of 4 indicated normal behavior. RESULTS Pigs treated with GL + NM had significantly higher mean postoperative recovery scores (3.8 +/- 0.4, essentially normal behavior with no early deaths) compared with animals within the shock only and shock + GL groups (2.1 +/- 1 with one early death and 2.2 +/- 1.2 with two early deaths, respectively, analysis of variance p < 0.003). CONCLUSION The inhibition of intraluminal pancreatic enzymes using enteroclysis with the serine protease inhibitor, NM, after hemorrhagic shock significantly improves the clinical outcome.

Prevalence of Ideal Cardiovascular Health Metrics in the Million Veteran Program

Moderate alcohol consumption has been associated with a lower risk of coronary artery disease (CAD) in the general population but has not been well studied in US veterans. We obtained self-reported alcohol consumption from Million Veteran Program participants. Using electronic health records, CAD events were defined as 1 inpatient or 2 outpatient diagnosis codes for CAD, or 1 code for a coronary procedure. We excluded participants with prevalent CAD (n = 69,995) or incomplete alcohol information (n = 8,449). We used a Cox proportional hazards model to estimate hazard ratios and 95% confidence intervals for CAD, adjusting for age, gender, body mass index, race, smoking, education, and exercise. Among 156,728 participants, the mean age was 65.3 years (standard deviation = 12.1) and 91% were men. There were 6,153 CAD events during a mean follow-up of 2.9 years. Adjusted hazard ratios (95% confidence intervals) for CAD were 1.00 (reference), 1.02 (0.92 to 1.13), 0.83 (0.74 to 0.93), 0.77 (0.67 to 0.87), 0.71 (0.62 to 0.81), 0.62 (0.51 to 0.76), 0.58 (0.46 to 0.74), and 0.95 (0.85 to 1.06) for categories of never drinker; former drinker; current drinkers of ≤0.5 drink/day, >0.5 to 1 drink/day, >1 to 2 drinks/day, >2 to 3 drinks/day, and >3 to 4 drinks/day; and heavy drinkers (>4 drinks/day) or alcohol use disorder, respectively. For a fixed amount of ethanol, intake at ≥3 days/week was associated with lower CAD risk compared with ≤1 day/week. Beverage preference (beer, wine, or liquor) did not influence the alcohol-CAD relation. Our data show a lower risk of CAD with light-to-moderate alcohol consumption among US veterans, and drinking frequency may provide a further reduction in risk.

T1754 Changes in Inflammatory Biomarkers Across Weight Classes in a Representative US Population: A Link Between Obesity and Inflammation

Background While adherence to healthful dietary patterns has been associated with a lower risk of coronary artery disease (CAD) in the general population, limited data are available among US veterans. We tested the hypothesis that adherence to Dietary Approach to Stop Hypertension (DASH) food pattern is associated with a lower risk of developing CAD among veterans. Methods and Results We analyzed data on 153 802 participants of the Million Veteran Program enrolled between 2011 and 2016. Information on dietary habits was obtained using a food frequency questionnaire at enrollment. We used electronic health records to assess the development of CAD during follow‐up. Of the 153 802 veterans who provided information on diet and were free of CAD at baseline, the mean age was 64.0 (SD=11.8) years and 90.4% were men. During a mean follow‐up of 2.8 years, 5451 CAD cases occurred. The crude incidence rate of CAD was 14.0, 13.1, 12.6, 12.3, and 11.1 cases per 1000 person‐years across consecutive quintiles of Dietary Approach to Stop Hypertension score. Hazard ratios (95% confidence interval) for CAD were 1.0 (ref), 0.91 (0.84–0.99), 0.87 (0.80–0.95), 0.86 (0.79–0.94), and 0.80 (0.73–0.87) from the lowest to highest quintile of Dietary Approach to Stop Hypertension score controlling for age, sex, body mass index, race, smoking, exercise, alcohol intake, and statin use (P linear trend, <0.0001). Conclusions Our data are consistent with an inverse association between Dietary Approach to Stop Hypertension diet score and incidence of CAD among US veterans.