The relationship between intracranial pressure and obesity: an ultrasonographic evaluation of the optic nerve.

BACKGROUND: Measurements of optic nerve sheath diameter (ONSD) with noninvasive ocular ultrasonography have been shown to be accurate in determining increased intracranial pressure. Obesity is associated with chronic increases in intraabdominal pressure that could consequently result in intracranial hypertension. By utilizing ONSD ultrasonographic measurements, we compare the difference that may exist between obese and non-obese patients. STUDY DESIGN: We prospectively collected data from patients who underwent laparoscopic procedures in the supine position between July 2013 and March 2014. Ophthalmic pathology was not present in any patient. Ultrasonographic measurement of the ONSD was obtained sagittally with a 12-MHz transducer 3 mm from its origin. The measurements were taken at 0, 15, and 30 min, and at the end of surgery. RESULTS: There were 62 subjects, 28 females (45.2 %) and 34 males (54.8 %), with a mean age of 44.22 ± 10.44 years (range 23-66). Forty-eight percent of patients were non-obese, and 52 % of patients were obese. The mean body mass index was 30.70 ± 7.61 kg/m(2) (range 20.0-59.5). The mean ONSD of non-obese and obese patients was 4.7 and 5.5 mm at baseline (p = 0.01), 5.4 and 6.2 mm at 15 min (p = 0.01), 5.8 and 6.6 mm at 30 min (p = 0.01), and 5.1 and 5.7 mm after deflation of pneumoperitoneum (p = 0.03), respectively. CONCLUSIONS: Utilizing a noninvasive method to measure the ONSD, a chronic increase in intracranial pressure in obese patients was demonstrated. The increase in the ONSD during laparoscopic procedures reflects a temporary increase in the intracranial pressure from baseline.

Impact of controlled intraabdominal pressure on the optic nerve sheath diameter during laparoscopic procedures.

BACKGROUND: Acute elevations of intraabdominal pressure (IAP) are seen in many clinical scenarios with a consequent elevation in intracranial pressure (ICP). With the optic nerve sheath (ONS) being a part of the dura mater and the optic nerve surrounded by cerebral spinal fluid, a change in pressure within the subarachnoid space would be detected by ultrasonography, and invasive methods could be avoided. The study objective was to evaluate ultrasonographic modifications observed on the optic nerve sheath diameter during acute elevations of IAP in patients undergoing laparoscopic procedures. STUDY DESIGN: We prospectively collected data from patients who underwent laparoscopic procedures between July and August 2013. The optic nerve sheath diameter was measured sagittally with a 12-MHz transducer. The measurements were obtained at baseline, 15 and 30 min, and at the end of surgery. RESULTS: There were 16 females (36.4%) and 28 males (63.6%), with a mean age of 44.22 ± 10.44 years (range 23-66) and body mass index of 29.45 ± 6.53 kg/m(2) (range 21-39). The mean optic nerve sheath diameter was 4.8 ± 1.0 mm at baseline, 5.5 ± 1.1 mm at 15 min, 5.9 ± 1.0 mm at 30 min, and 5.1 ± 1.2 mm after deflation of pneumoperitoneum. The diameter increased significantly at 15 min by a median of 0.6 mm (interquartile range 0.3, 0.8; p < 0.0001) and at 30 min by a median of 1.0 mm (interquartile range 0.7, 1.4; p < 0.0001), returning close to baseline after surgery. CONCLUSION: The acute elevation in IAP during laparoscopy significantly increased the optic nerve sheath diameter. The changes in the ONSD reflect a temporary and reversible increase in the ICP due to the acute elevation of IAP.

Subclavian Artery Injury Following Central Venous Catheter Placement.

Mechanical complications following central venous catheterization are not uncommon. We discuss a case of iatrogenic intra-arterial central venous catheter placement requiring neck exploration in a 93-year-old woman. The catheter was inadvertently passed through the jugular vein and into the right subclavian artery by a junior surgical resident. Adequate technique and supervision, ultrasound guidance, and immediate diagnostic workup in the event of suspected arterial injury are factors necessary for physicians to minimize complications and provide safe medical treatment.

Bariatric surgery is associated with reduced admission for aortic dissection: a nationwide case-control analysis.

BACKGROUND: Aortic dissection (AD) is an uncommon but life-threatening condition associated with high morbidity and mortality. Hypertension (HTN) and hyperlipidemia (HLD) are common modifiable risk factors. OBJECTIVES: Since bariatric surgery is associated with remission of obesity-related co-morbidities, we hypothesize that surgical weight loss might be protective against this feared aortic pathology. SETTING: A cross-sectional analysis was performed using the National Inpatient Sample database from 2010 to 2015. METHODS: The treatment group included bariatric patients and the control group patients with obesity (body mass index [BMI] ≥ 35kg/m2) without previous bariatric surgery. Analyzed covariates included demographics, co-morbidities, aortic diseases, and AD. A multivariate logistic regression analysis (MLRA) was performed to assess the odds of admission for AD in both groups. RESULTS: A total of 2,300,845 patients were identified (2,004,804 controls and 296,041 cases). The mean (SEM) age was 54.4 (.05) versus 51.9 (.05) years, for the control and treatment groups, respectively (P < .0001). Bariatric patients posed a significantly lower prevalence of type 2 diabetes (T2D), HTN, HLD, aortic aneurysm, and bicuspid aortic valve (P < .0001) than control subjects. In the control group, 1411 individuals (.070%) had AD, whereas only 94 patients (.032%) in the bariatric surgery group had such diagnosis (P < .0001). The MLRA showed that non-bariatric obese patients had a significantly higher likelihood of suffering from AD (OR = 1.8 [95%CI 1.44-2.29] P < .0001). Considering different age groups, bariatric surgery was found to be less associated with admission for AD for individuals below and above 40 years of age (OR = 2.95 [95%CI 1.09-7.99] P = .0345) and (OR = 1.75 [95%CI 1.38-2.22] P < .0001), respectively. CONCLUSIONS: Bariatric surgery could be a protective factor against aortic dissection and should be considered in patients with obesity and risk factors for this cardiovascular complication.

Pharmacomechanical Thrombolysis for Deep Vein Thrombosis in May-Thurner Syndrome.

OBJECTIVE: Patients with May-Thurner syndrome presenting with acute deep vein thrombosis benefit from early lysis of clot and endovascular treatment. We evaluated the outcome of patients with May-Thurner syndrome who presented with deep vein thrombosis, managed with pharmacomechanical thrombolysis as the primary mode of intervention, in combination with angioplasty and stent placement. METHODS: We reviewed all patients with May-Thurner syndrome managed in our institution between January 2009 to December 2015. Patency rate and postthrombotic syndrome were evaluated as primary end points. RESULTS: A total of seven patients (6 females, 1 male) with a mean ± SD age of 48 ± 17 years and mean ± SD body mass index of 29.64 ± 7.25 kg/m were identified. Six patients presented with acute deep vein thrombosis and one presented with chronic venous insufficiency. Five patients underwent pharmacomechanical thrombolysis (TRELLIS and altepase) with concomitant stenting of the common iliac vein, one had only angioplasty with stent placement, and one had only pharmacomechanical thrombolysis. Median time from presentation to pharmacomechanical thrombolysis was 4 days (range = 1-9). Patency rate and postthrombotic syndrome at 12 months were 100% and 0%, respectively. No patient experienced major bleeding or pulmonary embolism. The median length of stay was 3 days (range = 0-4). There was no mortality associated with the procedure. The mean ± SD follow-up was 26 ± 15 months. CONCLUSIONS: In patients with May-Thurner syndrome, pharmacomechanical thrombolysis is an effective approach for the management of acute deep vein thrombosis, decreasing thrombus burden, and long-term postthrombotic syndrome when used in conjunction with stenting.

Comparison between major and minor surgical procedures for the treatment of chronic staple line disruption after laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become the most common weight loss surgery procedure. The procedure's most dreaded surgical complication is staple-line disruption (SLD). So far, no definitive treatment modality has been established for this complication. OBJECTIVES: The aim of this study is to review the treatment options used at our institution for patients with SLD after LSG and to evaluate the outcome of different interventions. METHODS: A retrospective review of a prospectively collected database of all patients who underwent SLD between January 2005 and April 2014 was performed. SLD was defined as a leak identified on computed tomography or upper gastrointestinal series. We compared the cure rate between a major surgical procedure and patients treated with a variety of other minor treatment modalities. Special focus is given to the technique of proximal gastrectomy with Roux-en-Y esophagojejunostomy (PGEJ). The procedure consists of the en bloc resection of the proximal stomach immediately proximal to the gastroesophageal junction and including the fistulous tract. The jejunum is transected 50 cm distal to the ligament of Treitz and reconstruction of the gastrointestinal tract is performed with a Roux-en-Y esophagojejunostomy. RESULTS: Thirty-one patients had SLD after their LSG. Patients were divided into 2 groups based on the treatment modality: Group A (PGEJ) and Group B (minor surgical procedure). Group A (n = 19) had 1 releak. Group B (n = 11) had 5 releaks. The cure rate for patients who underwent PGEJ was 94.7%. The cure rate for patients who were treated with a different approach was 54.5% (P = .01). CONCLUSION: Our experience demonstrates that the cure rate of PGEJ is high. Minor surgical procedures are effective in approximately half of the patients, so when the leak becomes chronic, PGEJ can provide a long-term solution.

Prevalence and associated factors of obesity among Panamanian adults. 1982-2010.

BACKGROUND: In Central America, there has been a marked increase in obesity in the last 30 years. Over this time frame, in Panama, there have been lifestyle changes associated with economic development and urbanization that may have facilitated increases in body weight. The aim of the study is to describe the change in the prevalence of obesity in the country since 1982 and to analyze the association of obesity with gender, place of residence and socioeconomic factors. METHODS: We analyzed three nationally representative cross-sectional studies and one sub-national study of Panamanian adults that evaluated anthropometric and socioeconomic variables; ENPA-1982 (n = 11 611), ENV-II 2003 (n = 14 737), ENV-III 2008 (n = 15 484), PREFREC-2010 (n  = 3 590). We also evaluated one nationally representative study that evaluated people's perception of their body weight, ENSCAVI-2007 (n = 25 748). RESULTS: In 1982, the prevalence in males of a body mass index (BMI) ≥ 30 kg/m2 was 3.8% (3.3-4.2) and in females 7.6% (6.9-8.2). In 2003, the prevalence in males increased to 14.4% (13.6-15.2) and in females to 21.8% (20.8-22.7). In 2008, the prevalence in males was 16.9% (16.0-17.7) and in females it was 23.8% (22.8-24.7). Nevertheless, in 2007, the national perception of being obese was only 4% among males and 6.7% among females. The highest prevalence of obesity was noted in urban areas. Female gender and higher income were found to be positively associated with obesity. Income level was positively associated with abdominal obesity in men but not in women. CONCLUSIONS: There has been a marked increase of obesity in Panama in the last 3 decades. Initiatives to control this problem will have to take into consideration the observed gender difference and the lifestyle changes that have contributed to the rise of this problem.