Mapping utility scores from a disease-specific quality-of-life measure in bariatric surgery patients.

OBJECTIVES: To develop algorithms for a conversion of disease-specific quality-of-life into health state values for morbidly obese patients before or after bariatric surgery. METHODS: A total of 893 patients were enrolled in a prospective cross-sectional multicenter study. In addition to demographic and clinical data, health-related quality-of-life (HRQoL) data were collected using the disease-specific Moorehead-Ardelt II questionnaire (MA-II) and two generic questionnaires, the EuroQoL-5D (EQ-5D) and the Short Form-6D (SF-6D). Multiple regression models were constructed to predict EQ-5D- and SF-6D-based utility values from MA-II scores and additional demographic variables. RESULTS: The mean body mass index was 39.4, and 591 patients (66%) had already undergone surgery. The average EQ-5D and SF-6D scores were 0.830 and 0.699. The MA-IIwas correlated to both utility measures (Spearman's r = 0.677 and 0.741). Goodness-of-fit was highest (R(2) = 0.55 in the validation sample) for the following item-based transformation algorithm: utility (MA-II-based) = 0.4293 + (0.0336 x MA1) + (0.0071 x MA2) + (0.0053 x MA3) + (0.0107 x MA4) + (0.0001 x MA5). This EQ-5D-based mapping algorithm outperformed a similar SF-6D-based algorithm in terms of mean absolute percentage error (P = 0.045). CONCLUSIONS: Because the mapping algorithm estimated utilities with only minor errors, it appears to be a valid method for calculating health state values in cost-utility analyses. The algorithm will help to define the role of bariatric surgery in morbid obesity.

Timeline of Intestinal Adaptation After Malabsortive Surgery: Effect of Luminal Nutrients, Biliopancreatic Secretion, and Glutamine Supplementation.

BACKGROUND: The aim of this study was to study the process of intestinal adaptation in the three limbs of the small intestine after malabsorptive bariatric surgery: the biliopancreatic limb, the alimentary limb, and the common channel. These limbs are exposed to different stimuli, namely, gastrointestinal transit and nutrients in the alimentary limb, biliopancreatic secretions in the biliopancreatic limb, and a mix of both in the common channel. We also wished to investigate the effect of glutamine supplementation on the adaptation process. METHODS: Three types of surgery were performed using a porcine model: biliopancreatic bypass (BPBP), massive (75%) short bowel resection as the positive control, and a sham operation (transection) as the negative control. We measured the height and width of intestinal villi, histidine decarboxylase (HDC) activity, and amount of HDC messenger RNA (mRNA) (standard diet or a diet supplemented with glutamine). RESULTS: An increase in HDC activity and mRNA expression was observed in the BPBP group. This increase coincided with an increase in the height and width of the intestinal villi. The increase in villus height was observed immediately after surgery and peaked at 2 weeks. Levels remained higher than those observed in sham-operated pigs for a further 4 weeks. CONCLUSIONS: The intestinal adaptation process in animals that underwent BPBP was less intense than in those that underwent massive short bowel resection and more intense than in those that underwent transection only. Supplementation with glutamine did not improve any of the parameters studied, although it did appear to accelerate the adaptive process.

Catecholamines and Paroxysmal Sympathetic Hyperactivity after Traumatic Brain Injury.

Paroxysmal sympathetic hyperactivity (PSH) affects a significant minority of people in the intensive care unit after severe traumatic brain injury. Systematic research has yet to elucidate or quantify the extent of the role of the catecholamines or adrenocortical and thyroid axis hormonal influences in the condition. Data were prospectively collected on 80 consecutive patients, 18 of whom developed clinical signs of PSH (22.5%). Catecholamine and hormonal data were collected sequentially at 4-h intervals or during and between episodes of PSH. Evaluated variables showed 200-300% increases in catecholamines and, to a lesser extent, adrenocortical hormones during paroxysms. The majority of PSH episodes (72%) were noted to be in response to an observable triggering event. These changes were not observed in subjects without PSH. These data go some way to explain why PSH produces adverse consequences in survivors of TBI with the condition.

[Not Available].

Aim: The aim of this study was to assess the prevalence of hypovitaminosis D in candidates to bariatric surgery (BS) and its relationship with risk factors and components of the metabolic syndrome. Material and methods: Clinical, anthropometric and biochemical parameters were measured in 56 Caucasian patients included in a protocol of BS between January and June 2014. Patients were stratified into three groups according to their vitamin D status: sufficiency (≥ 40 ng/ml), insufficiency (40-20 ng/ml) and deficiency (< 20 ng/ml). Results: Data showed vitamin D deficiency in 75% of patients. These patients had greater BMI (p = 0.006) and lower PTH concentrations in plasma (p = 0.045). In addition, there were more patients with diabetes mellitus type 2 (DM2) and dyslipidemia (DLPM) in the group with 25 (OH) D < 20 ng/ml levels. Another finding was that 25(OH) D levels were observed to be negatively correlated with fat mass (r = -0.504; p = 0.009), BMI (r = -0.394; p = 0.046) and hypertension (r = -0.637; p = 0.001). Conclusion: We conclude that vitamin D deficiency is extremely common among candidates to BS, who are associated with DM2 and DLPM. Although there are limited data regarding the best treatment for low Vitamin D status in BS candidate patients, screening for vitamin D deficiency should be regularly performed in cases of morbid obesity

Objetivo: el objetivo de este estudio fue evaluar la prevalencia de hipovitaminosis D en los candidatos a cirugía bariátrica (CB) y su relación con factores de riesgo y los componentes del síndrome metabólico. Material y métodos: los parámetros clínicos, antropométricos y bioquímicos se midieron en 56 pacientes caucásicos incluidos en un protocolo de cirugía bariátrica entre enero y junio de 2014. Los pacientes fueron estratificados en tres grupos de acuerdo al status de vitamina D: suficiencia (≥ 40 ng/ml), insuficiencia (40-20 ng/ml) y deficiencia (< 20 ng/ml). Resultados: se observó deficiencia de vitamina D en el 75% de los pacientes. Estos pacientes tenían mayor índice de masa corporal (p = 0,006) y concentraciones plasmáticas mas bajas de PTH (p = 0,045). Además, hubo más pacientes con diabetes mellitus tipo 2 (DM2) y dislipemia (DLPM) en el grupo con niveles de 25 (OH) D < 20 ng/ml. Asimismo la 25 (OH) D se correlacionó negativamente con la masa grasa (r = -0,504; p = 0,009), el IMC (r = -0,394; p = 0,046) y la hipertensión arterial (r = -0,637; p = 0,001). Conclusión: De nuestros hallazgos concluimos que la deficiencia de vitamina D es muy común entre los candidatos a CB y que la misma está asociada con DM2 y DLPM.Aunque hay pocos datos sobre el mejor tratamiento para el bajo nivel de vitamina D en los pacientes candidatos CB, la detección de la deficiencia de vitamina D debe realizarse de forma rutinaria en estos casos.

Drain erosion and gastro-jejunal fistula after one-anastomosis gastric bypass: endoscopic occlusion by fibrin sealant.

Leakage and fistula are feared complications after gastro-intestinal anastomosis. A 36-year-old female underwent an one-anastomosis gastric bypass. The 24-h routine radiological study before oral intake showed a tiny leak, which was treated by NPO and I.V. fluids. After 5 days, despite output reduction, total parenteral nutrition was commenced. After 8 days, the leak remained with reduced output. It was then occluded endoscopically by fibrin glue. To our surprise, we found the drain that we had left behind the anastomosis, inside the gastric pouch. We began withdrawing the drain and occluded the defect with 4 ml Tissucol. After 48-h of no output, a repeat radiological study showed persistence of the leak. 6 days later, a radiological study demonstrated total closure of the leak.

One-anastomosis gastric bypass by laparoscopy: results of the first 209 patients.

BACKGROUND: One-Anastomosis Gastric Bypass (OAGB) by laparoscopy consists of constructing a divided 25-ml (estimated) gastric pouch between the esophago-gastric junction and the crow's foot level, parallel to the lesser curvature, which is anastomosed latero-laterally to a jejunal loop 200 cm distal to the ligament of Treitz. METHODS: The results of our first 209 OAGB patients operated from July 2002 to June 2004 are reported. Mean age was 41 years (14-66), BMI 48 (39-86) and mean excess body weight 66 kg (35-220). In 144 patients, OAGB was the only operation performed, and in 61 patients it was accompanied by other surgery (18 cholecystectomies, 5 incisional hernia repairs, and 38 adhesiolysis), and in 4 patients a restrictive bariatric operation had been performed previously. RESULTS: 2 patients (0.9%) were converted to open surgery due to uncontrollable bleeding. 3 patients (1.4%) needed re-operation in the immediate postoperative period. 5 patients (2.3%) needed prolonged hospital stay due to acute pancreatitis in 1 and anastomotic leakage in 4, all resolving with conservative treatment. 2 patients died (0.9%), 1 from fulminant pulmonary thromboembolism and 1 from nosocomial pneumonia. Long-term complications have occurred in only 2 patients who developed clinically significant iron-deficiency anemia. Mean excess weight loss was 75% after 1 year and >80% at 2 years. CONCLUSION: OAGB is a simple, safe and effective operation with less perioperative risk than conventional gastric bypass, quicker return to normal activities, and better quality of life.

Glycemic and lipid metabolic disorders in diabetic and non-diabetic patients bmi < 35 or > 35 before gastric bypass.

INTRODUCTION: Obesity and diabetes are diseases with high prevalence worldwide. There is currently no effective medical treatment for combat the weight gain. It is precursor of diseases such as diabetes or metabolic syndrome. It is necessary to know if weight gain has cumulative effects on the glycemic and lipid metabolism as precursors of complications or comorbidities. PATIENTS AND METHODS: We studied 131 patients (78 nondiabetic and 53 diabetic), 37 BMI ≤35 (3 BMI < 25, 18 BMI 25-29.9, 16 BMI 30-34.9) and 94 BMI ≥35 (81 BMI 35-49.9 and 13 BMI ≥50).We analyzed BMI, gender, diabetes and the time of evolution. Lipid profile, glucose, HbA1c and C-peptide evaluated after 12-hour fasting. RESULTS: Diabetic and diabese patients showed high triglycerides. Non-diabetics have impaired glucose (58% BMI < 35 and 36% BMI > 35). The 20% of non-diabetics BMI < 35 had high C-peptide, and 19% of BMI > 35 had high levels. The 5% of diabetics BMI < 35 had low Cpeptide and 36% of BMI > 35 had high levels. HbA1c was higher in 40% of non-diabetic patients BMI < 35 compared to 13% BMI > 35. CONCLUSIONS: Glucose and triglycerides increase with age and years of development of T2DM. Age of 51 and more, and men are more affected. The weight increase has cumulative effect by altering the metabolism favoring the onset of diabetes and comorbidities. Despite having intensive control treatment of diabetes, it continues its deleterious effects on patients through the years.

Introducción: La obesidad y la diabetes son enfermedades de alta prevalencia a nivel mundial. Actualmente no existe un tratamiento médico eficaz para combatir el aumento de peso. La obesidad es precursora de enfermedades tales como la diabetes o el síndrome metabólico. Es necesario saber si el aumento de peso tiene efectos acumulativos sobre el metabolismo de la glucemia y los lípidos como precursores de complicaciones o comorbilidades. Pacientes y métodos: Se estudiaron 131 pacientes (78 no diabéticos y 53 diabéticos), 37 IMC ≤35 (3 IMC < 25, 18 IMC 25-29,9, 16 IMC 30-34,9) y 94 IMC ≥35 (81 IMC 35- 49,9 y 13 de IMC ≥50). Se analizó el IMC, el género, la diabetes y su tiempo de evolución. El perfil lipídico, glucosa, HbA1c y el péptido C fueron evaluados después de un ayuno de 12 horas. Resultados: Los pacientes diabéticos y diabesos mostraron niveles altos de triglicéridos. Los pacientes no diabéticos tienen alteración de la glucosa (58% IMC 35). El 20% de los no diabéticos IMC 35 tenían niveles altos. El 5% de los diabéticos IMC < 35 tenía bajos niveles de péptido C y 36% de IMC > 35 tenían niveles altos. HbA1c fue mayor en 40% de pacientes no diabéticos IMC < 35 frente al 13% de IMC > 35. Conclusiones: La glucosa y los triglicéridos aumentan con la edad y los años de evolución de la DMT2. La edad de ≥51 años y los hombres son los más afectados. El aumento de peso tiene efecto acumulativo alterando el metabolismo favoreciendo la aparición de la diabetes y sus comorbilidades. A pesar de tener un tratamiento de control intensivo de la diabetes, esta continúa con sus efectos nocivos sobre los pacientes a través de los años.

Paroxysmal sympathetic hyperactivity after traumatic brain injury: clinical and prognostic implications.

A proportion of patients surviving severe traumatic brain injury (TBI) have symptoms suggestive of excessive sympathetic discharge, here termed paroxysmal sympathetic hyperactivity (PSH). The goals of this study were: (1) to describe the clinical associations and radiological findings of PSH, its incidence, and features in subjects with severe TBI in the intensive care unit (ICU); (2) to investigate the potential role of increased intracranial pressure in the pathogenesis of PSH; and (3) to determine the prognostic influence of PSH during the ICU stay, on discharge from the ICU, and at 12 months post-injury. A prospective cohort study was undertaken of all ICU admissions with severe TBI older than 14 years over an 18-month period. The PSH symptoms consisted of paroxysmal increases in blood pressure, respiratory rate, and heart rate; worsening level of consciousness; muscle rigidity; and hyperhidrosis. Subjects demonstrating PSH episodes were compared with a group of non-PSH consecutive subjects studied over the first 6 months of the study period. Data were recorded on the clinical variables associated with PSH episodes, early post-injury cerebral CT findings, and neurological status at 1 year. Of 179 severe TBI patients admitted over the study period, 18 (10.1%) experienced PSH. Injury severity-related variables (e.g., initial APACHE II score, admission coma level, and proportion with intracranial hypertension) were similar between the two groups. The PSH group had a longer ICU stay and a greater incidence of infectious complications. At 1 year post-injury, 20% of this group demonstrated ongoing PSH episodes. Over 18 months, 10.1% of admissions following severe TBI demonstrated PSH features in ICU. Subjects with PSH had a longer ICU stay and higher rate of complications, although this did not appear to compromise their long-term neurological recovery.

25-hydroxy vitamin D and syndrome metabolic components in candidates to bariatric surgery / Vitamina D y componentes del síndrome metabólico en candidatos a cirugía bariátrica

Aim: The aim of this study was to assess the prevalence of hypovitaminosis D in candidates to bariatric surgery (BS) and its relationship with risk factors and components of the metabolic syndrome. Material and methods: Clinical, anthropometric and biochemical parameters were measured in 56 Caucasian patients included in a protocol of BS between January and June 2014. Patients were stratified into three groups according to their vitamin D status: sufficiency (≥ 40 ng/ml), insufficiency (40-20 ng/ml) and deficiency (< 20 ng/ml). Results: Data showed vitamin D deficiency in 75% of patients. These patients had greater BMI (p = 0.006) and lower PTH concentrations in plasma (p = 0.045). In addition, there were more patients with diabetes mellitus type 2 (DM2) and dyslipidemia (DLPM) in the group with 25 (OH) D < 20 ng/ml levels. Another finding was that 25(OH) D levels were observed to be negatively correlated with fat mass (r = -0.504; p = 0.009), BMI (r = -0.394; p = 0.046) and hypertension (r = -0.637; p = 0.001). Conclusion: We conclude that vitamin D deficiency is extremely common among candidates to BS, who are associated with DM2 and DLPM. Although there are limited data regarding the best treatment for low Vitamin D status in BS candidate patients, screening for vitamin D deficiency should be regularly performed in cases of morbid obesity (AU)

Objetivo: el objetivo de este estudio fue evaluar la prevalencia de hipovitaminosis D en los candidatos a cirugía bariátrica (CB) y su relación con factores de riesgo y los componentes del síndrome metabólico. Material y métodos: los parámetros clínicos, antropométricos y bioquímicos se midieron en 56 pacientes caucásicos incluidos en un protocolo de cirugía bariátrica entre enero y junio de 2014. Los pacientes fueron estratificados en tres grupos de acuerdo al status de vitamina D: suficiencia (≥ 40 ng/ml), insuficiencia (40-20 ng/ml) y deficiencia (< 20 ng/ml). Resultados: se observó deficiencia de vitamina D en el 75% de los pacientes. Estos pacientes tenían mayor índice de masa corporal (p = 0,006) y concentraciones plasmáticas mas bajas de PTH (p = 0,045). Además, hubo más pacientes con diabetes mellitus tipo 2 (DM2) y dislipemia (DLPM) en el grupo con niveles de 25 (OH) D < 20 ng/ml. Asimismo la 25 (OH) D se correlacionó negativamente con la masa grasa (r = -0,504; p = 0,009), el IMC (r = -0,394; p = 0,046) y la hipertensión arterial (r = -0,637; p = 0,001). Conclusión: De nuestros hallazgos concluimos que la deficiencia de vitamina D es muy común entre los candidatos a CB y que la misma está asociada con DM2 y DLPM. Aunque hay pocos datos sobre el mejor tratamiento para el bajo nivel de vitamina D en los pacientes candidatos CB, la detección de la deficiencia de vitamina D debe realizarse de forma rutinaria en estos casos (AU)

Validity of the Czech, German, Italian, and Spanish version of the Moorehead-Ardelt II questionnaire in patients with morbid obesity.

BACKGROUND: The Moorehead-Ardelt II (MA-II) questionnaire is the most frequently applied instrument to assess quality of life (QoL) in bariatric surgery patients. Our aim was to validate the Czech, German, Italian, and Spanish version of the MA-II. METHODS: A total of 893 patients were enroled in a prospective cross-sectional European study. Two thirds of the patients(n = 591) were postsurgical cases. In addition to demographicand clinical data, QoL data was collected using the MA-II questionnaire, the EuroQoL-5D (EQ-5D), and the Short Form 36 Health Survery (SF-36). Statistical parameters for contingency (Cronbach's alpha), construct and criterion validity(Pearson's r), and responsiveness (standardised effect sizes) were calculated for each language version. RESULTS: In the different languages, Cronbach's alpha ranged from 0.817 to 0.885 for the MA-II. These values were higher than those obtained for the SF-36 (0.418-0.607). The MA-II was well correlated to the EQ-5D (r = 0.662) and to 3 of the 8 health domains of the SF-36 (0.615, 0.548, and 0.569 for physical functioning,physical role, and general health, respectively). As expected, there was a negative correlation between the MA-II and the BMI (r = -0.404 for all patients), but no significant correlation with age was found.When comparing both the heaviest and the lightest third of the patients, mean responsiveness was higher for the MA-II (-1.138) than for the domains of the SF-36 (range -0.111 to -1.070) and the EQ-5D (-0.874). CONCLUSION: The Czech, German, Italian, and Spanish version of the MA-II questionnaire are valid instruments and should be preferred to generic questionnaires as they provide better responsiveness.

Cirugía de la diabetes tipo ii: ¿un descubrimiento casual? / Type 2 diabetes surgery: A casual finding?

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Guías para la reposición de las pérdidas sanguíneas en cirugía abdominal de urgencia / Guidelines for blood loss replacement in emergency abdominal surgery

La reposición de la pérdidas sanguíneas en cirugía abdominal urgente desempeña un papel clave para la supervivencia, sobre todo en los pacientes que presentan una pérdida de sangre masiva provocada por la rotura del hígado, el bazo y los vasos mesentéricos, así como en el hemoperitoneo masivo secundario a un embarazo ectópico. Para manejar con éxito a estos pacientes debe seguirse un algoritmo claro previamente consensuado y aceptado por los miembros del servicio, tanto para el rápido diagnóstico y utilización de maniobras quirúrgicas precisas para el control de la fuente de hemorragia como, sobre todo, para el control de la alteración de los factores de la coagulación y la consecuente necesidad de una precisa pauta de uso de los distintos componentes sanguíneos que deben utilizarse en su reposición. El uso de estas guías reduce la mortalidad de forma significativa. En este contexto, el uso de la autotransfusión intraoperatoria ha demostrado ser un procedimiento seguro y con un buena relación coste-efectividad que se puede utilizar incluso por vía laparoscópica. Sin embargo, su utilización está poco extendida, sistematizada y mal organizada, a tenor de los datos publicados en la bibliografía (AU)