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1.
Am J Nephrol ; 55(2): 196-201, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-37487472

RESUMEN

Nephrogenic calciphylaxis is associated with multiple risk factors including long-term dialysis dependence, hyperphosphatemia, hypercalcemia, parathyroid hormone derangements, vitamin K deficiency, obesity, diabetes mellitus, warfarin use, and female sex. Bariatric surgery is known to cause altered absorption, leading to mineral and hormonal abnormalities in addition to nutritional deficiency. Prior case reports on calciphylaxis development following bariatric surgery have been published, though are limited in number. We report a case series of five bariatric patients from a single institution who developed nephrogenic calciphylaxis between 2012 and 2018. These patients had a history of bariatric surgery, and at the time of calciphylaxis diagnosis, demonstrated laboratory abnormalities associated with surgery including hypercalcemia (n = 3), hyperparathyroidism (n = 2), hypoalbuminemia (n = 5), and vitamin D deficiency (n = 5), in addition to other medication exposures such as vitamin D supplementation (n = 2), calcium supplementation (n = 4), warfarin (n = 2), and intravenous iron (n = 1). Despite the multifactorial etiology of calciphylaxis and the many risk factors present in the subjects of this case series, we submit that bariatric surgery represents an additional potential risk factor for calciphylaxis directly stemming from the adverse impact of malabsorption and overuse of therapeutic supplementation. We draw attention to this phenomenon to encourage early consideration of calciphylaxis in the differential for painful skin lesions arising after bariatric surgery as swift intervention is essential for these high-risk patients.


Asunto(s)
Cirugía Bariátrica , Calcifilaxia , Hipercalcemia , Humanos , Femenino , Calcifilaxia/diagnóstico , Calcifilaxia/etiología , Calcifilaxia/terapia , Warfarina , Hipercalcemia/etiología , Diálisis Renal/efectos adversos , Cirugía Bariátrica/efectos adversos
2.
Surg Endosc ; 38(3): 1249-1256, 2024 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-38097748

RESUMEN

BACKGROUND: While some studies have reported improvement in gastro-esophageal reflux disease (GERD) symptoms after sleeve gastrectomy (SG), others have reported higher incidence of de-novo GERD, worsening of prior GERD symptoms and erosive esophagitis post SG. Furthermore, GERD unresponsive to medical management is one of the most common indications for conversion of SG to Roux-en-Y gastric bypass (RYGB). Real-world data on safety of primary SG, primary RYGB and SG to RYGB conversion for obese patients with GERD would be helpful for informing surgeons and patient procedure selection. We sought to evaluate the trends in utilization and safety of primary RYGB and primary SG for patients with GERD requiring medications, and compare the peri-operative outcomes between primary RYGB and conversion surgery from SG to RYGB for GERD using the MBSAQIP database. METHODS: A comparative analysis of post-operative outcomes within 30 days was performed for primary RYGB and primary SG after 1:1 nearest neighbor propensity score matching for patient demographics and preoperative comorbidities using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry from 2015 to 2021. This was followed by comparison of peri-operative outcomes between conversion surgery from SG to RYGB for GERD and primary RYGB using MBSAQIP 2020-2021 data. RESULTS: Utilization of primary RYGB increased from 38% in 2015 to 45% in 2021, while primary SG decreased from 62% in 2015 to 55% in 2021 for bariatric patients with GERD. Post-operative outcomes including reoperation, reintervention, readmission, major complications, and death within 30 days were significantly higher for patients undergoing primary RYGB compared to primary SG. Increased readmissions and ED visits were seen with conversion surgery. However, there was no difference in rates of reoperation, reintervention, major complications, or death between primary RYGB and SG conversion to RYGB cohorts. CONCLUSIONS: This data suggests that a strategy of performing a primary SG and subsequent SG-RYGB conversion for those with recalcitrant GERD symptoms is not riskier than a primary RYGB. Thus, it may be reasonable to perform SG in patients who are well informed of the risk of worsening GERD requiring additional surgical interventions. However, the impact of such staged approach (SG followed by conversion to RYGB) on long-term outcomes remains unknown.


Asunto(s)
Cirugía Bariátrica , Derivación Gástrica , Reflujo Gastroesofágico , Obesidad Mórbida , Humanos , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Obesidad Mórbida/cirugía , Obesidad Mórbida/complicaciones , Reflujo Gastroesofágico/etiología , Reflujo Gastroesofágico/cirugía , Reflujo Gastroesofágico/diagnóstico , Cirugía Bariátrica/métodos , Gastrectomía/métodos , Estudios Retrospectivos , Resultado del Tratamiento
3.
Surg Endosc ; 36(2): 1601-1608, 2022 02.
Artículo en Inglés | MEDLINE | ID: mdl-33620566

RESUMEN

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgical procedure. Little is known about how surgeon training background influences the learning curve of this procedure. We examined operating times (OT), weight loss outcomes, and 30-day complications between surgeons with and without fellowship training in LSG. We hypothesize that post-residency training specific to LSG influences learning curves. METHODS: Surgeons from a single institution were split into two groups: those who had not completed fellowship training in LSG (NF, n = 3), and those who had completed LSG specific training in fellowship (SGF, n = 3). OTs, BMI changes at 1 year, and 30-day readmissions, reoperations, and complications were extracted for the first 100 LSG cases of each surgeon. Data were analyzed in bins of 20 cases. Comparisons were made between cohorts within a bin and between adjacent bins of the same surgeon cohort. Logistic regression analyses were performed of OT and weight loss outcomes. RESULTS: SGF surgeons showed no difference in OTs over their first 100 cases. NF surgeons had statistically significant increased OTs compared to SGF surgeons during their first 60 cases and progressively shortened OTs during that interval (109 min to 78 min, p < 0.001 for NF surgeons vs. 73 min to 69 min, SGF surgeons). NF surgeons had a significantly steeper slope for improvement in OT over case number. There was no correlation between case number and weight loss outcomes in either group, and no differences in 30-day outcomes between groups. CONCLUSION: Surgeons who trained to perform LSG in fellowship demonstrate faster and consistent OR times on their initial independent LSG cases compared to surgeons who did not, with no correlation between case number and weight loss outcomes or safety profiles for either group. This suggests that learning curves for LSG are achieved during formal case-specific fellowship training.


Asunto(s)
Laparoscopía , Obesidad Mórbida , Becas , Gastrectomía/métodos , Humanos , Laparoscopía/métodos , Curva de Aprendizaje , Obesidad Mórbida/cirugía , Estudios Retrospectivos , Resultado del Tratamiento
4.
J La State Med Soc ; 169(3): 71-77, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-28644155

RESUMEN

BACKGROUND: Historically, persistent atrial fibrillation (PeAF) and long standing persistent atrial fibrillation (LSPeAF) have demonstrated limited clinical success despite hybrid approaches. OBJECTIVE: We describe our experience with the endocardial-before-epicardial approach defined by a comprehensive endovascular approach preceding and guiding the epicardial approach which includes an extensive posterior wall ablation. METHODS: 40 patients were followed over a 12 month period. The procedure was performed in a single center. Patients had a mean duration of atrial fibrillation of 6.0 ± 4.5 years with 22.5% having undergone prior ablations. Mean age was 61.7 ± 7.9 years with a mean left atrial volume of 131.5 ± 46.9 mL. The endovascular procedure remained uniform with antral pulmonary vein isolation, posterior left atrial roof and right atrial cavo-tricuspid isthmus (CTI) linear lesions with mapping and ablation of left atrial complex electrograms (CFAEs) and prior existing atrial arrhythmias. The epicardial procedure included a thorascopic approach with ganglionated plexus (GP) mapping and ablation, left atrial posterior wall ablation, directed CFAE ablation and left atrial appendage ligation. All patients received implantable cardiac monitoring. RESULTS: All 40 patients remained in sinus rhythm at their 12 month follow-up. During the monitoring period, episodes of paroxysmal atrial arrhythmias including fibrillation were documented, without persistence, after discontinuation of oral antiarrhythmic medications. CONCLUSION: The endo-before-epi approach resulted in improved management of persistent and long standing persistent atrial fibrillation over reported results for conventional approaches with no procedural complications, making this a promising option for the management of these arrhythmias.


Asunto(s)
Antiarrítmicos/administración & dosificación , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Electrocardiografía , Anciano , Fibrilación Atrial/tratamiento farmacológico , Ablación por Catéter/efectos adversos , Enfermedad Crónica , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Cuidados Preoperatorios/métodos , Estudios Prospectivos , Recurrencia , Reoperación/métodos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento
5.
Surg Endosc ; 30(12): 5453-5458, 2016 12.
Artículo en Inglés | MEDLINE | ID: mdl-27129555

RESUMEN

BACKGROUND: We conducted the following study to evaluate the safety and efficacy of single-stage conversion of failed laparoscopic adjustable gastric band (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) as compared to a cohort of primary LRYGB patients. METHODS: A single-institution, prospectively maintained bariatric database was used to retrospectively identify consecutive patients who underwent single-stage removal of LAGB with concomitant conversion to LRYGB between the years of 2007 and 2013. The study cohort was matched 1:1 for age, gender, body mass index (BMI), and approximate date of operation to patients who underwent primary LRYGB. Primary endpoints were operative time, complication rate, length of hospital stay (LOS), and percent excess BMI lost (%EBMIL) at 24-month follow-up. RESULTS: Ninety-four conversion patients met inclusion criteria. There were no statistically significant differences in the mean LOS (3.1 vs. 3.0 days, p = 0.97) or the major complication rate (3.2 vs. 1.1 %, p = 0.62) at 30 days postoperatively. Likewise, 30-day minor complication rates, including readmission, were similar between groups (7.5 vs. 6.4 %, p = 0.77). The average operative time was significantly longer for conversion compared to primary LRYGB (193.5 vs. 132 min; p < 0.01). At most recent follow-up after conversion or primary LRYGB, median %EBMIL was 61.3 and 77.3 % (p < 0.01), percent total weight loss was 23.6 and 30.5 % (p < 0.01), and percent change in BMI was 23.4 and 30.5 % (p < 0.01), respectively. Median follow-up time was 17 and 18.6 months after conversion and primary LRYGB, respectively. CONCLUSION: Single-stage conversion of LAGB to LRYGB is safe with an acceptable complication rate and similar LOS compared to primary LRYGB.


Asunto(s)
Derivación Gástrica/métodos , Gastroplastia/métodos , Laparoscopía/métodos , Obesidad Mórbida/cirugía , Adulto , Estudios de Casos y Controles , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Gastroplastia/instrumentación , Humanos , Masculino , Persona de Mediana Edad , Seguridad del Paciente , Estudios Retrospectivos , Resultado del Tratamiento
7.
Crit Care Med ; 43(12): 2605-15, 2015 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-26427592

RESUMEN

OBJECTIVES: The association between nutritional status and mortality in critically ill patients is unclear based on the current literature. To clarify this relation, we analyzed the association between nutrition and mortality in a large population of critically ill patients and hypothesized that mortality would be impacted by nutritional status. DESIGN: Retrospective observational study. SETTING: Single academic medical center. PATIENTS: Six thousand five hundred eighteen adults treated in medical and surgical ICUs between 2004 and 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All cohort patients received a formal, in-person, standardized evaluation by a registered dietitian. The exposure of interest, malnutrition, was categorized as nonspecific malnutrition, protein-energy malnutrition, or well nourished and determined by data related to anthropometric measurements, biochemical indicators, clinical signs of malnutrition, malnutrition risk factors, and metabolic stress. The primary outcome was all-cause 30-day mortality determined by the Social Security Death Master File. Associations between nutrition groups and mortality were estimated by bivariable and multivariable logistic regression models. Adjusted odds ratios were estimated with inclusion of covariate terms thought to plausibly interact with both nutrition status and mortality. We used propensity score matching on baseline characteristics to reduce residual confounding of the nutrition status category assignment. In the cohort, nonspecific malnutrition was present in 56%, protein-energy malnutrition was present in 12%, and 32% were well nourished. The 30-day and 90-day mortality rates for the cohort were 19.1% and 26.6%, respectively. Nutritional status is a significant predictor of 30-day mortality following adjustment for age, gender, race, medical versus surgical patient type, Deyo-Charlson index, acute organ failure, vasopressor use, and sepsis: nonspecific malnutrition 30-day mortality odds ratio, 1.17 (95% CI, 1.01-1.37); protein-energy malnutrition 30-day mortality odds ratio, 2.10 (95% CI, 1.70-2.59), all relative to patients without malnutrition. In the matched cohort, the adjusted odds of 30-day mortality in the group of propensity score-matched patients with protein-energy malnutrition was two-fold greater than that of patients without malnutrition. CONCLUSION: In a large population of critically ill adults, an association exists between nutrition status and mortality.


Asunto(s)
Enfermedad Crítica/epidemiología , Enfermedad Crítica/mortalidad , Unidades de Cuidados Intensivos/estadística & datos numéricos , Desnutrición/epidemiología , Estado Nutricional , Centros Médicos Académicos , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales
8.
Crit Care Med ; 43(1): 87-100, 2015 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-25289931

RESUMEN

INTRODUCTION: The association between obesity and mortality in critically ill patients is unclear based on the current literature. To clarify this relationship, we analyzed the association between obesity and mortality in a large population of critically ill patients and hypothesized that mortality would be impacted by nutritional status. METHODS: We performed a single-center observational study of 6,518 adult patients treated in medical and surgical ICUs between 2004 and 2011. All patients received a formal, in-person, and standardized evaluation by a registered dietitian. Body mass index was determined at the time of dietitian consultation from the estimated dry weight or hospital admission weight and categorized a priori as less than 18.5 kg/m (underweight), 18.5-24.9 kg/m (normal/referent), 25-29.9 kg/m (overweight), 30-39.9 kg/m (obesity class I and II), and more than or equal to 40.0 kg/m (obesity class III). Malnutrition diagnoses were categorized as nonspecific malnutrition, protein-energy malnutrition, or well nourished. The primary outcome was all-cause 30-day mortality determined by the Social Security Death Master File. Associations between body mass index groups and mortality were estimated by bivariable and multivariable logistic regression models. Adjusted odds ratios were estimated with inclusion of covariate terms thought to plausibly interact with both body mass index and mortality. We utilized propensity score matching on baseline characteristics and nutrition status to reduce residual confounding of the body mass index category assignment. RESULTS: In the cohort, 5% were underweight, 36% were normal weight, 31% were overweight, 23% had class I/II obesity, and 5% had class III obesity. Nonspecific malnutrition was present in 56%, protein-energy malnutrition was present in 12%, and 32% were well nourished. The 30-day and 90-day mortality rate for the cohort was 19.1 and 26.6%, respectively. Obesity is a significant predictor of improved 30-day mortality following adjustment for age, gender, race, medical versus surgical patient type, Deyo-Charlson index, acute organ failure, vasopressor use, and sepsis: underweight odds ratio 30-day mortality is 1.09 (95% CI, 0.80-1.48), overweight 30-day mortality odds ratio is 0.93 (95% CI, 0.80-1.09), class I/II obesity 30-day mortality odds ratio is 0.80 (95% CI, 0.67-0.96), and class III obesity 30-day mortality odds ratio is 0.69 (95% CI, 0.49-0.97), all relative to patients with body mass index 18.5-24.9 kg/m. Importantly, there is confounding of the obesity-mortality association on the basis of malnutrition. Adjustment for only nutrition status attenuates the obesity-30-day mortality association: underweight odds ratio is 0.74 (95% CI, 0.54-1.00), overweight odds ratio is 1.05 (95% CI, 0.90-1.23), class I/II obesity odds ratio is 0.96 (95% CI, 0.81-1.15), and class III obesity odds ratio is 0.81 (95% CI, 0.59-1.12), all relative to patients with body mass index 18.5-24.9 kg/m. In a subset of patients with body mass index more than or equal to 30.0 kg/m (n = 1,799), those with either nonspecific or protein-energy malnutrition have increased mortality relative to well-nourished patients with body mass index more than or equal to 30.0 kg/m: odds ratio of 90-day mortality is 1.67 (95% CI, 1.29-2.15; p < 0.0001), fully adjusted. In a cohort of propensity score matched patients (n = 3,554), the body mass index-mortality association was not statistically significant, likely from matching on nutrition status. CONCLUSIONS: In a large population of critically ill adults, the association between improved mortality and obesity is confounded by malnutrition status. Critically ill obese patients with malnutrition have worse outcomes than obese patients without malnutrition.


Asunto(s)
Enfermedad Crítica/mortalidad , Estado Nutricional , Obesidad/complicaciones , Índice de Masa Corporal , Enfermedad Crítica/epidemiología , Femenino , Humanos , Masculino , Desnutrición/complicaciones , Desnutrición/mortalidad , Persona de Mediana Edad , Obesidad/mortalidad , Sobrepeso/complicaciones , Sobrepeso/mortalidad , Delgadez/complicaciones , Delgadez/mortalidad
9.
Eur J Clin Nutr ; 78(3): 274-276, 2024 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-38057413

RESUMEN

Monoamine oxidase inhibitors (MAOIs) prevent the breakdown of tyramine in the body, and can cause a sudden increase in blood pressure with significant tyramine build up. This phenomenon, when it occurs, is known as tyramine pressor response. It is unknown if tyrosine administered in parenteral nutrition (PN) leads to tyramine build-up with concomitant use of MAOIs. It is also unknown if PN patients who are taking MAOI are at risk for the tyramine pressor response. This is a theoretical possibility as tyrosine endogenously undergoes decarboxylation to produce tyramine. We describe our experience with a 67-year-old woman with severe depression who was on the MAOI, transdermal selegiline. Her clinical course was complicated by an inability to take adequate per oral (PO) intake and she met criteria for unspecified severe protein-calorie-malnutrition in the context of social or environmental circumstances. Therefore, she required PN initiation. PlenamineTM (B. Braun, Bethlehem, PA, USA) was used as the amino acid source in the PN, which contains 39 mg of tyrosine per 100 ml of solution. The patient was monitored closely for any signs of hypertensive crisis while on PN and selegiline. She safely tolerated the combined therapy without any side effects. This is the first documented report of co-administration of PN containing tyrosine along with a MAOI. Our findings suggest that the dose of selegiline used in this patient can be co-administered safely in the setting of PN. However, further study is needed to verify our findings beyond this one patient. In conclusion, we recommend initiating PN and increasing it to goal in patients taking MAOIs, gradually, while monitoring for hypertensive crisis given the theoretical possibility of the tyramine pressor response.


Asunto(s)
Trastorno Depresivo , Inhibidores de la Monoaminooxidasa , Femenino , Humanos , Anciano , Inhibidores de la Monoaminooxidasa/uso terapéutico , Inhibidores de la Monoaminooxidasa/farmacología , Selegilina/uso terapéutico , Selegilina/efectos adversos , Tirosina/farmacología , Tirosina/uso terapéutico , Presión Sanguínea , Tiramina/efectos adversos
10.
J Am Coll Surg ; 238(6): 1023-1034, 2024 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-38376072

RESUMEN

BACKGROUND: With increasing implementation of Enhanced Recovery After Surgery protocols and rising demand for inpatient hospital beds accentuated by COVID-19, there has been interest in same-day discharge (SDD) for bariatric surgery. The aim of this study was to determine the national trends, safety profile, and risk factors for complications of SDD for minimally invasive bariatric surgery. STUDY DESIGN: We analyzed the MBSAQIP database from 2016 to 2021 to characterize trends in SDD for minimally invasive bariatric operation. Multivariate logistic regression was performed on preoperative patient characteristics predictive of increased complications associated with SDD. A comparative analysis of postoperative outcomes within 30 days was performed for SDD and admission after 1:1 nearest neighbor propensity score matching for patient demographics and preoperative comorbidities. RESULTS: SDD increased from 2.4% in 2016 to 7.4% in 2021. Major preoperative factors associated with increased complications for SDD included Black race, history of MI, renal insufficiency, deep vein thrombosis, and smoking. SDD for Roux-en-Y gastric bypass had 72% increased risk of postoperative complications compared with sleeve gastrectomy. The overall major complications were lower in SDD cohort vs admission cohort (odds ratio [OR] 0.62, p < 0.01). However, there was a significant increase in deaths within 30 days (OR 2.11, p = 0.01), cardiac arrest (OR 2.73; p < 0.01), and dehydration requiring treatment (OR 1.33; p < 0.01) in SDD cohort compared with admission cohort. CONCLUSIONS: Nationally, there has been a rise in SDD for bariatric operation from 2016 to 2021. Matched analysis demonstrates that SDD is associated with a significantly higher mortality rate. Additionally, the risk of complications with SDD is higher for RYGB compared with sleeve gastrectomy. Therefore, further studies are required to appropriately select patients for whom bariatric surgery can be safely performed as an outpatient.


Asunto(s)
Cirugía Bariátrica , Alta del Paciente , Complicaciones Posoperatorias , Humanos , Femenino , Masculino , Estudios Retrospectivos , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/métodos , Cirugía Bariátrica/estadística & datos numéricos , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Adulto , Alta del Paciente/estadística & datos numéricos , Factores de Riesgo , COVID-19/epidemiología , Obesidad Mórbida/cirugía , América del Norte/epidemiología , Puntaje de Propensión
11.
Obes Surg ; 33(10): 3090-3096, 2023 10.
Artículo en Inglés | MEDLINE | ID: mdl-37453989

RESUMEN

PURPOSE: Eighty percent of patients who undergo metabolic-bariatric surgery self-identify as female. It is unclear why there is a disparate use of metabolic-bariatric surgery by men compared to women given the widely accepted safety of weight loss surgical procedures. One possible explanation is that post-operative outcomes of metabolic-bariatric surgery have been shown to be worse for men compared to women in prior studies. The purpose of this study was to characterize the impact of gender on outcomes of metabolic-bariatric surgery using the most recent MBSAQIP data registry from 2017-2021. MATERIALS AND METHODS: Data entered into the MBSAQIP registry from 2017-2021 for patients who underwent primary metabolic-bariatric surgery procedures was identified. The data was then matched for multiple pre-operative factors and comorbidities, and outcomes were assessed and compared for men and women. RESULTS: No significant difference was observed in anastomotic leak, wound complications, and bleeding between men and women. However, men were at 0.15% (p < 0.01) higher risk of major complications (encompassing unplanned ICU admission, deep organ space infection, unplanned intubation, bleeding, anastomotic leak, sepsis, pneumonia, myocardial infarction, cardiac arrest, cerebrovascular accident, pulmonary embolism, reoperation, and death) compared to women. While men had higher major complications compared to women for SG, there was no significant difference between the two cohorts for RYGB, BPD and LAGB. CONCLUSION: While there are some differences in outcomes between male and female patients, the difference is modest. Male gender should not be considered a high-risk factor for all bariatric procedures and cannot explain the difference in utilization of metabolic-bariatric surgery by men compared to women.


Asunto(s)
Cirugía Bariátrica , Derivación Gástrica , Obesidad Mórbida , Humanos , Masculino , Femenino , Derivación Gástrica/métodos , Obesidad Mórbida/cirugía , Fuga Anastomótica/etiología , Estudios Retrospectivos , Resultado del Tratamiento , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/métodos , Estudios de Cohortes , América del Norte , Gastrectomía/métodos
12.
Arthritis Care Res (Hoboken) ; 75(3): 491-500, 2023 03.
Artículo en Inglés | MEDLINE | ID: mdl-35657632

RESUMEN

OBJECTIVE: Class III obesity (body mass index [BMI] ≥40 kg/m2 ) is associated with worse knee pain and total knee replacement (TKR) outcomes. Because bariatric surgery yields sustainable weight loss for individuals with BMI ≥40 kg/m2 , our objective was to establish the value of Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) in conjunction with usual care for knee osteoarthritis (OA) patients with BMI ≥40 kg/m2 . METHODS: We used the Osteoarthritis Policy model to assess long-term clinical benefits, costs, and cost-effectiveness of RYGB and LSG. We derived model inputs for efficacy, costs, and complications associated with these treatments from published data. Primary outcomes included quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs), all discounted at 3%/year. This analysis was conducted from a health care sector perspective. We performed sensitivity analyses to evaluate uncertainty in input parameters. RESULTS: The usual care + RYGB strategy increased the quality-adjusted life expectancy by 1.35 years and lifetime costs by $7,209, compared to usual care alone (ICER = $5,300/QALY). The usual care + LSG strategy yielded less benefit than usual care + RYGB and was dominated. Relative to usual care alone, both usual care + RYGB and usual care + LSG reduced opioid use from 13% to 4%, and increased TKR usage from 30% to 50% and 41%, respectively. For cohorts with BMI between 38 and 41 kg/m2 , usual care + LSG dominated usual care + RYGB. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $50,000/QALY, usual care + RYGB and usual care + LSG were cost-effective in 70% and 30% of iterations, respectively. CONCLUSION: RYGB offers good value among knee OA patients with BMI ≥40 kg/m2 , while LSG may provide good value among those with BMI between 35 and 41 kg/m2 .


Asunto(s)
Derivación Gástrica , Laparoscopía , Obesidad Mórbida , Osteoartritis de la Rodilla , Humanos , Análisis Costo-Beneficio , Osteoartritis de la Rodilla/cirugía , Obesidad/cirugía , Pérdida de Peso , Gastrectomía , Obesidad Mórbida/cirugía
13.
Arthritis Care Res (Hoboken) ; 75(8): 1752-1763, 2023 08.
Artículo en Inglés | MEDLINE | ID: mdl-36250415

RESUMEN

OBJECTIVE: Class III obesity (body mass index >40 kg/m2 ) is associated with higher complications following total knee replacement (TKR), and weight loss is recommended. We aimed to establish the cost-effectiveness of Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), and lifestyle nonsurgical weight loss (LNSWL) interventions in knee osteoarthritis patients with class III obesity considering TKR. METHODS: Using the Osteoarthritis Policy model and data from published literature to derive model inputs for RYGB, LSG, LNSWL, and TKR, we assessed the long-term clinical benefits, costs, and cost-effectiveness of weight-loss interventions for patients with class III obesity considering TKR. We assessed the following strategies with a health care sector perspective: 1) no weight loss/no TKR, 2) immediate TKR, 3) LNSWL, 4) LSG, and 5) RYGB. Each weight-loss strategy was followed by annual TKR reevaluation. Primary outcomes were cost, quality-adjusted life expectancy (QALE), and incremental cost-effectiveness ratios (ICERs), discounted at 3% per year. We conducted deterministic and probabilistic sensitivity analyses to examine the robustness of conclusions to input uncertainty. RESULTS: LSG increased QALE by 1.64 quality-adjusted life-years (QALYs) and lifetime medical costs by $17,347 compared to no intervention, leading to an ICER of $10,600/QALY. RYGB increased QALE by 0.22 and costs by $4,607 beyond LSG, resulting in an ICER of $20,500/QALY. Relative to immediate TKR, LSG and RYGB delayed and decreased TKR utilization. In the probabilistic sensitivity analysis, RYGB was cost-effective in 67% of iterations at a willingness-to-pay threshold of $50,000/QALY. CONCLUSION: For patients with class III obesity considering TKR, RYGB provides good value while immediate TKR without weight loss is not economically efficient.


Asunto(s)
Artroplastia de Reemplazo de Rodilla , Derivación Gástrica , Obesidad Mórbida , Osteoartritis de la Rodilla , Humanos , Análisis Costo-Beneficio , Artroplastia de Reemplazo de Rodilla/efectos adversos , Obesidad/diagnóstico , Obesidad/cirugía , Derivación Gástrica/métodos , Pérdida de Peso , Osteoartritis de la Rodilla/cirugía , Gastrectomía/métodos , Obesidad Mórbida/diagnóstico , Obesidad Mórbida/cirugía
14.
Surg Obes Relat Dis ; 18(1): 95-101, 2022 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-34666948

RESUMEN

BACKGROUND: Patients are increasingly referred for conversion of laparoscopic adjustable gastric band (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (SG). The safety of a 1- versus 2-stage approach to this revision is debated. OBJECTIVES: We examined the safety and efficacy of 1-stage conversion of LAGB to SG at our institution. SETTING: University hospital. METHODS: An institutional database was used to retrospectively identify patients who underwent single-stage LAGB-to-SG conversion between 2010 and 2018. Patients were matched 1:1 for age, sex, and body mass index with primary SG patients during this same period. Primary endpoints were operative time, complication rate, length of hospital say, and weight loss 12 months from surgery. RESULTS: Two-hundred and twenty-nine patients undergoing conversion of LAGB to SG were identified. Median postoperative length of hospital stay was 2 days. Two patients (.8%) developed surgical site infection. One patient (.4%) developed a postoperative myocardial infarction. There were 4 total readmissions (1.7%) and 1 reoperation within 30 days (.4%). There were no statistically significant differences in 30-day complication rates between groups. Weight loss at 12 months was significantly different: Median body mass index loss for conversion patients was 5.1 kg/m2 compared with 8.85 kg/m2 for patients in the primary SG group (P < .0001). CONCLUSION: Single-stage conversion of LAGB to SG is safe and effective. Patients may not experience the same extent of weight loss as those with primary SG. Our findings represent the largest single-institutional experience to date and support a 1-stage approach whenever feasible.


Asunto(s)
Derivación Gástrica , Gastroplastia , Laparoscopía , Obesidad Mórbida , Estudios de Casos y Controles , Gastrectomía/efectos adversos , Gastroplastia/efectos adversos , Humanos , Laparoscopía/efectos adversos , Obesidad Mórbida/cirugía , Reoperación , Estudios Retrospectivos , Resultado del Tratamiento
16.
Dig Dis Sci ; 55(2): 338-45, 2010 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-19557517

RESUMEN

PURPOSE: To provide additional efficacy data in patients treated with rabeprazole through week 4, and to validate sustained relief of gastroesophageal reflux disease symptoms through week 8 as well as to further analyze rabeprazole safety in patients with wide-ranging demographic and clinical characteristics. RESULTS: Patients in this study (N = 2,449) demonstrated significant overall improvement versus baseline (P < 0.001). Substantial symptom relief was seen throughout 8 weeks of treatment. By week 4, complete relief of daytime and nighttime heartburn, belching, regurgitation, and dysphagia was observed in 87.5, 90.7, 50.7, 77.6, and 75.1% of patients, respectively. Improvements were seen in rabeprazole-treated patients (<65 or >or=65 years) with a range of baseline symptom severities and across different racial groups. Rabeprazole was well tolerated. CONCLUSIONS: In patients with endoscopy-confirmed erosive esophagitis treated with once-daily rabeprazole 20 mg, prompt and continuing improvements were seen in daytime and nighttime heartburn, belching, regurgitation, and dysphagia.


Asunto(s)
2-Piridinilmetilsulfinilbencimidazoles/administración & dosificación , Inhibidores Enzimáticos/administración & dosificación , Esofagitis Péptica/tratamiento farmacológico , Anciano , Relación Dosis-Respuesta a Droga , Endoscopía Gastrointestinal , Esofagitis Péptica/complicaciones , Esofagitis Péptica/diagnóstico , Femenino , Estudios de Seguimiento , Pirosis/tratamiento farmacológico , Pirosis/epidemiología , Pirosis/etiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , ATPasas de Translocación de Protón/antagonistas & inhibidores , Rabeprazol , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología
17.
Obes Surg ; 30(4): 1560-1563, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-32030614

RESUMEN

Postoperative vitamin and mineral supplementation are integral components of the management of the weight loss surgery patient. Supplements differ in type, amount, and salt form. No recent publication has compared bariatric branded commercially available products with current practice guidelines. Registered dietitians belonging to the New England Bariatric Dietitians LinkedIn group were surveyed to identify their recommendation practices. These results were then used to compare and discuss in a comprehensive fashion the most widely recommended bariatric branded chewable supplements to the 2016 American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines.


Asunto(s)
Cirugía Bariátrica , Terapia Nutricional , Obesidad Mórbida , Suplementos Dietéticos , Humanos , Obesidad Mórbida/cirugía , Estados Unidos , Vitaminas
18.
Curr Nutr Rep ; 8(4): 317-322, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31420855

RESUMEN

PURPOSE OF REVIEW: Obesity and malnutrition are frequently encountered in the hospitalized population. Although malnutrition associated with low or normal body mass index (BMI) is easily identified, malnutrition in obese patients goes frequently unrecognized as their fat mass masks underlying muscle mass deterioration. The purpose of this review is to explore if malnutrition has been studied in the obese hospitalized population and if that may be one of the reasons for the variable results in the obesity outcome data. RECENT FINDINGS: Various studies have shown a conflicting association between obesity and outcomes in hospitalized patient population. Most prior studies used BMI alone as an indicator of obesity and although some recent studies have included body fat percentage, muscle mass, and functional status, they still showed variable outcomes. Unfortunately, there are not many studies that looked into nutrition status specifically in obese patients to study the outcomes. Studies evaluating clinical outcomes in obese patients showed a wide range of outcomes; some showed a protective effect while others were neutral. We explored recent data about obesity, malnutrition, and outcomes, where researchers more precisely defined malnutrition and obesity to determine health outcomes.


Asunto(s)
Hospitales , Desnutrición/complicaciones , Obesidad/complicaciones , Índice de Masa Corporal , Bases de Datos Factuales , Humanos , Desnutrición/epidemiología , Estado Nutricional , Obesidad/epidemiología , Factores de Riesgo
19.
Nutr Clin Pract ; 34(1): 12-22, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30580456

RESUMEN

Critical illness is a hypercatabolic state. It has been hypothesized that timely and adequate nutrition support may optimize the host response and thereby minimize nutritionally related complications while improving overall outcome. Any illness in due course can lead to a malnourished state-critical illness can worsen this state as patients may become immunocompromised and unable to mount an adequate inflammatory response and therefore susceptible to poor outcomes. Data indicate that prevalence of malnutrition in the ICU ranges from 38% to 78% and is independently associated with poor outcomes. Hence, exploring the role of nutrition as a way to mitigate critical illness is important. In this review, the basic pathophysiology of critical illness and how it alters carbohydrate, protein, and fat metabolism are discussed. This is followed by a discussion of malnutrition and how it affects patient and hospital outcomes. Finally, a summary of the available evidence regarding nutrition support and its impact on outcomes are provided. This review is not intended to provide practice-based guidelines; instead, it intends to highlight available data on the role of nutrition support in critically ill patients.


Asunto(s)
Enfermedad Crítica , Estado Nutricional , Apoyo Nutricional , Humanos , Unidades de Cuidados Intensivos , Desnutrición
20.
J Vasc Interv Radiol ; 19(8): 1171-5, 2008 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-18656009

RESUMEN

PURPOSE: To assess the utility of maintaining and analyzing a quality-management database while investigating a subjectively perceived increase in the incidence of tunneled catheter and port dysfunction in a cohort of oncology outpatients. MATERIALS AND METHODS: All 152 patients undergoing lytic therapy (2-4 mg alteplase) of a malfunctioning indwelling central venous catheter (CVC) from January through June 2004 at a single cancer center in the United States were included in a quality-management database. Patients were categorized by time to device failure and the initial method of catheter placement (surgery vs interventional radiology). Data were analyzed after 3 months, and areas of possible improvement were identified and acted upon. Three months of follow-up data were then collected and similarly analyzed. RESULTS: In a 6-month period, 152 patients treated for catheter malfunction received a total of 276 doses of lytic therapy. A 3-month interim analysis revealed a disproportionately high rate (34%) of early catheter malfunction (ECM; <30 days from placement). Postplacement radiographs demonstrated suboptimal catheter positioning in 67% of these patients, all of whom had surgical catheter placement. There was a 50% absolute decrease in the number of patients presenting with catheter malfunction in the period from April through June (P < .001). Evaluation of postplacement radiographs in these patients demonstrated a 50% decrease in the incidence of suboptimal positioning (P < .05). CONCLUSIONS: Suboptimal positioning was likely responsible for some, but not all, cases of ECM. Maintenance of a quality-management database is a relatively simple intervention that can have a clear and important impact on the quality and cost of patient care.


Asunto(s)
Atención Ambulatoria/estadística & datos numéricos , Antineoplásicos/administración & dosificación , Cateterismo Venoso Central/estadística & datos numéricos , Neoplasias/tratamiento farmacológico , Neoplasias/epidemiología , Garantía de la Calidad de Atención de Salud/estadística & datos numéricos , Radiología Intervencionista/estadística & datos numéricos , Boston/epidemiología , Femenino , Humanos , Incidencia , Infusiones Intravenosas/estadística & datos numéricos , Masculino , Falla de Prótesis
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