Banded sleeve gastrectomy--initial experience.

BACKGROUND: Isolated sleeve gastrectomy is being used with increasing frequency for the treatment of morbid obesity. This study was done to determine the potential benefit of placing a band of processed human dermis around the upper portion of a sleeve gastrectomy to prevent late dilatation and weight gain. METHODS: Twenty-seven patients underwent a sleeve gastrectomy followed by placement of a band of biological tissue (AlloDerm) placed 6 cm from the gastroesophageal junction. The results were compared to 54 patients with a Roux-en-Y gastric bypass (GBP), matched for sex, age, and initial body mass index. RESULTS: All 27 patients had improvement or resolution of their diabetes, hypertension, hyperlipidemia, and sleep apnea after banded sleeve gastrectomy (BSG) similar to the control GBP group. There were no deaths, but one patient had a pulmonary embolus and another had a presumed leak. Symptoms of gastroesophageal reflux disease generally improved. Overall, results were almost identical to patients with GBP. CONCLUSIONS: BSG provides results comparable to GBP in the short-term follow-up, but avoids potential long-term complications including internal hernias, postoperative bowel obstructions, anastomotic complications of the jejunojejunostomy, hypoglycemia, bacterial overgrowth, and a spectrum of malabsorptive problems. While this study documents the feasibility and possible benefits of this modification, prospective controlled studies with long-term follow-up are needed to establish its place in procedures for surgical weight loss.

Prevention of surgical site infections by an infusion of topical antibiotics in morbidly obese patients.

BACKGROUND: The reported incidence of surgical site infection after abdominal surgery in morbidly obese patients is high (about 15% in most studies), and this is associated with considerable disability and an increased economic burden. Topical antibiotics may reduce the incidence of serious infections. METHODS: Standard techniques for the prevention of surgical site infections were used along with the introduction of kanamycin into the subcutaneous space of morbidly obese patients at the time of closure and allowing it to dwell for 2 h. Eight hundred thirty-seven evaluable patients were followed for the development of site complications for at least six weeks postoperatively. RESULTS: One of the 65 patients with a revisional procedure had a primary deep incisional surgical site infection, as did one of the 772 patients with a primary operation. Secondary deep incisional surgical site infections occurred in four patients, two after spontaneous evacuation of a seroma, one from excessive superficial contamination, and one following separation of a nonhealing surgical site. Additionally, 21 patients had minor surgical site complications including incisional separation and stitch-related infections, which required no significant expenditure of resources. CONCLUSIONS: Prolonged contact (2 h) of topical kanamycin solution with the surgical site greatly reduces the incidence of primary infections in the deep subcutaneous space of laparotomy sites in morbidly obese patients.

Improvement and stabilization of chronic kidney disease after gastric bypass.

BACKGROUND: To more clearly establish the extent to which surgical weight loss can alter the course of established renal disease at a bariatric surgical service at a university-affiliated hospital. METHODS: Of a series of 45 nontransplant patients with established renal disease who had undergone gastric bypass, 9 had resolution, improvement, or stabilization of their kidney function. Two of these patients were already receiving, or were ready for, dialysis. Their average age at gastric bypass was 43.0+/-4.3 years, and their mean body mass index was 48.9+/-1.9 kg/m2. Of these 9 patients, 5 had a primary diagnosis of focal segmental glomerulosclerosis, 2 had membranous glomerulonephritis, and 2 had diabetic nephropathy. RESULTS: No leaks, splenic injury, transfusions, infections starting in the deep parts of the wound, death, or serious complications occurred. One patient had biopsy-proven membranous glomerulonephritis that completely resolved and has had 9 years of postoperative follow-up. The 2 dialysis patients were able to discontinue dialysis for 27 and 7 months, respectively. The remaining patients had stable renal function for 2-5 years postoperatively. CONCLUSION: In some patients with chronic kidney disease, gastric bypass results in stabilization or improvement of their kidney disease. Excess body weight loss seems to have the most positive effect in patients with obesity-related focal segmental glomerulosclerosis.

Influence of long chain polyunsaturated fatty acids and ornithine concentrations on complications after renal transplant.

OBJECTIVES: The present study, registered at clinicaltrials.gov with the unique registration number NCT00560014, sought to evaluate the relations between fatty acid concentrations in red blood cells or plasma and amino acid concentrations in plasma on rejection, calcineurin inhibitor toxicity, and new-onset diabetes mellitus. MATERIALS AND METHODS: Lipid profiles on plasma or red blood cell samples were performed preoperatively and postoperatively in 54 patients. Plasma amino acid profiles were obtained in 49 of these patients. RESULTS: High concentrations of total omega-3 fatty acids, eicosapentaenoic and docosahexaenoic acids in red blood cells, and ornithine in plasma, all were associated with a significantly lower incidence of rejection, whereas high total omega-6 fatty acids were associated with a high rejection rate. Calcineurin inhibitor toxicity was associated with low levels of docosahexaenoic acid, ornithine, and the omega-3 index, and high total omega-6 and omega-3/omega-6 ratios. Inhibition of new-onset diabetes mellitus was seen only with high levels of ornithine. Peak concentrations of fatty acids in red blood cells were not obtained until after 30 days. High levels of arginine were not associated with reduced complications. CONCLUSIONS: The levels of selected nutrients in plasma and red blood cell membranes appear to have a profound effect on complications after renal transplant. These preliminary results need confirmation in prospective randomized clinical trials.

The impact of medicaid status on outcome after gastric bypass.

BACKGROUND: Socioeconomic status has been a predictor of poor outcome in many surgical diseases including morbid obesity. Potential differences in treatment and initial severity of disease have often not been well controlled in patients with bariatric surgery. This study was performed to compare the results of bariatric procedures in financially disadvantaged Medicaid patients compared to patients with Medicare and those with Commercial insurance under controlled conditions. METHODS: Prospectively collected data from 183 Medicaid, 77 Medicare and 570 Commercial/self-pay insurances were compared to determine the influence of poor economic status on outcome. All the patients received surgical care by the same surgeon at a large University-affiliated private hospital. RESULTS: Medicaid patients were larger (BMI 58.4 vs. 52.8 and 50.9, respectively) and had a greater incidence of serious comorbid conditions at outset. The death rate and complications were also significantly higher postoperatively in Medicaid patients. However, when the patients were matched for age and BMI, results became similar. CONCLUSION: Increases in postoperative mortality and morbidity appear to be associated with advanced disease because of poor access to care. When matched for age, BMI, and severity of disease, outcomes are similar. Changes in Medicaid policies could improve access and outcome.

Gastric bypass for morbidly obese patients with established cardiac disease.

BACKGROUND: Bariatric surgery has often been avoided in patients with known cardiac disease because of the risks inherent in this patient population. This study was done to evaluate both the risks and benefits of Roux-en-Y gastric bypass (RYGBP) in morbidly obese patients with established cardiac disease. METHODS: Data were analyzed to compare preoperative with postoperative co-morbid cardiac risk factors, peri-operative and postoperative complications, and change in body mass index (BMI) in 77 consecutive patients who had a preoperative diagnosis of cardiac disease and underwent RYGBP between March 1998 and January 31, 2006. Findings were compared to a concomitant control group without cardiac disease. RESULTS: The preoperative presence of cardiac disease was manifested primarily as coronary artery disease (CAD) (45 patients) or as congestive heart failure (CHF) (32 patients). Of the patients with CAD, 60% had diabetes, 91% had hypertension and 39% had hyperlipidemia. 58% had one or more prior invasive cardiac procedures. In the CHF group, 50% had diabetes, 71% had hypertension and 44% had hyperlipidemia. The average length of stay was 3.7 days for CAD patients and 3.3 days for CHF compared to 3.0 days for controls. All co-morbid conditions were improved, and no patient died from cardiac disease. However, one patient died as a complication of GI bleeding, one patient subsequently underwent revascularization and another underwent stenting. Other complications up to 5 years postoperatively were frequent but seldom life-threatening. CONCLUSION: RYGBP surgery in patients with existing cardiac disease appears to have acceptable risk and is effective in reducing the co-morbid conditions of diabetes, hypertension, hyperlipidemia, sleep apnea and arthritis, but longer term data are needed.

Simultaneous corticosteroid avoidance and calcineurin inhibitor minimization in renal transplantation.

Steroids and calcineurin inhibitors (CNI) have been mainstays of immunosuppression but both have numerous side effects that are associated with substantial morbidity and mortality. This study was carried out to determine if steroids can be eliminated with early discontinuation of cyclosporine A (CsA) and later discontinuation of mycophenolate mofetil (MMF). Ninety-six patients with kidney transplants were entered into four subgroups of two pilot studies. All patients received Thymoglobulin induction, rapamycin (RAPA), and the immunonutrients arginine and an oil containing omega-3 fatty acids. Mycophenolate mofetil was started in standard doses and discontinued by 2 years. CsA was given in reduced doses for either 4, 6, or 12 months. Follow-up was 12-36 months. Thirteen first rejection episodes occurred during the first year (14%). Combining all patients, 86% were rejection-free at 1 year, 80% at 2 years and 79% at 3 years. No kidney has been lost to acute rejection. Ninety percent of the 84 patients at risk at the end of the study were steroid-free and 87% were off CNI. Fifty-seven percent of 54 patients with a functioning kidney at 3 years were receiving monotherapy with RAPA. We conclude that this therapeutic strategy is worthy of a prospective multi-center clinical trial.

The influence of immunomodulatory diets on transplant success and complications.

BACKGROUND: Animal studies have shown that dietary supplementation with arginine and lipids containing the omega-3 and omega-9 fatty acids prolong allograft survival in animals receiving a short course of low-dose cyclosporine. They also reduce cardiovascular complications and infections in humans. METHODS: Adult renal transplant patients receiving standard immunosuppression were stratified according to gender, diabetic state, donor source (LD or CD), and first versus repeat transplant, and randomized to receive or not receive supplemental arginine and canola oil (containing both omega-3 and omega-9 fatty acids) twice daily. Patients were followed for a minimum of 3 years. RESULTS: Seventy-six patients were randomized to the supplement group (S) and 71 patients to the control group (C). Intent-to-treat analysis revealed that S patients had fewer post-30 day first rejection episodes (5.4%) when compared with the C group (23.7%) (P=0.01) and fewer post-30 day episodes of calcineurin inhibitor (CNI) drug toxicity (9.2% vs. 35.3%, P=0.003). S patients developed new onset diabetes mellitus (NODM) less frequently by 3 years (2.3% vs. 14.5%, P=0.04), had fewer cardiac events (5.0% vs. 17.1%, P=0.05), and fewer episodes of sepsis (6.5% vs. 18.7%, P=0.05). CONCLUSIONS: Dietary supplementation with L-arginine and canola oil is a safe, inexpensive, and unique treatment, which is associated with decreased rejection rates and CNI toxicity after the first month in renal transplant patients. Due to reductions in NODM and cardiac events, long-term benefits for patient survival may be particularly important.

Can immunonutrients reduce rejection rates in African Americans?

OBJECTIVES: African-American kidney allograft recipients have higher rates of rejection than do white patients. This study was performed to determine whether the use of immunonutrients may reduce the incidence of rejection in African Americans. MATERIALS AND METHODS: Two studies have been done at our institution that demonstrate that immunonutrients can reduce the incidence of rejection, calcineurin inhibitor toxicity, and cardiovascular risk factors. The data were analyzed to determine whether or not a preferential benefit exists for race. RESULTS: Twenty-four African-American patients received supplements and 28 did not. One patient (4.2%) who had received supplements had a rejection episode in the first year compared with 7 patients (25%) who did not receive supplements (P < .011). This compares with our rejection rate of 25% (14/56) for African Americans on other protocols without concurrent immunonutrients (P < .003). CONCLUSIONS: Immunonutrients appear to have a preferential beneficial response in reducing rejection in African-American patients. A randomized, prospective, clinical trial is warranted to further elucidate these results.

Gastric bypass in morbidly obese patients with chronic renal failure and kidney transplant.

BACKGROUND: Morbid obesity occurs frequently in patients with renal failure and is associated with an increased mortality, particularly from cardiovascular disease, as well as a marked increase in comorbid conditions affecting quality of life. Morbid obesity is also associated with an increased risk of complications and death in transplant patients and is often a cause for denial for access to transplantation. METHODS: Thirty morbidly obese patients with chronic renal failure or transplantation underwent gastric bypass (GBP). Nineteen patients had chronic renal failure at the time of GBP, eight had transplantation followed by GBP, and three had GBP and then transplantation. RESULTS: The reduction in excess body mass index (above 25) after GBP at 1, 2, and 3 years was similar to patients without transplantation or chronic renal failure, approximately 70% at 1 year. Comorbid conditions were diminished in each subset of patients, decreasing their risk for potential cardiovascular complications. One patient died 7.9 years after a GBP and 6.1 years after transplantation from cardiovascular disease related to longstanding diabetes that was present before her renal failure. CONCLUSIONS: GBP is a safe and effective means for achieving significant long-term weight loss and relief of comorbid conditions in patients with renal failure on dialysis, in preparation for transplantation, or after transplantation.