Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD.

INTRODUCTION: Obesity is an increasingly prevalent public health problem often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has been shown to have limited long-term efficacy in patients with morbid obesity and does not address additional weight-related co-morbidities. Roux-en-Y gastric bypass (RYGB) is the gold standard operation for durable resolution of GERD in patients with obesity, and is also used as a salvage operation for GERD after prior foregut surgery. Surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown. METHODS: A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to surgeon members of the SAGES Foregut Taskforce and to surgeons participating in the SAGES Bariatrics and/or Foregut Facebook groups. RESULTS: 187 surgeons completed the survey. 89% reported using the RYGB as an anti-reflux procedure. 44% and 26% used a BMI of 35 kg/m2 and 30 kg/m2 respectively as cutoff for the RYGB. 89% viewed RYGB as the procedure of choice for GERD after bariatric surgery. 69% reported using RYGB to address recurrent reflux secondary to failed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGB for GERD indications in their patient populations. CONCLUSION: For many patients, GERD and obesity are related diseases that are best addressed with RYGB. However, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine. Advocacy is critical to improve access to appropriate surgical care for GERD in patients with obesity.

The impact of sarcopenia on survival and complications in surgical oncology: A review of the current literature.

Sarcopenia is the subclinical loss of skeletal muscle and strength and has been extensively studied in both the cancer and surgical literature. Specifically, sarcopenia has gained significant recognition as an important prognostic factor for both complications and survival in cancer patients. Herein, we review the current literature to date highlighting the specific impact of sarcopenia in patients undergoing oncologic procedures.

Transgastric endoscopic peritoneoscopy does not lead to increased risk of infectious complications.

BACKGROUND: It remains important to determine the risk of bacterial contamination and infectious complications of the peritoneal cavity as it pertains to transgastric natural orifice translumenal endoscopic surgery (NOTES) procedures. The infectious implications of such procedures have been quantified in animal models. This report discusses the infectious risks of transgastric endoscopic peritoneoscopy (TEP) in a human clinical trial. METHODS: Under institutional review board approval, 40 patients scheduled for laparoscopic Roux-en-Y gastric bypass (LRYGB) participated in this study. The TEP procedure was performed without preoperative gastric decontamination and without laparoscopic guidance. Preoperative intravenous antibiotics were given. Saline aspirates were taken from the gastric lumen before endoscopic gastrotomy creation and from the peritoneal cavity after transgastric access. Samples were sent for culture, identification, and bacterial counts. Subgroup analysis was performed on patients taking proton pump inhibitors (PPIs). These data were compared with data for "sterile" peritoneal aspirates from a historical cohort of 50 patients undergoing LRYGB. RESULTS: The median number of bacteria isolated from the gastric aspirates was 980 colony-forming units (CFU)/ml (n=40). The median number of bacteria isolated from the peritoneal aspirates was 323 CFU/ml. Cross-contamination from the stomach to the peritoneal cavity was documented in eight cases. No abscesses or anastomotic leaks were recorded. One port-site infection occurred. Subgroup analysis of 15 patients receiving PPIs showed elevated bacterial counts in gastric aspirates and the post-TEP peritoneal samples compared with patients not receiving PPIs (n=25). This subgroup on PPI's did not have an increase in infectious complications. CONCLUSIONS: Contamination of the peritoneal cavity does occur with TEP, but this does not lead to an increased risk of infectious complications. Similarly, patients receiving PPIs have an increased gastric bacterial load and increased contamination after TEP but not an increased risk of infectious complications.

Regulation of myocardial glucose transporters GLUT1 and GLUT4 in chronically anemic fetal lambs.

Little is known about the chronic adaptations that take place in the fetal heart to allow for increased substrate delivery in response to chronic stress. Because glucose is an important fuel for the fetal cardiomyocytes, we hypothesized that myocardial glucose transporters 1 and 4 (GLUT1 and GLUT4, respectively) are up-regulated in the fetal sheep heart that is chronically stressed by anemia. Fetal sheep at 128 d gestation underwent daily isovolumic hemorrhage and determination of myocardial blood flow, oxygen consumption, and substrate utilization. At the end of 3 or 7 d of anemia, myocardial levels of GLUT1 and GLUT4 mRNA and protein were measured and subcellular localization was determined. Despite stable heart rate and blood pressure, anemia caused a nearly 4-fold increase in right and left ventricular (RV and LV) free wall blood flow. No significant change in myocardial glucose uptake was found and serum insulin levels remained stable. Both 3-d RV and LV and 7-d RV mRNA and protein levels of GLUT1 and GLUT4 were unchanged; 7-d LV GLUT1 and GLUT4 mRNA levels were also stable. However, LV GLUT1 protein levels declined significantly, whereas LV GLUT4 protein levels were increased. In the steady state, GLUT4 protein localized to the sarcolemma membrane. These findings suggest that the glucose transporters are post-transcriptionally regulated in myocardium of chronically anemic fetal sheep with changes that mimic normal postnatal development. Unlike the postnatal heart, localization of GLUT4 to the cell membrane suggests the importance of GLUT4 in basal glucose uptake in the stressed fetal heart.

Metabolic adaptation of the fetal and postnatal ovine heart: regulatory role of hypoxia-inducible factors and nuclear respiratory factor-1.

Numerous metabolic adaptations occur in the heart after birth. Important transcription factors that regulate expression of the glycolytic and mitochondrial oxidative genes are hypoxia-inducible factors (HIF-1alpha and -2alpha) and nuclear respiratory factor-1 (NRF-1). The goal of this study was to examine expression of HIF-1alpha, HIF-2alpha, and NRF-1 and the genes they regulate in pre- and postnatal myocardium. Ovine right and left ventricular myocardium was obtained at four time points: 95 and 140 d gestation (term = 145 d) and 7 d and 8 wk postnatally. Steady-state mRNA and protein levels of HIF-1alpha and NRF-1 and protein levels of HIF-2alpha were measured along with mRNA of HIF-1alpha-regulated genes (aldolase A, alpha- and beta-enolase, lactate dehydrogenase A, liver and muscle phosphofructokinase) and NRF-1-regulated genes (cytochrome c, Va subunit of cytochrome oxidase, and carnitine palmitoyltransferase I ). HIF-1alpha protein was present in fetal myocardium but dropped below detectable levels at 7 d postnatally. HIF-2alpha protein levels were similar at the four time points. Steady-state mRNA levels of alpha-enolase, lactate dehydrogenase A, and liver phosphofructokinase declined significantly postnatally. Aldolase A, beta-enolase, and muscle phosphofructokinase mRNA levels increased postnatally. Steady-state mRNA and protein levels of NRF-1 decreased postnatally in contrast to the postnatal increases in cytochrome c, subunit Va of cytochrome oxidase, and carnitine palmitoyltransferase I mRNA levels. The in vivo postnatal regulation of enzymes encoding glycolytic and mitochondrial enzymes is complex. As transactivation response elements for the genes encoding metabolic enzymes continue to be characterized, studies using the fetal-to-postnatal metabolic transition of the heart will continue to help define the in vivo role of these transcription factors.