Bariatric and metabolic surgery.

In the beginning of the 21st century obesity still represents health, social and economical threat for most of economically wealthy countries worldwide. Estimated direct costs for obesity and related comorbidities treatment exceed 5% of the total health care costs both in the US and in European Union. However, in addition there are obesity-related indirect costs linked to more frequent work sickness leave, higher unemployment rates and overall lower productivity of obese patients. Surgical treatment of obesity (bariatric surgery) is the most effective long-term treatment modality for those patients suffering from higher degrees of obesity. Bariatric surgery has not only positive effects on weight loss, but is also extremely effective in improving or resolving many of obesity-related comorbidities, which have evolved rapidly into the so-called metabolic surgery. T2DM may serve as excellent example of metabolic, obesity-related comorbidity which can be treated with bariatric-metabolic procedure even without direct relation to weight loss. In such cases bariatric surgery evolves into metabolic surgery. Thus metabolic operations (namely from the malabsorptive end) deeply influence hormonal secretion especially in the proximal part of small bowel, change parametres of entero-insular axis and have positive influence on insulin secretion, sensitivity and on the entire complex of glucose tolerance. Nowadays we can witness dramatic changes in perception of T2DM from bariatric surgeons, diabetologists, and many other medical specialists. T2DM has evolved from primarily medical disease into a condition where surgeons may play a more active role in the management of the diabetic patient. However, it has to be stressed that metabolic treatment of T2DM and other metabolic disorders need multidisciplinary approach and collaboration and that surgeon should play very important role as a multidisciplinary team member, however metabolic surgery should not yet be considered as stand-alone treatment modality.

Post-prandial reflux suppression by a raft-forming alginate (Gaviscon Advance) compared to a simple antacid documented by magnetic resonance imaging and pH-impedance monitoring: mechanistic assessment in healthy volunteers and randomised, controlled, double-blind study in reflux patients.

BACKGROUND: Alginates form a raft above the gastric contents, which may suppress gastro-oesophageal reflux; however, inconsistent effects have been reported in mechanistic and clinical studies. AIMS: To visualise reflux suppression by an alginate-antacid [Gaviscon Advance (GA), Reckitt Benckiser, UK] compared with a nonraft-forming antacid using magnetic resonance imaging (MRI), and to determine the feasibility of pH-impedance monitoring for assessment of reflux suppression by alginates. METHODS: Two studies were performed: (i) GA and antacid (Alucol, Wander Ltd, Switzerland) were visualised in the stomach after ingestion in 12 healthy volunteers over 30 min after a meal by MRI, with reflux events documented by manometry. (ii) A randomised controlled, double-blind cross-over trial of post-prandial reflux suppression documented by pH-impedance in 20 patients randomised to GA or antacid (Milk of Magnesia; Boots, UK) after two meals taken 24 h apart. RESULTS: MRI visualized a "mass" of GA form at the oesophago-gastric junction (OGJ); simple antacid sank to the distal stomach. The number of post-prandial common cavity reflux events was less with GA than antacid [median 2 (0-5) vs. 5 (1-11); P < 0.035]. Distal reflux events and acid exposure measured by pH-impedance were similar after GA and antacid. There was a trend to reduced proximal reflux events with GA compared with antacid [10.5 (8.9) vs. 13.9 (8.3); P = 0.070]. CONCLUSIONS: Gaviscon Advance forms a 'mass' close to the OGJ and significantly suppresses reflux compared with a nonraft-forming antacid. Standard pH-impedance monitoring is suitable for clinical studies of GA in gastro-oesophageal reflux disease patients where proximal reflux is the primary outcome.

Barriers to accessing care in patients with chronic hepatitis C: the impact of depression.

BACKGROUND: Patients with hepatitis C viral (HCV) may perceive barriers to accessing speciality care for HCV, and these barriers may be related to depressive symptoms. AIM: To evaluate the relationship between barriers to care, demographics, and depressive symptoms. METHODS: A cross-sectional analysis of 126 patients referred for HCV at two speciality HCV clinics. Barriers to care, depressive symptoms and sociodemographics were measured using standardized instruments. A retrospective chart review was conducted to collect clinical outcome data. RESULTS: Depressive symptoms were reported in 26%. Common barriers included lack of personal financial resources; lack of HCV knowledge in the community; lack of professionals competent in HCV care; stigmatization of HCV; and long distances to clinics offering care. After we controlled for sociodemographics, depression accounted for an additional 7-18% of variability in all barriers (all p values <0.01). Lower depression, marital and employment status were associated with subsequent receipt of HCV treatment in 38% (45/120) of patients; perceived barriers were not. CONCLUSIONS: Depression is independently associated with perceived barriers to care. Higher depressive scores, but not perceived barriers, were associated with nontreatment. Healthcare providers who diagnose HCV need to be cognizant of numerous perceived barriers to accessing HCV care, and the impact that depression may have on these perceptions and receipt of treatment.

Excellent agreement between genetic and hydrogen breath tests for lactase deficiency and the role of extended symptom assessment.

Clinical manifestations of lactase (LCT) deficiency include intestinal and extra-intestinal symptoms. Lactose hydrogen breath test (H2-BT) is considered the gold standard to evaluate LCT deficiency (LD). Recently, the single-nucleotide polymorphism C/T(-13910) has been associated with LD. The objectives of the present study were to evaluate the agreement between genetic testing of LCT C/T(-13910) and lactose H2-BT, and the diagnostic value of extended symptom assessment. Of the 201 patients included in the study, 194 (139 females; mean age 38, range 17-79 years, and 55 males, mean age 38, range 18-68 years) patients with clinical suspicion of LD underwent a 3-4 h H2-BT and genetic testing for LCT C/T(-13910). Patients rated five intestinal and four extra-intestinal symptoms during the H2-BT and then at home for the following 48 h. Declaring H2-BT as the gold standard, the CC(-13910) genotype had a sensitivity of 97% and a specificity of 95% with a κ of 0.9 in diagnosing LCT deficiency. Patients with LD had more intense intestinal symptoms 4 h following the lactose challenge included in the H2-BT. We found no difference in the intensity of extra-intestinal symptoms between patients with and without LD. Symptom assessment yielded differences for intestinal symptoms abdominal pain, bloating, borborygmi and diarrhoea between 120 min and 4 h after oral lactose challenge. Extra-intestinal symptoms (dizziness, headache and myalgia) and extension of symptom assessment up to 48 h did not consistently show different results. In conclusion, genetic testing has an excellent agreement with the standard lactose H2-BT, and it may replace breath testing for the diagnosis of LD. Extended symptom scores and assessment of extra-intestinal symptoms have limited diagnostic value in the evaluation of LD.

Assessment of the airway in obstructive sleep apnea syndrome with 3-dimensional airway computed tomography.

OBJECTIVE: The goal was to evaluate 3-dimensional airway CT for upper airway assessment in obstructive sleep apnea syndrome (OSAS). DESIGN: Airway CT was obtained and 3-dimensional airway models were constructed prospectively for 40 patients with OSAS and 10 controls. Airway dimensions were correlated with polysomnography, and comparison was made between patients with and without OSAS. RESULTS: OSAS patients had a mean respiratory distress index of 51.9 events per hour. The mean minimum cross-sectional area (XSA) in the neutral position was 67.1 mm(2). Minimum XSA decreased in both the inspiratory and expiratory phases to 16.3 mm(2) and 15.0 mm(2), respectively (P<0.001). Complete airway obstruction occurred in 1 or more phases of respiration in 28 patients. Neither airway XSA nor length of obstruction correlated with sleep apnea parameters. No statistically significant differences in airway dimensions were found between OSAS and control patients. CONCLUSIONS: Airway CT demonstrates dynamic airway obstruction in OSAS but does not correlate well with clinically important disease parameters.

Abortion in the United States: barriers to access.

The legalization of abortion in the United States has brought a dramatic improvement in women's health and reductions in maternal and infant mortality. For young women, low-income women, and women of color, however, access to abortion has been increasingly restricted. This article describes the obstacles to abortion access, including lack of federal funding; restrictive laws, encompassing those requiring parental consent or notification for a minor seeking an abortion, as well as those attempting to ban a certain procedure; stigmatization and marginalization of abortion; decreasing abortion services; and a shortage of providers. The article connects the erosions in rights relating to abortion to policies undermining poor women's rights in relation to having children.

Cost analysis of antibiotic prophylaxis for PEG.

BACKGROUND: There are conflicting recommendations regarding the prophylactic use of antibiotics in patients undergoing placement of percutaneous endoscopic gastrostomy tubes. The purpose of this decision analysis was to assess the cost-effectiveness of antibiotic prophylaxis in percutaneous endoscopic gastrostomy. METHODS: A decision tree was modeled using the data of 7 published prospective placebo-controlled trials. Infectious complications were classified as grade I (requiring local care), grade II (requiring intravenous antibiotics), or grade III (requiring surgery). Medication costs were estimated from the United States average wholesale prices of the 1998 Red Book. Physician and facility costs were estimated based on the 1998 Medicare costs. A one-way sensitivity analysis was performed by varying the probability rates of the complications associated with percutaneous endoscopic gastrostomy and the costs of their treatment. RESULTS: The average cost of prophylactic antibiotics was $13.10. Antibiotic prophylaxis led to expected cost savings of $76.72 per percutaneous endoscopic gastrostomy. A sensitivity analysis suggested that antibiotic prophylaxis for percutaneous endoscopic gastrostomy was the preferred strategy unless the average probability of grade III complications dropped below an improbably low threshold value of 0.09%. CONCLUSION: Antibiotic prophylaxis in percutaneous endoscopic gastrostomy is a cost-effective strategy.

Assessment of gastric motor function during the emptying of solid and liquid meals in humans by MRI.

Gastric emptying and motility have previously been assessed by magnetic resonance imaging (MRI) using liquid test meals. The aim of this study was to extend the applicability of our MRI method to the assessment of gastric emptying and motility of solid meals. Gastric emptying and motility of a liquid and a solid meal, of similar chemical properties, were studied in eight volunteers. The MRI protocol combined a multislice turbo spin-echo (TSE) sequence (volume scan, resolution: 1.5 mm) and a dynamic FFE sequence (motility scan, 1 sec/image, resolution: 3.1 mm). Gastric emptying of the liquid meal was faster than emptying of the solid meal when considering half-times of emptying. However, during the first 15 minutes after ingestion, the liquid meal emptied more slowly. This was related to reduced motility with the liquid meal. In conclusion, with our MRI method it is feasible to assess gastric emptying and motility of liquid and solid meals.

The role of laparoscopy in the treatment of morbid obesity.

BACKGROUND: Laparoscopic surgery was established as a regular surgical technique 11 years ago. There are still some controversies among surgeons about the benefits of this method. METHOD: A retrospective 3-year analysis of immediate and long-term complication rates, hospitalization length, and weight loss following laparotomic and laparoscopic nonadjustable gastric banding in 150 and 145 patients, respectively, was undertaken. Some of the criteria usually used for comparison of results in laparotomy and laparoscopy in general surgery were used in this analysis as background for the comparison of the two groups of obese patients. One example of the different results of the laparotomic and laparoscopic approaches in bariatric surgery was provided by obese monozygotic twins who underwent surgery the same day in our department, one by laparotomy and the other by laparoscopy. There was a significant difference in hospitalization length, in required postoperative analgesia, and in levels of c-reactive protein. RESULTS: There was no statistical difference in intraoperative complication rates in the two groups, but there was a significant difference in immediate and long-term postoperative complications of wound discharge and incisional hernias. The obese twins illustrate the significant difference in postoperative c-reactive protein levels and in length of operating time and hospitalization in favor of laparoscopy, and this difference supports our results in much larger groups of genetically unrelated patients who were studied. CONCLUSION: At the end of the 10-year period of laparoscopic surgery for bariatric procedures, the results were impressive. The laparoscopic approach to surgery for morbid obesity was of considerable value in terms of low morbidity and mortality.

Gastric emptying and motility: assessment with MR imaging--preliminary observations.

PURPOSE: To evaluate a magnetic resonance (MR) imaging method for simultaneous assessment of gastric emptying and motility. MATERIALS AND METHODS: Gastric emptying and motility were measured in nine volunteers after ingestion of a liquid meal. A specially designed MR imaging protocol was used that allowed simultaneous assessment of gastric emptying (spatial resolution, 1.5 mm; corrected for gastric secretion volume) and gastric motility (temporal resolution, 1.2 seconds; spatial resolution, 3.1 mm). To evaluate the ability to detect small changes in gastric motor activity with findings from this method, the influence of a prokinetic agent (loxiglumide) on gastric emptying and motility was tested in five volunteers. RESULTS: Each contraction could be individually visualized at MR imaging. Administration of loxiglumide resulted in decreased gastric half-emptying time (mean +/- 1 standard error of the mean, 88.1 minutes +/- 6.3 for the placebo and 39.1 minutes +/- 6.7 for loxiglumide) and increased gastric motility (contraction frequency, 2.26 contractions per minute +/- 0.15 for the placebo and 3.04 per minute +/- 0.04 for loxiglumide). CONCLUSION: MR imaging makes it feasible to study gastric emptying and gastric motility and to determine the influence of drugs on gastric motor activity.

Assessment of the outcome of laparoscopic nonadjustable gastric banding and stoma adjustable gastric banding: surgeon's and patient's view.

BACKGROUND: The results of nonadjustable gastric banding (NAGB) and stoma adjustable gastric banding (SAGB) in the treatment of morbid obesity are compared. Of 300 patients operated laparoscopically with NAGB since 1993 and of 25 with SAGB since 1994, 65 in the NAGB and 11 in the SAGB group were available for a 3-year follow-up study. METHODS: For assessment of the outcome of our laparoscopic approach in terms of weight loss, length of hospitalization, immediate and late postoperative wound complications, postoperative changes in the band and pouch area, were compared in patients from both groups. The patient's opinion on the outcome of the operation and the quality of postoperative digestion was recorded. RESULTS: There was no significant difference in the length of hospital stay and wound complication rate in the two groups or the weight loss at 36 months after surgery. There was a statistically significant lower incidence of postoperative food intolerance and vomiting and a lower rate of immediate and long-term reoperation rate in the SAGB group. CONCLUSION: SAGB is a method with less postoperative complications in food intolerance and vomiting in comparison with NAGB.

Assessment of monoethylglycinexylidide as measure of liver function for patients with chronic viral hepatitis.

The liver metabolizes lidocaine by oxidative deethylation to form monoethylglycinexylidide (MEGX), an analyte proposed as an index of liver function. We determined MEGX and lidocaine serum concentrations with the TDx (Abbott Laboratories) at baseline and 15, 30, 60, and 90 min after the intravenous administration of lidocaine (1 mg/kg), analyzing specimens from 12 apparently healthy volunteers and 40 patients with chronic viral hepatitis diagnosed by liver biopsy and serum tests. The patients were grouped on the basis of the histology activity index. The following laboratory tests were performed on serum specimens from all subjects: albumin (ALB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, total bilirubin, and prothrombin time. The results showed no significant difference among the four groups for the concentrations of MEGX, lidocaine, and lidocaine/MEGX at the four time points. However, the concentrations of ALB, ALT, AST, AST/ALT, and prothrombin time were substantially different among the four groups. Thus, we conclude that assay of MEGX in our patients with chronic viral hepatitis did not contribute to the assessment of liver function when compared with apparently healthy volunteers and traditional tests of liver function.

Preliminary assessment of three-dimensional magnetic resonance imaging for various colonic disorders.

BACKGROUND: Improvements in magnetic resonance imaging (MRI) technology have enabled the acquisition of three-dimensional MRI datasets in a single breath hold. We adopted this technique to make a three dimensional intraluminal and extraluminal assessment of the colon in three patients with various colonic disorders. METHODS: One patient was studied after having a double-contrast barium enema. Two patients had MRI scans after colonoscopy, which showed three colonic tumours in one and multiple polyps in the ascending colon of the other. The process of rectal filling with 1.5-2.0 L water mixed with 15-20 mL 0.5 mol/L gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA) was monitored with MR fluoroscopic sequence. Three-dimensional datasets of the contrast-filled colon were taken with patients in prone (before and after intravenous administration of 0.1 mmol/kg bodyweight Gd-DTPA) and supine positions. 64 sections with a voxel-resolution of 2.0 x 2.0 x 1.25 mm3-were taken during a 28 s breath hold. Three-dimensional maximum intensity projection, multiplanar reconstruction, and virtual colonoscopic images of the colon were created from these. FINDINGS: Analysis of the coronal source images in conjunction with multiplanar reconstructions revealed all relevant abnormalities, including diverticula, carcinomas, and polyps. Three dimensional maximum-intensity projections gave a morphological overview of the whole colon. Targeted projections, made up of a limited number of coronal source images, showed diverticula and smaller polyps more clearly. After patients were given intravenous contrast all colonic mass lesions were enhanced. Datasets obtained in prone patients gave the best intraluminal views of the colon. Virtual magnetic resonance colonoscopy showed colonic haustra as well as the ileocaecal valve, but did not show clearly the diverticula. All intraluminal mass lesions, on the other hand, were easy to see. INTERPRETATION: The potential of three-dimensional colonic MRI to provide accurate, minimally invasive, cost-effective polyp screening, as well as comprehensive colonic tumour staging, warrants further investigation.

Underutilization of upper gastrointestinal endoscopy.

BACKGROUND & AIMS: Efforts to reduce costs in health care may raise concerns about underuse of medical procedures. This study prospectively assessed underuse of upper gastrointestinal endoscopy in a cohort of patients in whom we have recently published data on overuse of endoscopy. METHODS: Underuse was identified by formal necessity criteria for endoscopy, obtained by an explicit panel process. Outpatients were consecutively included in two clinical settings. Setting A consisted of 20 primary care physicians and 7215 patient visits that occurred within 1 month. Setting B consisted of 920 visits that occurred during 3 weeks at an outpatient clinic. RESULTS: During these 8135 visits, 611 patients complained of upper digestive symptoms; 63 of them underwent endoscopy. Underuse was identified in 72 patients (11.8%). The two clinical situations mainly responsible for underuse of endoscopy were uninvestigated peptic symptoms resistant to treatment and dysphagia. At first follow-up, 29 of the patients with initial underuse still fulfilled criteria of necessity (underuse rate, 4.7%). One-year follow-up showed underuse of endoscopy in 5 patients. CONCLUSIONS: This prospective evidence shows that underuse of a medical procedure exists. The estimated overuse and underuse of endoscopy in this cohort were approximately equal (5%). Improving quality of care will require reductions of both overuse and underuse of medical procedures.

[Assessment of gastric emptying]. / Messung der Magenentleerung.

In the absence of overt mucosal lesions, abnormalities of gastroduodenal motorfunction are considered to be important in the pathogenesis of many upper abdominal symptoms. These may be idiopathic, occur following gastric surgery, or in association with diseases such as diabetes mellitus. A variety of investigations have been developed to examine the motility of the stomach and duodenum. To date the most reliable and useful techniques are those which assess gastric transit either radiologically or scintigraphically. Assessment of the expulsion of radio-opaque gastric markers with a single abdominal x-ray can be performed as a simple outpatient screening procedure. More precise radioisotopic definition of delayed gastric emptying, however, requires access to a Nuclear Medicine Department. A number of other approaches are currently under investigation as potential diagnostic tests. The future role of these techniques is unclear, although 13C breath testing may soon permit rapid and simple screening of gastric emptying abnormalities without exposure to ionizing radiation. At present, other techniques such as ultrasound, antropyloroduodenal manometry, and magnetic resonance imaging have application only in research centers.

[Motility disorders and assessment methods of the esophagus]. / Motilitätsstörungen und Untersuchungsmethoden des Osophagus.

Esophageal diseases frequently cause symptoms such as heartburn, epigastric pain and dysphagia. This article discusses the indications, techniques and limitations of currently available diagnostic procedures. Investigation of symptoms should proceed in a logical stepwise manner, beginning with endoscopy to exclude esophagitis or neoplasia. Symptoms due to acid reflux can be identified by 24h esophageal pH-metry to document a temporal association between symptoms and episodes of esophageal acidification. Stationary or ambulatory manometric recording of esophageal pressures can be used to diagnose esophageal motor disorders such as achalasia, nutcracker esophagus, diffuse esophageal spasm, or dysfunction of the upper or lower esophageal sphincter. Combined 24 h pH-manometry should be used to test the temporal association between pain, reflux, or abnormal motility in patients with non-cardiac chest pain. Video-fluoroscopy is the most appropriate technique to diagnose swallowing disorders. Pulmonary aspiration of gastro-esophageal reflux can be documented with scintigraphy.

The cystic fibrosis gene and resting energy expenditure.

To determine whether the increase in resting energy expenditure in cystic fibrosis is associated with the primary genetic defect (delta F508) or with declining pulmonary function, or both, we tested resting every energy expenditure prospectively in 32 male subjects (aged 7 to 39 years) who were normally nourished and had good pulmonary function. They were categorized into three genotype groups on the basis of the presence or absence of delta F508 and pancreatic function. Mean resting energy expenditure was 104% of the predicted value and was not associated with genotype. When 29 subjects with normal nutritional status but variable lung function were added to the group, there was a strong correlation between declining pulmonary function and increased resting energy expenditure. We conclude that increased resting energy expenditure in normally nourished boys and men with cystic fibrosis appears to be more closely associated with declining pulmonary function than with genotype.

Negative BACTEC 460-TB cultures. How long to incubate?

Current guidelines for all mycobacterial cultures require at least eight weeks of incubation. Thirty months' experience of 3,662 specimens with the BACTEC TB was reviewed. At the end of four weeks of incubation, 96.8% of the 343 isolates were detected and by the end of the fifth week, 98.8%. The additional three weeks' incubation cost estimates were $1,016.20 for 92 hours of labor. Of the four late yields, only one may have had any clinical significance. The authors' recommendation is that the eight weeks' incubation guidelines for all mycobacterial cultures and especially for the BACTEC TB be comprehensively reviewed to determine clinical relevance and cost effectiveness of incubation of the BACTEC TB vial beyond five weeks.

An animal model for the assessment of microvascular patency.

A tubed superficial epigastric flap (TSEF), based on a single vascular pedicle, was designed in a rat. Forty TSEFs were created in three control groups: in 20 TSEFs both the femoral artery and vein were ligated proximal to the take-off of the superficial epigastric vessels, in 10 TSEFs the femoral artery and in the other 10 the femoral vein were ligated and transected at the same location. All TSEFs in the control groups sloughed, reflecting the dependence on the axial vasculature. A further 232 TSEFs were made with a survival rate of 84.5% (196/232). Delayed arterial or venous ligation was then performed up to 42 days after the initial surgery. The patency of the axial vein was crucial for survival for only the first postoperative week. The axial arterial patency was needed for survival of the TSEF for 6 weeks. The creation of this TSEF fulfills the need for a simple model that is as readily constructed as other models, is reproducible, has a high success rate and most importantly, reflects the patency of its nutrient vessels for a prolonged period of time.