Association between Helicobacter pylori infection, MASLD, and liver fibrosis in patients with severe obesity: a single-center experience.

BACKGROUND AND METHODS: Our study sought to evaluate if an association exists between Helicobacter pylori (H. pylori), metabolic dysfunction- associated steatotic liver disease (MASLD), and liver fibrosis in patients with severe obesity (BMI > 35). Our retrospective study included 584 patients over the age of 18 years with severe obesity, who underwent preoperative liver transient elastography (VCTE), upper endoscopy, blood work, and intra-operative liver biopsy concurrent with bariatric surgery at a single institution from July 2020 to September 2021. Liver fibrosis scores including FIB-4, APRI, NAFLD fibrosis score, BARD score, AST: ALT ratio, and NAFLD activity score (NAS) were calculated from the laboratory results and liver biopsy findings. The presence or absence of H. pylori was determined based on gastric biopsies obtained during upper endoscopy. Other variables collected included age, gender, mean preoperative weight, BMI, and the presence or absence of comorbidities. Student's t-test and non-parametric testing were used for the analysis of continuous variables and Chi-square analysis was used for categorical data. RESULTS: Of the 584 patients, 14.7% were H. pylori positive and 85.3% were negative. Liver fibrosis scores including FIB-4, APRI, and NAFLD fibrosis scores were significantly higher in the positive group (p < 0.05), but there was no difference in AST: ALT ratio and BARD score. A significantly higher VCTE steatosis and fibrosis scores were noted in the H. pylori-positive group (p < 0.05). Similarly, a significantly higher NAS (NAFLD activity score) on liver biopsies was noted in the positive group, with all the individual components of NAS (steatosis, lobular inflammation, and hepatocyte ballooning) being significantly higher in the positive group (p < 0.05). A significantly higher incidence of fibrosis on liver biopsies was noted in the positive group overall and across all stages of fibrosis (p < 0.05). There were no significant differences between the groups in relation to gender, mean weight, BMI, presence of comorbidities including Diabetes Mellitus, and laboratory values. CONCLUSION: Our study demonstrates that H. pylori colonization or infection is associated with a higher risk of development of MASLD and progression to fibrosis. Further, population-based studies are needed to corroborate our findings.

Reduction of opioid use after implementation of enhanced recovery after bariatric surgery (ERABS).

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been extensively proven in lower gastrointestinal surgery to decrease postoperative physiologic stress and length of stay (LOS). ERAS in bariatric surgery (ERABS) varies immensely from each program with inconsistent results with a predominant goal of reducing LOS. Our focus in implementing enhanced recovery after bariatric surgery (ERABS) protocols is aimed at reducing postoperative pain and opioid use. METHODS: This is a retrospective review of patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (VSG) at a single high-volume center from June 2016 to October 2017. Patients on previous standard protocol were categorized into "Pre-Liposomal Bupivacaine (LB) group." After routine use of Exparel™, patients were grouped into "LB group." After ERABS protocol was initiated, patients were categorized into "ERABS/LB group." Postoperative opioids were converted to morphine equivalents units (MEU); pain scores, LOS, and 30-day outcomes were analyzed using combination of t test and Mann-Whitney U. RESULTS: A total of 1340 patients were included in the study: 304 patients in pre-LB group; 754 patients in LB group, and 282 patients in ERABS/LB group. Total hospital opioid use was 58.6 MEU in pre-LB, 40.8 MEU in LB, and 23.8 MEU in ERABS/LB (p = 0.01). ERABS/LB group found a 59.5% decline in MEU requirements compared to pre-LB (p < 0.001) and 44.9% of patients did not require any additional narcotics on the floor compared to 0% in pre-LB group (p < 0.001). ERABS/LB LOS was an average of 1.48 days compared to 1.54 days in pre-LB group (p = 0.03) with an overall decrease of 3.74% in readmission rates (p = 0.03). CONCLUSIONS: Implementation of ERABS significantly reduced postoperative opioid use, LOS, and readmissions. With ERABS, a more profound effect was observed than simply adding Exparel™ to preexisting protocols. Almost half of these patients did not require narcotics while recovering on the surgical floor. More studies are required to assess the true effect of ERABS without use of Exparel™.

Reversal of Roux en Y gastric bypass: largest single institution experience.

BACKGROUND: There is a paucity of literature on patients who have undergone reversal of Roux-en-Y gastric bypass (RYGB) to normal anatomy. We present the largest single institution experience with reversal of RYGB for serious chronic complications. OBJECTIVE: To describe our experience including indications, outcomes, and complications of RYGB reversal. SETTING: Academic-affiliated private practice. METHODS: Retrospective review of 48 patients who underwent laparoscopic reversal of RYGB between 2012 and 2016. RESULTS: Ninety-six percent (n = 46) of patients were female, and the mean age was 48.6 (range, 23-72). Indications for reversal of RYGB included marginal ulcer (n = 25, 12 of whom were malnourished and 17 had coexisting substance abuse), malnutrition alone (n = 11), chronic pain and nausea (n = 7), and postprandial hyperinsulinemic hypoglycemia (n = 5). Overall 30-day complication rate was 29% (n = 14), including gastrogastric anastomotic leak (n = 5), sepsis (n = 5), and bleeding requiring transfusion (n = 3). Weight gain after surgery increased in all patients, especially those patients deemed severely malnourished. All patients reported resolution of symptoms leading to reversal of RYGB, although 58% of patients were lost to follow-up at 1 year after surgery. CONCLUSIONS: Laparoscopic reversal of Roux-en-Y gastric bypass is a complex revisional operation that can be safely performed in a select group of patients with serious complications. The main indications for reversal of RYGB included malnutrition with and without recalcitrant marginal ulcers. Weight gain and resolution of malnutrition occurred soon after reversal of gastric bypass. Because the complication rates are high, reversal should be considered only after all salvage attempts have failed. Reversal to normal anatomy carries high morbidity, including sepsis, leaks and bleeding, high reoperative rates, and readmission. Although reversal of RYGB has a role in the treatment of a select group of patients, it should be undertaken by surgeons with considerable experience in RYGB revision.

Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery program: a randomized clinical trial.

BACKGROUND: Use of liposomal bupivacaine (LB) in surgery is reported with decreased postoperative opioid requirements. The efficacy of LB versus standard bupivacaine injections at laparoscopic port sites during bariatric surgery is unknown. OBJECTIVES: To determine whether there was a difference in postoperative hospital opioid requirements after port site injections of LB versus standard bupivacaine during laparoscopic bariatric surgeries. Primary endpoint was total in hospital opioid use expressed as morphine-equivalent use. Secondary endpoints included home opioid use, pain scores, hospital length of stay, and adverse events. SETTING: Academic-affiliated private practice. METHODS: A 2-group randomized, double-blinded trial from November 2017 to August 2018 with patients randomly assigned to receive either LB or bupivacaine alone at trocar site injections during laparoscopic Roux-en-Y gastric bypass (LRYGB) or vertical sleeve gastrectomy (VSG). All patients underwent enhanced recovery after bariatric surgery protocols. RESULTS: All patients undergoing LRYGB or VSG assessed for eligibility. Of 682 patients undergoing LRYGB or VSG, 231 met inclusion criteria, 52 patients excluded intraoperatively. Among 231 patients (mean age, 39.2 years; 79% women; mean body mass index 45.0), 179 patients (77%) completed the trial. Patients randomly assigned to receive either LB (n = 89) or bupivacaine alone (n = 90) at trocar site injection during LRYGB or VSG. Postoperative morphine-equivalent use were similar (LB 8.3 [standard deviation 4.0-13.9] versus bupivacaine group 7.5 [standard deviation 3.6-13.1] P = .94) with highest requirement in first 4 hours after surgery. There was no significant difference in length of stay, pain scores, or complications. There were more patients in the bupivacaine group that did not take pain medications on postoperative days 2 to 4 (P = .032, P = .23, P = .005, respectively). There were more patients in the bupivacaine group 48.1% (n = 39) compared with the LB group 34.2% (n = 27) that did not consume any narcotic tablets at home but this not found to be statistically significant (P value = .07). CONCLUSIONS: Among patients undergoing primary bariatric surgery under enhanced recovery after bariatric surgery protocol, there was no significant difference in postoperative hospital opioid use in those receiving LB compared with standard bupivacaine. A greater percentage of patients in the standard bupivacaine group did not require any narcotics at home, which was significant on postoperative days 2 to 4. To become completely opioid free after bariatric surgery, resources should be focused on multimodal approaches instead of reliance on type of anesthetic medication used.

Characteristics of the healthcare information technology workforce in the HITECH era: underestimated in size, still growing, and adapting to advanced uses.

OBJECTIVE: There is little readily available data about the size and characteristics of the healthcare information technology workforce. We sought to update a previous description of the size, growth, and characteristics of this workforce based on the Healthcare Information Management Systems Society (HIMSS) Analytics® Database, a resource that includes hospital size, number of beds, amount of staffing, and an eight-stage model of electronic health record adoption (Electronic Medical Record Adoption Model, EMRAM℠). MATERIALS AND METHODS: We updated an analysis done using a 2007 snapshot of the HIMSS Analytics Database with a comparable snapshot from 2014 in order to estimate the size of the current workforce and project future needs. For the 2014 data, we applied the same weighted average analysis used in 2007 to obtain a ratio of information technology (IT) hospital full-time equivalent (FTE) to staffed beds, extrapolate the results to all US hospitals, and project the workforce needs as hospitals achieve higher EMRAM stages. RESULTS: Our estimated size of the healthcare information technology workforce in the US in 2014 was 161 160, which was 8.0% larger than the estimate based on the 2007 data. Based on the new data, we project a potential need for an additional 19 852 and 153 114 FTE, if all hospitals were to achieve EMRAM Stages 6 and 7, respectively. The distribution of FTE across job function category varies by EMRAM stage. DISCUSSION AND CONCLUSIONS: Although these data are limited, especially for EMRAM Stage 7, there is likely need for substantial workforce growth as hospitals increase their adoption of advanced healthcare information technology. Further research with data better focused on workforce characteristics will provide a better picture of staffing requirements.

Conversion of standard Roux-en-Y gastric bypass to distal bypass for weight loss failure and metabolic syndrome: 3-year follow-up and evolution of technique to reduce nutritional complications.

BACKGROUND: Standard proximal Roux-en-Y gastric bypass (RYGB) fails to achieve long-term weight maintenance and/or control of metabolic syndrome in up to 35% of patients. OBJECTIVES: To improve the performance of the standard proximal gastric bypass by increasing the biliopancreatic limb length at the expense of the common channel. SETTINGS: Academic-affiliated private practice. METHODS: A retrospective review of all patients who underwent conversion to distal RYGB from 2010 to 2016 was performed. RYGB was modified by dividing the Roux limb at the jejunojejunostomy and transposing it distally to create a shortened total alimentary limb length (TALL) of 250 to 300 cm in the initial 11 patients. Of these, 7 developed protein calorie malnutrition and diarrhea requiring a second procedure to lengthen the common channel an additional 100 to 150 cm (TALL 400-450 cm), leading to resolution of all symptoms. The subsequent 85 patients were converted to distal RYGB with TALL 400 to 450 in a single-stage operation. RESULTS: Ninety-six RYGB patients underwent conversion to distal RYGB. The mean body mass index and mean excess weight loss at the time of distalization was 40.6 kg/m2 and 33.6%. At 1, 2, and 3 years after distalization, the mean body mass index was reduced to 34.4, 33.1, and 32.2 kg/m2, respectively, and excess weight loss improved to 41.9%, 53.7%, and 65.7%, respectively. Diabetes resolved in 66.7%, hypertension resolved in 28.6%, hyperlipidemia resolved in 40%, and sleep apnea resolved in 50% at 1 year. The 30-day complication rate and reoperation rates were 6.3% and 5.2%; an additional 7.3% (7/96) required reoperation for limb lengthening. Hypoalbuminemia developed in 21% at 3 years, but no increase in iron deficiency was observed. Calcium metabolism was affected by the distalization procedure to a greater degree as 21% of patients had low corrected calcium levels, 77% were deficient in vitamin D, and parathyroid hormone levels were above normal in 64% at 3 years. CONCLUSION: Revision of proximal RYGB to distal RYGB results in substantial improvement in weight loss and resolution of co-morbidities at 3 years. Diarrhea and protein calorie malnutrition were seen frequently in patients with TALL of 250 to 300 cm, whereas patients with TALL 400 to 450 cm demonstrated a lower incidence of nutritional issues, but the effect on calcium, parathyroid hormone, and the fat soluble vitamins A and D is still a major concern.

Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGBP) has been shown to be a safe and effective alternative to traditional "open" RYGBP. Although lack of postoperative adhesions is one advantage of minimally invasive surgery, this is also responsible for a higher incidence of internal hernias. These patients often present with intermittent abdominal pain or small bowel obstruction with completely normal contrast radiographs. METHODS: Data was obtained concurrently on 2,000 consecutive patients from February 1998 to October 2001 and analyzed retrospectively. Radiographs, when available, were interpreted by both the operative surgeon and radiologist before intervention. RESULTS: 66 internal hernias occurred in 63 patients, an incidence of 3.1%. 1 patient presented with a traditional adhesive band and small bowel obstruction. 20% of patients had normal preoperative small bowel series and/or CT scans. The site of internal hernias varied: 44 - mesocolon; 14 - jejunal mesentery; 5 - Petersen's space. Although most patients were symptomatic, 5% were incidental findings at the time of another surgical procedure. 5 patients required open repair. 6 patients presented with perforation either at the time of diagnosis or as a result of manipulation of the bowel. There was 1 death associated with complications of the internal hernia. The negative exploration rate was 2%. CONCLUSION: Internal hernias are more common following laparoscopic RYGBP than "open" RYGBP. Contrast radiographs alone are unreliable in ruling out this diagnosis. Early intervention is crucial; most repairs can be performed laparoscopically. This diagnosis should be entertained in all patients with unexplained abdominal pain following laparoscopic RYGBP. Meticulous closure of all potential internal hernia sites is essential to limit this potentially lethal complication.

Laparoscopic Roux-en-Y gastric bypass: 10-year follow-up.

BACKGROUND: The short-term benefits of bariatric surgery are well documented; however, few reports with data beyond 10 years exist. Those that have been published have described only open procedures. We present our 10-year follow-up results with laparoscopic Roux-en-Y gastric bypass with hand-sewn gastrojejunal anastomosis in a group private practice. METHODS: We performed an institutional review board-approved retrospective review of a prospectively maintained database, combined with office visits and telephone questionnaires, for patients who underwent laparoscopic Roux-en-Y gastric bypass between February 1998 and April 1999. RESULTS: A total of 242 patients underwent surgery from February 1998 to April 1999. The office follow-up rate was 33% at 2 years and 7% at 10 years. An additional 19% had telephone follow-up at 10 years. The mean excess weight loss was 57% at 10 years. Of the 242 patients, 65 (33.2%) failed to achieve an excess weight loss of >50%; 86 (35%) had ≥1 complication during follow-up. However, 83%, 87%, 67%, and 76% of patients with diabetes, hypertension, dyslipidemia, and obstructive sleep apnea, respectively, experienced improvement or resolution. The internal hernia rate was 16%, and the gastrojejunal stenosis rate was 4.9%. No surgery-related deaths occurred. Of the 242 patients, 136 (51%) had nutritional testing at least once after postoperative year 1. Of these 136 patients, only 24 (18%) had remained nutritionally intact during follow-up. CONCLUSION: The obstacles to follow-up have continued to impede the collection of accurate long-term data. Of the 26% of patients with data, laparoscopic Roux-en-Y gastric bypass provided sustainable weight loss and resolution of co-morbidities. However, nutritional deficiencies presented sporadically over time and underscore the importance of routine testing.

Pediatric palliative care and eHealth opportunities for patient-centered care.

BACKGROUND: Pediatric palliative care currently faces many challenges including unnecessary pain from insufficiently personalized treatment, doctor-patient communication breakdowns, and a paucity of usable patient-centric information. Recent advances in informatics for consumer health through eHealth initiatives have the potential to bridge known communication gaps, but overall these technologies remain under-utilized in practice. PURPOSE: This paper seeks to identify effective uses of existing and developing health information technology (HIT) to improve communications and care within the clinical setting. METHODS: A needs analysis was conducted by surveying seven pediatric oncology patients and their extended support network at the Lombardi Pediatric Clinic at Georgetown University Medical Center in May and June of 2010. Needs were mapped onto an existing inventory of emerging HIT technologies to assess what existing informatics solutions could effectively bridge these gaps. RESULTS: Through the patient interviews, a number of communication challenges and needs in pediatric palliative cancer care were identified from the interconnected group perspective surrounding each patient. These gaps mapped well, in most cases, to existing or emerging cyberinfrastructure. However, adoption and adaptation of appropriate technologies could improve, including for patient-provider communication, behavioral support, pain assessment, and education, all through integration within existing work flows. CONCLUSIONS: This study provides a blueprint for more optimal use of HIT technologies, effectively utilizing HIT standards-based technology solutions to improve communication. This research aims to further stimulate the development and adoption of interoperable, standardized technologies and delivery of context-sensitive information to substantially improve the quality of care patients receive within pediatric palliative care clinics and other settings.

[Mesenteric closure in laparoscopic gastric bypass: surgical technique and literature review]. / Cierre mesentérico en el bypass gástrico laparoscópico: técnica quirúrgica y revisión de la literatura.

Despite the advantages offered by laparoscopy in bariatric surgery, the incidence of a new complication that was uncommon in the previous era of open surgery--internal hernias--has increased. Most publications in the literature dealing with internal hernia describe the incidence and form of presentation of this entity but few explain how these complications can be prevented. In this review article we describe a technique to close mesenteric defects in retrocolic Roux-en-Y laparoscopic gastric bypass with permanent, continuous running suture (ethibond). We also review the literature in MEDLINE (www.ncbi.nlm.nih.gov/entrez/ using the key words: obesity, laparoscopy, gastric bypass, internal hernia, Petersen hernia) and references from articles of interest to determine the real incidence of this complication. Our technique has proven to be safe, reliable and reproducible and has greatly diminished the incidence of internal hernias. However, our data need to be analyzed in the future to determine whether the technique described eliminates this complication. The optimal results achieved with complete closure of all mesenteric defects have also been observed by other authors.