Relation of body mass index to long-term survival and cardiac remodelling for patients undergoing mitral valve replacement surgery.

BACKGROUND AND AIMS: Studies have demonstrated that obesity is paradoxically associated with reduced mortality following cardiac surgery. However, these studies have treated various types of cardiac surgery as a single entity. With mitral valve (MV) surgeries being the fastest-growing cardiac surgical interventions in North America, the purpose of this study was to identify the impact of body mass index (BMI) on long-term survival and cardiac remodelling of patients undergoing MV replacement (MVR). METHODS AND RESULTS: In this retrospective, single-center study, 1071 adult patients who underwent an MVR between 2004 and 2018 were stratified into five BMI groups (<20, 20-24.9, 25-29.9, 30-34.9, >35). Cox proportional hazard regression models were used to determine the association between BMI and all-cause mortality. Patients who were underweight had significantly higher all-cause mortality rates at the longest follow-up (median 8.2 years) than patients with normal weight (p = 0.01). Patients who were in the obese group had significantly higher readmission rates due to myocardial infarction (MI) at the longest follow-up (p = 0.017). Subgroup analysis revealed a significant increase in long-term all-cause mortality for female patients who were underweight. Significant changes in left atrial size, mitral valve peak and mean gradients were seen in all BMI groups. CONCLUSIONS: For patients undergoing mitral valve replacement, BMI is unrelated to operative outcomes except for patients who are underweight.

The effects of body mass index on long-term outcomes and cardiac remodeling following mitral valve repair surgery.

BACKGROUND: Previous literature has demonstrated equivalent or improved survival post mitral valve (MV) surgery amongst patients with obesity when compared to their normal-weight counterparts. This relationship is poorly understood and the impact of body mass index (BMI) on cardiac remodeling has not been established. METHODS: In this retrospective, single-center study, we sought to identify the impact that BMI may have on long-term outcomes and cardiac remodeling post-MV repair. Outcomes were compared between patients of varying BMI undergoing MV repair between 2004 and 2018. The primary outcome was mortality and secondary outcomes included stroke, myocardial infarction, reoperation of the MV, rehospitalization, and cardiac remodeling. RESULTS: A total of 32 underweight, 249 normal weight, 249 overweight, 121 obese, and 50 morbidly obese patients were included in this study. Underweight patients had increased mortality at longest follow-up. Patients with morbid obesity were found to have higher rates of readmission for heart failure. Only underweight patients did not demonstrate a significant reduction in LVEF. Patients with normal weight and overweight had a significant reduction in left atrial size, and patients with obesity had a significant reduction in MV area. CONCLUSIONS: An obesity paradox has been identified in cardiac surgery. While patients with obesity have higher rates of comorbidities preoperatively, their rates of mortality are equivalent or even superior to those with lower BMI. The results of our study confirm this finding with patients of high BMI undergoing MV repair demonstrating equivalent rates of morbidity to their normal BMI counterparts. While the obesity paradox has been relatively consistent in the literature, the understanding of its cause and long-term impacts are not well understood. Further focused investigation is necessary to elucidate the cause of this relationship.

The effects of body mass index on outcomes for patients undergoing surgical aortic valve replacement.

BACKGROUND: Most of the studies of obesity and postoperative outcome have looked predominantly at coronary artery bypass grafting with fewer focused on valvular disease. The purpose of this study was to compare the outcomes of patients undergoing aortic valve replacement stratified by body mass index (BMI, kg/m^2). METHODS: The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry captured 4780 aortic valve replacements in Alberta, Canada from January 2004 to December 2018. All recipients were stratified by BMI into five groups (BMI: < 20, 20-24.9, 25-29.9, 30-34.9, and > = 35). Log-rank test and Cox regression were used to examine the crude and adjusted survival differences. RESULTS: Intra-operative clamp time and pump time were similar among the five groups. Significant statistical differences between groups existed for the incidence of isolated AVR, AVR and CABG, hemorrhage, septic infection, and deep sternal infection (p < 0.05). While there was no significant statistical difference in the mortality rate across the BMI groups, the underweight AVR patients (BMI < 20) were associated with increased hazard ratio (1.519; 95% confidence interval: 1.028-2.245) with regards to all-cause mortality at the longest follow-up compared with normal weight patients. CONCLUSION: Overweight and obese patients should be considered as readily for AVR as normal BMI patients.

LINX® magnetic esophageal sphincter augmentation versus Nissen fundoplication for gastroesophageal reflux disease: a systematic review and meta-analysis.

BACKGROUND: The LINX® magnetic sphincter augmentation system (MSA) is a surgical technique with short-term evidence demonstrating efficacy in the treatment of medically refractory or chronic gastroesophageal reflux disease (GERD). Currently, the Nissen fundoplication is the gold-standard surgical treatment for GERD. We are the first to systematically review the literature and perform a meta-analysis comparing MSA to the Nissen fundoplication. METHODS: A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science and the Cochrane Library) using search terms "Gastroesophageal reflux or heartburn" and "LINX or endoluminal or magnetic" and "fundoplication or Nissen" was completed. All randomized controlled trials, non-randomized comparison study and case series with greater than 5 patients were included. Five hundred and forty-seven titles were identified through primary search, and 197 titles or abstracts were screened after removing duplicates. Meta-analysis was performed on postoperative quality of life outcomes, procedural efficacy and patient procedural satisfaction. RESULTS: Three primary studies identified a total of 688 patients, of whom 273 and 415 underwent Nissen fundoplication and MSA, respectively. MSA was statistically superior to LNF in preserving patient's ability to belch (95.2 vs 65.9%, p < 0.00001) and ability to emesis (93.5 vs 49.5%, p < 0.0001). There was no statistically significant difference between MSA and LNF in gas/bloating (26.7 vs 53.4%, p = 0.06), postoperative dysphagia (33.9 vs 47.1%, p = 0.43) and proton pump inhibitor (PPI) elimination (81.4 vs 81.5%, p = 0.68). CONCLUSION: Magnetic sphincter augmentation appears to be an effective treatment for GERD with short-term outcomes comparable to the more technically challenging and time-consuming Nissen fundoplication. Long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation.

Quality of Follow-up: Systematic Review of the Research in Bariatric Surgery.

OBJECTIVE: We aim to systematically review the bariatric surgery literature with regards to adequacy of patient follow-up, meeting the McMaster criteria of ≥80% follow-up. BACKGROUND: Loss to follow-up is a major concern and can potentially bias the outcome and interpretation of a study. The quality of follow-up in bariatric surgery is quite variable with recent systematic reviews criticizing the field for its lack of overall follow-up. METHODS: A complete search of PubMed was performed. Literature was restricted to a range of 5 years (2007-2012), English language, and publications listed in PubMed. The McMaster Evidence-based Criteria for High Quality Studies was used to assess the follow-up data adequacy and a logistic meta-regression was performed to identify factors associated with high quality follow-up studies. RESULTS: Ninety-nine published manuscripts were included. For follow-up at study end, only 40/99 (40.4%) of papers had adequate patient follow-up, 42/99 (42.4%) failed to meet the McMaster criteria and 17/99 (17.2%) failed to report any follow-up results. On average, 31% were lost to follow-up at the study's end. Only shorter study duration, and if the study was performed in the US, were associated with studies meeting the McMaster criteria. CONCLUSIONS: Only 40% of studies in the bariatric surgery literature meet criteria for adequate follow-up. On average, studies have 30% of patients lost to follow-up at the stated end-point. Identified study characteristics associated with high quality follow-up included shorter study duration and studies performed in the US.

Comparative effectiveness and safety of gastric bypass, sleeve gastrectomy and adjustable gastric banding in a population-based bariatric program: prospective cohort study.

BACKGROUND: Bariatric surgery in Canada is primarily delivered within publicly funded specialty clinics. Previous studies have demonstrated that bariatric surgery is superior to intensive medical management for reduction of weight and obesity-related comorbidities. Our objective was to compare the effectiveness and safety of laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (LSG) and adjustable gastric banding (LAGB) in a publicly funded, population-based bariatric treatment program. METHODS: We followed consecutive bariatric surgery patients for 2 years. The primary outcome was weight change (in kilograms). Between-group changes were analyzed using multivariable regression. Last-observation-carried-forward imputation was used for missing data. RESULTS: We included 150 consecutive patients (51 RYGB; 51 LSG; 48 LAGB) in our study. At baseline, mean age was 43.5 ± 9.5 years, 87.3% of patients were women, and preoperative body mass index (BMI) was 46.2 ± 7.4. Absolute and relative (% of baseline) weight loss at 2 years were 36.6 ± 19.5 kg (26.1 ± 12.2%) for RYGB, 21.4 ± 16.0 kg (16.4 ± 11.6%) for LSG and 7.0 ± 9.7 kg (5.8 ± 7.9%) for LAGB (p < 0.001). Change in BMI was greater for the RYGB (-13.0 ± 6.6) than both the LSG (-7.6 ± 5.7) and the LAGB (-2.6 ± 3.5) groups (p < 0.001). The reduction in diabetes, hypertension and dyslipidemia was greater after RYGB than after LAGB (all p < 0.05). There were no deaths. The anastomotic and staple leakage rate was 1.3%. CONCLUSION: In a publicly funded, population-based bariatric surgery program, RYGB and LSG demonstrated greater weight loss than the LAGB procedure. Bypass resulted in the greatest reduction in obesity-related comorbidities. All procedures were safe.

BACKGROUND: Au Canada, la chirurgie bariatrique est effectuée principalement dans des cliniques spécialisées financées par le secteur public. Des études ont démontré que les interventions de cette nature sont supérieures à la prise en charge médicale intensive pour la perte de poids et la réduction des affections comorbides liées à l'obésité. L'objectif de notre étude était de comparer l'efficacité et l'innocuité de la dérivation gastrique Roux-en-Y par laparoscopie (DGRY), de la gastrectomie longitudinale (GL) et de la gastroplastie par anneau gastrique modulable (GAGM) dans le cadre d'un programme de traitement bariatrique basé sur la population financé par les deniers publics. METHODS: Nous avons suivi pendant 2 ans des patients ayant subi une chirurgie bariatrique. Le résultat primaire à l'étude était la variation pondérale (en kilogrammes). Nous avons analysé la variation intergroupe au moyen d'une régression multivariable et utilisé la méthode d'imputation des données manquantes par report de la dernière observation. RESULTS: Nous avons retenu 150 patients consécutifs (51 DGRY; 51 GL; 48 GAGM). Au début de l'étude, l'âge moyen était de 43,5 ± 9,5 ans, 87,3 % des patients étaient des femmes, et leur indice de masse corporelle (IMC) avant l'opération était de 46,2 ± 7,4. Après 2 ans, la perte de poids moyenne (pourcentage du poids de départ) était de 36,6 ± 19,5 kg (26,1 ± 12,2 %) pour la DGRY, de 21,4 ± 16,0 kg (16,4 ± 11,6 %) pour la GL, et de 7,0 ± 9,7 kg (5,8 ± 7,9 %) pour la GAGM (p < 0,001). La variation de l'IMC était plus grande pour le groupe DGRY (13,0 ± 6,6) que pour les 2 autres groupes (7,6 ± 5,7 pour la GL et 2,6 ± 3,5 pour la GAGM; p < 0,001). L'incidence sur le diabète, l'hypertension et la dyslipidémie était également plus grande après la DGRY qu'après la GAGM (p < 0,05 pour tous). Il n'y a eu aucun décès. Le taux de fuites anastomotiques et liées aux sutures était de 1,3 %. CONCLUSION: Dans le cadre d'un programme de chirurgie bariatrique basé sur une population et financé par le secteur public, la DGRY et la GL ont entraîné une plus grande perte de poids que la GAGM. La dérivation a donné lieu à la plus forte réduction des affections comorbides liées à l'obésité. Toutes les interventions se sont avérées sécuritaires.

Endoscopic versus open component separation: systematic review and meta-analysis.

BACKGROUND: The component separation technique (CST) was developed to improve the integrity of abdominal wall reconstruction for large, complex hernias. Open CST necessitates large subcutaneous skin flaps and, therefore, is associated with significant ischemic wound complications. The minimally invasive or endoscopic component separation technique (MICST) has been suggested in preliminary studies to reduce wound complication rates post-operatively. In this study, we systematically reviewed the literature comparing open versus endoscopic component separation and performed a meta-analysis of controlled studies. METHODS: A comprehensive search of electronic databases was completed. All English, randomized controlled trials, non-randomized comparison study, and case series were included. All comparison studies included in the meta-analysis were assessed independently by two reviewers for methodological quality using the Cochrane Risk of Bias tools. RESULTS: 63 primary studies (3,055 patients) were identified; 7 controlled studies and 56 case series. The total wound complication rate was lower for MICST (20.6 %) compared to Open CST (34.6 %). MICST compared to open CST was shown to have lower rates of superficial infections (3.5 vs 8.9 %), skin dehiscence (5.3 vs 8.2 %), necrosis (2.1 vs 6.8 %), hematoma/seroma formation (4.6 vs 7.4 %), fistula tract formation (0.4 vs 1.0 %), fascial dehiscence (0.0 vs 0.4 %), and mortality (0.4 vs 0.6 %.) The open component CST did have lower rates of intra-abdominal abscess formation (3.8 vs 4.6 %) and recurrence rates (11.1 vs 15.1 %). The meta-analysis included 7 non-randomized controlled studies (387 patients). A similar suggestive overall trend was found favoring MICST, although most types of wound complications did not show to significance. MICST was associated with a significantly decreased rate of fascial dehiscence and was shown to be significantly shorter procedure. CONCLUSION: This systematic review and meta-analysis comparing MICST to open CST suggests MICST is associated with decreased overall post-operative wound complication rates. Further prospective studies are needed to verify these findings.

The effect of bariatric surgery on gastroesophageal reflux disease.

Obesity is an epidemic that is known to play a role in the development of gastroesophageal reflux disease (GERD). Studies have shown that increasing body mass index plays a role in the incompetence of the gastroesophageal junction and that weight loss and lifestyle modifications reduce the symptoms of GERD. As a method of producing effective and sustainable weight loss, bariatric surgery plays a major role in the treatment of obesity. We reviewed the literature on the effects of different types of bariatric surgery on the symptomatic relief of GERD and its complications. Roux-en- Y gastric bypass was considered an effective method to alleviate symptoms of GERD, whereas laparoscopic sleeve gastrectomy appeared to increase the incidence of the disease. Adjustable gastric banding was seen to initially improve the symptoms of GERD; however, a subset of patients experienced a new onset of GERD symptoms during long-term follow-up. The literature suggests that different surgeries have different impacts on the symptomatology of GERD and that careful assessment may be needed before performing bariatric surgery in patients with GERD.

L'obésité atteint des proportions épidémiques et on sait qu'elle joue un rôle dans l'apparition du phénomène de reflux gastro-oesophagien (RGO). Des études ont montré que l'augmentation de l'indice de masse corporelle contribue à l'incompétence de la jonction entre l'oesophage et l'estomac et que la perte de poids et des modifications de l'hygiène de vie réduisent les symptômes de RGO. Comme mé - thode pour obtenir une perte de poids efficace et durable, la chirurgie bariatrique occupe une place importante dans le traitement de l'obésité. Nous avons passé en revue la littérature traitant des effets de différents types de chirurgie bariatrique sur le soulagement des symptômes du RGO et ses complications. La dérivation gastrique Roux-en-Y a été considérée comme une méthode efficace pour le soulagement des symptômes de RGO, tandis que la gastrectomie verticale par laparoscopie a semblé faire augmenter l'incidence de la maladie. Quant au cerclage gastrique ajustable, il a semblé améliorer initialement le RGO; toutefois chez une catégorie de patients, le RGO s'est manifesté de nouveau lors du suivi à long terme. Selon la littérature, chaque type d'intervention exerce un impact différent sur la symptomatologie du RGO et une évaluation soigneuse s'impose avant de procéder à une chirurgie bariatrique chez les patients souffrant de RGO.

Prioritization and willingness to pay for bariatric surgery: the patient perspective.

BACKGROUND: Access to publicly funded bariatric surgery is limited, potential candidates face lengthy waits, and no universally accepted prioritization criteria exist. We examined patients' perspectives regarding prioritization for surgery. METHODS: We surveyed consecutively recruited patients awaiting bariatric surgery about 9 hypothetical scenarios describing patients waiting for surgery. Respondents were asked to rank the priority of these hypothetical patients on the wait list relative to their own. Scenarios examined variations in age, clinical severity, functional impairment, social dependence and socioeconomic status. Willingness to pay for faster access was assessed using a 5-point ordinal scale and analyzed using multivariable logistic regression. RESULTS: The 99 respondents had mean age of 44.7 ± 9.9 years, 76% were women, and the mean body mass index was 47.3 ± SD 7.6. The mean wait for surgery was 34.4 ± 9.4 months. Respondents assigned similar priority to hypothetical patients with characteristics identical to theirs (p = 0.22) and higher priority (greater urgency) to those exhibiting greater clinical severity (p < 0.001) and functional impairment (p = 0.003). Lower priority was assigned to patients at the extremes of age (p = 0.006), on social assistance (p < 0.001) and of high socioeconomic status (p < 0.001). Most (85%) respondents disagreed with payment to expedite access, although participants earning more than $80 000/year were less likely to disagree. CONCLUSION: Most patients waiting for bariatric surgery consider greater clinical severity and functional impairments related to obesity to be important prioritization indicators and disagreed with paying for faster access. These findings may help inform future efforts to develop acceptable prioritization strategies for publicly funded bariatric surgery.

CONTEXTE: Les régimes publics donnent un accès limité à la chirurgie bariatrique; les candidats potentiels font face à des attentes prolongées et il n'existe pas de critères de priorisation universellement acceptés. Nous avons analysé le point de vue des patients relativement à la priorisation des candidats à la chirurgie. MÉTHODES: Nous avons recruté consécutivement des patients en attente de chirurgie bariatrique et nous les avons interrogés au sujet de 9 scénarios hypothétiques décrivant des patients en attente de chirurgie. Nous avons demandé aux répondants de classer ces patients hypothétiques par ordre de priorité sur la liste d'attente par rapport à la priorité de leur propre cas. Les scénarios présentaient des variations d'âge, de gravité de l'état clinique, d'atteintes fonctionnelles, de dépendance sociale et de statut socioéconomique. Nous avons déterminé au moyen d'une échelle ordinale en 5 points si les patients étaient disposés à payer pour accéder plus rapidement au traitement et nous avons analysé les réponses par régression logistique multivariée. RÉSULTATS: Les 99 répondants avaient en moyenne 44,7 ± 9,9 ans, 76 % étaient des femmes dont l'indice de masse corporelle moyen était de 47,3 ± 7,6. Le temps d'attente moyen pour la chirurgie était de 34,4 ± 9,4 mois. Les répondants ont assigné une priorité similaire aux patients hypothétiques dont les caractéristiques étaient identiques aux leurs (p = 0,22) et une priorité plus élevée (urgence supérieure) à ceux qui présentaient un état clinique plus grave (p < 0,001) et une détérioration fonctionnelle plus prononcée (p = 0,003). Une priorité moins grande a été assignée aux patients qui se trouvaient aux 2 extrémités de l'éventail des âges (p = 0,006), aux bénéficiaires de l'aide sociale (p < 0,001) et aux personnes de statut socioéconomique élevé (p < 0,001). La plupart des répondants (85 %) se sont exprimés contre le paiement pour accélérer l'accès, même si les participants qui gagnaient plus de 80 000 $ par année étaient moins enclins à s'y opposer. CONCLUSION: La plupart des patients en attente d'une chirurgie bariatrique considèrent que la gravité de l'état clinique et les atteintes fonctionnelles associées à l'obésité sont d'importants indicateurs de priorisation et s'opposent à payer pour un accès plus rapide à l'intervention. Ces observations pourraient guider une éventuelle mise au point de stratégies de priorisation pour la chirurgie bariatrique financée par les régimes publics.

Postresuscitation cyclosporine treatment attenuates myocardial and cardiac mitochondrial injury in newborn piglets with asphyxia-reoxygenation.

OBJECTIVES: Cardiovascular dysfunction occurs in the majority of asphyxiated neonates and has been suggested to be a major cause of neonatal morbidity and mortality. We previously demonstrated that cyclosporine A treatment during resuscitation can significantly improve cardiovascular performance in asphyxiated newborn piglets. However, the mechanisms through which cyclosporine elicits its protective effect in neonates have not yet been fully characterized. We hypothesized that cyclosporine A treatment would attenuate myocardial and cardiac mitochondrial injury during the resuscitation of asphyxiated newborn piglets. DESIGN: After acute instrumentation, piglets received normocapnic alveolar hypoxia (10% to 15% oxygen) for 2 hours followed by reoxygenation with 100% oxygen (0.5 hr) and then 21% oxygen (3.5 hr). At 4 hours of reoxygenation, plasma troponin level, left ventricle myocardial levels of lipid hydroperoxides, cytochrome-c, and mitochondrial aconitase activity were determined. SETTING: Neonatal asphyxia and reoxygenation. SUBJECTS: Twenty-four newborn (1-4 days old) piglets. INTERVENTIONS: Piglets were randomized to receive an IV bolus of cyclosporine A (10 mg/kg) or normal saline (placebo, control) at 5 minutes of reoxygenation (n=8/group). Sham-operated piglets (n=8) underwent no asphyxia-reoxygenation. MEASUREMENTS AND MAIN RESULTS: Asphyxiated piglets treated with cyclosporine had lower plasma troponin and myocardial lipid hydroperoxides levels (vs. controls, both p<0.05, analysis of variance). Cyclosporine treatment also improved mitochondrial aconitase activity and attenuated the rise in cytosol cytochrome-c level (vs. controls, all p<0.05). The improved mitochondrial function significantly correlated with cardiac output (p<0.05, Spearman rank-correlation test). CONCLUSIONS: We demonstrate that the postresuscitation administration of cyclosporine attenuates myocardial and cardiac mitochondrial injury in asphyxiated newborn piglets following resuscitation.

Pharmacokinetic characterization of intravenous cyclosporine treatment for cardioprotection during resuscitation of asphyxiated newborn piglets.

OBJECTIVES: Cyclosporine treatment, as a single intravenous bolus, during resuscitation has been shown to attenuate myocardial injury in asphyxiated newborn piglets. However, the pharmacokinetics of cyclosporine treatment for cardioprotection in newborns has not been studied. We aimed to assess the pharmacokinetics of a single intravenous cyclosporine treatment during resuscitation of asphyxiated newborn piglets and compare these parameters with healthy newborn piglets. DESIGN: Newborn piglets were acutely instrumented and normocapnic alveolar hypoxia was induced for 2 hours followed by 4 hours of reoxygenation. Piglets were block-randomized to receive a single intravenous bolus of cyclosporine (2.5-25 mg/kg) (n = 8 per group). Eight piglets underwent no hypoxia-reoxygenation and received 10 mg/kg cyclosporine at the corresponding time point. Plasma cyclosporine and troponin concentrations during reoxygenation period were determined by high-pressure liquid chromatography and enzyme-linked immunosorbent assay, respectively. Noncompartmental methods were used to calculate the pharmacokinetic parameters. Cyclosporine concentrations and pharmacokinetic parameters were analyzed by one-way analysis of variance. SETTING: University animal laboratory. SUBJECTS: Piglets (1-4 days old, weighing 1.4-2.5 kg). INTERVENTIONS: Intravenous cyclosporine (2.5, 10, or 25 mg/kg) given during resuscitation. MEASUREMENTS AND MAIN RESULTS: In the hypoxic-reoxygenated piglets, the plasma AUC(0-4 hrs) and C(max) of cyclosporine at reoxygenation were in the following rank order: 25 > 10 > 2.5 mg/kg treatment (p < 0.001 between groups, analysis of variance). Plasma AUC(0-4 hrs) and C(max) in piglets treated with cyclosporine at 25 mg/kg was associated with increased plasma troponin levels, a marker of myocardial injury, relative to piglets treated with 2.5 and 10 mg/kg. Asphyxiated newborn piglets had higher clearance and lower AUC(0-∞), but similar AUC(0-4 hrs), steady-state volume of distribution, and mean residence time compared with those of healthy newborn piglets. CONCLUSIONS: This is the first study to demonstrate the pharmacokinetics of intravenous cyclosporine treatment during resuscitation of asphyxiated newborn piglets, which did not appear to different from that of healthy piglets.

Cyclosporine treatment improves cardiac function and systemic hemodynamics during resuscitation in a newborn piglet model of asphyxia: a dose-response study.

OBJECTIVES: Asphyxiated neonates often have myocardial depression, which is a significant cause of morbidity and mortality. Cardioprotective effects of cyclosporine have been observed in adult patients and animals with myocardial infarction. However, the cardioprotective effect of cyclosporine in neonates has not yet been studied. We hypothesize that cyclosporine will improve cardiac function and reduce myocardial injury in asphyxiated newborn piglets. DESIGN: Thirty-six piglets (1-4 days old, weighing 1.4-2.5 kg) were acutely instrumented for continuous monitoring of cardiac output and systemic arterial pressure. After stabilization, normocapnic alveolar hypoxia (10% to 15% oxygen) was instituted for 2 hrs followed by reoxygenation with 100% oxygen for 0.5 hrs and then 21% for 3.5 hrs. A nonasphyxiated, sham-operated group was included (n = 4) to control for effects of the surgical model. Plasma troponin and myocardial lactate concentrations were determined as well as morphologic examinations. SETTING: Neonatal asphyxia and reoxygenation. SUBJECTS: Newborn (1-4 days old) piglets. INTERVENTIONS: Piglets were block-randomized to receive intravenous boluses of cyclosporine A (2.5, 10, or 25 mg/kg) or normal saline (control) at 5 mins of reoxygenation (n = 8/group). MEASUREMENTS AND MAIN RESULTS: Cardiac index, heart rate, systemic oxygenation, plasma troponin, and left ventricular lactate were measured. Hypoxic piglets had cardiogenic shock (cardiac output 40% to 48% of baseline), hypotension (mean arterial pressure 27-31 mm Hg), and acidosis (pH 7.04). Cyclosporine treatment caused bell-shaped improvements in cardiac output, stroke volume, and systemic oxygen delivery (p < .05 vs. controls). Plasma troponin and left ventricle lactate were higher in controls than that of 2.5 and 10 mg/kg cyclosporine-treated groups (p < .05). Although histologic features of myocardial injury were not different among groups, severe damage was observed in mitochondria of control piglets but attenuated in that of cyclosporine (10 mg/kg) treatment. CONCLUSIONS: Postresuscitation administration of cyclosporine causes preservation of cardiac function and attenuates myocardial injury in newborn piglets after asphyxia-reoxygenation.

Therapeutic strategies to protect the immature newborn myocardium during resuscitation following asphyxia.

Perinatal asphyxia contributes to over one million newborn deaths worldwide annually, and may progress to multiorgan failure. Cardiac dysfunction, of varying severity, is seen in 50%-70% of asphyxiated newborns. Resuscitation is necessary to restore oxygenation to deprived tissues, including the heart. However, reoxygenation of asphyxiated newborns may lead to generation of reactive oxygen species (ROS) and further myocardial damage, termed reperfusion injury. The newborn heart is especially vulnerable to oxidative stress and reperfusion injury due to immature antioxidant defense mechanisms and increased vulnerability to apoptosis. Currently, newborn myocardial protective strategies are aimed at reducing the generation of ROS through controlled reoxygenation, boosting antioxidant defenses, and attenuating cellular injury via mitochondrial stabilization.

The clinical significance of incidental intra-abdominal findings on positron emission tomography performed to investigate pulmonary nodules.

BACKGROUND: Lung cancer is a common cause of cancer-related death. Staging typically includes positron emission tomography (PET) scanning, in which (18)F-fluoro-2-dexoy-D-glucose (FDG) is taken up by cells proportional to metabolic activity, thus aiding in differentiating benign and malignant pulmonary nodules. Uptake of FDG can also occur in the abdomen. The clinical significance of incidental intraabdominal FDG uptake in the setting of pulmonary nodules is not well established. Our objective was to report on the clinical significance of incidental intra-abdominal FDG activity in the setting of lung cancer. METHODS: Fifteen hundred FDG-PET reports for studies performed for lung cancer were retrospectively reviewed for the presence of incidental FDG-positive intraabdominal findings. Patient charts with positive findings were then reviewed and information extracted. RESULTS: Twenty-five patients (25/1500) demonstrated incidental intraabdominal FDG uptake thought to be significant (1.7%) with a mean patient age of 71 years. Colonic uptake was most common (n = 17) with 9 (52%) being investigated further. Of these 9 cases, a diagnosis of malignancy was made in 3 patients, pre-malignant adenomas in 2 patients, a benign lipoma in 1 patient and no abnormal findings in the remaining patients. 8 patients were not investigated further (3 diagnosed with metastatic lung cancer and 2 were of advanced age) secondary to poor prognosis. CONCLUSION: Incidental abdominal findings in the colon on FDG-PET scan for work-up of pulmonary nodules need to be further investigated by colonoscopy.

Predictors of attrition in a multidisciplinary adult weight management clinic.

BACKGROUND: Worldwide, more than 1.7 billion individuals may be classified as overweight and are in need of appropriate medical and surgical treatments. The primary goal of a comprehensive weight management program is to produce sustainable weight loss. However, for such a program to be effective, the patient must complete it. We analyzed attrition rates and predictors of attrition within a publicly funded, multidisciplinary adult weight management program. METHODS: We retrospectively reviewed charts from an urban multidisciplinary adult weight management clinic program database. Patients received medical or surgical treatment with appropriate follow-up. We collected information on demographics and comorbidities. Patients in the surgical clinics received either laparoscopic gastric band insertion or gastric bypass. We conducted univariate analysis and multivariate analyses on predictors of attrition. RESULTS: A total of 1205 patients were treated in the weight management program: 887 in the medical clinic and 318 with surgery and follow-up in a surgical clinic. Overall, 516 patients left the program or were lost to follow-up (attrition rate 42.8%). The attrition rate was 53.9% in the medical clinic and 11.9% in the surgical clinic. Multivariate analyses identified participation in the medical clinic, younger patient age and lower body mass index as predictors of attrition. CONCLUSION: We found lower attrition rates among surgically than medically treated patients in a multidisciplinary weight management clinic. Further research is needed to understand those variables that lead to improved attrition rates.

Enterocolic fistula: A rare presentation of cytomegalovirus infection.

In the present report, the first reported case of cytomegalovirus (CMV)-associated enterocolic fistula in an HIV/AIDS patient is described. CMV colitis is the second most common presentation of CMV infection in immunocompromised patients. CMV-associated enteric fistulae are an exceedingly rare complication, with only four previous cases described: a gastrocolic, an enterocutaneous, a rectovaginal and a colocutaneous fistula. Management of these patient demonstrates the importance of treating the precipitating viral infection before considering surgical intervention of the enterocolic fistula.

Dans le présent rapport, les auteurs décrivent le premier cas déclaré de fistule entérocolique associée au cytomégalovirus (CMV) chez un patient atteint du VIH-sida. La colite à CMV est la deuxième présentation en importance d'infection par le CMV chez les patients immunodéprimés. Les fistules entériques liées au CMV représentent une complication extrêmement rare puisque seulement quatre cas ont déjà été décrits : une fistule gastrocolique, une fistule entérocutanée, une fistule rectovaginale et une fistule colocutanée. La prise en charge de ce patient démontre l'importance de traiter l'infection virale déclencheuse avant d'envisager une intervention chirurgicale de la fistule entérocolique.

Treatment of gastric cancer with peritoneal carcinomatosis by cytoreductive surgery and HIPEC: a systematic review of survival, mortality, and morbidity.

Gastric cancer with peritoneal carcinomatosis has an extremely poor prognosis, which may be improved with cytoreductive surgery (CRS) combined with heated intraperitoneal chemotherapy (HIPEC). We systematically reviewed the literature regarding the efficacy of CRS + HIPEC in these patients. Electronic databases were searched from 2000 to 2010. Following CRS + HIPEC, overall median survival was 7.9 months and improved to 15 months for patients with completeness of cytoreduction scores of 0/1, however with a 30-day mortality rate of 4.8%.

Image inversion and digital mirror-image technology aid laparoscopic surgery task performance in the paradoxical view: a randomized controlled trial.

BACKGROUND: As laparoscopic surgical procedures increase in complexity, surgeons may find themselves with the laparoscope opposite to their laparoscopic instruments, thus creating the paradoxical viewpoint. We assessed whether surgical task performance in the paradoxical viewpoint would be improved by digitally altering the image or by changing the camera orientation. METHODS: Sixty-one laparoscopically naïve operators performed a Peg Transfer task using a trainer box. In the first "round," naïve operators were block-randomized to perform the Peg-Transfer task either in the standard view or the paradoxical view. In the second "round," naïve operators were positioned in the paradoxical view and block-randomized to having the monitor image as paradoxical (n = 19) or altered by being digitally flipped (mirror-image) (n = 22) or inverted (n = 20). The task consisted of transferring six plastic objects in 5 min (300 s). Scoring was based on the formula of total time = time to completion (max = 300 s) + penalty time (50 s/peg not transferred). RESULTS: In the first round, average total time to perform the Peg Transfer task using the standard view was 215 ± 20 s, which was significantly less (P < 0.001) than the 563 ± 13 s for the paradoxical view. In the second round (with all naïve operators in the paradoxical viewpoint), the total time for the paradoxical image, digitally flipped image (mirror-image), and inverted image were 561 ± 12, 449 ± 25, and 259 ± 37 s, respectively. The total time for the inverted image was significantly less than both the paradoxical image and digitally flipped image (P < 0.001). The total time for the digitally flipped image was also less than paradoxical image (P < 0.05). The group with the paradoxical image completed 0.8 ± 0.2 peg transfers, which was less than both the digitally flipped and inverted-view groups (P < 0.05). CONCLUSIONS: This is the first study to demonstrate that when in the paradoxical viewpoint, altering the image on the video monitor, either by digitally flipping or inverting the image, can improve surgical task performance.

Revisional Bariatric Surgery.

Revisional bariatric procedures are increasingly common. With more primary procedures being performed to manage severe obesity and its complications, 5% to 8% of these procedures will fail, requiring revisional operation. Reasons for revisional bariatric surgery are either primary inadequate weight loss, defined as less than 25% excess body weight loss, or weight recidivism, defined as a gain of more than 10 kg based on the nadir weight; however, each procedure also has inherit specific complications that can also be indications for revision. This article reviews the history of each primary bariatric procedure, indications for revision, surgical options, and subsequent outcomes.

Sleeve Gastrectomy and Type 2 Diabetes Mellitus: a Systematic Review of Long-Term Outcomes.

Long-term T2DM resolution rates are not well established following the laparoscopic sleeve gastrectomy (LSG). The aim of this paper was to systematically review the evidence on the efficacy of the LSG on long-term T2DM resolution. A comprehensive electronic literature search was conducted. Included studies reported 5-year follow-up of T2DM outcomes following the LSG. Eleven studies (n = 1354) were included in the systematic review. T2DM patients (n = 402) encompassed 29.7 % of patients. Diabetes prevalence decreased post-operatively to 20.5 % at 5 years, with diabetes resolution occurring in 60.8 % of patients. Mean plasma glucose levels and haemoglobin A1c values fell from 170.3 to 112.0 mg/dL and 8.3 to 6.7 % respectively at the 5-year mark. The LSG is an effective long-term metabolic surgery for patients with T2DM.