billingsMentor: Adapting natural family planning to information technology and relieving the user of unnecessary tasks.

BillingsMentor is an automated Web-based service for the Billings Method of natural family planning in which the guidance and interpretation previously communicated from teacher to student is provided by programmed algorithms. There are two functions: (1) to instruct the client to generate proper descriptions of her fertility symptoms; and (2) to interpret the symptoms efficiently according to the Billings Method and to communicate the results to the client. The efficiency of billingsMentor was tested by using the historical records of students who were under the guidance of a teacher to emulate their experience under the guidance of billingsMentor. The results indicate that billingsMentor performs as well as the teacher/student in recognizing the peak of fertility but it is slightly less efficient than the teacher/student in establishing the basic infertile pattern. Advantages that arise from adapting natural family planning to information technology are discussed.

Risk of massive upper gastrointestinal bleeding in gastric bypass patients taking clopidogrel.

BACKGROUND: The antiplatelet drug clopidogrel (Plavix) is widely used in patients who have undergone coronary artery stenting or had a stroke. Because morbid obesity is associated with atherosclerosis, some of these patients are candidates for weight loss surgery. We chose to determine the risk of upper gastrointestinal bleeding after gastric bypass in patients taking clopidogrel. METHODS: Patients who took clopidogrel after gastric bypass were identified by specific review of the subset of patients who had had upper gastrointestinal bleeding requiring hospital admission and transfusion. All who bled underwent emergency endoscopy. RESULTS: Of 11 patients taking clopidogrel, 4 (36%) presented with significant upper gastrointestinal bleeding 25-234 days after gastric bypass. All stopped bleeding with discontinuation of the drug and treatment with an intravenous proton pump inhibitor. CONCLUSION: Gastric bypass patients appear to be at high risk of bleeding complications when taking clopidogrel. On the basis of the available published data from another high-risk group (i.e., those with a history of peptic ulcer disease), co-treatment with omeprazole may be indicated when clopidogrel must be continued.

Incidence of symptomatic gallstones after gastric bypass: is prophylactic treatment really necessary?

BACKGROUND: Because rapid weight loss after bariatric surgery increases gallstone formation, a 6-month treatment regimen with ursodiol has been recommended. Even prophylactic cholecystectomy at the time of gastric bypass in the absence of stones has been proposed. However, the incidence of symptomatic gallstones requiring cholecystectomy in untreated patients after gastric bypass has not yet been established. METHODS: The patients in our study were not treated with ursodiol after open Roux-en-Y gastric bypass. Additional inclusion criteria were no palpable gallstones at bypass, at least 16 months of follow-up after bypass, and continuous coverage by the same health insurance plan extending from the time of the operation to study completion, to track subsequent cholecystectomies by claims paid. RESULTS: A total of 100 females and 25 males met the study inclusion criteria. Follow-up extended from 16 to 48 months. Symptomatic gallstones requiring cholecystectomy developed in 10 patients, all females. Laparoscopic cholecystectomy was performed in 9 of these patients and open cholecystectomy was performed in the remaining patient, between 3 and 21 months after bypass. There were no serious complications from the stones or the cholecystectomy. CONCLUSIONS: Prophylactic cholecystectomy would have been unnecessary in 115 of the 125 patients in the study group. A 6-month course of ursodiol for all 125 patients, at a cost of 56,250 dollars, would have had to decrease the number of cholecystectomies from 10 to 3 to demonstrate a treatment effect (P < .05). Therefore, most newly formed gallstones after gastric bypass are likely asymptomatic, prophylactic cholecystectomy is not indicated, and ursodiol therapy may be better reserved for symptomatic patients who refuse surgery.

Roux en Y gastric bypass by single-incision mini-laparotomy: outcomes in 3,300 consecutive patients.

BACKGROUND: Although the laparoscopic technique of Roux en Y gastric bypass (LRYGB) has popularized this weight loss procedure, the costs are justifiable if outcomes are superior to the open technique. We report our results with single-incision mini-laparotomy. METHODS: From June 2000 through November 2009, RYGB was performed in 3,300 consecutive patients using a 10-15-cm single-abdominal incision. Established guidelines for patient selection were followed and protocols were developed for patient education and for the prevention of perioperative complications. Weight loss (WL) over time and complications were recorded prospectively. Actual 90-day mortality was compared to that predicted by the Obesity Surgery Mortality Risk Score (OS-MRS). RESULTS: Eighty-four percent of patients were females with a mean body mass index (BMI) of 50 ± 13. BMI of males was 54 ± 9. There was a normal distribution of the WL response over 2,000 days. Complications included bleeding (1.4%), leak (1%), pulmonary embolism (0.7%), internal hernia (2.5%), and incisional hernia (5.6%). There were 1,793 Class A, 1,288 Class B, and 219 Class C patients. Eleven patients (0.3%) died within 90 days (one Class A, seven Class B, and three Class C), with mortality rates in all classes less than expected by the OS-MRS. Average hospital charges were $13,000. CONCLUSIONS: Our protocols and operative technique should be reproducible in other centers and may have a special appeal, if the costs of LRYGB limit access to bariatric surgery in qualified patients.