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1.
Curr Gastroenterol Rep ; 12(4): 296-303, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20556553

RESUMO

Bariatric operations are increasingly being used to induce weight loss and ameliorate or cure most of the morbidities that accompany obesity. These procedures not only produce substantial weight loss (>50% body weight), but they cure or ameliorate the comorbidities (diabetes type 2, hypertension, sleep apnea, hyperlipidemia) in the vast majority of patients. These procedures can usually be performed laparoscopically with a mortality of less than 0.5% and a hospital stay of 1 to 3 days. Presently they are the only effective treatment for weight loss in the extremely obese patient (body mass index >/= 35).


Assuntos
Cirurgia Bariátrica/métodos , Obesidade Mórbida/cirurgia , Seleção de Pacientes , Redução de Peso , Cirurgia Bariátrica/efeitos adversos , Desvio Biliopancreático , Índice de Massa Corporal , Humanos , Laparoscopia , Morbidade , Obesidade Mórbida/complicações , Obesidade Mórbida/epidemiologia , Complicações Pós-Operatórias , Resultado do Tratamento
2.
Surg Obes Relat Dis ; 4(5): 581-6, 2008.
Artigo em Inglês | MEDLINE | ID: mdl-18065290

RESUMO

BACKGROUND: Revisional bariatric surgery is increasing in frequency, but the morbidity and efficacy have not been well defined. The primary aim of this study was to determine the clinical efficacy with respect to weight loss, and associated morbidity, of revisional bariatric surgery in an academic university hospital bariatric surgery program. METHODS: A retrospective review of all patients who underwent revisional bariatric surgery for failed primary restrictive procedures, including gastroplasty and gastric bypass, but not including gastric banding or malabsorptive procedures, during a 10-year period at a single university hospital was performed. The perioperative morbidity and long-term weight loss and clinical results were determined from the medical charts. RESULTS: A total of 41 patients met the inclusion criteria. The primary bariatric procedures included vertical banded gastroplasty in 20 and Roux-en-Y gastric bypass in 21. The indications for revisional surgery included poor weight loss, weight regain, and various technical problems, including anastomotic stenosis and ulcer. The major morbidity rate was 17%. No patients died. The weight loss results varied depending on the indication for the revisional surgery and reoperative solution applied. The resolution of technical problems was achieved in all patients. CONCLUSION: Revisional bariatric surgery can be performed with minimal mortality, albeit significant morbidity. The efficacy with respect to weight loss appeared acceptable, although the results were not as good as those after primary bariatric surgery. The analysis of patient subsets stratified by surgical history and revisional strategy provided important insights into the mechanisms of failure and efficacy of different revisional strategies.


Assuntos
Derivação Gástrica/métodos , Gastroplastia/métodos , Obesidade/cirurgia , Adulto , Idoso , Feminino , Seguimentos , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Complicações Pós-Operatórias/epidemiologia , Reoperação , Estudos Retrospectivos , Falha de Tratamento
3.
Obes Surg ; 16(3): 359-64, 2006 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-16545169

RESUMO

Roux-en-Y gastric bypass (RYGBP) is a mainstay of bariatric surgical therapy. Gastro-gastric fistula (GGF) is an infrequent but potentially serious complication of gastric bypass, and diagnosis may be difficult. We report two patients who underwent RYGBP complicated by development of GGF who nevertheless achieved excellent, durable weight loss. The pathogenesis, diagnosis, prevention and management of GGF after RYGBP is reviewed. GGF may not result in poor weight loss after RYGBP and is not an absolute indication for surgical revision.


Assuntos
Derivação Gástrica/efeitos adversos , Fístula Gástrica/etiologia , Adulto , Algoritmos , Anastomose em-Y de Roux , Feminino , Fístula Gástrica/diagnóstico , Fístula Gástrica/prevenção & controle , Fístula Gástrica/cirurgia , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade
4.
Arch Surg ; 141(3): 262-8, 2006 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-16549691

RESUMO

HYPOTHESIS: As the demand for bariatric surgery increases, it becomes increasingly important to define predictors of morbidity and mortality. We hypothesize that specific clinical variables predict postoperative morbidity after bariatric surgery. DESIGN, SETTING, AND PATIENTS: This is a retrospective review of 452 patients undergoing inpatient bariatric surgery at an academic tertiary care institution. INTERVENTIONS: Patients underwent open or laparoscopic gastric bypass or biliopancreatic diversion with duodenal switch at Oregon Health & Science University, Portland, from 2000 to 2003. Patient data were prospectively entered into a database. MAIN OUTCOME MEASURES: Postoperative morbidity and mortality were analyzed among all patients, and logistic regression was used to identify clinical predictors of morbidity. RESULTS: Major and minor morbidity rates were 10% and 13%, respectively; mortality was 0.9%. Age was associated with postoperative complications (odds ratio = 1.056 for each additional year). Duodenal switch was also associated with higher morbidity than gastric bypass (odds ratio = 2.149). Body mass index, sex, diabetes, surgical approach, and surgeon experience did not predict complications. CONCLUSIONS: Increased age is a predictor of complications after bariatric surgery. Duodenal switch is also associated with a higher morbidity rate than gastric bypass. Surgeons should caution older patients (>/=60 years) of a higher risk of postoperative complications, and a higher risk associated with duodenal switch. Large multicenter studies will be necessary to accurately define other clinical predictors of morbidity and mortality after bariatric surgery.


Assuntos
Desvio Biliopancreático/efeitos adversos , Derivação Gástrica/efeitos adversos , Fatores Etários , Anastomose Cirúrgica , Índice de Massa Corporal , Feminino , Hospitais Universitários , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Morbidade , Obesidade Mórbida/cirurgia , Razão de Chances , Estudos Retrospectivos , Fatores de Risco
5.
Am J Surg ; 189(5): 536-40; discussion 540, 2005 May.
Artigo em Inglês | MEDLINE | ID: mdl-15862492

RESUMO

BACKGROUND: The optimal common channel (CC) length for malabsorptive weight loss surgeries is unknown even though these surgeries were developed in the 1970s (biliopancreatic diversion [BPD]) and the 1990s (biliopancreatic diversion with a duodenal switch [BPD DS]). We hypothesized that the length of the CC correlates with a successful weight loss result. METHODS: We evaluated 3 groups of patients based on the length of the CC whose duration of follow-up evaluation was at least 1 year. We reviewed all patients who had either an open BPD (5 patients) or a BPD DS (119 patients) from August 1998 to October 2003, for which D.B.M. was the participating surgeon. RESULTS: Group I comprised 15 patients: their preoperative body mass index (BMI) was 53.9 kg/m(2); 73.3% of patients had a BMI more than 50, and the CC length was 150 cm. Group II comprised 76 patients: their preoperative BMI was 54.25 kg/m(2); 73.3% of patients had a BMI more than 50, and the CC length was 100 cm. Group III comprised 33 patients: their preoperative BMI was 60.1 kg/m(2); 84% of patients had a BMI more than 50, and the CC length was 80 to 90 cm. The mean weight loss in group I was 45 kg (44% mean excess weight loss). The mean weight loss in groups II and III was 55.8 and 61.5 kg, respectively (a 57% and 54.8% mean excess weight loss, respectively) (all P < .05 by analysis of variance). A weight loss of greater than 50% of excess body weight occurred in 40% of patients in group I versus 63% of patients in groups II and III combined (P < .01 by chi(2)). CONCLUSIONS: The length of the CC contributes significantly to successful excess weight loss in BPD and BPD DS patients. In general, the length of the CC should not exceed 100 cm.


Assuntos
Desvio Biliopancreático/métodos , Duodeno/cirurgia , Obesidade Mórbida/cirurgia , Análise de Variância , Distribuição de Qui-Quadrado , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Redução de Peso
6.
Arch Surg ; 137(10): 1096-100, 2002 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-12361411

RESUMO

HYPOTHESIS: The diagnosis of Clostridium difficile colitis is increasing in frequency, with worsening patient outcomes. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENTS: One hundred fifty-seven patients diagnosed with C difficile colitis between 1994-2000. MAIN OUTCOME MEASURES: Resolution of disease, operative intervention, and death. RESULTS: Compared with our previous 10-year experience, overall cases of C difficile colitis have risen by more than 30%, and immunocompromised patients comprise a larger proportion of those affected. One third of patients were receiving posttransplantation medication, chemotherapy, or had human immunodeficiency virus. Of these, 2 (4%) of 51 required surgical intervention and 10 (20%) of 51 died. An additional 18.5% of patients had diabetes, renal failure, or both. Of these, 2 (7%) of 30 required surgery and 4 (13%) of 30 died. Only 9.5% of patients had prophylactic perioperative antibiotics as a sole risk factor; 2 (13%) of 15 required surgery and 3 (20%) of 15 died. The overall mortality rate was 15.3%, increased from 3.5% in our previous series. Neither need for surgery nor mortality differed among these patient groups. CONCLUSIONS: The frequency of C difficile colitis remains high and seems to be associated with increasing mortality. Among patients with positive C difficile toxin assay results, immunocompromise and delayed diagnosis no longer seem to be associated with higher risk for death. All patients taking antibiotics are at risk and require early recognition and aggressive medical intervention.


Assuntos
Infecção Hospitalar , Enterocolite Pseudomembranosa , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Criança , Pré-Escolar , Estudos de Coortes , Comorbidade , Infecção Hospitalar/diagnóstico , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/mortalidade , Enterocolite Pseudomembranosa/diagnóstico , Enterocolite Pseudomembranosa/tratamento farmacológico , Enterocolite Pseudomembranosa/mortalidade , Feminino , Humanos , Hospedeiro Imunocomprometido , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
7.
J Gastrointest Surg ; 6(2): 181-8; discussion 188, 2002.
Artigo em Inglês | MEDLINE | ID: mdl-11992803

RESUMO

We wished to evaluate the long-term effectiveness of the laparoscopic Hill repair in the treatment of type III hiatal hernia. Fifty-two patients underwent laparoscopic repair of a type III hiatal hernia. No esophageal lengthening procedures were performed. Short esophagus was determined from the operative record. Late symptomatic follow-up and a satisfaction questionnaire were completed in 71% (37/52) of patients at a mean of 39 months (range 6 to 84 months). Esophagrams were completed in 65% (34/52) of patients at a mean of 37 months (range to 84 months) after repair. Eighty-one percent were without any adverse symptoms, and 86% rated outcome as excellent or good at 39 months. Symptoms requiring treatment were present in 19% (7/37). Esophagrams revealed a recurrent hernia in 32% (11/34) of patients of whom 36% (4/11) were asymptomatic. Six patients with short esophagus underwent esophagram with one recurrence identified (17%). This was compared with 28 patients without short esophagus, of whom 10 had a recurrence (35%) (P = 0.70). The laparoscopic Hill repair provides long-term satisfaction and relief of symptoms. The incidence of anatomic recurrence on video esophagram is high and does not always correlate with symptoms. The presence of short esophagus does not play a role in recurrence when the Hill repair is used.


Assuntos
Esôfago/fisiopatologia , Hérnia Hiatal/diagnóstico , Hérnia Hiatal/cirurgia , Laparoscopia/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Esôfago/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Complicações Pós-Operatórias , Radiografia , Recidiva , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
8.
J Gastrointest Surg ; 7(1): 68-76, 2003 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-12559187

RESUMO

Helicobacter pylori may protect against the development of dysplasia in Barrett's epithelium of patients with gastroesophageal reflux disease. The aim of this study was to determine whether H. pylori preferentially induces apoptosis in Barrett's-derived cancer cells compared to normal cells. A Barrett's-derived adenocarcinoma cell line (OE33) was grown. H. pylori wild-type, isogenic vacA-, cagA(-), and picB-/cagE- mutant strains were grown on agar plates. Intact or sonicated bacteria were used to treat normal and OE33 cells for 24 hours, and Hoechst dye binding was performed to measure apoptosis. FAS protein expression was determined by Western immunoblotting. OE33 cells treated with intact H. pylori wild-type strains produced significant (P < 0.05) dose-dependent increases in apoptosis compared to normal esophageal cells. H. pylori wild-type and vacA- isogenic strains were more effective than cagA- and picB-/cage- isogenic strains in inducing apoptosis in OE33 cells. In OE33 cells, H. pylori sonicates produced lower levels of apoptosis than intact bacteria. Wild-type H. pylori strains increased Fas protein expression in OE33 cells at 18 hours. H. pylori induced apoptosis at a higher rate in the Barrett's-derived human esophageal adenocarcinoma cells than in normal esophageal cells. The H. pylori-induced apoptosis was primarily dependent on intact bacteria and the presence of the cagA and picB/cagE gene products. H. pylori-induced apoptosis may involve the Fas-caspase cascade.


Assuntos
Adenocarcinoma/fisiopatologia , Antígenos de Bactérias , Apoptose , Esôfago de Barrett/microbiologia , Neoplasias Esofágicas/fisiopatologia , Esôfago/patologia , Helicobacter pylori/fisiologia , Receptores do Fator de Necrose Tumoral , Adenocarcinoma/etiologia , Adenocarcinoma/microbiologia , Proteínas de Bactérias/análise , Esôfago de Barrett/complicações , Western Blotting , Células Cultivadas , Neoplasias Esofágicas/etiologia , Neoplasias Esofágicas/microbiologia , Esôfago/microbiologia , Helicobacter pylori/genética , Humanos , Neuropeptídeos/análise , Células Tumorais Cultivadas , Receptor fas
9.
Am J Surg ; 185(5): 481-4, 2003 May.
Artigo em Inglês | MEDLINE | ID: mdl-12727571

RESUMO

BACKGROUND: We wished to determine the type of diseases in patients who received bone marrow transplant (BMT) that potentially involve the general surgeon at our institution. METHODS: The records of 542 patients who underwent bone marrow transplant at Oregon Health and Sciences University between January 1990 and December 2000 were retrospectively reviewed. Gastrointestinal complications included in the study were gastrointestinal bleeding, venoocclusive disease of the liver, intestinal graft versus host disease, pneumatosis intestinalis, necrotizing enteritis, as well as other more common surgical diseases (eg, appendicitis). RESULTS: Gastrointestinal complications or surgical consultations were noted in 92 of 542 patients (17%). Of these, formal general surgical consultation was obtained in 48 patients (9%). The most common causes for surgical consult were cholecystitis (5), abdominal pain of unknown etiology (5), central line complications (5), small bowel obstruction (4), and appendicitis (4). Twenty-eight (58%) of these patients received an operation. Six patients (13%) died during the same hospitalization as their surgery consult. Forty-four patients with these gastrointestinal symptoms related to transplantation did not receive surgical consult. The mortality in this group was 45%. CONCLUSIONS: The majority of gastrointestinal complications after bone marrow transplant do not require surgical intervention. However, these conditions may overlap the more common reasons for surgical consult and must be identifiable by the general surgeon. Of patients who did require surgical intervention, it was primarily for common surgical diseases.


Assuntos
Transplante de Medula Óssea/efeitos adversos , Gastroenteropatias/etiologia , Adulto , Idoso , Feminino , Gastroenteropatias/epidemiologia , Gastroenteropatias/cirurgia , Doença Enxerto-Hospedeiro/epidemiologia , Doença Enxerto-Hospedeiro/cirurgia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
10.
Am J Surg ; 187(5): 655-9, 2004 May.
Artigo em Inglês | MEDLINE | ID: mdl-15135686

RESUMO

BACKGROUND: The 2 weight loss procedures most commonly performed in the United States are Roux-en-Y gastric bypass (RYGBP) and lateral gastrectomy with duodenal switch (BPD/DS). RYGB is a restrictive procedure, whereas BPD/DS relies on mild restriction of intake as well as malabsorption. Many physicians believe that weight loss is greater after BPD/DS than after RYGBP. However, these procedures have not been compared using groups of patients operated on by the same surgeons at the same institution. METHODS: We compared weight loss (expressed as percent of excess body weight [%EBW]) after 1 and 2 years in patients who underwent open RYGB or BPD/DS at our institution. RESULTS: Average length of stay was longer in BPD/DS patients than in those undergoing RYGBP (8.7 vs. 5.9 days, P <0.05). Anastomotic leaks were higher after BPD/DS (6% vs. 3%), but the difference did not achieve statistical significance. Mortality did not differ between the 2 groups (0.8% vs. 0.9%). In the group of patients followed-up for 1 to 2 years, age and distribution of men and women did not differ. Those patients undergoing BPD/DS had higher body mass index (59 vs. 55, P <0.05). Weight loss expressed as %EBW was similar between the 2 groups: 54% versus 53% at 1 year and 67% versus 64% at 2 years. CONCLUSIONS: Our data suggested that weight loss expressed as %EBW is similar between patients undergoing RYGBP and those undergoing BPD/DS. However, BPD/DS was associated with a longer hospital stay.


Assuntos
Desvio Biliopancreático/métodos , Duodeno/cirurgia , Gastrectomia/métodos , Derivação Gástrica/métodos , Obesidade Mórbida/cirurgia , Redução de Peso , Adulto , Anastomose em-Y de Roux/efeitos adversos , Anastomose em-Y de Roux/métodos , Anastomose em-Y de Roux/mortalidade , Desvio Biliopancreático/efeitos adversos , Desvio Biliopancreático/mortalidade , Índice de Massa Corporal , Peso Corporal , Diabetes Mellitus/etiologia , Feminino , Seguimentos , Gastrectomia/efeitos adversos , Gastrectomia/mortalidade , Derivação Gástrica/efeitos adversos , Derivação Gástrica/mortalidade , Humanos , Hipertensão/etiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Fatores de Risco , Síndromes da Apneia do Sono/etiologia , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Resultado do Tratamento
11.
Am J Surg ; 183(5): 539-43, 2002 May.
Artigo em Inglês | MEDLINE | ID: mdl-12034388

RESUMO

BACKGROUND: Gastroesophageal reflux disease (GERD) is common in patients with head and neck carcinoma. The impact of laparoscopic fundoplication on laryngectomy patients with tracheoesophageal prostheses for voice restoration is unknown. METHODS: Nine laryngectomy patients who use tracheoesophageal speech underwent laparoscopic fundoplication for documented reflux. Preoperative and postoperative symptoms were recorded. Quality of speech was documented before and after fundoplication. RESULTS: Although 88% of patients had resolution of GERD symptoms, all developed bloating and hyperflatulence. There was no difference in quality of esophageal speech after laparoscopic fundoplication. CONCLUSIONS: Fundoplication in laryngectomy patients that use tracheoesophageal speech eliminates symptoms of gastroesophageal reflux and resolves regurgitation associated prosthesis erosion. Although nearly all patients are satisfied with outcome, there is a high incidence of postfundoplication bloating and hyperflatulence that may be life limiting. Poor quality tracheoesophageal speech should not be used as an indication for antireflux surgery.


Assuntos
Carcinoma de Células Escamosas/cirurgia , Fundoplicatura , Refluxo Gastroesofágico/cirurgia , Laringectomia , Neoplasias Otorrinolaringológicas/cirurgia , Voz Esofágica , Idoso , Carcinoma de Células Escamosas/complicações , Feminino , Flatulência/etiologia , Fundoplicatura/efeitos adversos , Refluxo Gastroesofágico/complicações , Humanos , Intestinos/fisiopatologia , Laparoscopia/efeitos adversos , Laringectomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Neoplasias Otorrinolaringológicas/complicações , Satisfação do Paciente , Qualidade de Vida , Estudos Retrospectivos , Resultado do Tratamento
12.
Am J Surg ; 183(5): 544-6, 2002 May.
Artigo em Inglês | MEDLINE | ID: mdl-12034389

RESUMO

PURPOSE: To assess causes and treatment of late failures of colon interposition. METHODS: We reviewed the charts of 6 patients who underwent one or more revisions of a colonic interposition at a mean of 16 years after colon interposition (CI). RESULTS: Symptoms of problems with the CI were dysphagia (67%), regurgitation (67%), pneumonia (40%), and chest pain (33%). Findings that accounted for failure were colonic redundancy (67%), and gastrocolonic reflux (50%). Approach was resection of redundant colon or management of reflux. Four patients underwent segmental resection of the colon preserving blood supply. Three patients had gastric resection or diversion of bile and acid for management of reflux. Treatment was successful in all patients. CONCLUSION: Late failure of colon interposition is secondary to conduit redundancy and severe reflux. Resection of redundant colon will correct colonic redundancy. Gastric resection or diversion of bile and acid corrects gastrocolonic reflux.


Assuntos
Colo/transplante , Doenças do Esôfago/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Esofagectomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Reoperação , Fatores de Tempo , Falha de Tratamento
13.
Comput Methods Programs Biomed ; 113(1): 153-61, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24184112

RESUMO

An abdominal wall hernia is a protrusion of the intestine through an opening or area of weakness in the abdominal wall. Correct pre-operative identification of abdominal wall hernia meshes could help surgeons adjust the surgical plan to meet the expected difficulty and morbidity of operating through or removing the previous mesh. First, we present herein for the first time the application of image analysis for automated identification of hernia meshes. Second, we discuss the novel development of a new entropy-based image texture feature using geostatistics and indicator kriging. Third, we seek to enhance the hernia mesh identification by combining the new texture feature with the gray-level co-occurrence matrix feature of the image. The two features can characterize complementary information of anatomic details of the abdominal hernia wall and its mesh on computed tomography. Experimental results have demonstrated the effectiveness of the proposed study. The new computational tool has potential for personalized mesh identification which can assist surgeons in the diagnosis and repair of complex abdominal wall hernias.


Assuntos
Hérnia Ventral/diagnóstico por imagem , Telas Cirúrgicas , Tomografia Computadorizada por Raios X , Humanos , Probabilidade
14.
Surg Clin North Am ; 93(5): 1041-55, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24035075

RESUMO

The success of hernia repair is measured by absence of recurrence, appearance of the surgical scar, and perioperative morbidity. Perioperative surgical site occurrence (SSO), defined as infection, seroma, wound ischemia, and dehiscence, increases the risk of recurrent hernia by at least 3-fold. The surgeon should optimize all measures that promote healing, reduce infection, and enhance early postoperative recovery. In the population with ventral hernia, the most common complication in the immediate perioperative period is surgical site infection. This article reviews several preoperative measures that have been reported to decrease SSOs and shorten length of hospital stay.


Assuntos
Hérnia Ventral/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Antibioticoprofilaxia , Antissepsia , Dieta , Hérnia Ventral/complicações , Hérnia Ventral/prevenção & controle , Humanos , Hiperglicemia/complicações , Hiperglicemia/prevenção & controle , Apoio Nutricional , Obesidade/complicações , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Comportamento de Redução do Risco , Prevenção Secundária , Abandono do Hábito de Fumar , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
15.
Am J Surg ; 205(5): 602-7; discussion 607, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23592170

RESUMO

BACKGROUND: Currently, >200 meshes are commercially available in the United States. To help guide appropriate mesh selection, the investigators examined the postsurgical experiences of all patients undergoing ventral hernia repair at their facility from 2008 to 2011 with ≥12 months of follow-up. METHODS: A retrospective review of prospectively collected data was conducted. All returns (surgical readmission, office or emergency visit) for complications or recurrences were examined. The impact of demographics (age, gender, and body mass index [BMI]), risk factors (hernia grade, hernia size, concurrent and past bariatric surgery, concurrent and past organ transplantation, any concurrent surgery, and American Society of Anesthesiologists score), and prosthetic type (polypropylene, other synthetic, human acellular dermal matrix, non-cross-linked porcine-derived acellular dermal matrix, other biologic, or none) on the frequency of return was evaluated. RESULTS: A total of 564 patients had 12 months of follow-up, and 417 patients had 18 months of follow-up. In a univariate regression analysis, study arm (biologic, synthetic, or primary repair), hernia grade, hernia size, past bariatric surgery, and American Society of Anesthesiologists score were significant predictors of recurrence (P < .05). Multivariate analysis, stepwise regression, and interaction tests identified three variables with significant predictive power: hernia grade, hernia size, and BMI. The adjusted odds ratios vs hernia grade 2 for surgical readmission were 2.6 (95% confidence interval [CI], 1.3 to 5.1) for grade 3 and 2.6 (95% CI, 1.1 to 6.4) for grade 4 at 12 months and 2.3 (95% CI, 1.1 to 4.6) for grade 3 and 4.2 (95% CI, 1.7 to 10.0) for grade 4 at 18 months. Large hernia size (adjusted odds ratio vs small size, 3.2; 95% CI, 1.6 to 6.2) and higher BMI (adjusted odds ratio for BMI ≥50 vs 30 to 34.99 kg/m(2), 5.7; 95% CI, 1.2 to 26.2) increased the likelihood of surgical readmission within 12 months. CONCLUSIONS: The present data support the hypothesis that careful matching of patient characteristics to choice of prosthetic will minimize complications, readmissions, and the number of postoperative office visits.


Assuntos
Hérnia Ventral/cirurgia , Herniorrafia/instrumentação , Telas Cirúrgicas , Adulto , Idoso , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Fatores de Risco , Prevenção Secundária , Resultado do Tratamento
18.
Am J Cardiol ; 110(8): 1130-7, 2012 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-22742719

RESUMO

Primary prevention guidelines recommend calculation of lifetime cardiovascular disease (CVD) predicted risk in patients who may not meet criteria for high short-term (10-year) Adult Treatment Panel III risk for coronary heart disease (CHD). Extreme obesity and bariatric surgery are more common in women who often have low short-term predicted CHD risk. The distribution and correlates of lifetime CVD predicted risk, however, have not yet been evaluated in bariatric surgical candidates. Using established 10-year (Adult Treatment Panel III) CHD and lifetime CVD risk prediction algorithms and presurgery risk factors, participants from the Longitudinal Assessment of Bariatric Surgery-2 study without prevalent CVD (n = 2,070) were stratified into 3 groups: low 10-year (<10%)/low lifetime (<39%) predicted risk, low 10-year (<10%)/high lifetime (≥39%) predicted risk, and high 10-year (≥10%) predicted risk or diagnosed diabetes. Participants were predominantly white (86%) and women (80%) with a median age of 45 years and median body mass index of 45.6 kg/m(2). High 10-year CHD predicted risk was common (36.5%) and associated with diabetes, male gender, and older age, but not with higher body mass index or high-sensitivity C-reactive protein. Most participants (76%) with low 10-year predicted risk had high lifetime CVD predicted risk, which was associated with dyslipidemia and hypertension but not with body mass index, waist circumference, high-density lipoprotein cholesterol, or high-sensitivity C-reactive protein. In conclusion, bariatric surgical candidates without diabetes or existing CVD are likely to have low short-term, but high lifetime CVD predicted risk. Current data support the need for long-term monitoring and treatment of increased CVD risk factors in bariatric surgical patients to maximize lifetime CVD risk decrease (clinical trial registration, Long-term Effects of Bariatric Surgery, indentifier NCT00465829, available at: http://www.clinicaltrials.gov/ct2/results?term=NCT00465829).


Assuntos
Cirurgia Bariátrica , Doenças Cardiovasculares/epidemiologia , Adulto , Fatores Etários , Algoritmos , Biomarcadores/análise , Índice de Massa Corporal , Doenças Cardiovasculares/prevenção & controle , Distribuição de Qui-Quadrado , Feminino , Humanos , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Inquéritos Nutricionais , Prevalência , Prevenção Primária , Fatores de Risco , Fatores Sexuais , Estados Unidos/epidemiologia
19.
Arch Surg ; 144(8): 713-21, 2009 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-19687374

RESUMO

HYPOTHESIS: There is an effect of patient and hospital characteristics on perioperative outcomes for pancreatic resection in the United States. DESIGN: Retrospective cohort study. SETTING: Academic research. PATIENTS: Patient data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project from January 1988 to January 2003. MAIN OUTCOME MEASURES: In-hospital mortality, perioperative complications, and mortality following a major complication. RESULTS: A total of 103 222 patients underwent major pancreatic surgery. The annual number of pancreatic resections increased 15.0% during the 16-year study period. Resection for benign pancreatic disease increased 26.8%. Overall in-hospital mortality, perioperative complications, and mortality following a major complication were 6.5%, 35.6%, and 15.6%, respectively. Multivariate analysis demonstrated that significant independent predictors for these 3 perioperative outcomes were advancing age, male sex, medical comorbidity, and hospital volume for each type of pancreatic resection. The in-hospital mortality for pancreatoduodenectomy increases with age and ranges from 1.7% to 13.8% (P < .001). After adjusting for other confounders, the odds of in-hospital mortality for pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy in those 65 years or older were 4.78-fold, 3.84-fold, and 2.60-fold, respectively, lower in the high-volume hospitals compared with those in the lower-volume hospitals. CONCLUSIONS: Perioperative complications derived from this population-based study were higher than those reported in many case series. A significant disparity was noted in perioperative outcomes among surgical centers across the United States. An outcome-based referral guideline may have an immediate effect on improving the quality of care in patients who undergo pancreatic resection for benign and malignant disease.


Assuntos
Mortalidade Hospitalar , Avaliação de Resultados em Cuidados de Saúde , Pancreatopatias/cirurgia , Complicações Pós-Operatórias/mortalidade , Adulto , Idoso , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Pancreatectomia/mortalidade , Pancreatopatias/mortalidade , Pancreaticoduodenectomia/mortalidade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia
20.
Ann Surg ; 245(5): 790-4, 2007 May.
Artigo em Inglês | MEDLINE | ID: mdl-17457173

RESUMO

OBJECTIVE: To determine long-term quality of life after bilateral adrenalectomy for persistent Cushing's disease after transsphenoidal pituitary tumor resection. SUMMARY BACKGROUND DATA: Bilateral adrenalectomy for symptomatic relief of persistent hypercortisolism appears to be an effective treatment option. However, few studies have examined long-term outcomes in this patient population. METHODS: Retrospective review of 39 patients treated by bilateral laparoscopic adrenalectomy for Cushing's disease from 1994 to 2004. Patients completed a follow-up phone survey, including our Cushing-specific questionnaire and the SF-12v2 health survey. Patients then refrained from taking their steroid replacement for 24 hours, and serum cortisol and ACTH levels were measured. RESULTS: Three patients died at 12, 19, and 50 months following surgery from causes unrelated to adrenalectomy. The remaining 36 patients all responded to the study questionnaire (100% response rate). Patients were between 3 months and 10 years post-adrenalectomy. We had zero operative mortalities and a 10.3% morbidity rate. Our incidence of Nelson's syndrome requiring clinical intervention was 8.3%; 89% of patients reported an improvement in their Cushing-related symptoms, and 91.7% would undergo the same treatment again. Twenty of 36 (55%) and 29 of 36 (81%) patients fell within the top two thirds of the national average for physical and mental composite scores, respectively, on the SF-12v2 survey. An undetectable serum cortisol level was found in 79.4% of patients. CONCLUSIONS: Laparoscopic bilateral adrenalectomy for symptomatic Cushing's disease is a safe and effective treatment option. The majority of patients experience considerable improvement in their Cushing's disease symptoms, and their quality of life equals that of patients initially cured by transsphenoidal pituitary tumor resection.


Assuntos
Adrenalectomia , Laparoscopia , Hipersecreção Hipofisária de ACTH/cirurgia , Qualidade de Vida , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos Retrospectivos , Inquéritos e Questionários , Fatores de Tempo , Resultado do Tratamento
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