Prevalence of Upper Gastrointestinal Pathology in Patients with Obesity on Preoperative Endoscopy.

BACKGROUND AND OBJECTIVES: The preoperative work up for bariatric surgery is variable and not all centers perform a preoperative upper gastrointestinal endoscopy. A study was undertaken to determine the frequency of clinically significant gross endoscopic and pathological diagnoses in a large sample of patients with obesity undergoing work-up for bariatric surgery. METHODS: Routine endoscopy was performed on all preoperative bariatric patients. A retrospective chart review of 1000 consecutive patients was performed. Patients were divided into three groups: Group A (no endoscopic findings), Group B (clinically insignificant findings), Group C (clinically significant findings). RESULTS: Patients had a mean body mass index (BMI) of 49 kg/m2 and 79% were female. In this sample one finding was found on preoperative EGD in 95.2% of patients, 33.9% had at least two diagnoses, and 29.9% had three or more diagnoses. Group A (no findings) consisted of 4.8% of patient, 52.5% in Group B (clinically insignificant findings), and 42.7% were in Group C (clinically significant findings). Clinically significant findings included hiatal hernia 23.5%, esophagitis 9.5%, H. pylori 7.1%, gastric erosions 5.7%, duodenitis 3.7%, Barrett's esophagus 3.1%, and Schatzki ring 1.2%. There was no significant correlation between preoperative BMI and any endoscopic findings (all p-value 0.05). Patients in Group C were statistically older than Groups A and B. CONCLUSION: Upper gastrointestinal pathology is highly common in patients with obesity. There is a significant rate of clinically significant endoscopy findings and all bariatric surgery patients should undergo preoperative endoscopy.

Reoperations for Long-Term Complications Following Laparoscopic Adjustable Gastric Banding: Analysis of Incidence and Causality.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) gained popularity in the early 2000s as a purely restrictive procedure with modest weight loss. The potential for complications requiring reoperation has since become evident. A retrospective review was performed to determine the incidence of long-term complications and predictive factors requiring surgical reintervention after LAGB. METHODS: Institutional review board approval was obtained, and a retrospective review of 200 consecutive patients undergoing LAGB over a period of six years was conducted at a single institution with American Society of Metabolic and Bariatric Surgery Center of Excellence designation. Data were collected on patient characteristics, comorbid conditions and complications requiring reintervention. Statistical analysis was performed using SPSS Statistics software (IBM Corp., Armonk, NY). RESULTS: Of the 200 patients, 176 (90.7%) were female with an average age of 53.6 years and preoperative body mass index (BMI) of 44.2 kg/m2. The average follow-up was 46 months. Complications occurred in 55 (28.4%) patients with band slippage/prolapse as the most common need for reoperation. Younger age, lack of comorbidities and diet/exercise compliance were associated with reintervention. CONCLUSIONS: LAGB has a high rate of reoperation secondary to complications associated with younger age. Alternative bariatric procedures may be more appropriate in these patients who have fewer comorbid conditions and are motivated to improve his or her health.

Urinary Bladder Matrix Reinforcement for Laparoscopic Hiatal Hernia Repair.

BACKGROUND AND OBJECTIVES: Synthetic mesh reinforcement during laparoscopic hiatal hernia repair (LHHR) reduces recurrence. Biologically derived mesh is also associated with reduced recurrence. Urinary bladder matrix (UBM), a biologically derived extracellular matrix mesh, has shown clinical success. We wanted to determine the safety and efficacy of LHHR with porcine UBM reinforcement. METHODS: This retrospective, single-surgeon study reviewed clinical data on patients who underwent LHHR from August 2009 through May 2014, with diaphragmatic reinforcement with porcine UBM mesh. Primary outcomes were (1) recurrence-a >2-cm defect above the diaphragm at 3 months; (2) intra- and postoperative complications; (3) pre- and postoperative esophageal reflux (GERD) or dysphagia; and (4) cessation of proton pump inhibitor (PPI). RESULTS: Sixty-two patients who had LHHR with UBM mesh were studied (mean age, 62 years, 53 women, mean body mass index 32.7 kg/m2) Before surgery 98% had GERD, 19% had dysphagia, and 98% were on PPI. Postoperative UGIS was performed on 66% 3 months after surgery, and 19% had a recurrence of >2 cm; 56% remained on PPI, and 16% (P < .001) remained symptomatic. Dysphagia improved in 75% (P = .05). No intraoperative complications were recorded. One postoperative mortality occurred secondary to an unrelated cardiac event. CONCLUSIONS: UBM mesh was effective and safe for LHHR. In addition to reducing the rate of recurrence compared to unreinforced primary repair, the properties of UBM, including site-specific constructive tissue remodeling, may add benefits over other biologic products. This study represents an evaluation of UBM mesh in a large cohort of patients who underwent LHHR.

Laparoscopic Roux-en-Y Gastric Bypass: Surgical Technique and Perioperative Care.

Obesity is a global epidemic with multiple associated comorbid conditions. The laparoscopic Roux-en-Y gastric bypass is the gold standard operation in the fight against obesity. This review outlines the common technical aspects of the procedure, as well as the evidence based recommendations for preoperative and postoperative care.

Tumor size predicts long-term survival in colon cancer: an analysis of the National Cancer Data Base.

BACKGROUND: American Joint Committee on Cancer uses tumor size for "T" staging of many solid tumors for its effect on prognosis. However, tumor size has not been incorporated in tumor (T), nodal status (N), metastasis (M) staging for colon cancer. Hence, the National Cancer Data Base was used to determine whether tumor size correlates with TNM staging and survival. METHODS: For the 300,386 patients, tumor size was divided into S1 (0 to 2 cm), S2 (>2 to 4 cm), S3 (>4 to 6 cm), and S4 (>6 cm). Statistical comparison was done for TNM stage, grade, and nodal status with tumor size. Kaplan-Meier survival analysis was done for each "S" stage. RESULTS: Of the 300,386 patients, 13% were classified as S1, 39% S2, 30% S3 and 18% as S4. Right colon was the most common site (48%). Tumor size positively correlated with grade, T stage, and nodal stage. Tumor size was inversely associated with survival. CONCLUSION: Tumor size is positively correlated with important prognostic factors and negatively impacted survival.

Patterns of early mortality after trauma in a neighborhood urban trauma center: can we improve outcomes?

Even with specialized trauma systems, a significant number of deaths occur within the early postinjury period. Our goal was to examine deaths within this period for cause and determine if care could improve outcomes. A retrospective chart review was performed on all patients who were dead on arrival or died within 4 hours of arrival between January 1, 2005, and December 31, 2011. Survival probabilities and Injury Severity Score (ISS) were calculated. Chart review and trauma review processes were used to determine cases with opportunities for care improvement. Two hundred eighty-nine patients were dead on arrival (DOA), and 176 patients died within 4 hours of arrival. The most common mechanism of injury was gunshot wounds (68.4%). The most common causes of death were uncontrolled hemorrhage (68.2%) and neurologic trauma (23.4%). Average ISS was 32. Twenty-nine patients had survival probability percentages over 50. Ten of 176 (5.7%) deaths were found to have opportunities for care improvement. In three cases (1.7%), errors contributed to death. The majority of trauma patients DOA or dying within 4 hours of hospital arrival have nonsurvivable injuries. Regular trauma review processes are invaluable in determining opportunities for care improvement. Autopsy information increases the reliability of the review process.