A comparative analysis of Type 2 diabetes and binge eating disorder in a bariatric sample.

An emerging literature has illuminated an important link between Type 2 diabetes mellitus (DM) and binge eating disorder (BED) within obese cohorts. However, prior work has not examined this relationship specifically in a weight loss surgery (WLS) sample or fully explored potential psychosocial factors associated with this co-occurrence. Therefore, the present investigation sought to identify socio-demographic (i.e. age, education, BMI, ethnicity, gender, age of obesity onset) and psychological (i.e. depressive symptoms, hedonic hunger/food locus of control beliefs, severity of binge eating-related cognitions) correlates of the co-occurrence of Type 2 DM and BED among bariatric surgery candidates. An archival sample of 488 patients seeking surgical treatment for clinical obesity completed a standard battery of pre-operative psychosocial measures. The presence of BED was evaluated using a semi-structured clinical interview based on the DSM-IV TR (APA, 2000) and was further corroborated by responses on the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R; Spitzer, Yanovski, & Marcus, 1993). Results indicated that 8.2% of the sample was classified as having both Type 2 DM and BED concurrently. A multivariate logistic regression model revealed that in addition to other psychological (e.g., binge eating-related cognitions, hedonic hunger) and demographic variables (i.e. male gender), African American ethnicity (OR=3.3: 1.41-7.73) was a particularly robust indicator of comorbid status. Findings support and extend previous health disparity research urging greater attention to the needs of traditionally underserved, at-risk populations seeking treatment for obesity complicated by dysregulated eating and metabolism. Additionally, these preliminary results underscore the relevance of considering the potential benefits of providing quality comprehensive pre- and post-operative psychological care among bariatric patients towards optimizing both short- and long-term health and well-being.

Nutritional support in acute and chronic pancreatitis.

Nutritional support can have a significant beneficial impact on the course of moderate to severe acute pancreatitis. Enteral nutrition is preferred, with emphasis on establishment of jejunal access; however, parenteral nutrition can also be of value if intestinal failure is present. Early initiation of nutritional support is critical, with benefits decreasing rapidly if begun after 48 hours from admission. Severe malnutrition in chronic pancreatitis can be avoided or treated with dietary modifications or enteral nutrition.

Preoperative weight gain does not predict failure of weight loss or co-morbidity resolution of laparoscopic Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: Success with preoperative weight loss (PWL) is often mandated by the bariatric team to assess patient compliance and has been suggested to correlate with improved postoperative weight loss outcomes. METHODS: We performed a retrospective analysis of 1629 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass at Duke University Medical Center. Patients with a preoperative weight gain (PWG) or loss of > or =10 lb were compared. Patients with <12 months of follow-up were excluded. RESULTS: We found no difference between the 2 groups (PWG, n = 115, PWL, n = 88) with regard to age, gender, race, preoperative body mass index, presence of co-morbidities, or interval between the initial program-entry weight and surgery (149 versus 141 d). No difference was found in the percentage of excess weight loss (EWL) at 12 months, when calculated using the patient's immediate preoperative weight (PWG group, 63.5% EWL versus PWL group, 63.9% EWL, P = NS). If the %EWL was calculated using the initial program-entry weight, the PWL did confer a transient postoperative weight loss advantage; however, this did not persist past 24 months postoperatively. At both 12 and 24 months, the resolution rates of diabetes (82% versus 83% at 2 yr; P = NS), hypertension (48% versus 42% at 2 yr, P = NS), and continuous positive airway pressure discontinuation (87% versus 87% at 1 yr, P = NS) were equivalent. No differences in perioperative complications or conversion rates were detected. The operative time was slightly longer for the PWG group (119.7 versus 104.9 min, P = .02). CONCLUSION: The results of our study have shown that weight loss before laparoscopic Roux-en-Y gastric bypass is not mandatory and might deter patients from considering weight loss surgery. Laparoscopic Roux-en-Y gastric bypass can be performed safely with equivalent co-morbidity resolution and %EWL regardless of PWG or PWL.

Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity.

BACKGROUND: A scoring system for clinical assessment of mortality risk has been previously proposed for bariatric surgery (Demaria EJ, Portenier D, Wolfe L, Surg Obes Relat Dis. 2007;3:34-40.). The Obesity Surgery Mortality Risk Score (OS-MRS) was developed from a single institution experience of 2075 patients. The current study provides multicenter validation of the value of the OS-MRS. The OS-MRS assigns 1 point to each of 5 preoperative variables, including body mass index>or=50 kg/m2, male gender, hypertension, known risk factors for pulmonary embolism (previous thromboembolism, preoperative vena cava filter, hypoventilation, pulmonary hypertension), and age>or=45 years. Patients with total score of 0 to 1 are classified as 'A' (lowest) risk group, score 2 to 3 as 'B' (intermediate) risk group, and score 4 to 5 as 'C' (high) risk group. METHODS: Prospectively-collected data from 4431 consecutive patients undergoing a primary gastric bypass at 4 bariatric programs recruited to validate the proposed system were analyzed to assess OS-MRS as a means of stratifying surgical mortality risk. RESULTS: There were 33 total deaths for an overall mortality for the validation cohort of 0.7% consistent with published standards. Mortality for 2164 class A patients was 0.2%, for 2142 class B patients was 1.1%, and for 125 class C patients was 2.4%. Mortality was significantly different between each of the class A, B, and C groupings (P<0.05, chi2). Mortality was 5-fold greater in the class B group than in class A. Only 6 patients with all 5 risk factors were identified. Class C patients (n=125, 3% of total cohort) were characterized by a 12-fold greater mortality than the lowest risk group (A) and a disproportionate 9% of all mortalities. CONCLUSION: The OS-MRS was found to stratify mortality risk in 4431 patients from 4 validation centers that were nonparticipants in the original defining cohort study. The score represents the first validated scoring system for risk stratification in bariatric surgery and is anticipated to aid informed consent discussions, guide surgical decision-making, and allow standardization of outcome comparisons between treatment centers.

Anaphylaxis to leuprolide acetate depot injection during treatment for prostate cancer.

A 66-year-old man with clinically localized prostate cancer had elected brachytherapy as the primary management of his disease. During induction of neoadjuvant androgen deprivation for purposes of cytoreduction, the patient experienced anaphylaxis immediately after his first injection of a leuprolide acetate depot. He required emergent intubation and extended hospitalization. Anaphylactic reactions to leuprolide acetate depots have been described as exceedingly rare. To our knowledge, we report the first case of an anaphylactic reaction to a leuprolide acetate depot injection in an American man undergoing treatment for prostate cancer.

Psychological correlates of obese patients seeking surgical or residential behavioral weight loss treatment.

BACKGROUND: The purpose of this study was to gain a better understanding of the psychological factors related to obese individuals self-selecting for either a residential cognitive-behavioral-based program or surgical treatment program for weight loss. METHODS: Two patient samples with a body mass index of > or =35 kg/m(2) were administered a battery of psychological questionnaires, including the Beck Depression Inventory, Binge Eating Scale, and Impact of Weight on Quality of Life-Lite, at the evaluation for entry into either a surgical weight loss treatment program (n = 76) or cognitive-behavioral-based weight loss treatment program (n = 101). RESULTS: No significant difference was found in the mean body mass index of the 2 samples. No significant difference was found in the self-reported level of depressive symptoms of the 2 samples, with both samples obtaining a mean depressive symptom score in the mild range. Surgical treatment seekers, however, reported significantly greater emotional eating and attributed greater impairment in their quality of life to their weight. CONCLUSION: Individuals seeking a surgical approach to weight loss might perceive their weight as having a greater negative impact on their life than those selecting a residential behavioral lifestyle change approach, even when their weight and depressive symptoms are equivalent. Therefore, an individual's own cognitive appraisal of the negative consequences of their weight might correlate with their treatment choice.

Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass.

BACKGROUND: Because of the claim that about one third of patients develop gallstones within 6 months of Roux-en-Y gastric bypass (RYGB), many have recommended preoperative ultrasonography for all patients and/or prophylactic cholecystectomy (CCY), or ursodiol to prevent stone formation. METHODS: Prospective data were collected from 1391 consecutive patients followed up for > or = 6 months after RYGB (2000-2005) to assess our practice of not routinely removing the gallbladder and not administering ursodiol. RESULTS: Of the 1391 patients, 334 (24%) had undergone CCY before RYGB. Of the remaining 1057 asymptomatic patients, 516 had undergone preoperative ultrasonography. Stones were identified in 99 (19%), sludge in 5 (0.97%), and polyps in 6 (1.1%). Of the 984 patients with gallbladders left in situ after RYGB, only 80 (8.1%) became symptomatic and required delayed CCY. The average excess weight loss at the delayed CCY was 65%. The risk of undergoing delayed CCY seemed to be restricted to the first 29 months after RYGB, because none of 165 patients followed up for 30-144 months required CCY. CONCLUSION: Although CCY should be performed whenever symptoms mandate, the value of routine preoperative ultrasonography and CCY was not apparent from the results of our study. Waiting until symptoms develop might simplify the operative procedure because of the significant weight loss that should have occurred after RYGB. Using an expectant approach, most patients undergoing RYGB will not require CCY.

Surgical revision of loop ("mini") gastric bypass procedure: multicenter review of complications and conversions to Roux-en-Y gastric bypass.

BACKGROUND: The claim that the "mini"-gastric bypass (MGB) procedure with its loop gastrojejunostomy is safer and equally effective to the Roux-en-Y gastric bypass (RYGB) procedure has been promoted before validation. Rumors of unreported complications and the accuracy of follow-up are additional concerns. This study was undertaken to identify MGB patients who require or required revisional surgery at 5 hospitals within the region of the United States where the MGB procedure originated to assess the claim that revision to RYGB is rarely needed. METHODS: The databases of 5 medical centers were retrospectively searched to identify patients undergoing surgical revision after a MGB procedure, all of which had been done elsewhere. RESULTS: A total of 32 patients were identified who presented with complications after undergoing an MGB procedure and required or require revisional surgery. The complications included gastrojejunostomy leak in 3, bile reflux in 20, intractable marginal ulcer in 5, malabsorption/malnutrition in 8, and weight gain in 2. Of the 32 patients, 21 required conversion to RYGB and an additional 5 have planned revisions in the future. Also, 2 patients were treated with Braun enteroenterostomies and 4 required 1 or more abdominal explorations. CONCLUSIONS: The results of this preliminary review have confirmed that MGB does require revision in some patients and that conversion to RYGB is a common form of revision. A national registry to record the complications and number of revisions is proposed to gain insight into the need for revision after MGB and other nontraditional bariatric procedures.

Anatomy and physiology of the luminal gut: enteral access implications.

Successful long-term enteral nutrition requires enteral access that is comfortable and easy to maintain. However, to be successful, the enteral access must also satisfy conditions of gut anatomy and physiology.

Anatomy and physiology of venous system vascular access: implications.

Ideal characteristics for long-term vascular access that can be managed in the home environment include a large vascular lumen in a high-flow blood system to minimize risks of obstruction and phlebitis, ease of sterile dressing maintenance, patient comfort, and longevity of the access site. Additionally, adaptation to placement at the bedside or in the home, technical ease and safety of placement, and minimal expense would be beneficial. With these considerations, possible anatomical sites would include the external and internal jugular veins, subclavian vein, cephalic vein, basilic vein, femoral vein, right atrial appendage, and translumbar and transhepatic access to the inferior vena cava. Of these, the internal jugular vein, subclavian vein, cephalic vein, basilic vein, and femoral vein would seem best suited for long-term venous access.

Binge eating, quality of life and physical activity improve after Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: Severe obesity has been associated with disordered eating, impaired quality of life (QoL), and decreased physical activity. This study examines changes in these variables 6 months after Roux-en-Y gastric bypass (RYGBP). METHODS: 40 morbidly obese patients were evaluated at baseline and at 6 months after RYGBP on the following measures: Binge Eating Scale, Three Factor Eating Questionnaire, Impact of Weight on Quality of Life-Lite (IWQoL-Lite), and the Baseline Questionnaire of Activity. RESULTS: 6 months after RYGBP, weight loss averaged 26.7%, and scores on measures of disordered eating, weight-related QoL, and physical activity showed statistically significant improvement from baseline. At the time of follow-up, 100% of participants achieved a score on the Binge Eating Scale that indicated no binge eating problems, and weight-related QoL scores approached those obtained by a reference sample of community volunteers. There were also improvements in the level of self-reported physical activity and television watching behavior. CONCLUSIONS: RYGBP resulted in significant improvements in disordered eating, weight-related QoL, and physical activity in addition to weight loss.

Poor outcome and quality of life in female patients undergoing secondary surgery for recurrent peptic ulcer disease.

Secondary peptic ulcer surgery is uncommon given the success of a wide variety of medical therapies, plus the good outcome expected after primary peptic ulcer surgery. Early reports of secondary peptic ulcer surgery in the 1950s and 1960s suggested good long-term outcome in most patients; however, recent data suggest that patients operated in the Helicobacter pylori era have a worse outcome. We have attempted to quantify the poor outcome in these patients and measure the effect of sex, a previously unrecognized risk factor for poor outcome after peptic ulcer surgery. We reviewed the outcomes of 35 patients who underwent secondary peptic ulcer surgery for symptoms of persistent or recurrent peptic ulcer symptoms or complications of the condition. These patients were compared to a "control" group of patients to determine long-term quality of life as measured by the SF-36 and Visick scores (average follow-up 60 months). Visick and SF-36 scores were obtained through telephone interviews. The two groups of patients were age matched to eliminate age as a variable in the SF-36 results. There were more females than males in the secondary peptic ulcer surgery group (4.5/1 female-to-male ratio). Although perioperative mortality was zero for both groups, patients undergoing secondary peptic ulcer surgery had a high number of complications (57% of patients had complications). Patients undergoing secondary peptic ulcer surgery scored lower in seven of the eight subclasses of the SF-36 questionnaire compared to their age-matched cohorts. In contrast, average Visick scores showed slight improvement for three out of four symptoms reported. Immediate postoperative complications were not related to long-term quality of life issues. Secondary peptic ulcer surgery is more prevalent in females than in males. Although secondary peptic ulcer surgery is partially effective in alleviating symptoms, quality of life is poor.