Systematic Literature Review of Health-Related Quality-of-Life Measures for Caregivers of Older Adult Trauma Patients.

INTRODUCTION: As the older adult population increases, hospitals treat more older adults with injuries. After leaving, these patients suffer from decreased mobility and independence, relying on care from others. Family members often assume this responsibility, mostly informally and unpaid. Caregivers of other older adult populations have increased stress and decreased caregiver-related quality of life (CRQoL). Validated CRQoL measures are essential to capture their unique experiences. Our objective was to review existing CRQoL measures and their validity in caregivers of older adult trauma patients. METHODS: A professional librarian searched published literature from the inception of databases through August 12, 2022 in MEDLINE (via PubMed), Embase (via Elsevier), and CINAHL Complete (via EBSCO). We identified 1063 unique studies of CRQoL in caregivers for adults with injury and performed a systematic review following COnsensus-based Standards for the selection of health Measurement Instruments guidelines for CRQoL measures. RESULTS: From the 66 studies included, we identified 54 health-related quality-of-life measures and 60 domains capturing caregiver-centered concerns. The majority (83%) of measures included six or fewer CRQoL content domains. Six measures were used in caregivers of older adults with single-system injuries. There were no validated CRQoL measures among caregivers of older adult trauma patients with multisystem injuries. CONCLUSIONS: While many measures exist to assess healthcare-related quality of life, few, if any, adequately assess concerns among caregivers of older adult trauma patients. We found that CRQoL domains, including mental health, emotional health, social functioning, and relationships, are most commonly assessed among caregivers. Future measures should focus on reliability and validity in this specific population to guide interventions.

Development of a prospective biliary dashboard to compare performance and surgical cost.

BACKGROUND: Transparency around surgeon level data may align healthcare delivery with quality care for patients. Biliary surgery includes numerous procedures performed by both general surgeons and subspecialists alike. Cholecystectomy is a common surgical procedure and an optimal cohort to measure quality outcomes within a healthcare system. METHODS: Data were collected for 5084 biliary operations performed by 68 surgeons in 11 surgical divisions in a health system including a tertiary academic hospital, two regional community hospitals, and two ambulatory surgery centers. A privacy protected dashboard was developed to compare surgeon performance and cost between July 2018 and June 2022. A sample cohort of patients ≥ 18 years who underwent cholecystectomy were compared by operative time, cost, and 30-day outcomes. RESULTS: Over 4 years, 4568 cholecystectomy procedures were performed by 57 surgeons. Operations were done by 57 surgeons in four divisions and included 3846 (84.2%) laparoscopic cholecystectomies, 601 (13.2%) laparoscopic cholecystectomies with cholangiogram, and 121 (2.6%) open cholecystectomies. Patients were admitted from the emergency room in 2179 (47.7%) cases while 2389 (52.3%) cases were performed in the ambulatory setting. Individual surgeons were compared to peers for volume, intraoperative data, cost, and outcomes. Cost was lowest at ambulatory surgery centers, yet only 4.2% of elective procedures were performed at these facilities. Prepackaged kits with indocyanine green were more expensive than cholangiograms that used iodinated contrast. The rate of emergency department visits was lowest when cases were performed at ambulatory surgery centers. CONCLUSION: Data generated from clinical dashboards can inform surgeons as to how they compare to peers regarding quality metrics such as cost, time, and complications. In turn, this may guide strategies to standardize care, optimize efficiency, provide cost savings, and improve outcomes for cholecystectomy procedures. Future application of clinical dashboards can assist surgeons and administrators to define value-based care.

Optimal Nutrition in the Older Adult: Beneficial Versus Ineffective Supplements.

PURPOSE OF REVIEW: Proper nutrition in older adults is essential, as nutritional deficiencies are common in this population. This review aims to summarize the benefits and risks of nutritional supplementation in the older adult population including the efficacy of various supplements, their risks, and common drug interactions with frequently prescribed medications. RECENT FINDINGS: In recent years, a growing percentage of older adults have been found to take multiple daily nutritional supplements. This population has complex nutritional needs due to the physiology of aging and the presence of comorbidities. However, many primary care providers are unaware of the benefits and drawbacks of nutritional supplementation in the elderly. This review summarizes the current literature to provide more clarity to providers on how to support this population's nutritional needs. Nutritional supplementation is essential for elderly populations who may not be able to obtain adequate nutrition from dietary sources. Supplements vary widely in efficacy and safety. As such, supplementation should be individualized and guided by a qualified healthcare provider to ensure patients receive effective, beneficial nutrition.

Evaluation of malnutrition via modified GLIM criteria for in patients undergoing emergent gastrointestinal surgery.

BACKGROUND: Malnutrition remains a critical public health issue in the US, particularly in surgery where perioperative malnutrition is commonly underdiagnosed and undertreated. In 2016, the Global Leadership Initiative on Malnutrition (GLIM) proposed a set of consensus criteria for the diagnosis of malnutrition. Our project aims to assess the post-operative outcomes of patients meeting a modified GLIM-defined (mGLIM) malnutrition criteria undergoing emergent gastrointestinal surgery (EGS) in the NSQIP database. Current GLIM-criteria were modified with addition of admission albumin (a NSQIP-defined malnutrition variable). METHODS: Adapting NSQIP data, mGLIM criteria are (1) BMI of ≤20 for age ≤ 70 and BMI ≤22 for age ≥ 71, (2) weight loss > 10% within the past 6 months, (3) admission albumin ≤ 3.5, and (4) emergent bowel surgery as etiologic criteria of acute disease/injury. All patients undergoing emergent small bowel, colon, and rectal procedures were extracted from the NSQIP database and included in the study. Multivariate linear and logistic regression models controlling for relevant covariates were developed to evaluate mGLIM criteria on length of stay (LOS), mortality, and overall complication rates. RESULTS: We included 31,029 patients who underwent emergent bowel surgeries from years 2011-2016. Demographically, 53.6% (n = 16,622) were female, 13.0% (n = 4023) were African American, and 78.3% (n = 24,292) were Caucasian. Case composition included 71.5% colon operations, 28.0% small bowel, and 0.5% rectal cases. Overall, 1.7% (n = 517) had data necessary to qualify as malnourished as per mGLIM. Controlling for covariates, multivariate linear and logistic regression analyses show that these patients have significantly higher mortality for both colon (p < 0.001, CI 1.55 | 2.61) and small bowel (p = 0.022, CI 1.08 | 2.67) procedures, longer LOS for colon (p < 0.001, CI 1.93 | 4.33) operations, and higher post-operative complications for both colon (p < 0.001, CI 1.61 | 2.62) and small bowel (p < 0.001, CI 1.57 | 3.37) cases. CONCLUSION: This analysis shows that mGLIM criteria malnutrition is associated with poor clinical outcomes following EGS affecting LOS and mortality. Our data indicates the new mGLIM criteria can be a powerful and simple predictive score for malnutrition that can be used to predict malnutrition-related risk of poor outcomes after EGS.

Consensus statement of the consortium for LESS cholecystectomy.

Many surgeons attempting Laparo-Endoscopic Single Site (LESS) cholecystectomy have found the operation difficult, which is inconsistent with our experience. This article is an attempt to promote a standardized approach that we feel surgeons with laparoscopic skills can perform safely and efficiently. This is a four-trocar approach consistent with the four incisions utilized in conventional laparoscopic cholecystectomy. After administration of general anesthesia, marcaine is injected at the umbilicus and a 12-mm vertical incision is made through the already existing anatomical scar of the umbilicus. A single four-trocar port is inserted. A 5-mm deflectable-tip laparoscope is placed through the trocar at the 8 o'clock position, a bariatric length rigid grasper is inserted through the trocar at the 4 o'clock position (to grasp the fundus), and a rigid bent grasper is placed through the 10-mm port (to grasp the infundibulum). This arrangement of the instruments promotes minimal internal and external instrument clashing with simultaneous optimization of the operative view. This orientation allows retraction of the gallbladder in a cephalad and lateral direction, development of a window between the gallbladder and the liver which promotes the "critical view" of the cystic duct and artery, and provides triangulation with excellent visualization of the operative field. The operation is concluded with diaphragmatic irrigation of marcaine solution to minimize postoperative pain. Standardization of LESS cholecystectomy will speed adoption, reduce intraoperative complications, and improve the efficiency and safety of the approach.

Effect of staple height on gastrojejunostomy during laparoscopic gastric bypass: a multicenter prospective randomized trial.

BACKGROUND: Gastrointestinal (GI) bleeding and anastomotic stricture are frequent complications associated with the construction of the gastrojejunostomy during laparoscopic gastric bypass. Staplers with shorter staple height can reduce the rate of postoperative GI hemorrhage. The aim of the present study was to assess the outcomes of patients who had undergone gastric bypass with construction of the gastrojejunostomy using a 25-mm circular stapler with a 3.5- versus 4.8-mm staple height. METHODS: From January 2007 to February 2009, 357 patients underwent laparoscopic gastric bypass using a circular stapler for construction of the gastrojejunostomy were randomly assigned to either the 3.5-mm (n = 180) or 4.8-mm (n = 177) group. Two patients randomized to the 4.8-mm group did not undergo the operative procedure and were excluded from the analysis. The primary outcome measures included the rate of GI hemorrhage, anastomotic stricture, and wound infection. RESULTS: The 2 groups were similar with regard to the demographics and baseline body mass index (47 versus 48 kg/m(2)). The operative time, blood loss, and postoperative hematocrit on day 2 were similar between the 2 groups. No significant differences were seen in the overall rate of intraoperative GI bleeding or postoperative GI bleeding from all sources (3.3% for 3.5 mm versus 6.3% for 4.8 mm, P >.05); however, a trend was seen toward a lower rate of postoperative GI bleeding from the gastric pouch or gastrojejunostomy (.5% for 3.5 mm versus 3.4% for 4.8 mm, P = .06). The rate of anastomotic stricture was significantly lower in the 3.5-mm group (3.9% versus 16.0%, P <.01). No significant differences were seen in rate of wound infection between the 2 groups. Other morbidities for the entire study cohort included leaks (1.1%), pulmonary embolism (.6%), gastrointestinal obstruction (1.4%), and reoperation (3.4%). The overall in-hospital mortality rate was .3%, and the 30-day mortality rate was .8%. CONCLUSIONS: In the present prospective, randomized trial, using a circular stapler with a shorter staple height (3.5 mm) during construction of the gastrojejunostomy, significantly reduced the rate of postoperative anastomotic stricture, with a trend toward a lower rate of GI bleeding from the gastrojejunostomy.

Postoperative hypoxemia: common, undetected, and unsuspected after bariatric surgery.

BACKGROUND: Patients undergoing gastric bypass are at greater than ordinary risk for postoperative respiratory insufficiency, presumably related to obstructive sleep apnea (OSA) and patient-controlled analgesia (PCA). This study was proposed to quantify the magnitude of the problem. METHODS: Fifteen patients undergoing gastric bypass had oxygen saturation (SpO(2)) recorded continuously, but not displayed, for 24h postoperatively; eight also had arterial blood analysis every 4h. All received narcotic PCA. SpO(2)<90% lasting more than 10 s was reviewed. Results are mean+/-SEM. RESULTS: Mean age was 44+/-4 y, and mean BMI was 48+/-2kg/m(2); 77% had OSA. Every patient had more than one episode with SpO(2)<90% for longer than 30s undetected by routine monitoring; most had multiple episodes. Nadir SpO(2) averaged 75% +/- 8%. Mean longest duration of desaturation below 90% averaged 21+/-15min. Mean PaCO(2) was 37+/-3mm Hg; maximum PaCO(2) was 47mm Hg. CONCLUSIONS: Severe and prolonged episodes of hypoxemia were a consistent finding, despite aggressive preoperative diagnosis and treatment of OSA, including use of CPAP postoperatively. Although some postoperative hypoventilation was expected, the degree and frequency of desaturation were surprising. No patient exhibited arterial PaCO(2) evidence of hypoventilation. No patient experienced cardiopulmonary arrest/instability, in spite of severe, repeated episodes of hypoxemia. In no instance was a significant hypoxemic episode suspected or detected. Continuous pulse oximetry monitoring, with an audible alarm set for a saturation less than 90% for 10 s, would have alerted providers to 100% of significant hypoxemic episodes. Our recommendation is routinely monitoring (with alarm capability enabled) every bariatric surgical patient, to prevent such occurrence.

High-definition multidetector computed tomography for evaluation of coronary artery stents: comparison to standard-definition 64-detector row computed tomography.

BACKGROUND: The assessment of coronary stents with present-generation 64-detector row computed tomography scanners that use filtered backprojection and operating at standard definition of 0.5-0.75 mm (standard definition, SDCT) is limited by imaging artifacts and noise. OBJECTIVES: We evaluated the performance of a novel, high-definition 64-slice CT scanner (HDCT), with improved spatial resolution (0.23 mm) and applied statistical iterative reconstruction (ASIR) for evaluation of coronary artery stents. METHODS: HDCT and SDCT stent imaging was performed with the use of an ex vivo phantom. HDCT was compared with SDCT with both smooth and sharp kernels for stent intraluminal diameter, intraluminal area, and image noise. Intrastent visualization was assessed with an ASIR algorithm on HDCT scans, compared with the filtered backprojection algorithms by SDCT. RESULTS: Six coronary stents (2.5, 2.5, 2.75, 3.0, 3.5, 4.0mm) were analyzed by 2 independent readers. Interobserver correlation was high for both HDCT and SDCT. HDCT yielded substantially larger luminal area visualization compared with SDCT, both for smooth (29.4+/-14.5 versus 20.1+/-13.0; P<0.001) and sharp (32.0+/-15.2 versus 25.5+/-12.0; P<0.001) kernels. Stent diameter was higher with HDCT compared with SDCT, for both smooth (1.54+/-0.59 versus1.00+/-0.50; P<0.0001) and detailed (1.47+/-0.65 versus 1.08+/-0.54; P<0.0001) kernels. With detailed kernels, HDCT scans that used algorithms showed a trend toward decreased image noise compared with SDCT-filtered backprojection algorithms. CONCLUSIONS: On the basis of this ex vivo study, HDCT provides superior detection of intrastent luminal area and diameter visualization, compared with SDCT. ASIR image reconstruction techniques for HDCT scans enhance the in-stent assessment while decreasing image noise.

Current management of adrenal tumors.

PURPOSE OF REVIEW: Adrenal tumors evoke considerable interest and diagnostic challenges. This rare group of tumors includes functional tumors with a gamut of clinical presentations, as well as adrenocortical carcinoma, with its advanced disease at presentation and dismal prognosis posing additional challenge. Increasing detection of incidentalomas adds further interest with the concomitant diagnostic and management dilemmas. RECENT FINDINGS: Significant advances have been made in diagnostic imaging modalities for identifying malignancy risk in adrenal incidentalomas. Considerable progress has occurred in understanding adrenocortical carcinoma pathogenesis from the study of genetics at the germline level in familial carcinomas, as well as at the somatic level by analyzing molecular alterations in sporadic tumors; this research supplies opportunities to develop novel therapeutic agents against a tumor with poor prognosis. SUMMARY: Laparoscopic adrenalectomy has emerged as standard of care in the treatment of functional benign adenomas and nonfunctional tumors larger than 4 cm when adrenocortical carcinoma is not suspected. Open adrenalectomy with en-bloc excision has been the mainstay for primary and recurrent adrenocortical carcinoma due to the lack of effective adjuvant therapy. International consensus conferences have attempted to standardize diagnostic and treatment approaches in the management of adrenal tumors; further research is necessary.

Trends in adrenalectomy rates, indications, and physician volume: A statewide analysis of 1816 adrenalectomies.

BACKGROUND: Adrenalectomy rates seem to be increasing in Florida, possibly due to increased availability of laparoscopic adrenalectomy, identification of incidentalomas, and access to care for minorities. We hypothesized that the rate of adrenalectomies in Florida increased from 1998-2005 while characteristics of patients, diagnoses, operations, and operating physicians changed over this period. METHODS: Prospectively-collected, mandatory-reported, hospital discharge data for all inpatient adrenalectomies undertaken in Florida from 1998-2005 were obtained along with Florida census and physician certification and education data. Characteristics of adrenalectomy patients, diagnoses, operations, and physicians were analyzed. RESULTS: 1816 adrenalectomies were available for analysis. Yearly rates of adrenalectomy nearly doubled from 1.20 to 2.26 per 100,000 Florida residents (P = .0024). Overall, patient characteristics such as demographics, indications and comorbidities did not change, whereas hospital charges increased and length-of-stay (LOS) significantly decreased (P = .0031 and P < .0001, respectively). There was a non-significant trend toward a yearly increase in physician volume and an inverse relationship between physician volume categories and mean LOS (P < .0001). CONCLUSIONS: The rate of adrenalectomies is increasing in Florida. This increase was not associated with distinct trends in patient characteristics, although a significant decrease in LOS was identified. As these trends continue and adrenalectomy is applied more liberally, indications for adrenalectomy may need to be re-evaluated.

Bariatric surgery improves urinary incontinence in morbidly obese individuals.

BACKGROUND: Urinary incontinence is common in obese individuals. We report on the prevalence of urinary incontinence in patients undergoing bariatric surgery and the effect of surgically induced weight loss on urinary incontinence. METHODS: The prospectively collected data from 201 consecutive candidates for bariatric surgery were evaluated. The patients were surveyed using a questionnaire regarding the duration of incontinence, stress/urge incontinence symptoms, and incontinence severity before and after undergoing bariatric surgery. Severity was quantified using a validated index developed Data are presented as the mean +/- standard deviation. RESULTS: Of 201 patients, 65 (32%) reported urinary incontinence. Of the 65 patients, 44 women and 1 man (age 49 +/- 11 years, body mass index 48 +/- 7 kg/m(2)) underwent Roux-en-Y gastric bypass (n = 42) or laparoscopic-assisted gastric banding (n = 3). Of the 38 patients who reported mild (2%), moderate (48%), and severe (50%) urinary incontinence preoperatively who had complete follow-up at > or = 6 months postoperatively, 19 (50%) had demonstrated resolution of urinary incontinence and 19 had reported residual slight-moderate (37%) or severe (13%) urinary incontinence. The overall severity score improved from 5.4 +/- 2.3 to 2.3 +/- 2.8 postoperatively (P <.001); the percentage of excess body weight loss was 61% +/- 19%. The patients reported subjective improvement within 4 months postoperatively or after a 50-lb weight loss. CONCLUSION: Urinary incontinence is prevalent in bariatric surgery patients. Surgically induced weight loss results in improvement or resolution of urinary incontinence in 82% of patients. The findings from this large cohort warrant additional investigation with urodynamic studies.

Morbidity of anastomotic leaks in patients undergoing Roux-en-Y gastric bypass.

OBJECTIVE: To document the effect of anastomotic leaks on morbidity and mortality after Roux-en-Y gastric bypass (RYGB) for obesity. DESIGN: Prospectively collected data on 840 consecutive patients who underwent RYGB between 1998 and 2005. Multivariate logistic regression analysis was used to determine the effect of anastomotic leaks on postoperative morbidity independent of sex, age, preoperative body mass index, access (open vs laparoscopic), calendar year of RYGB, and comorbidities. P < .05 was considered significant. RESULTS: A total of 36 patients (4.3%) developed leaks after RYGB. Patients who developed anastomotic leaks had a significantly higher overall complication rate (61% vs 20%, P < .001), mortality (14% vs 4%, P = .01), and duration of hospital stay (24.5 vs 4.5 days, P < .001) compared with patients who did not develop leaks. In a multivariate logistic regression model, anastomotic leaks increased the likelihood of mortality (odds ratio [OR], 15; 95% confidence interval [CI], 3-80; P = .002) and overall complications (OR, 6; 95% CI, 3-13; P < .001), specifically sepsis (OR, 27; 95% CI, 2-472; P = .02), renal failure (OR, 16; 95% CI, 3-99; P = .003), small-bowel obstruction (OR, 11; 95% CI, 2-68; P = .008), internal hernia (OR, 10; 95% CI, 2-51; P = .008), thromboembolism (OR, 9; 95% CI, 3-27; P < .001), and incisional hernia (OR, 5; 95% CI, 2-13; P = .001). CONCLUSIONS: Anastomotic leaks significantly increase the likelihood of developing additional life-threatening complications after RYGB. Close and aggressive monitoring is recommended for early detection and management of added complications, should they occur.

Protein kinase C-zeta is critical in pancreatitis-induced apoptosis of Kupffer cells.

Protein kinase C-zeta (PKC-zeta) regulates cell death via NF-kappaB; therefore, we tested the hypothesis that PKC-zeta plays a critical role in pancreatitis-induced Kupffer cell apoptosis. Acute pancreatitis was induced in rats by cerulein injection 24 h later, livers were assayed for PKC-zeta, IKKalpha, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, and apoptosis was assessed with Caspase-3 and DNA fragmentation. Kupffer cells from unoperated rats were infected with a PKC-zeta domain-negative adenovirus (AdPKCzeta-DN) to inhibit PKC-zeta, or transfected with pCMVPKC-zeta to overexpress PKC-zeta, and then stimulated with pancreatic elastase; cellular extracts were assayed for PKC-zeta, IKKalpha, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, Caspase-3, and DNA fragmentation. Cerulein-induced pancreatitis upregulated PKC-zeta protein and activity, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, Caspase-3 and increased DNA fragmentation in rat livers (all p < 0.001 vs control). AdPKCzeta-DN abolished elastase-induced upregulation of PKC-zeta activity, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, Caspase-3 and DNA fragmentation (all p < 0.001 vs infection control), whereas overexpression of PKC-zeta augmented elastase-induced upregulation of IKKbeta, IKKgamma, Fas/FasL, Caspase-3 and DNA fragmentation (p < 0.001 vs control). PKC-zeta plays a critical role in pancreatitis-induced Kupffer cell apoptosis via NF-kappaB and Fas/FasL. The ability of Kupffer cells to autoregulate their stress response by upregulating their death receptor/ligand and key proapoptotic cell signaling systems warrants further investigation.

A state-wide review of contemporary outcomes of gastric bypass in Florida: does provider volume impact outcomes?

OBJECTIVES: To report contemporary outcomes of gastric bypass for obesity and to assess the relationship between provider volume and outcomes. BACKGROUND: Certain Florida-based insurers are denying patients access to bariatric surgery because of alleged high morbidity and mortality. SETTINGS AND PATIENTS: The prospectively collected and mandatory-reported Florida-wide hospital discharge database was analyzed. Restrictive procedures such as adjustable gastric banding and gastroplasty were excluded. RESULTS: The overall complication and in-hospital mortality rates in 19,174 patients who underwent gastric bypass from 1999 to 2003 were 9.3% (8.9-9.7) and 0.28% (0.21-0.36), respectively. Age and male gender were associated with increased duration of hospital stay (P < 0.001), increased in-hospital complications [age: odds ratio (OR) = 1.11, CI: 1.08-1.13; male: OR = 1.53, CI: 0.36-1.72] and increased in-hospital mortality (age: OR = 1.51, CI: 1.32-1.73; male: CI = 2.66, CI: 1.53-4.63), all P < 0.001. The odds of in-hospital complications significantly increased with diminishing surgeon or hospital procedure volume (surgeon: OR = 2.0, CI: 1.3-3.1; P < 0.001, 1-5 procedures relative to >500 procedures; hospital volume: OR = 2.1, CI: 1.2-3.5; P < 0.001, 1-9 procedures relative to >500 procedures). The percent change of in-hospital mortality in later years of the study was lowest, indicating higher mortality rates, for surgeons or hospitals with fewer (< or =100) compared with higher (> or =500) procedures. CONCLUSION: Increased utilization of bariatric surgery in Florida is associated with overall favorable short-term outcomes. Older age and male gender were associated with increased morbidity and mortality. Surgeon and hospital procedure volume have an inverse relationship with in-hospital complications and mortality.

Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with obesity. Our aim in this study is to report objective improvement of obesity-related OSA and sleep quality after bariatric surgery. METHODS: Prospective bariatric patients were referred for polysomnography if they scored >or=6 on the Epworth Sleepiness Scale. The severity of OSA was categorized by the respiratory disturbance index (RDI) as follows: absent, 0 to 5; mild, 6 to 20; moderate, 21 to 40; and severe, <40. Patients were referred for repeat polysomnography 6 to 12 months after bariatric surgery or when weight loss exceeded 75 lbs. Means were compared using paired t tests. Chi-square tests and linear regression models were used to assess associations between clinical parameters and RDI; P<.05 was considered statistically significant. RESULTS: Of 349 patients referred for polysomnography, 289 patients had severe (33%), moderate (18%), and mild (32%) OSA; 17% had no OSA. At a median of 11 months (6 to 42 months) after bariatric surgery, mean body mass index (BMI) was 38 +/- 1 kg/m2 (P<.01 vs 56 +/- 1 kg/m2 preoperatively) and the mean RDI decreased to 15 +/- 2 (P<.01 vs 51 +/- 4 preoperatively) in 101 patients who underwent postoperative polysomnography. In addition, minimum oxygen saturation, sleep efficiency, and rapid eye movement latency improved, and the requirement for continuous positive airway pressure was reduced (P

Predictive factors of thromboembolic events in patients undergoing Roux-en-Y gastric bypass.

BACKGROUND: Obesity is a major risk factor for postoperative deep venous thrombosis (DVT) and pulmonary embolism (PE). Identifying those patients at the greatest risk for DVT/PE is essential to prevent thromboembolic events among patients undergoing Roux-en-Y gastric bypass (RYGB) for clinically significant obesity. This aim of the study is to identify factors associated with an increased likelihood of developing DVT/PE after RYGB. METHODS: Prospectively collected data from 660 consecutive patients who underwent RYGB were reviewed. Patients received perioperative prophylaxis with low molecular weight heparin and sequential compression devices. Diagnosis was based on clinical, radiologic, and/or necropsy findings. Patients with and without postoperative DVT/PE were compared using chi(2) and multivariate logistic regression analysis. RESULTS: A total of 23 patients (3.5%) developed postoperative DVT/PE. Age > 50 years (P = .04), previous DVT/PE (P = .02), history of smoking (P < .01), revisional operation (P = .03), open RYGB (P = .02), and anastomotic leak (P < .0001) significantly increased the likelihood of developing DVT/PE. On the other hand, gender, body mass index > 50 kg/m(2) and history of sleep apnea, hypertension, diabetes, or myocardial infarction did not increase the likelihood of DVT/PE. Multivariate analysis revealed that age > 50 years (P = .04), postoperative anastomotic leak (P < .001), smoking (P < .01), and previous DVT/PE (P < .001) increased the likelihood of postoperative DVT/PE. CONCLUSIONS: Age > 50 years, anastomotic leak, smoking, and history of DVT/PE all increase the likelihood of postoperative thromboembolic events in patients undergoing RYGB. Further preoperative screening and/or postoperative prophylaxis may be needed in this subset of high-risk patients.

Spectrum and treatment of small bowel obstruction after Roux-en-Y gastric bypass.

BACKGROUND: Small bowel obstruction (SBO) is a well-recognized complication of bariatric surgery. Many factors that play a role in the etiology of SBO affect the presentation, timing, and treatment after Roux-en-Y gastric bypass (RYGB). We reviewed our experience with SBO after open and laparoscopic RYGB. METHODS: We reviewed prospectively collected data from 784 consecutive patients who had undergone RYGB (458 open and 326 laparoscopic) from July 1998 to March 2005. The operative techniques were standardized, including closure of the mesenteric defects. The follow-up data were taken from clinic visit records and follow-up questionnaires. The mean follow-up period was 16 +/- 1 months (range 1-75). The data presented are the mean +/- SEM. RESULTS: The overall incidence of SBO after RYGB was 3.2%. Thirteen patients developed SBO after laparoscopic RYGB (4%) and 12 patients did so after open RYGB (2.6%, P = NS). Obstruction at the jejunojejunostomy was more common after laparoscopic RYGB (77%, P <.05), and adhesive SBO was more common after open RYGB (50%, P <.05). The incidence of SBO from internal hernia was low, regardless of the operative approach (open 0.7% versus laparoscopic 0.3%). Early SBO resolved with nonoperative treatment in 30% of patients. CONCLUSION: Understanding the anatomic considerations of RYGB in the development of SBO after open and laparoscopic approach is essential to timely and effective treatment.

The role of p65 NF-kappaB/RelA in pancreatitis-induced Kupffer cell apoptosis.

Acute pancreatitis induces liver injury by upregulating Kupffer cell-derived Fas/FasL; on the other hand, acute pancreatitis induces apoptosis of Kupffer cells via NF-kappaB-dependent pathways. The balance between upregulation of Fas/FasL and Fas/FasL-induced apoptosis of its originator cell may determine the severity of pancreatitis-related liver injury. The aim of our study was to determine the role of p65 NF-kappaB/RelA in pancreatitis-induced Kupffer cell apoptosis. Acute pancreatitis was induced in NIH Swiss mice by a choline-deficient ethionine-supplement (CDE) diet. In vitro mouse Kupffer cell line was transfected with p65 siRNA and treated with pancreatic elastase to mimic pancreatitis. CDE pancreatitis upregulated nuclear translocation of p65 NF-kappaB/RelA, Fas/FasL, caspase-3, and DNA fragmentation in mice livers (all P < 0.001). In vitro, pancreatic elastase mimicked CDE-pancreatitis by upregulating nuclear translocation of p65 NF-kappaB/RelA, Fas/FasL, caspase-3, DNA fragmentation, and apoptosis in Kupffer cells (all P < 0.001). Transfection with p65 siRNA attenuated the elastase-induced nuclear translocation of p65 NF-kappaB/RelA, upregulation of Fas/FasL, caspase-3, DNA fragmentation, and apoptosis in Kupffer cells (all P < 0.001). Acute pancreatitis activates p65 NF-kappaB/RelA and induces apoptosis of Kupffer cells. Inhibition of p65NF-kappaB/RelA attenuates elastase-induced upregulation of proapoptotic pathways and apoptosis in Kupffer cells. The ability of Kupffer cells to autoregulate their stress response by inducing self-apoptosis warrants further investigation.

Nuclear factor-kappaB mediates Kupffer cell apoptosis through transcriptional activation of Fas/FasL.

INTRODUCTION: Nuclear factor (NF)-kappaB is a key transcriptional factor for cell survival, inflammation, and stress response. We demonstrated that Kupffer cell-derived FasL plays a central role in pancreatitis-induced hepatocyte injury. The aim of this study was to determine the role of NF-kappaB in regulating death ligand/receptor pathway in Kupffer cells during conditions that mimic acute pancreatitis. MATERIALS AND METHODS: Tissue cultures of rat Kupffer cells were treated with elastase (1 U/L) to mimic pancreatitis before and after infection with AdIkappaB to block activation of NF-kappaB. Tumor necrosis factor (enzyme-linked immunoassay), Fas/FasL, and caspase-3 (Western), tumor necrosis factor and Fas/FasL mRNA (reverse-transcription polymerase chain reaction), and NF-kappaB DNA binding (electrophoretic mobility shift assay) were determined. Apoptosis was measured by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling (TUNEL) and DNA fragmentation. Gels were quantified by densitometry. Data (n=3) are mean+/-SEM; student's t test was used for statistical analysis. RESULTS: AdIkappaB infection up-regulated mutated IkappaBalpha that maintained its binding properties to NF-kappaB. Promoter-reporter assay demonstrated that FasL gene promoter was regulated by NF-kappaB. Infection with AdIkappaB attenuated the elastase-induced up-regulation of Fas/FasL (all P<0.01 versus elastase) and NF-kappaB DNA binding but did not affect elastase-induced up-regulation of TNF. AdIkappaB attenuated elastase-induced cleavage of caspase-3, DNA fragmentation and TUNEL staining (all P<0.01 versus elastase). CONCLUSIONS: Inhibition of NF-kappaB DNA binding down-regulates Fas/FasL and attenuates elastase-induced apoptosis; however, it has no effect on TNF production, suggesting that regulation of Fas/FasL and TNF may occur via different pathways. The ability of Kupffer cells to autoregulate their stress response by up-regulating their death ligand/receptor and apoptosis warrants further investigation.