When is the best time to deliver behavioral intervention to bariatric surgery patients: before or after surgery?

BackgroundMany comprehensive bariatric surgery programs have implemented preoperative behavioral interventions for patients presenting with problematic eating behaviors in an effort to enhance postoperative weight loss and improve psychosocial adjustment. However, it is unknown whether these interventions are best delivered pre- or postoperatively. The purpose of this study was to determine when bariatric surgery patients are most receptive to a behavioral intervention, before or after surgery.MethodsA total of 32 pre- and postoperative patients were referred to a 10-week intervention designed to reduce eating behaviors associated with postoperative weight gain (e.g., loss of control while eating, grazing). The sample was 78.1% female and 84.4% white, with an average age of 49.43 ± 9.13 years and a body mass index of 44.22 ± 6.48 kg/m². Of the 32 patients, 21 were referred preoperatively and 11 were referred postoperatively (5.63 ± 2.91 months after surgery). These patients were tracked prospectively to determine whether pre- or postoperative patients were more likely to attend and complete the behavioral intervention.ResultsCompared with the preoperative patients, the postoperative patients were more likely to follow-up with their referral and initiate treatment [χ²(1) = 10.06, P = .002]. Of the postoperative patients, 100% attended the first intervention session compared with only 43% of preoperative patients. The postoperative patients also attended more intervention sessions [t(18) = 2.51, P = .02] and were more likely to complete the intervention [χ²(1) = 7.21, P = .007]. Only 14% of the preoperative referral patients completed the program compared with 91% of the postoperative patients.ConclusionComprehensive bariatric surgery programs ought to consider balancing the needs of the preoperative patients presenting with maladaptive eating behavior with the likelihood of them participating in a behavioral intervention before surgery.     

When is the best time to initiate peri-operative heparin therapy in general surgery patients? A risk-benefit dilemma

We sought optimal timing for heparin therapy in general surgery (GS) patients. From 2001 to 2008, 95 GS patients with documented thromboembolic events (TE) were identified and compared with matched controls (age, gender, type of operation, date of operation, malignancy, and body mass index [BMI]). Timing of heparin therapy, characteristics of TE or bleeding events, and risk factors for TE were collected. Mean age (57 years), BMI (33 kgM-2), gender (55% male), malignancy (53%), and duration of operation (204 vs 191 minutes, P = not significant) were similar in both groups. Peri-operative (within 24 hours) heparin administration (study 56% vs control 64%, P = 0.2) was no different. Preoperative therapy was more common in the control group (77% vs 51%, P = 0.001). The regression model showed a protective effect for heparin if given preoperatively (odds ratio = 0.37, P = 0.047) with no effect if started >10 hours from incision. Mean blood transfusion (97 and 106 mL) and hemorrhagic events (4.5% and 5%) were similar in both groups (P = not significant). Median (range) length of hospital stay and mortality was higher in TE cases [19 (0-201) vs 6 (0-66) days, 11 vs 2 mortality in 100-person-years (P < 0.05)]. Heparin administration before GS is associated with >2-fold reduction in TE. The optimal time to start heparin seems to be 1 to 10 hours before the time of incision.     

When is the risk acceptable to proceed to noncardiac surgery following an acute myocardial infarction?

There is a large degree of uncertainty regarding the optimal time delay between an acute (≤ 7 days) or recent (8-30 days) myocardial infarction and a patient undergoing scheduled, noncardiac surgery. Historically, the re-infarction rate for patients undergoing non-cardiac surgery within three months of a myocardial infarction has been 5%, with a very high associated mortality rate. The American Heart Association has suggested that non-cardiac surgery is acceptable six weeks after a myocardial infarction. This review considers the pathophysiology of resolution, the therapeutic responses to acute myocardial infarctions and the predictors of outcome, which may assist with the risk-benefit analysis concerning an appropriate time to proceed with non-cardiac surgery following an acute myocardial infarction. These predictors include the presence of cardiac failure, as evaluated clinically by cardiac echocardiography and increases in B-type natriuretic proteins, and the presence of persistent ischemia, as evaluated by elevations in troponin levels and ST-segment depression.     

Acute appendicitis or diverticulitis of the right colon? Diagnostic dilemma in emergency surgery

Diverticulitis of the right colon is a rare disease in the Western countries, so that the diagnosis still remains very difficult and frequently indistinguishable from acute appendicitis preoperatively. In presence of acute abdominal discomfort with pain referred to the right lower quadrant region, fever and hyperleukocytosis, nausea and vomiting, surgeons operate with a margin of uncertainty, because of the increased morbidity and mortality associated with delay in diagnosis and consequent perforation of acute appendicitis. Moreover the unexpected inflammatory colonic mass of uncertain etiology is sometimes mistaken for carcinoma at laparotomy and consequently a right hemicolectomy is performed. In these cases it should be better that right-sided colonic diverticulitis should be taken into account allowing a more correct surgical approach and even conservative treatment alone. Therefore, in case of suspected appendicitis, since our experience and literature data indicate that the mean age for right diverticulitis is over 40 years, also in presence of a significative Alvarado's score, computed tomography is strongly recommended, if the age is over 40 years.     

When is an anesthesiologist needed in a helicopter emergency medical service in northern Norway?

Background: A national air ambulance service, including helicopters and airplanes, was implemented in Norway in 1988. The main intention was to offer advanced medical services when needed. All helicopters are manned by anesthesiologists. Catchment areas for the 11 helicopters span from cities to scarcely populated areas, particularly in the north. Our aim was to assess what proportion of ambulance missions carried out by the rescue helicopter in Bodø, northern Norway, delivered advanced medical treatment needing the skills of an anesthesiologist. Methods: Flight and ambulance records (n = 2078) from 1988 and 1990–98 (10 years) were analyzed retrospectively. Inter‐hospital transfers (n = 147) and search‐ and rescue missions (n = 332) were not included. According to the level of medical treatment given missions were categorized into three groups (A, B and C). Treatment in groups A and B would not require an anesthesiologist. Results: Two thousand and seventy‐eight ambulance missions carried 2166 patients (114 per 100 000 per year). Median take‐off and on‐scene times were 29 and 55 min, respectively. Seven hundred and fifty‐five patients (35%) suffered from cardiovascular disease, 495 (23%) were injured and 250 (12%) were parturients. One hundred and seven patients (5.0%) received advanced prehospital emergency treatment requiring an anesthesiologist. Forty‐five of the 107 patients survived to discharge from hospital, amongst whom 28 had received intravenous nitroglycerin for angina or suspected myocardial infarction. Conclusion: In our rural area, with a widely scattered population, 95% of patients received medical treatment not requiring an anesthesiologist. A selective use of the anesthesiologist seems indicated.     

Intestinal Tuberculosis: When to Operate?

Background

Tuberculosis (TB) continues to be a worldwide problem. In most cases the lungs are involved, but the infection can also occur in the gastrointestinal tract, in which case the diagnosis is often delayed.

Case

The case presented is of a 68-year-old man of Indian descent with a history of abdominal discomfort for several months, requiring multiple visits to the emergency department. Intestinal TB was diagnosed and treated, but small bowel occlusion resulted in two admissions of the patient to the surgical ward. During his second admission the decision was made for surgical removal of the stricture, as the patient had discontinued his medical treatment.

Conclusion

This case report illustrates the position of our team in favor of conservative measures for the treatment of intestinal TB and of reserving surgery for complications or failure of conservative treatment.

     

When is it appropriate to order an ionized calcium?

Convincing evidence demonstrates that ionized calcium and not total calcium is the physiologically relevant component of blood calcium. Direct measurement of ionized calcium, however, is limited by difficulties in accurate analysis, lack of standardization, and need for special handling, all resulting in increased cost; therefore, strategies have been developed to estimate ionized calcium from total calcium adjusted for levels of albumin, measurements that are more available and relatively inexpensive. This commentary compares the advantages and limitations of direct or calculated determinations of ionized calcium. Also examined are available data illustrating the settings in which measurement of ionized calcium is preferred and, in some cases, necessary for clinical decision-making.     

Optimizing transfusion in vascular surgery: is bloodless surgery an option?

The prospect of surgery without blood loss is an emerging reality. Use of a blood conservation strategy is gaining increasing recognition as a sound and practical approach, especially for the majority of large blood loss surgeries. However, critical situations still occur in which transfusions are necessary or unavoidable for the short-term survival of the patient. The decision-making processes for determining when to transfuse, which blood products to give, and how much are presented here with an evaluation of the risks of transfusion and a discussion on blood conservation strategies. Modalities that may be used in such strategies include restricted phlebotomy, the implementation of restrictive transfusion triggers, acute normovolemic hemodilution, intraoperative and postoperative blood salvage, and refined operative techniques to achieve meticulous hemostasis. In addition, the proper use of erythropoiesis-stimulating agents well before surgery can reduce the number of units transfused. The risks and costs of allogeneic blood transfusions underscore the need for and value of blood conservation techniques. Increasingly, hospitals are adopting blood conservation strategies as part of their routine practice. Blood conservation is a rapidly evolving field in which active research is expanding our understanding of the molecular, physiologic, and clinical aspects of hematopoiesis, circulatory response, coagulation enigmas, artificial oxygen carriers, and the impact of anemia on organ function. Ongoing research offers the possibility of replacement or elimination of allogeneic blood transfusions in a variety of clinical settings.     

Appendicitis, is it an emergency?

Prompt appendectomy has always been a standard of care because of the risk of progression in pathology. This time honored practice has been recently challenged by studies, suggesting that appendicitis can be operated on electively. The aim of this study is to examine whether delayed intervention in acute appendicitis is safe by correlating the interval from presentation to operation with the operative and postoperative complications. Retrospective review of patients who underwent appendectomy for acute appendicitis in 2009 was done. The following parameters were recorded: demographics, duration from presentation to evaluation by emergency room attending, performing CT scan, surgical consult, and operation. The pathology, post operative complications, and length of stay were also recorded. Patients were divided into two groups: incision time < 10 hours (early group) and incision time > 10 hours (delayed group). The end points chosen for comparison were: 1) laparoscopic to open conversion rate, 2) complications, 3) readmissions, and 4) length of stay. Number of cases totaled 201, with 76 in the < 10 hours group and 125 in the > 10 hours group. The male to female ratio for the < 10 hours group was 54:22 and for the > 10 hours group was 59:66 (P < 0.001). Length of stay for the early group was 75.52 hours and for the delayed group, 89.15 hours (P = 0.04). There was one intra-abdominal abscess in the early group and 10 in the delayed group (P = 0.04). The early group had 0.2 (2.6%) open conversions, and the delayed group had five (4.1%) conversions (P = 0.58). There were six (4.8%) readmissions in the delayed group and none in the early group (P = 0.05). Our study reveals that the complication rate, length of stay, and readmissions are more in the delayed group. Conversion rate was more in the delayed group, but the difference was not significant. We conclude that early surgical intervention is beneficial in acute appendicitis.