Is it More Difficult to Cannulate the Right Internal Jugular Vein in Morbidly Obese Patients than in Nonobese Patients?

BACKGROUND: The placement of an internal jugular vein (IJV) catheter is considered to be more difficult in morbidly obese patients. The objective of this study was to compare the success of simulated IJV puncture between morbidly obese patients and a nonobese control group. METHODS: Thirty-four morbidly obese patients with body mass index (BMI, kg/m(2)) >/=40 were compared with 36 patients with BMI < 30. Right IJV puncture was simulated using an ultrasound probe directed towards the sternal notch at the midpoint between the sternal notch and the mastoid process. The investigator placing the probe was blinded as to the image being created on the ultrasound machine. Success rate was assessed at three different head rotation angles from midline; 0 degrees , 30 degrees , and 60 degrees . RESULTS: There was no statistically significant difference in successful simulated IJV puncture between two groups for any of the head positions. However, there was a higher incidence of the carotid artery (CA) puncture in the morbidly obese patient group when the head rotation was advanced from neutral position to 60 degrees (p < 0.05). In addition, the ultrasound showed significantly more overlapping of the IJV over the CA in morbidly obese patients at 0 degrees (p < 0.05) and 30 degrees (p < 0.05). Our results show no statistically significant difference in success rate of IJV puncture between morbidly obese patients and nonobese patients. Keeping the head in a neutral position in morbidly obese patients minimizes the overlapping of the IJV over the CA and the risk of CA puncture. CONCLUSION: However, due to the fact that even in the neutral position there is a significant increase in overlap between IJV and CA, we recommend the use of ultrasound guidance for IJV cannulation in obese patients.     

Is Resected Stomach Volume Related to Weight Loss After Laparoscopic Sleeve Gastrectomy?

Background

Laparoscopic sleeve gastrectomy (LSG) was initially performed as the first stage of biliopancreatic diversion with duodenal switch for the treatment of super-obese or high-risk obese patients but is now most commonly performed as a standalone operation. The aim of this prospective study was to investigate outcomes after LSG according to resected stomach volume.

Methods

Between May 2011 and April 2013, LSG was performed in 102 consecutive patients undergoing bariatric surgery. Two patients were excluded, and data from the remaining 100 patients were analyzed in this study. Patients were divided into three groups according to the following resected stomach volume: 700–1,200 mL (group A, n?=?21), 1,200–1,700 mL (group B, n?=?62), and >1,700 mL (group C, n?=?17). Mean values were compared among the groups by analysis of variance.

Results

The mean percentage excess body weight loss (%EBWL) at 3, 6, 12, and 24 months after surgery was 37.68?±?10.97, 50.97?±?13.59, 62.35?±?11.31, and 67.59?±?9.02 %, respectively. There were no significant differences in mean %EBWL among the three groups. Resected stomach volume was greater in patients with higher preoperative body mass index and was positively associated with resected stomach weight.

Conclusions

Mean %EBWL after LSG was not significantly different among three groups of patients divided according to resected stomach volume. Resected stomach volume was significantly greater in patients with higher preoperative body mass index.     

Variation in Lipid Levels in Morbidly Obese Patients Operated with the LAP-BAND® Adjustable Gastric Banding System: Effects of Different Levels of Weight Loss

Background: A moderate weight loss is known to improve the lipid levels in simple obesity.The extent of weight loss needed to achieve a clinically meaningful effect on lipid abnormalities in morbid obesity is little understood.We analyzed the effects of different levels of body weight loss on the lipid levels of morbidly obese patients operated with the LAPBAND? System. Methods: 225 morbidly obese patients (172 F and 53 M) in which a complete lipid profile has been collected both before and 12-18 months after surgery were studied. The changes of the lipid profile were analyzed according to different levels of percent weight loss (%WL: <10%, 10-20%, 20-30%, >30%). Results: Mean weight loss was 30.7±15.2 kg, corresponding to a 23.1±9.7% reduction of body weight. A large variability in the weight loss was observed. A significant difference in the change of the lipid parameters between the group with <10%WL and the group with 10-20%WL was observed for total-cholesterol (+10.0±17.2% vs-0.7±14.7%; p<0.05), for the LDL (+18.7±26.3% vs +3.1±22.9%; p<0.05), and for the triglycerides (+7.7±26.3% vs -21.9±25.4%; p<0.05). No further significant differences were found between the two groups with greater weight loss (20-30%WL and >30%WL) and the group with 10-20%WL, the only exception being the percent change in triglycerides levels, i.e. higher in the group with %WL >30 (-33.6±31.5% vs -21.9±25.4%; p<0.05). Conclusion: A moderate weight loss of 10-20% of initial body weight produced the maximal effects on the lipid levels in morbid obesity.     

Is There Any Role for Antithymocyte Induction in Renal Transplantation?

The use of an antibody induction agent in kidney transplantation lowers the risk of an acute rejection episode and may improve graft outcomes. Antithymocyte globulin (ATG) is the most commonly used antibody induction agent for kidney transplantation in the United States, despite its significant side effect profile and cost compared to the interleukin-2 receptor antagonists (IL2-RA). Our review suggests the IL2-RA are safe and well tolerated, and provide equal clinical benefit to ATG at a lower cost. We propose that there is insufficient evidence to justify the use of ATG induction in kidney transplantation.     

Is Routine Invasive Monitoring Indicated in Surgery for the Morbidly Obese?

Background: Morbid obesity is generally considered to be a surgical and anesthetic risk. Some surgeons have advised the routine use of invasive monitoring for morbidly obese individuals undergoing surgery. The purpose of this study was to identify morbidly obese individuals undergoing primary gastric bypass procedures who required central or other forms of invasive monitoring for their management. Methods: We reviewed a series of 521 morbidly obese individuals undergoing consecutively performed primary vertical banded gastroplasty-gastric bypasses, a form of gastric bypass (performed at two community hospitals), for patients who had central, arterial, or urinary catheters placed during their hospital course for monitoring purposes. The patient population was also analyzed for age, preoperative co-morbidities, body mass index, length of operation, and for whether technical complications were encountered intraoperatively. Results: At one of the two hospitals, 10% of patients had arterial catheters placed intraoperatively. In each case, the catheters were removed in the recovery room. At the second hospital, no patient had invasive monitoring intraoperatively. In the entire study group, only five patients required the use of invasive monitoring postoperatively. In each of these patients, technical perioperative complications occurred. The five patients and two hospital groups did not differ significantly in age, sex, number of co-morbidities or preoperative BMI from the study group as a whole. Conclusion: Morbid obesity itself is not an indication for invasive monitoring. The majority of morbidly obese individuals can be safely managed through primary gastric bypass procedures without invasive monitoring.     

Mapping of Ghrelin Gene Expression and Cell Distribution in the Stomach of Morbidly Obese Patients—a Possible Guide for Efficient Sleeve Gastrectomy Construction

Background  

Ghrelin is secreted mainly in the stomach and plays a role in food intake regulation. Morbidly obese (MO) individuals report a decline in appetite after sleeve gastrectomy (SG), presumably due, in part, to ghrelin cell removal. Ghrelin cell distribution and expression were determined in three areas of resected stomach specimens from MO patients subjected to SG.     

Nutritional Deficiencies in Morbidly Obese Patients: A New Form of Malnutrition?

Even though in the Western world there is almost no limitation to a wide variety of food supply, nutritional deficiencies can be found in both normal-weight population and in the obese population. In this review, we examine the prevalence and manifestations of various mineral deficiencies in obese patients.     

Management of Ulcerative Colitis in the Morbidly Obese Patient: Is Bariatric Surgery Indicated?

Ulcerative colitis and obesity share a systemic chronic inflammatory response manifested by increased inflammatory markers. There are data suggesting a benefit in both diseases after inflammatory markers are decreased. We present a 39-year-old morbidly obese male with a history of ulcerative colitis who manifested significant symptomatic improvement after an 86.8% excess weight loss following gastric bypass surgery. We believe that this result may have been due to a reduction of inflammatory markers secondary to considerable weight loss. Although to our knowledge there are no publications showing a direct relationship between symptomatic improvement of ulcerative colitis and weight loss in the obese patient, we believe that weight loss surgery could become a promising tool in the treatment of ulcerative colitis when associated with morbid obesity.     

Predictive Factors of Weight Loss 1 Year after Laparoscopic Gastric Bypass in Obese Patients

Background  

Substantial weight loss is achieved in majority of severely obese subjects undergoing laparoscopic gastric bypass (LGBP) but some fail to obtain expected results. Our aim was to identify preoperative factors that could influence weight loss (WL) 1 year after LGBP.     

What is the Role of HbA1c in Diabetic Hemodialysis Patients?

The definition of a good glycemic control in patients with diabetes mellitus on hemodialysis is far from settled. In the general population, hemoglobin A1c is highly correlated with the average glycemia of the last 8–12 weeks. However, in hemodialysis patients, the correlation of hbA1c with glycemia is weaker as it also reflects changes in hemoglobin characteristics and red blood cells half‐life. As expected, studies show that the association between HbA1c and outcomes in these patients differ from the general population. Therefore, the value of HbA1c in the treatment of hemodialysis patients has been questioned. Guidelines are generally cautious in their recommendations about possible targets of HbA1c in this population. Indeed, the risk of not treating hyperglycemia should be weighed against the particularly high risk of precipitating hypoglycemia in dialysis patients. In this review, a critical analysis of the current role of HbA1c in the care of hemodialysis patients is presented.     

Adjuvant Postoperative Radiotherapy to the Cervical Lymph Nodes in Cutaneous Melanoma: Is There Any Benefit for High-Risk Patients?

Background  The use of adjuvant radiotherapy after lymph node dissection for metastatic melanoma remains controversial. This study examined the effectiveness of adjuvant radiotherapy in controlling regional disease in high-risk patients. Methods  A total of 716 patients were identified from a large prospective database who underwent cervical lymph node surgery between 1990 and 2004. Patients with high-risk disease were offered radiotherapy (n = 129), and this group was compared with the group of patients who did not receive radiotherapy (n = 587) in the same period. Results  Radiotherapy did not improve regional control in patients who had metastatic melanoma of the cervical lymph nodes (P = .2). There were 10% fewer regional recurrences in patients with extracapsular spread who received adjuvant radiotherapy, although this was not statistically significant (P = .34). Adjuvant radiotherapy conferred no overall survival benefit to patients with nodal metastases (P = .39). There was a statistically significant trend for worse survival with increasing nodal tumor burden that remained unchanged with adjuvant radiotherapy. Conclusion  This large, nonrandomized retrospective study found no evidence to support the use of adjuvant radiotherapy for high-risk melanoma. A multicenter randomized, controlled trial investigating this important clinical dilemma is advocated.