Does diabetes affect weight loss after gastric bypass?

BACKGROUND: Weight loss in diabetics improves glycemic control. We investigated whether diabetes mellitus (DM) adversely affects postgastric bypass weight loss. METHODS: Our database was queried for the demographics and outcomes of patients with and without DM who had undergone gastric bypass surgery. DM was subdivided by severity: diet-controlled, oral hypoglycemic agents, and insulin. RESULTS: Of the 3193 patients, 655 (20%) had DM. The DM group was older (45.8 +/- 10.4 yr versus 39.1 +/- 9.9 yr, P <.0001), with more co-morbidities: hypertension (70.5% versus 44.2%, P <.0001), sleep apnea (36.7% versus 26.1%, P <.0001), and venous stasis (5.6% versus 2.6%, P <.0001). More men had DM (25.6% versus 19.3%, P = .0006). The age-adjusted, preoperative weight, and body mass index were equal. A direct relationship was found between DM severity and age, weight, and co-morbidities. At 1 year, the DM group had a lower percentage of excess weight loss (60.8% +/- 16.6% versus 67.6% +/- 16.7%, P <.0001) and greater body mass index (34.2 +/- 7.1 kg/m(2) versus 32.3 +/- 7.2 kg/m(2), P <.0001). The percentage of excess weight loss was 67.6% for those without DM, 63.5% for those with diet-controlled DM, 60.5% for those with DM controlled by oral hypoglycemic agents, and 57.5% for those requiring insulin. DM resolved in 89.8% of those with diet-controlled DM, 82.7% of those taking oral hypoglycemic medication, and 53.3% of those requiring insulin. Hypertension resolution was greatest in patients without DM (74.4% versus 63.5%, P <.0001). CONCLUSION: The results of our study have shown that those with DM typically have more co-morbidities, despite having no difference in preoperative weight compared with those without DM. Despite the lower weight loss, those with DM had significant resolution of their DM and hypertension and should not be deterred from undergoing gastric bypass surgery.     

Outcomes among elderly bariatric patients at a high-volume center

BACKGROUND: Bariatric surgery in elderly patients remains controversial. With a growing morbidly obese elderly population, management strategies and treatment outcomes need to be evaluated. METHODS: We reviewed all bariatric cases from 2001 to 2005 at a single institution. The preoperative factors (body mass index, smoking status, co-morbid conditions, number of medications) and surgical information (operation and length of stay) were recorded. Patients >60 years old who had undergone Roux-en-Y gastric bypass (RYGB) were followed up, and their surgical outcomes were analyzed (reduction in medications, resolution of diabetes mellitus and hypertension, percentage of excess body weight loss, complications, and mortality). RESULTS: Of 1065 patients, 76 (7.1%) were aged > or =60 years. Of these 76 patients, 61 (5.7%) underwent RYGB. The other 989 patients (92.9%) were <60 years old, and 952 of these underwent RYGB. In the older group, the mean number of co-morbid conditions was 10 +/- 3.3, 70.5% had diabetes, and 83.6% had hypertension. In the younger group, the mean number of co-morbidities was 4.7 +/- 2.3. The mean number of preoperative medications was 10 +/- 4.5 in the older group compared with 6.0 +/- 4.3 in the younger group. The mean length of stay was 2.9 days in both groups. Postoperatively, medications were reduced by nearly 50% in both groups. Diabetes and hypertension resolved or improved significantly in both groups. The mean percentage of excess body weight loss was lower in the older patients (54.9% versus 60.1%; P = .09). The 90-day operative mortality rate was 1.64% in the older group versus 0.53% for the younger group (P = NS). CONCLUSION: Our data support the use of RYGB in older patients in programs prepared to comprehensively manage the medical co-morbidities. Although the percentage of excess body weight loss was less, the mortality was acceptable despite the greater number of co-morbidities. Both diabetes and hypertension were more common in this population, with trends toward better improvement after RYGB than in younger patients.     

Surgical treatment for multinodular goitres in geriatric patients

Background Although age is not a contraindication for thyroid surgery, few elderly patients undergo surgery due to the greater risk of morbidity. The aims of this study are to determine in patients aged >65 years: (1) whether the indications for surgery on multinodular goitre (MG) differ with respect to younger patients; (2) the surgical results; and (3) whether the postsurgery morbidity and mortality rates are higher.Patients and method Eighty-one patients aged over 65 years who were receiving surgery for MG were analysed; 40 49%) presented with associated co-morbidities. Sixty percent had thyroid symptoms, either compressive and/or toxic. All underwent programmed surgery following stabilisation and strict control of their co-morbidities. As a control group we used 510 MG patients receiving surgery and aged between 30 and 65 years.Results Compared with the control group the geriatric patients had a longer time of goitre evolution (P=0.032), greater presence of symptoms (P=0.001) and a higher percentage of intrathoracic component (P=0.001). Compressive symptoms were the major indication for surgery (P=0.001). Postoperative complications occurred in 40% of the patients, a higher rate than in the control group (28%; P=0.011), although a large percentage of those complications were transitory. Definitive complications included two recurrent laryngeal nerve injuries (2.5%). The preoperative symptoms remitted in all the patients, and only three were associated with a thyroid carcinoma, one of which was anaplastic.Conclusions MG operated on in elderly patients has a longer evolution and an intrathoracic component, and surgery is indicated restrictively. With close monitoring of the co-morbidities and a programmed operation the results with regard to morbidity and mortality are similar to those obtained at younger ages.     

Co-Morbidities and Survival of Men with Localized Prostate Cancer Treated with Surgery or Radiation Therapy

Purpose

We determined the impact of preexisting co-morbidities on survival of men with clinical stages T1b and T2NXM0 prostate cancer treated with surgery or radiation therapy.

Materials and Methods

A weighted co-morbidity score was determined for 276 consecutive men treated with surgery (138) or radiation therapy (138) at a Veterans Affairs medical center and was correlated with actuarial freedom from death due to co-morbid disease.

Results

After a median potential followup of 7.0 years 91 patients (33 percent) died of co-morbid disease and 20 (7 percent) died of cancer related causes. There were highly significant correlations between actuarial survival and weighted co-morbidity (p less than 0.000001), and the 10-years actuarial survivals in men with no or severe co-morbidities were 66 and 9 percent, respectively. Associations between patient age and co-morbidity score were highly significant (p less than 0.0001). The age adjusted risk of co-mobid death was 5.7 times greater in men with severe compared to no co-morbidities. There were also significant correlations between actuarial survival and weighted co-mobidity among patients treated with surgery (p = 0.02) and radiation therapy (p = 0.0002). Patient age and severity of co-morbidities were significantly greater among men treated with radiation therapy compared to surgery, and age adjusted risk of co-morbid death among men with a co-morbidity score of 1 was 3.8 times greater among men treated with radiation therapy (p = 0.025).

Conclusions

Cancer related deaths are unusual within 5 to 10 years after surgery or radiation therapy in men with stages T1b and 2 prostate cancer. The risk of death during this interval is directly related to the severity of co-morbid conditions, which should be factored in an individual when assessing the advisability of therapeutic intervention. Since patient co-morbidities impact all cause survival, quantitative assessment of co-morbidities using validated instruments offers a method to control partially for the variabilities of health status among men receiving different treatments for localized prostate cancer.     

Intragastric balloon for high-risk super-obese patients: a prospective analysis of efficacy.

BACKGROUND: Super-obese patients with many co-morbidities present a challenge in bariatric surgery because of the high perioperative morbidity and mortality. The BioEnterics intragastric balloon (BIB) is an endoscopic device used preoperatively to induce weight loss to reduce the risk of surgery for morbid obesity. METHODS: From November 2003 to April 2006, the BIB was endoscopically placed in 26 high-risk super-obese patients with a mean body mass index of 65.3 +/- 9.8 kg/m(2) and severe co-morbidities (mean 4.33 +/- 1.12, range 3-7). The BIB was endoscopically removed 6 months later, at which time the patients were evaluated in terms of weight loss and improvement of co-morbid conditions. RESULTS: BIB placement was uneventful in all patients. The major side effect related to the procedure was occasional vomiting during the first 2 days (65%). One patient died (3.8%) of cardiac arrest after aspiration on the first postinsertion day as a direct result of BIB placement. The mean weight loss was 28.5 +/- 19.6 kg, and clinical re-evaluation revealed significant improvement in patient co-morbidity status (mean 2.23 +/- .7, range 1-3; P = .024). Twenty patients underwent a primary bariatric surgical procedure the day after BIB removal; 2 patients were rejected for surgery because of inadequate weight loss. CONCLUSIONS: BIB placement can be considered an effective first-stage treatment of high-risk super-obese patients in need of surgical intervention. Although not without risk, it is generally a simple procedure leading to satisfactory weight loss, improvement in co-morbidities, and consequent reduction of the perioperative mortality and morbidity rates associated with surgery.     

Analgesia before performing a spinal block in the sitting position in patients with femoral shaft fracture: a comparison between femoral nerve block and intravenous fentanyl

We conducted this prospective, randomized study to compare the analgesic effect of femoral nerve block and IV fentanyl administration when given to facilitate the sitting position for spinal anesthesia in patients undergoing surgery for femoral shaft fracture. Five minutes before the placement of spinal block, group FEM patients (n = 10) received a femoral nerve block with lidocaine 1.5% 15 mL, and group IVA patients (n = 10) received IV fentanyl 3 microg/kg. Visual analog scale values during positioning (median and range) were lower in group FEM: 0.5 (0-1) versus 3 (2-6) (P < 0.001). Time to perform spinal anesthesia (mean +/- sd) was shorter in group FEM: 1.8 +/- 0.7 min versus 3.0 +/- 1.1 min (P < 0.05). Quality of patient positioning for spinal anesthesia (0 = not satisfactory, 1 = satisfactory, 2 = good, and 3 = optimal) (median and range) was higher in group FEM: 3 (2-3) versus 1.5 (1-3) (P < 0.005). Patient acceptance was less in group IVA (P < 0.05). In one group IVA patient, an oxygen saturation <90% was recorded during the procedure. We conclude that femoral nerve block is more advantageous than IV administration of fentanyl to facilitate the sitting position for spinal anesthesia in patients undergoing surgery for femoral shaft fractures.     

Carotid endarterectomy and local anaesthesia: reducing the disasters

PURPOSE: The study was designed to assess one surgeon's operative mortality and morbidity for carotid endarterectomy using local anaesthetic (LA) compared to general anaesthetic (GA) techniques. METHOD: Data were collected prospectively from 200 patients undergoing LA carotid surgery compared with 243 patients undergoing carotid surgery using GA technique. Indication for surgical, pathology, postoperative morbidity and mortality was assessed. RESULTS: No major strokes or deaths occurred in the LA group (0/200). Significantly more major strokes and/or deaths occurred in the GA group (11/243, 4.5%; P=0.016). Significant less shunt usage was associated with LA (LA 18/200, 9% versus 94/243, 39%; P=0.001). The absence of a shunt was associated with more major events in the GA group (5/143, P=0.001. Age greater than 74 yr was associated with greater major events (4/31, P=0.002). No significant difference in the frequency of cardiovascular complications was observed (LA, 15/200 (7.5%) vs GA, 19/243(7.8%); P=0.924). CONCLUSION: Local anaesthesia enables the surgeon to assess the level of cerebral perfusion with an awake patient, gives greater assurances of cerebral protection during arterial clamping and a provides for a more relaxed and cautious endarterectomy and repair. This study demonstrates reduction in mortality and major stroke events in patients operated on with these conditions.     

Rocuronium is not associated with more vocal cord injuries than succinylcholine after rapid-sequence induction: a randomized, prospective, controlled trial

Postoperative hoarseness (PH), sore throat (ST), and vocal cord injuries (VCI) are common complications after general anesthesia. Excellent endotracheal intubating conditions are associated with less laryngeal morbidity than good or poor intubating conditions. Thus, we tested the hypothesis that a rapid-sequence induction (RSI) with succinylcholine would lead to less PH and VCI than with rocuronium. In this prospective trial, 160 patients were randomized in 2 groups to receive thiopental 5.0 mg/kg, fentanyl 3.0 microg/kg, succinylcholine 1.0 mg/kg, or rocuronium 0.6 mg/kg during RSI. PH and ST were assessed at 24, 48, and 72 h after surgery, VCI were examined by stroboscopy in those patients who had PH >3 days. Excellent and clinically acceptable intubating conditions were significantly increased in the succinylcholine group compared with the rocuronium group: 57% versus 21% and 89% versus 59%, respectively (P < 0.001). The incidence and severity of PH, and VCI between the succinylcholine and the rocuronium groups did not differ significantly: PH: 50% versus 51% (P = 0.99) and VCI: 3% versus 1% (P = 0.98), respectively. Similar findings were found for ST, 39% versus 28% (P = 0.22), and postoperative myalgia, 39% versus 29% (P = 0.25), respectively. Intubating conditions were significantly better in the succinylcholine group compared with the rocuronium group. The incidence and severity of ST and myalgia were not increased in the patients receiving succinylcholine. However, the rate of PH and VCI was similar to the rocuronium group.     

Attitudes, beliefs, and referral patterns of PCPs to bariatric surgeons

BACKGROUND: As severe obesity (BMI >40kg/m(2)) and its surgical treatment rise, primary care physicians (PCPs) will more frequently evaluate, refer, and oversee the long-term medical management of bariatric patients. A cross-sectional mail survey was conducted to assess the attitudes, knowledge, and bariatric referral practices among family and internal medicine physicians in North Carolina. MATERIALS AND METHODS: Forty-seven percent of 611 randomly chosen PCPs returned a self-completed questionnaire. The effect of demographics, PCP attitudes, and PCP knowledge on referral practices was evaluated. RESULTS: Over 85% (221) of PCPs have treated operated bariatric patients within the last year and 76% (203) have referred patients for surgical evaluation. Thirty-five percent of practitioners felt unprepared to provide good quality long-term medical care to operated patients, and just 45% felt competent to address medical complications of bariatric surgery. Compared with nonreferring PCPs, referring physicians provided medical care to a greater number of severely obese (mean 9.9 versus 7.5, P < 0.001) and postoperative (mean 4.6 and 2.3, P < 0.001) bariatric patients. Referring providers were younger (46 versus 49, P = 0.02), had higher BMI (25.3 versus 23.5, P = 0.001), were more familiar with NIH guidelines (14.7% versus 3.0%, P = 0.02), and had completed more bariatric continuing medical education (49.8% versus 34.9%, P = 0.03). Also, they reported better resources (71.4% versus 35.4%, P < 0.001) and competency to provide good quality long-term care to postoperative bariatric patients (54.2% versus 15.4%, P < 0.001) than nonreferring peers. CONCLUSIONS: Bariatric surgeons will optimize referrals and postoperative care for patients by working cooperatively with PCPs and by providing educational resources.     

Quality of life and resolution of co-morbidities in super-obese patients remaining morbidly obese after Roux-en-Y gastric bypass.

BACKGROUND: Not all patients undergoing Roux-en-Y gastric bypass with an initial body mass index (BMI) >50 kg/m(2) attain a BMI of <35 kg/m(2) postoperatively. We hypothesized that even though many of these patients remain morbidly obese after surgery, they still realize an improvement in co-morbidities and quality of life. METHODS: Patients who had undergone Roux-en-Y gastric bypass and who had a preoperative BMI >50 kg/m(2) and postoperative BMI >35 kg/m(2) were identified. The records of 120 patients were reviewed for the presence of diabetes, hypertension, hyperlipidemia, and gastroesophageal reflux disease. Patients were queried about their use of medications, medical problems, and quality of life. RESULTS: The average preoperative and postoperative BMI was 63.2 and 43.7 kg/m(2). Of the 120 patients, 77 responded to the survey. In the preoperative group, the rate of diabetes, hypertension, hyperlipidemia, and gastroesophageal reflux disease was 35%, 50.8%, 15%, and 34.2%, respectively. Postoperatively, 73.8%, 62.3%, 38.9%, and 87.8% of patients had been cured of these co-morbidities. The change in the incidence of diabetes, hypertension, and gastroesophageal reflux disease was significant at P = 0.0014, P = 0.037, and P <0.0001, respectively. More than 90% of patients considered themselves to be better postoperatively in the areas of overall health and ability to move about; 80-90% had improved ability to exercise, greater energy levels, more self esteem, and an improved physical appearance; 70-80% saw their ability to work and their social relationships as improved; and 56% believed their sexual relationships had improved. CONCLUSION: Super-obese patients experience significant improvements in co-morbidities and quality of life after Roux-en-Y gastric bypass even if their BMI remains >35 kg/m(2).     

An investigation of monoamine receptors involved in antinociceptive effects of antidepressants

In this prospective study, we evaluated the effects of remifentanil in ASA I-II patients undergoing transsphenoidal surgery. After the induction of anesthesia, patients were randomly allocated to the Isoflurane (n = 22, 60% nitrous oxide, isoflurane up to 2% end-tidal) or Remifentanil group (n = 21, 60% nitrous oxide, 0.5% end-tidal isoflurane, remifentanil up to 2 microg x kg(-1) x min(-1)). If mean arterial pressure (MAP) increased >80 mm Hg during maximal dosage of isoflurane or remifentanil, labetalol was administered. At the end of anesthesia, extubation and awakening times, respiratory rate, SpO(2), MAP, heart rate, and adverse effects were recorded. Hemodynamics and bleeding (minimal, mild, moderate, severe) were not different between groups. Bleeding grade increased with MAP >80 mm Hg (P < 0.001). Labetalol was administered to 20 patients in the Isoflurane group, and 10 patients in the Remifentanil group (P < 0.01). The dose of labetalol was larger in the Isoflurane group (1.0 +/- 0.6 versus 0.5 +/- 0.7 mg/kg, P < 0.05). Time to extubation did not differ, whereas time to follow commands was shorter in Remifentanil patients (16 +/- 8 versus 10 +/- 2 min, P < 0.01). No adverse effects occurred in the early postoperative period. IMPLICATIONS: In patients undergoing transsphenoidal surgery, balanced anesthesia with remifentanil (0.22 +/- 0.17 microg x kg(-1) x min(-1)) provides faster awakening time, as compared with large-dose volatile-based anesthesia, without the risk of postoperative opioid respiratory depression.     

Is mitral valve surgery safe in octogenarians?

OBJECTIVE: To evaluate the outcomes of mitral valve surgery in octogenarians. METHODS: Data were collected prospectively from January 1996 to March 2004 at two surgical centers. Of 1386 consecutive patients with mitral valve surgery, 58 (4.2%) were aged > or = 80 years. Survival data were analyzed using Cox proportional hazards modeling and Kaplan-Meier actuarial log rank statistics. RESULTS: Octogenarians were similar to younger patients for the presence of pre-operative hypertension, hyperlipidemia, diabetes mellitus, and smoking history. Octogenarians had a higher incidence of cerebrovascular disease (19.0 versus 7.8%, P = 0.003), urgent in-hospital surgery (55.2 versus 28.6%, P < 0.001), and presence of ischemic disease requiring combined mitral valve plus revascularization surgery (72.4 versus 41.0%, P < 0.001). Mitral valve repair was performed in a similar proportion of octogenarians and younger patients (44.8 versus 45.6%). Thirty-day mortality for octogenarians was significantly higher than younger patients (15.5 versus 5.6%, P = 0.002), and actuarial survival of octogenarians was significantly decreased (P = 0.009). However, 52.3% of the octogenarians were alive at 7-years following surgery. Independent predictors of mortality from multivariate risk adjusted modeling of the entire cohort were: emergency surgery (hazards ratio [HR] = 2.94, P < 0.001), combined mitral valve plus revascularization surgery (HR = 2.27, P < 0.001), mitral valve replacement (HR = 1.85, P < 0.01), and age > or = 80 years (HR = 1.80, P = 0.02). CONCLUSIONS: Octogenarians undergoing mitral valve surgery have significantly greater incidence of urgent surgery, ischemic disease requiring combined revascularization surgery, and have decreased rates of survival. While caution is required when operating on these higher risk elderly patients, overall 52.3% of the octogenarians are alive at 7-years following surgery, which is greater than the survival of octogenarians in the community. The greatest survival benefit within octogenarians occurred when mitral valve repair was possible over replacement. Further study will more clearly define subgroups of octogenarians with potentially greater benefit from mitral valve surgery.     

Short-term outcomes for super-super obese (BMI > or =60 kg/m2) patients undergoing weight loss surgery at a high-volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass

BACKGROUND: We previously reported significantly longer operating room times and a trend toward increased complications and mortality in the super-super obese (body mass index [BMI] > or =60 kg/m(2)) early in our experience with laparoscopic Roux-en-Y gastric bypass. The goal of this study was to re-examine the short-term outcomes for super-super obese patients undergoing weight loss surgery at our high-volume bariatric surgery center well beyond our learning curve. METHODS: The records for all patients who had undergone weight loss surgery at Hackensack University Medical Center from 2002 to June 2006 were harvested from the hospital's electronic medical database. This population was analyzed as 2 groups (those with a BMI <60 kg/m(2) and those with a BMI > or =60 kg/m(2)), as well as by type of operation. Step-wise and univariate logistic regression analyses assessed the effect of BMI on the outcome variables, including mortality, length of surgery, length of hospital stay, and disposition at discharge. RESULTS: A total of 3692 patients were studied. Of these patients, 3401 had a BMI <60 kg/m(2) and 291 had a BMI > or =60 kg/m(2). Of the 291 super-super obese patients, 130 underwent vertical banded gastroplasty-Roux-en-Y gastric bypass, 116 laparoscopic Roux-en-Y gastric bypass, and 45 laparoscopic adjustable gastric banding. The proportion of male patients, black patients, and patients with sleep apnea was increased in the BMI > or =60 kg/m(2) group. The number of co-morbid diseases per patient correlated with age but not BMI. The BMI > or =60 kg/m(2) group required a significantly longer total operating room time (136 versus 120 min). Hospital length of stay was significantly longer only in the laparoscopic Roux-en-Y gastric bypass patients (3 d for the BMI > or =60 kg/m(2) group versus 2 d for the BMI <60 kg/m(2) group). A significantly greater percentage of patients in the super-super obese group were discharged to chronic care facilities. The overall in-hospital mortality rate was 0.15% (5 of 3692) but did not significantly differ between the 2 groups: BMI <60 kg/m(2), rate of 0.12% (4 of 3401 patients), and BMI > or =60 kg/m(2), rate of 0.34% (1 of 291 patients). The type of operation did not significantly affect the disposition at discharge or in-hospital mortality. CONCLUSION: Super-super obese patients required longer total operating room times, a longer hospital length of stay, and were more likely to be discharged to chronic care facilities than were patients with a BMI <60 kg/m(2); however, the in-hospital mortality was similar for both groups.     

Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index

BackgroundThe current National Institutes of Health guidelines have recommended bariatric surgery for patients with a body mass index (BMI) >40 kg/m² or BMI >35 kg/m² with significant co-morbidities. However, some preliminary studies have shown that patients with a BMI that does not meet these criteria could also experience similar weight loss and the benefits associated with it.MethodsAn institutional review board-approved protocol was obtained to study the effectiveness of laparoscopic adjustable gastric banding in patients with a low BMI. A total of 66 patients with a BMI of 30–35 kg/m² and co-morbidities (n = 22) or a BMI of 35–40 kg/m² without co-morbidities (n = 44) underwent laparoscopic adjustable gastric banding. These patients were compared with 438 standard patients who had undergone laparoscopic adjustable gastric banding who met the National Institutes of Health criteria for bariatric surgery. The excess weight loss at 3, 6, 12, and 18 months and the status of their co-morbidities were compared between the 2 groups.ResultsThe average BMI for the study group was 36.1 ± 2.6 kg/m² compared with 46.0 ± 7.3 kg/m² for the control group. Both groups had significant co-morbidities, including hypertension, diabetes, hyperlipidemia, arthritis, gastroesophageal reflux disease, stress incontinence, and obstructive sleep apnea. The mean percentage of excess weight loss was 20.3% ± 9.0%, 28.5% ± 14.0%, 44.7% ± 19.3%, and 42.2% ± 33.7% at 3, 6, 12, and 18 months, respectively. This was not significantly different from the excess weight loss in the control group, except for at 12 months. Both groups showed similar improvement of most co-morbidities.ConclusionModerately obese patients whose BMI is less than the current guidelines for bariatric surgery will have similar weight loss and associated benefits. Laparoscopic adjustable gastric banding is a safe and effective treatment for patients with a BMI of 30–35 kg/m².     

Should Mild‐to‐Moderate and Moderate Ischemic Mitral Regurgitation Be Corrected in Patients with Impaired Left Ventricular Function Undergoing Simultaneous Coronary Revascularization?

INTRODUCTION: Mitral valve regurgitation (MR) occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction predicts poor outcome. This study assessed the feasibility of mitral valve (MV) surgery concomitant with coronary artery bypass grafting (CABG) in patients with mild-to-moderate and moderate ischemic MR and impaired LV function. MaTERIALS AND METHOD: From January 1996 to July 2000, 49 patients (group 1) and 50 patients (group 2) with grade II and grade III ischemic MR and LV ejection fraction (EF) between 17% and 30% underwent combined MV surgery and CABG (group 1) or isolated CABG (group 2). LVEF (%), LV end-diastolic diameter (EDD) (mm), LV end-diastolic pressure (EDP) (mmHg), and LV end-systolic diameter (ESD) (mm) were 27.5 +/- 5, 67.7 +/- 7,27.7 +/- 4, and 51.4 +/- 7, respectively in group 1 versus 27.8 +/- 4, 67.5 +/- 6, 27.5 +/- 5, and 51.2 +/- 6, respectively in group 2. Groups 1 and 2 were divided into Groups 1A and 2A with mild-to-moderate MR (22 [45%] and 28 [56%] patients, respectively) and groups 1B and 2B with moderate MR (27 [55%] and 22 [46%], respectively). In group 1, MV repair was performed in 43 (88%) patients and MV replacement in 6 (12%) patients. RESULTS: Preoperative data analysis did not reveal any difference between groups. Five (10%) patients in group 1 died versus 6 (12%) in group 2 (p = ns). Within 6 months after surgery, LV function and its geometry improved significantly in group 1 versus group 2 (LVEF, p < 0.001; LVEDD, p = 0.002; LVESD, p = 0.003; and LVEDP (p < 0.001) improved significantly in group 1 instead of a mild improvement in Group 2). The regurgitation fraction decreased significantly in group 1 patients after surgery (p < 0.001). There was an inverse strong correlation between postoperative forward cardiac output and regurgitation fraction (p < 0.001). LVEF and LVESD improved significantly in group 1 versus group 2 patients (p = 0.04 and p = 0.02, respectively). The cardiac index increased significantly in group 1 and 2 (p < 0.001 and p = 0.03, respectively). LV function and geometry improved significantly postoperatively in group 1B versus group 2B (LVEDD, p = 0.027; LVESD, p = 0.014; LVEDP, p = 0.034; and LVEF, p = 0.02), instead of a mild improvement in group 1A versus group 2A (LVESD, p = 0.015; LVEF, p = 0.046; and LVEDD and LVEDP, p = 0.05). At follow-up, 4 (67%) of 6 patients undergoing MV replacement died versus 5 (11.5%) of 43 patients undergoing MV repair in group 1 (p = 0.007). The overall survival at 3 years in Group 2 was significantly lower than group 1 (p < 0.009). Conclusion: MV repair and replacement-preserving subvalvular apparatus in patients with impaired LV function offered acceptable outcomes in terms of morbidity and survival. Surgical correction of mild-to-moderate and moderate MR in patients with impaired LV function should be taken into consideration since it yields better survival and improved LV function.     

Outcome and Complications after Laparoscopic Swedish Adjustable Gastric Banding: 5-Year Results of a Prospective Clinical Trial

BACKGROUND: Bariatric surgery is currently the only effective treatment for morbid obesity in terms of inducing and maintaining satisfactory weight loss and decreasing weight-related co-morbidities. A study was conducted to assess the effects, complications and outcome after laparoscopic Swedish adjustable gastric banding (SAGB) to 5 years. METHODS: Between June 1998 and December 2005, all patients with implantation of a SAGB were enrolled in a prospective clinical trial. Results were recorded and classified, with special regard to long-term complications and re-operation rate. RESULTS: SAGB was performed in 128 patients (87 female, 41 male). Mean age was 40.2 +/- 5.3 years, with mean preoperative BMI 44.5 +/- 3.9 kg/m2. Overall mortality was 0%. Patient follow-up was 94.5%. BMI after 1, 2 and 5 years was 35.7 +/- 3.7 kg/m2 (P < 0.005), 33.7 +/- 3.8 kg/m2 (P < 0.001) and 31.8 +/- 3.8 kg/m2 (P < 0.001), respectively. Mean EWL after 1, 2 and 5 years was 33.3 +/- 6.8% (P < 0.005), 45.5 +/- 6.4% (P < 0.001) and 57.4 +/- 6.5% (P < 0.001), respectively. The nonresponder rate (EWL < 30%) after 2 and 5 years was 17.0% and 6.8%, respectively. The early complication rate (< 30 d) was 6.25% (8/128), with 5 minor and 3 major complications. Late complications (> 30 d) occurred in 10.9% (14/128), of whom 2 were minor and 12 were major complications. The overall re-operation rate was 11.7% (15/128). CONCLUSIONS: At 5-year follow-up, laparoscopic SAGB is a safe and effective surgical treatment for morbid obesity. Our results appear to confirm that SAGB is a safer surgical treatment regarding rate and severity of complications compared with gastric bypass and malabsorptive procedures.     

Audit of extrapleural local anaesthetic infusion in neonates following repair of tracheo-oesophageal fistulae and oesophageal atresia via thoracotomy

In order to reduce postoperative opioid requirement, extrapleural local anaesthetic infusion dosing recommendations and guidelines for extrapleural catheter insertion were developed in our institution for 'extubatable' neonates requiring short-gap neonatal tracheo-oesophageal fistula/oesophageal atresia repair (via thoracotomy) and audited prospectively. Data audited included patient characteristics, analgesia details and ventilation duration. We divided patients into two groups: group 1 - term patients (=36 weeks gestational age) with birth-weights =2.5 kg; group 2 - pre-term patients (<36 weeks gestational age), with birth weights <2.5 kg and those with co-morbidities. There were 26 neonates in group 1 and 11 in group 2. All received extrapleural infusions of bupivacaine or levobupivacaine: the majority (90%) =300 μg.kg(-1).hour(-1) (median duration 43 hours, range 1.5 to 72 hours); 36% required morphine infusion and 39% were ventilated (median duration 34 hours, range 3 to 140 hours). In group 1, 24% required morphine infusion compared with 64% in group 2. Most group 1 patients (77%) were extubated immediately postoperatively; 20% had short duration ventilation (median 15 hours, range 11 to 37 hours); one required longer-term ventilation (231 hours). 82% of group 2 were ventilated for a median of 72 hours (range 3 to 140 hours). Review of patients' co-morbidities facilitated guideline revision. These now specify use in neonates requiring short-gap tracheo-oesophageal fistula/oesophageal atresia repair who are term at =36 weeks gestational age and =2.5 kg birth-weight, anticipated as ready for extubation either immediately or shortly after surgery.     

Sedation with midazolam leads to reduced pain after dental surgery

Our principal objective in this study was to evaluate the potential pain reducing effect of i.v. midazolam in patients undergoing oral surgery. One-hundred-twenty-five patients with impacted mandibular third molars requiring removal under local anesthetic were randomized into 2 groups. The first group (n = 64) was administered i.v. midazolam by titration until a clinical end-point of conscious sedation followed by local anesthetic before surgery; the second group (n = 61) was the control and was administered only local anesthetic before surgery. The surgery was performed in a standardized manner in both groups by the same surgeon. Outcome measures were four primary end-points: pain intensity as assessed by a 100-mm visual analogue scale and a 4-point categorized scale hourly for 8 h, time to first analgesic, total analgesic (ibuprofen) consumption over the first 48 h, and a 5-point categorical patient global assessment scale (0 = poor, 1 = fair, 2 = good, 3 = very good, and 4 = excellent). Throughout the 8-h investigation period, patients in the midazolam group reported significantly lower pain intensity scores than those in the control group (19.0 +/- 13.2 mm versus 28.1 +/- 12.8 mm, P < 0.05). The patients in the midazolam group also reported significantly longer time to first analgesic (165.5 +/- 56.5 min versus 202.2 +/- 79.0 min, P < 0.05), less analgesic consumption (1275 +/- 364 mg versus 1688 +/- 407 mg, P < 0.001) and better patient global assessment (3.34 +/- 0.8 versus 2.4 +/- 0.9, P < 0.001). We conclude that systemically administered midazolam is effective in reducing postoperative pain after third molar surgery. IMPLICATIONS: In this observer blinded study, we found that i.v. midazolam treatment (0.09 mg/kg) has a pain-reducing effect after third molar surgery, thus improving postoperative pain management.     

Short-term rapid weight loss induced by bariatric surgery improves ventricular ejection fraction in patients with severe obesity and heart failure

BackgroundObesity is a major risk factor for the development of metabolic syndrome, coronary artery disease, and heart failure (HF). Rapid weight loss following bariatric surgery can significantly improve outcomes for patients with these diseases.ObjectivesTo assess whether bariatric surgery improves ventricular ejection fraction in patients with obesity who have heart failure.SettingPrivate practice, United States.MethodsWe conducted a retrospective review of echocardiographic changes in systolic functions in patients with obesity that underwent bariatric surgery at our institution. Patients were divided into 2 groups, those (1) without known preoperative HF and (2) with preoperative HF. We compared the left ventricular ejection fraction (LVEF) before and after bariatric surgery in both groups. Common demographics and co-morbidities were also analyzed.ResultsA total of 68 patients were included in the analysis: 49 patients in group 1 and 19 in group 2. In group 1, 59.2% (n = 29) of patients were female, versus 57.9% (n = 11) in group 2. The excess body mass index lost at 12 months was 52.06 ± 23.18% for group 1 versus 67.12 ± 19.27% for group 2 (P = .0001). Patients with heart failure showed a significant improvement in LVEF, from 38.79 ± 13.26% before to 48.47 ± 14.57% after bariatric surgery (P = .039). Systolic function in patients from group 1 showed no significant changes (59.90 ± 6.37 mmHg) before and (59.88 ± 7.85 mmHg) after surgery (P = .98).ConclusionRapid weight loss after bariatric surgery is associated with a considerable increase in LVEF and a significant improvement of systolic function.     

Repair of complete atrioventricular septal defects in patients weighing less than 5 kg

BACKGROUND: The aim of this study was to evaluate the impact of weight less than 5 kg at operation on mortality and morbidity in patients with atrioventricular septal defect (AVSDc) undergoing total correction. METHODS: Between January 1990 and December 2002, 190 consecutive patients with AVSDc underwent total biventricular correction. They were divided into two groups: group I (n = 64 patients weighing < 5 kg) and group II (n = 126 patients weighing > 5 kg). Associated major cardiac malformations were found in 49 (25.8%) patients. Associated left atrioventricular valve (LAVV) malformations were found in 35 (18.4%) patients. The mean follow-up time was 4.1 +/- 2.9 years (range 2 months-10.7 years). RESULTS: The in-hospital mortality in group I was 7.8% (5 patients) versus 8.7% (11 patients) in group II (p = 0.95). Major associated cardiac malformations (p < 0.001) and pulmonary hypertension (p = 0.006) were found to be strong predictors for poor postoperative survival. At discharge the mean LAVVR grade in group I was 1.45 +/- 1.2 versus 1.2 +/- 1 in group II (p = 0.13). The actuarial overall survival rates at 1, 3, 5, and 7 years were 96.5%, 92.5%, 91.5%, and 89% respectively and the actuarial overall reoperation free survival rates at 1, 3, 5, and 7 years were 95%, 87%, 84%, and 73%. Twenty-three patients underwent reoperation due to severe left atrioventricular valve regurgitation (LAVVR). Strong predictors for overall reoperation free survival were the operation year before 1995 (p < 0.001), postoperative LAVVR greater than or equal to 2 (p = 0.006), major associated cardiac malformations (p = 0.00034), associated LAVV malformations (p = 0.0044), and non or partial LAVV cleft closure (p = 0.012). The actuarial survival rates between patients weighing less than 5 kg versus patients weighing more than 5 kg were similar (p = 0.51); instead the overall reoperation free survival was significantly lower in patients weighing less than 5 kg (p = 0.022) according to the log-rank test. Weight less than 5 kg (p = 0.023, beta = -0.6) was one of the predictors for reoperation due to severe LAVVR in this series. CONCLUSIONS: We may conclude that in the current era repair of AVSDc can be carried out successfully in patients less than 5 kg, however, weight less than 5 kg at initial complete repair seems to be a predictor for late reoperation due to LAVVR. Suture separation at the cleft site or between the leaflets of the newly created mitral valve and the patch remain the main causes of postoperative LAVVR in patients weighing less than 5 kg.