Binge Eating and its Relationship to Outcome after Laparoscopic Adjustable Gastric Banding

Background: The aim of this cross-sectional study was to examine short and long-term eating behavior after laparoscopic adjustable gastric banding (LAGB) and the relationship of binge eating with weight and quality of life outcome. Methods: 250 patients (221 female, 29 male, mean age 39.6 years, age range 22-61) filled out questionnaires to evaluate quality of life and eating behavior: 93 patients before LAGB, 48 with a follow-up duration of 8 through 24 months, and 109 patients 25 through 68 months after LAGB. Results: Compared with patients before surgery, patients after surgery, in both follow-up groups, reported less binge eating, fat intake, external eating, and more restrained eating and eating self-efficacy. After surgery, about one-third of the patients showed binge eating problems, which were associated with a worse postoperative outcome. Conclusion: Our results suggest that eating behavior improves both short- and long-term after surgery for severe obesity. Although LAGB could be a long-term solution to part of preoperatively eating disordered patients, the identification and treatment of postoperative binge eating appear critical to promote successful outcome after bariatric surgery.     

Short-term Changes in Insulin Resistance following Weight Loss Surgery for Morbid Obesity: Laparoscopic Adjustable Gastric Banding versus Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP) both effectively treat the insulin resistance associated with type 2 diabetes mellitus (T2DM). Restriction of caloric consumption, alterations in the entero-insular axis or weight loss may contribute to lowering insulin resistance after these procedures. The relative importance of these mechanisms, however, following LAGB and LRYGBP remain unclear. The aim of this study was to compare directly the short-term changes in insulin resistance following LAGB and LRYGBP in similar populations of patients. Methods: Patient preference determined operation type. The Homeostasis Model Assessment for Insulin Resistance (HOMA IR) was used to measure insulin resistance. Preoperative values were compared to postoperative levels obtained within 90 days of surgery. Significant differences between groups were tested by ANOVA. Results: There were no significant preoperative differences between groups. The 56 LAGB patients had a mean age of 42.5 years (25.7-63), BMI of 45.5 kg/m² (35-66) and preoperative HOMA IR of 4.1 (1.4-39.2). 75% of LAGB patients were female and 43% had T2DM. The 61 LRYGBP patients had a median age of 39.9 years (22.1-64.3), BMI of 45.0 kg/m² (36-62), and preoperative HOMA IR of 5.0 (0.6-56.5). 79% of LRYGBP patients were women and 44.3% had T2DM. Median follow-up for LAGB patients was 45 days (18-90) and for LRYGBP patients 46 days (8-88 days). LAGB patients had a median of 14.8% excess weight loss (6.9%-37.0%) and LRYGB patients 24.2% (9.8%-51.4%). Postoperative HOMA IR was significantly less after LRYGBP, 2.2 (0.7-12.2), than LAGB, 2.6 (0.8-29.6), although change in HOMA IR was not significantly different. Change in HOMA IR for both groups did not vary with length of follow-up or weight loss but correlated best with preoperative HOMA IR (LAGB r=0.8264; LRYGBP r=0.9711). Conclusions: Both LAGB and LRYGBP significantly improved insulin resistance during the first 3 months following surgery. Both operations generated similar changes in HOMA IR, although postoperative HOMA IR levels were significantly lower after LRYGBP. These findings suggest that caloric restriction plays a significant role in improving insulin resistance after both LAGB and LRYGBP.     

Initiation and Maintenance of Weight Loss after Laparoscopic Adjustable Gastric Banding. The role of Outcome Expectation and Satisfaction with the Psychosocial Outcome

Background  A premise of this study was that different psychological processes would predict the initiation and maintenance of weight loss after surgery for morbid obesity. Our aim was to examine whether more favorable preoperative expectations of psychosocial outcomes predict weight loss in the first year after laparoscopic adjustable gastric banding (LAGB) and whether postoperative satisfaction with these outcomes predicts weight maintenance in the second year after the operation. Methods  Six months before and 1 year after surgery, the “Obesity Psychosocial State Questionnaire” was filled out by 91 patients (77 female, 14 male, mean age 45 ± 9 years, mean preoperative body mass index 47 ± 6 kg/m²). We evaluated the preoperative outcome expectations and the postoperative satisfaction for the seven domains of psychosocial and physical functioning of this questionnaire, as well as the correlations between these scores and both weight loss and weight maintenance. Results  Patients showed high satisfaction with psychosocial outcomes after LAGB in all seven domains (p < 0.001), even though the improvement was less than expected in five of the domains (p ≤ 0.01). While weight loss 1 year after the operation was related to satisfaction with psychosocial outcomes (p ≤ 0.05), preoperative expectations were not related to weight loss in the first year after surgery, and satisfaction with the outcomes was not related to weight maintenance in the second year after surgery. Conclusion  Our study suggests that surgically induced effects of weight loss and weight maintenance are achieved independently of the patient’s preoperative expectations of and postoperative satisfaction with the psychosocial outcomes.     

Effect of medical comorbidity on self-assessed pain, function, and general health status after rotator cuff repair

BACKGROUND: In a previous study, we found that medical comorbidities have a negative effect on preoperative pain, function, and general health status in patients with a chronic rotator cuff tear. In this study, we evaluated the relationship between medical comorbidities and the postoperative outcome of rotator cuff repair. METHODS: One hundred and twenty-five patients were evaluated on the basis of a history (including medical comorbidities) and use of outcome tools preoperatively and at one year after rotator cuff repair. Outcome was evaluated with the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire, the Simple Shoulder Test (SST), visual analog scales (pain, function, and quality of life), and the Short Form-36 (SF-36). RESULTS: The mean number of medical comorbidities was 1.91 (range, zero to six). At one year after rotator cuff repair, there were no significant correlations between comorbidities and pain, shoulder function, or quality of life as determined with the SST, DASH, and visual analog scales (p > 0.05). A greater number of comorbidities was associated with a worse postoperative general health status (SF-36 role emotional [p = 0.045], SF-36 bodily pain [p = 0.032], SF-36 general health [p = 0.001], and SF-36 vitality [p = 0.033]). Nevertheless, a greater number of comorbidities was associated with greater improvement, compared with the preoperative status, in the pain score on the visual analog scale (p = 0.009), function as assessed with the visual analog scale (p = 0.022) and the DASH (p = 0.044), and quality of life as assessed with the visual analog scale (p = 0.041). CONCLUSIONS: Patients with more medical comorbidities have a worse general health status after rotator cuff repair. Interestingly, it also appears that these patients have greater improvement in overall shoulder pain, function, and quality-of-life scores compared with preoperative scores. Therefore, despite a negative effect of comorbidities on outcomes, patients with more comorbidities have greater improvement after the repair, to the point where postoperative shoulder function and pain are not significantly influenced by medical comorbidities. Consequently, a higher number of medical comorbidities should not be considered a negative factor in determining whether a patient should undergo rotator cuff repair.     

Effect of lung cancer surgery on quality of life

BACKGROUND: Health related quality of life (HRQOL) after surgery is important, although very limited data are available on the QOL after lung cancer surgery. METHODS: The effect of surgery on HRQOL was assessed in a prospective study of 110 patients undergoing potentially curative lung cancer surgery at Papworth Hospital, 30% of whom had borderline lung function as judged by forced expiratory volume in 1 second. All patients completed the EORTC QLQ-C30 and LC13 lung cancer module before surgery and again at 1, 3 and 6 months postoperatively. RESULTS: On average, patients had high levels of functioning and low levels of symptoms. Global QOL had deteriorated significantly 1 month after surgery (p = 0.001) but had returned to preoperative levels by 3 months (p = 0.93). Symptoms had worsened significantly at 1 month after surgery but had returned to baseline levels by 6 months. Low values on the preoperative HRQOL scales were not significantly associated with poor surgical outcome. However, patients with low preoperative HRQOL functioning scales and high preoperative symptom scores were more likely to have poor postoperative (6 months) QOL. The only lung function measurement to show a marginally statistically significant association with quality of life at 6 months after surgery was percentage predicted carbon monoxide transfer factor (Tlco). CONCLUSION: Although surgery had short term negative effects on quality of life, by 6 months HRQOL had returned to preoperative values. Patients with low HRQOL functioning scales, high preoperative symptom scores, and preoperative percentage predicted Tlco may be associated with worse postoperative HRQOL.     

Utility of the Temperament and Character Inventory (TCI) in Outcome Prediction of Laparoscopic Adjustable Gastric Banding: Preliminary Report

Background: Research about personality factors involved in successful outcome after bariatric surgery has led to contrasting results. The reasons for such discrepancies may include the lack of assessment of adaptive personality traits and of psychiatric co-morbidity, which may limit the reliability of personality findings. This study aimed to provide exploratory data regarding preoperative personality dimensions and weight loss prediction 1 year after laparoscopic adjustable gastric banding (LAGB). Both normal and deviant personality patterns were assessed by means of the Temperament and Character Inventory (TCI). Moreover, co-morbid psychiatric disturbances were evaluated both categorically and dimensionally. Methods: 65 morbidly obese subjects applying for LAGB were evaluated preoperatively by means of the TCI, standardized diagnostic interview, rating scales and questionnaires to assess co-morbid psychopathology. After intake screening, 35 subjects (mean age 41.2, mean BMI 45.5) were accepted for and underwent LAGB. BMI reduction 1 year following LAGB was used as an outcome measure and entered as a dependent variable in a stepwise multiple regression analysis. TCI scores, presence and severity of eating, depressive and anxiety disorders, sex, age, level of education and BMI at baseline were tested as independent variables. Results: Preoperative TCI 'Persistence' scores explained >40% of variance of BMI reduction 1 year following LAGB, irrespective of preoperative BMI, age, gender, educational level, psychiatric co-morbidity, psychopathology severity and other temperament and character features. Conclusions: Some personality dimensions, as measured by the TCI, may be involved in successful weight control after LAGB.     

Long-term outcomes of bilateral subthalamic nucleus stimulation in patients with advanced Parkinson's disease

BACKGROUND: In patients with advanced Parkinson's disease (PD), deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been shown to improve motor function and decrease medication requirements in the short term. However, the long-term benefits of DBS are not yet established. OBJECTIVE: It was the aim of this study to evaluate long-term outcomes of patients with PD treated with bilateral DBS of the STN. DESIGN AND METHODS: Thirty-three subjects who had bilateral STN DBS were followed prospectively after surgery. We evaluated subjects, using the Unified Parkinson's Disease Rating Scale (UPDRS), preoperatively, 12 months after surgery and at a long-term follow-up visit. Ratings were performed on and off dopaminergic medications. We compared postoperative UPDRS scores, dyskinesia ratings and medication dosages with preoperative values. RESULTS: Twenty-seven subjects had evaluations beyond 18 months (median 33.7 months). Total UPDRS scores in the 'medication-off' state were improved by 37% (p < 0.001) at 12 months and 17.7% (p = 0.0051) at the long-term evaluation. Medication-off state UPDRS part III scores were significantly improved at both 1 year and at the last evaluation (37.6 and 29.3%; p < 0.001). Dopaminergic medication requirements were decreased by 35.3% (p < 0.001) during the first postoperative year and remained below preoperative levels at the long-term evaluation. Average duration of 'off' time remained decreased by about 40% at both 1 year and at the time of last evaluation. Subjects had a sustained reduction in dyskinesia severity (88.6% at 1 year and 68.8% at last evaluation). CONCLUSIONS: In this cohort of subjects with advanced PD, bilateral STN stimulation improved 'off' medication motor function, reduced time spent in the medication-off state and reduced medication requirements for up to 4 years after surgery. We conclude that STN DBS is an effective long-term therapy for selected patients with advanced PD.     

Risk factors of postoperative atrial fibrillation after cardiac surgery

BACKGROUND: Postoperative atrial fibrillation (AF) occurs in up to 50% of cardiac surgery patients and represents the most common postoperative arrhythmic complication. The etiology of AF after open-heart surgery is incompletely understood and its prevention remains suboptimal. Identification of patients vulnerable for postoperative AF would allow targeting of those most likely to benefit from aggressive prophylactic intervention. The aim of the present study was to evaluate clinical predictors of postoperative AF. METHODS AND RESULTS: Patients undergoing elective cardiac surgery in the absence of significant left ventricular dysfunction (n = 253; average age 65 +/- 11 years) were recruited to the present prospective study. Ninety-nine patients (39.1%) of the total study population developed AF during the postoperative period. The median age for patients with postoperative AF was 69 years compared with 64 years for patients without (p < 0.001). In addition to advanced age, AF patients were more likely to have surgery for valvular heart disease and less likely to have preoperative beta-adrenergic blockers than patients without AF. Multivariate logistic regression analysis (odds ratio, +/-95% CI, p value) was used to identify the following independent clinical predictors of postoperative AF: increasing age (above vs. below median [OR = 2.6; CI, 1.2 to 3.9; p < 0.01]), and surgery for valvular heart disease (vs. coronary artery bypass grafting [OR 2.8; CI, 1.1 to 3.5; p < 0.01)]). Additionally, postoperative complications (stroke, infections, unstable hemodynamics [OR = 1.9; CI, 1.0 to 7.5; p < 0.05]), and preoperative nonuse of beta-adrenergic blockers (OR = 1.7; CI, 1.1 to 4.9; p < 0.05) were associated with increased risk for postoperative AF. Both, patients with and without AF had similar body mass index, preoperative heart rate, preoperative blood pressure, and duration of surgery. Male sex did not identify patients at high risk for development of AF after cardiac surgery. CONCLUSIONS: Postoperative AF remains the most common complication after cardiac surgery. A combination of advanced age and type of surgery identifies patients at high risk for development of AF after cardiac surgery.     

Psychosocial Functioning Before and After Laparoscopic Adjustable Gastric Banding: a Cross-Sectional Study

Background: The aim of this cross-sectional study was to examine short and long-term physical, mental and, particularly, social quality of life (QoL) of patients with severe obesity after laparoscopic adjustable gastric banding (LAGB). Methods: 250 patients (221 female, 29 male, mean age 39.6 years, age range 22-61) filled out questionnaires to evaluate several aspects of QoL: 93 patients before LAGB, 48 with a follow-up duration of 8 through 24 months, and 109 patients 25 through 68 months after LAGB. Results: Compared with patients before surgery, patients after surgery, in both follow-up groups, had lower weight and co-morbidity, felt and functioned better on physical and psychological dimensions of QoL, and on most aspects of social QoL. No significant differences emerged between the two postoperative groups. On average, the postoperative QoL was still lower than the age norm group. Mutual correlations between QoL and weight outcome were very low up to 2 years after surgery, but more strongly associated >2 years after surgery. Conclusion: LAGB could be a long-term solution to morbid obesity with regard to both weight and QoL outcome. The findings of our study emphasize the importance of including social QoL variables in outcome research. They further suggest that when the follow-up duration increases, especially in patients who are single, intervention and consultation should be simultaneously directed at weight and psychosocial variables.     

Health-related quality of life after laparoscopic and open nephrectomy

BACKGROUND: Postoperative recovery often is assessed with parameters (pain and return to work) susceptible to bias. This study sought objectively to compare postoperative health-related quality of life (HRQL) after laparoscopic and open nephrectomy with the Postoperative Recovery (PRS) (a validated questionnaire designed to assess pain), activities of daily living (ADL), and HRQL in postoperative patients. METHODS: Patients undergoing contemporaneous laparoscopic and open nephrectomy received the PRS pre- and postoperatively. The results were analyzed with analysis of covariance (ANCOV) and survival analysis. RESULTS: The 33 open nephrectomy and 38 laparoscopic patients in this study were comparable in age, gender, body mass index (BMI) and employment. Laparoscopic operative time was longer (p = 0.015), and the hospital stay was shorter (p<0.001). Laparoscopic patients had higher HRQL scores from postoperative days 3 to 365 (p<0.001), and they returned to preoperative HRQL faster (p<0.001). CONCLUSIONS: An objective HRQL instrument confirms that laparoscopic nephrectomy patients recover faster and with a higher HRQL than open surgery patients. The PRS can be modified for use after other abdominal procedures, and may prove useful for comparisons of other minimally invasive surgical techniques.     

Bariatric surgery in patients older than 65 years is safe and effective.

BACKGROUND: To review the short-term safety and efficacy of the laparoscopic adjustable gastric band (LAGB) and laparoscopic gastric bypass (GBP) in patients older than 65 years. METHODS: A single-institution review of all bariatric procedures was performed. RESULTS: Twenty-seven patients were identified. Of the 27 patients, 13 underwent primary GBP and 14 underwent LAGB placement. The average age was 68.1 +/- 2 years (range 65-73). The average follow-up for the GBP group and LAGB group was 9.3 months (range 1-21) and 19.6 months (range 4-31), respectively. One minor (stricture) complication and zero major complications occurred in the GBP group. In the LAGB group, one minor complication (port fracture) and one major complication (total weight loss failure requiring conversion to GBP) occurred. The percentage of excess weight loss at 1 year for the GBP group was 71%. At 1 and 2 years, it was 32% and 35%, respectively, for the LAGB group. Only in the GBP group did patients have a significant decrease in medication use and in the number of comorbidities. Quality-of-life measurements improved equally after both procedures. Weight loss was no different after GBP surgery regardless of age, but older LAGB patients had a 12% decrease in the expected excess weight lost (P < 0.05). CONCLUSION: Bariatric surgery can be performed with acceptable safety, excellent weight loss, resolution of comorbidities, and significant improvement in quality of life in patients older than 65 years. The GBP seems to be as safe as, and more effective than, the LAGB in this age group.     

Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors

BACKGROUND: Several studies have established a relationship between the preoperative hemoglobin level and the need for postoperative blood transfusion. We analyzed the relationship between preoperative hemoglobin levels, as well as other factors such as age, gender, weight, height, type and duration of the total joint replacement surgery, and the need for postoperative blood transfusion. METHODS: A retrospective study of 296 patients treated with 370 procedures (209 total hip arthroplasties [56.5%] and 161 total knee arthroplasties [43.5%]) from 1994 to 1998 was carried out. A univariate analysis was performed to establish the relationship between all independent variables and the need for postoperative transfusion. Variables that were determined to have a significant relationship were included in a multivariate analysis. RESULTS: The univariate analysis revealed a significant relationship between the need for postoperative blood transfusion and preoperative hemoglobin levels (p = 0.0001), duration of surgery (p = 0.0001), weight (p = 0.002), height (p = 0.019), and gender (p = 0.0056). However, the multivariate analysis identified a significant relationship only between the need for transfusion and the preoperative hemoglobin level (p = 0.0001) and weight (p = 0.011); height (p = 0.776) and gender (p = 0.122) were discounted as significant factors. Patients with a preoperative hemoglobin level of <130 g/L had a four times greater risk of having a transfusion than did those with a hemoglobin level between 130 and 150 g/L and a 15.3 times greater risk than did those with a hemoglobin level of >150 g/L. CONCLUSIONS: The preoperative hemoglobin level (p = 0.0001) and weight of the patient (p = 0.011) were shown to predict the need for blood transfusion after hip and knee replacement.     

Quality of Life in Morbidly Obese Patients after Surgical Weight Loss

Background Laparoscopic adjustable gastric banding (LAGB) is seen as a safe surgical procedure in individuals with morbid obesity, with satisfactory weight loss and significant postoperative improvement in quality of life (QoL). The present study investigates the predictive value of various parameters such as age, gender, weight loss, and preoperative psychiatric disorders with regard to QoL after LAGB. Methods 300 obesity surgery patients were sent questionnaires to assess a variety of personal parameters. QoL was assessed using the Ardelt-Moorehead Quality of Life Questionnaire. Questionnaires were completed by 140 (63%) female patients and 36 (45%) male patients. Results Average weight loss in both sexes was 14.7 kg/m²; however, not all patients successfully lost weight. No difference was seen in satisfaction with weight loss among the age groups. Some correlations were seen between the amount of weight loss and QoL scores in females, but not in males. Greater weight loss showed a statistically significant positive correlation to self-esteem, physical activity, social relationships, sexuality, and eating pattern. Obese females with no preoperative psychiatric diagnosis had better self-esteem, more physical activity, and more satisfying social and sexual relationships than those with psychiatric diagnoses at follow-up. Conclusion A majority of morbidly obese patients show psychological and interpersonal improvement after surgery. However, some obese patients, particularly those having a preoperative psychiatric or personality disorder, need more individual strategies for psychosocial intervention than do obese individuals with no psychiatric disorder.     

Weight loss during medical weight management does not predict weight loss after bariatric surgery: a retrospective cohort study

BackgroundMany bariatric surgical centers mandate achieving weight loss targets through medical weight management (MWM) programs before offering bariatric surgery, but the evidence for this is unclear.ObjectivesTo examine the relationship between weight changes during (1) MWM, and (2) preoperative low-energy-diet (LED), and weight changes at 12 and 24 months after surgery.SettingMulticenter community- and acute-based MWM services referring to one regional bariatric center, United Kingdom.MethodsA retrospective cohort study of patients who attended MWM and then underwent a primary laparoscopic bariatric procedure (adjustable gastric banding [LAGB], or Roux-en-Y gastric bypass [RYGB]) in a single bariatric center in the United Kingdom between 2013 and 2015. Data were collected from patient electronic records.ResultsTwo hundred eight patients were included (LAGB n = 128, RYGB n = 80). Anthropometric data were available for 94.7% and 88.0% of participants at 12 and 24 months, respectively. There was no relationship between weight loss during MWM and after surgery at either 12 or 24 months. Weight loss during the preoperative LED predicted greater weight loss after LAGB (β = .251, P = .006) and less weight loss after RYGB (β = −.390, P = .003) at 24 months, after adjusting for age, sex, ethnicity, baseline weight, and LED duration.ConclusionsWeight loss in MWM does not predict greater weight loss outcomes up to 24 months after LAGB or RYGB. Greater weight loss during the preoperative LED predicted greater weight loss after LAGB and less weight loss after RYGB. Our results suggest that patients should not be denied bariatric surgery because of not achieving weight loss in MWM. Weight loss responses to preoperative LEDs as a predictor of postsurgical weight loss requires further investigation.     

Laparoscopic Adjustable Gastric Banding in Adolescents: The Austrian Experience

Background: Morbid obesity is a rising problem in adolescents in the industrial nations. Up to 25% of children have a body mass index (BMI) higher than the 85th age- and sex-adjusted percentile. Obesity in youth is associated with increased risk for morbidity and mortality in adulthood. In addition, these patients suffer from psychological problems and decreased quality of life. Bariatric procedures have shown effective long-term results in adults, but they are still discussed controversially in adolescent patients. Methods: Between 1998 and 2004, 50 adolescent patients with a mean age of 17.1±2.2 years (range 9-19 years) underwent laparoscopic adjustable gastric banding (LAGB) in Austria. The psychological changes were analyzed by using Moorehead-Ardelt/BAROS questionnaire. Results: The mean BMI decreased from 45.2±7.6 kg/m² at time of surgery to 32.6±6.8 kg/m² after a mean follow-up of 34.7±17.5 months. The mean excess weight loss was 61.4±35.5%. Most of the adolescents showed remarkable improvements in their quality of life. The outcome was regarded as "excellent or very good" in 32 patients, "good" in 12 patients and "fair" in 5 patients. Only one patient noticed no alterations after surgery. Two-thirds of the preoperative co-morbidities resolved, and one-third improved during follow-up. Except for one port dislocation, no peri- or postoperative complications arose. Conclusion: LAGB is an effective and attractive treatment option in very carefully selected obese adolescents, because of its adjustability and the preservation of the gastrointestinal passage. The majority of patients showed a remarkable improvement in their quality of life.     

Laparoscopic Adjustable Gastric Banding in Patients ≥60 Years Old: Is it Worthwhile?

Background: Laparoscopic adjustable gastric banding (LAGB) is an effective treatment for morbid obesity in younger patients, leading to improvements in related co-morbidities and quality of life. Currently, little is known how these improvements apply to older patients. Methods: A prospective review was conducted of patients ≥60 years old undergoing LAGB. Weight loss, complications, changes in Short Form-36 (SF-36) scores, and a comprehensive post-operative co-morbidity, medication and quality of life questionnaire were used to assess performance. Results: 40 patients with mean age 65.8 years (range 60-72) and preoperative mean BMI of 42.2 kg/m² (range 33-54) underwent LAGB from February 2000 to September 2005. Mean excess weight lost at 2 years was 54%. 3 complications (7.5%) occurred (1 slippage and 2 access-port infections). There were no perforations, erosions or deaths. After a mean postoperative interval of 27 months, SF-36 scores improved significantly in 4 of 8 components and exceeded age-matched population controls in 3 components. Co-morbidity improvement was reported in 80% of patients with diabetes, 79% with dyslipidemia, 75% with obstructive sleep apnea, 72% with heartburn, 69% with hypertension, 60% with musculoskeletal pain, and 56% with anxiety/depression. Medication requirements reduced or ceased in 66% who required musculoskeletal analgesics, 43% of diabetics, 33% using bronchodilators, and 29% with hypertension. Sleep improved in 48%, self-esteem increased in 70%, and 72% had a better outlook on life. 82% were happy that they had undergone LAGB, and 91% would recommend LAGB to other older people. Conclusion: LAGB offers safe and effective weight loss, and improvement in co-morbidities and in quality of life in morbidly obese patients aged ≥60 years.     

Esophageal Motility and Reflux Symptoms Before and After Bariatric Surgery

Background: Surgical treatment is the most effective method for weight reduction in morbid obesity. The most common operations are gastric banding and gastric bypass. The effect of these interventions on esophageal function and gastroesophageal reflux symptoms has not been adequately investigated. Methods: Patients undergoing obesity surgery were prospectively included in an observational study. Before surgery, each of the 53 patients underwent pulmonary function tests, esophageal manometry, and gastroscopy. Drug medication and esophageal symptoms were recorded. "Non-sweet eater" patients with good compliance underwent laparoscopic adjustable gastric banding (LAGB). In "sweet-eating" or non-compliant patients, gastric bypass (GBP) was carried out. Results: Between July 1997 and April 2000, 53 patients (9 males and 44 females) were consecutively operated on. 32 patients (median BMI 46.4 kg/m² ±5.4 SD) received LAGB, and 21 patients (BMI 54.0 kg/m² ±10.7) GBP. Median follow-up was 22 months, and only 3 patients were lost to yearly follow-up. Preoperatively, 6 LAGB patients had reflux symptoms, which postoperatively resolved in 3 of them, while the other 3 noted no change. Three patients who had no preoperative reflux symptoms developed them after LAGB. In the GBP group, no patient had esophageal dysmotility or incompetent esophageal sphincter function pre- or postoperatively. The incidence of postoperative esophageal symptoms was independent of operative technique (Wilcoxon U-Test: p= 0.75). Conclusion: The present results do not show any effect of gastric reduction surgery on postoperative esophageal function or gastroesophageal reflux symptoms.     

The outcome of laparoscopic antireflux surgery in relation to patients' subjective degree of compliance with former antireflux medication

It is well known that several patient-related factors are able to affect the surgical outcome such as quality of life or symptom relief after laparoscopic antireflux surgery. The aim of the current study was to evaluate and compare surgical outcome up to 1 year after laparoscopic antireflux surgery in relation to patients' subjective degree of compliance with former antireflux medication. Based on a three-level grading of subjective compliance with primary antireflux medication, a total of 140 patients undergoing antireflux surgery were divided into three subgroups: group 1/TC (totally compliant; n = 60), group 2/PC (partially compliant; n = 49); and group 3/NC (noncompliant; n = 31). Gastrointestinal Quality of Life Index (GIQLI), satisfaction with surgery, and the subjective degree of dysphagia as well as traditional outcome data (e.g., DeMeester score, lower esophageal sphincter pressure, side effects) were evaluated in all patients. As a result of surgery, only patients out of group 1/TC (GIQLI, preoperative 86.3 + 9.3 vs. 1 year postoperatively 123.1 + 7.2 points) and group 2/PC (GIQLI, preoperative 94.2 + 8.6 vs. 1 year postoperatively 120.8 + 7.8 points) showed a significant quality of life improvement that remained stable for at least 1 year (P < 0.05-0.01). In contrast, group 3/NC (GIQLI, preoperative 100.2 + 6.1 vs. 1 year postoperatively 117.2 + 9.8 points) patients had no significant quality of life improvement and patient satisfaction with surgery was less good when compared with that of the other groups. In these patients, also the subjective degree of postoperative dysphagia was significantly (P < 0.05-0.001) higher during the 1-year follow-up when compared with patients from group 1/TC or group 2/PC. A total of 42% of group 3/NC patients reported surgical side effects, whereas only 3% from group 1/TC and 10% from group 2/PC stated to be affected by any new symptoms (P < 0.0001). None of group 1/TC or group 2/PC patients suffered from recurrent symptoms or underwent laparoscopic reoperation. Of group 3/NC, a total of four patients (13%) needed any kind of additional intervention in relation to antireflux surgery (reoperation, n = 3; pneumatic dilatation, n = 1). There were no significant differences between the three groups when postoperative values of esophageal manometry and 24-hour pH monitoring were compared. What the current study does show is that the efficacy and the surgical outcome after laparoscopic antireflux surgery partly depends on the subjective degree of patient compliance with primary antireflux medication. Patients with no compliance in relation to former antireflux medication should generally not be refused antireflux surgery. But these patients should be evaluated with great care before surgery and should also be informed that surgical outcome may be affected in several aspects.     

Mortality Risk Factors in Chronic Renal Failure Patients after Coronary Artery Bypass Grafting

Perioperative risk during coronary artery bypass grafting (CABG) is high in patients with chronic renal disease. We aimed to determine postoperative two-year mortality and identify the preoperative risk factors of mortality during CABG surgery in hemodialysis (HD)-dependent and HD-non-dependent CRF patients. We included 102 CRF patients who underwent CABG in Baskent University Hospital between 2000 and 2005. There were 47 patients with CRF undergoing HD (Group I) and 55 CRF patients without dialysis requirement (Group II). We retrospectively retrieved demographic variables; clinical, operative, and echocardiographic data; and biochemical parameters at the time of the operation and six months postoperation. Postoperative HD requirement in Group II patients and infectious complications were recorded. In the second postoperative year, mortality rate was 27.7% in group I and 16.4% in group II (p > .05). When preoperative risk factors evaluated by univariate Cox analysis, only age (RR = 1.06, p = .04) was a significant determinant of survival in Group I patients. Among the operative and postoperative risk factors of mortality such as duration of operation, numbers of coronary vessel bypass, HD requirement, and infection were investigated in Group I and II patients. Rate of infectious complication (including mediastinitis) was found to be a major determinant of mortality by multivariate Cox analyses in both group I (RR = 4.42, p ≤ .05) and group II (RR = 9.39, p ≤ .05). HD dependency did not increase mortality if the patients are younger and were electively prepared for CABG surgery. High infection rates have increased the postoperative mortality and hospitalization in CRF patients. Early diagnosis of infections in CRF patients is important for early recovery, shorter hospitalization, and lower mortality after CABG operation     

Reversible dementia in patients with chronic subdural hematomas

OBJECT: Neuropsychiatric changes following surgery for chronic subdural hematomas (CSDHs) were analyzed in 26 patients (21 men and five women) by using the Mini-Mental State Examination (MMSE) and the Hasegawa Dementia Scale-Revised (HDS-R) to determine factors that potentially contribute to neuropsychiatric recovery. METHODS: Burr hole irrigation was performed in every patient to treat the CSDH. The patients' profiles, including age and sex, neuroimaging findings (such as hematoma volume and thickness, as well as midline shift), and preoperative and postoperative scores on the MMSE, HDS-R, and activities of daily living (ADL) scale were recorded. According to preoperative MMSE scores, eight patients (30.8%) were classified as mentally healthy and 18 (69.2%) as suffering from dementia before surgery. Nine of the 18 patients with dementia recovered to a normal psychological state following surgery. Surgery improved not only the patients' independence in ADL (p = 0.0026), but also their neuropsychiatric functions such as orientation and calculation, as estimated by scores on the MMSE (p = 0.0002) and the HDS-R (p = 0.0008). Factors affecting neuropsychiatric status on admission were midline shift (p = 0.0398) and ADL score (p = 0.0124); factors that could be used to predict neuropsychiatric recovery after surgery were patient age (p = 0.0027) and ADL score (p = 0.0193). The results of a logistic regression analysis demonstrated that significant predictors of neuropsychiatric recovery after surgery include the following: patient age (p = 0.0049, odds ratio [OR] = 0.842) and preoperative ADL (p = 0.0056, OR = 0.471), MMSE (p < 0.0001, OR = 1.895), and HDS-R (p = 0.0073, OR = 1.303) scores. Results of subgroup analyses demonstrated that patients younger than 74 years of age and those who had preoperative scores lower than 5 on the converted ADL scale, higher than 10 on the MMSE, or higher than 9 on the HDS-R on admission were found to have a significantly better recovery of neuropsychiatric functions after surgery. CONCLUSIONS: Dementia is reversible in many patients with CSDH, and surgery can improve not only independence in ADL, but also neuropsychiatric functions. Patients who are younger and/or those who have lower preoperative ADL scores and/or higher preoperative MMSE or HDS-R scores will achieve a good recovery with regard to neuropsychiatric functions after surgery. Estimations of neuropsychiatric function based on MMSE and HDS-R scores were found to be useful in predicting functional outcomes in patients with CSDH.