Severe Obesity Increases Risk of Infection After Revision Total Hip Arthroplasty

BackgroundThe increasing prevalence of obesity has resulted in an increased number of revision total hip arthroplasties (rTHAs) performed in patients with a high body mass index (BMI). The aim of this study is to evaluate whether obesity negatively affects (1) complication rate, (2) reoperation and revision rate, and (3) patient-reported outcome in rTHA.MethodsIn this registry-based study, we prospectively followed 444 rTHAs (cup: n = 265, stem: n = 57, both: n = 122) performed in a specialized high-volume orthopedic center between 2013 and 2015. The number of complications, and reoperation and revision surgery was registered until 5 years postoperatively. Oxford Hip Score (OHS) was evaluated preoperatively, and at 1 and 2 years postoperatively. Patients were categorized based on BMI to nonobese (<30 kg/m², n = 328), obese (30-35 kg/m², n = 82), and severe obese (≥35 kg/m², n = 34).ResultsSevere obese patients, but not obese patients, had higher risks of complications and re-revision than nonobese patients. In particular, the risk of infection following rTHA was higher in severe obese patients (24%) compared to nonobese patients (3%; relative risk, 7.7). Severe obese patients had overall poorer OHS than nonobese patients, but improvement in OHS did not differ between severe obese and nonobese patients. No differences between obese and nonobese groups on OHS were observed.ConclusionIn our study, severe obesity was associated with an increased risk of infection following rTHA. Patients with high BMI should be counseled appropriately before surgery.     

Anterior and posterior cervical fusion in patients with high body mass index are not associated with greater complications

Background contextObesity has been associated with adverse surgical outcomes; however, limited information is available regarding the effect of obesity on cervical spinal fusion outcomes.PurposeTo determine the effect of obesity on complication rates after cervical fusions.Study design/settingRetrospective cohort analysis of prospectively collected data on cervical fusion surgeries.Patient samplePatients in the ACS-NSQIP database from 2005 to 2010 undergoing cervical anterior or posterior fusion.Outcome measuresPrimary outcome measures were 30-day postsurgical complications, including mortality, deep-vein thrombosis, pulmonary embolism, septic complications, system-specific complications, and having ≥1 complication overall. Secondary outcomes were time spent in the operating room, blood transfusions, length of stay, and reoperation within 30 days.MethodsPatients undergoing anterior or posterior cervical fusions in the 2005–2010 American College of Surgeons National Surgical Quality Improvement Program were selected using Current Procedural Terminology codes. Anterior cervical fusion patients were categorized into four groups on the basis of body mass index (BMI): nonobese (18.5–29.9 kg/m²), obese I (30–34.9 kg/m²), obese II (35–39.9 kg/m²), and obese III (≥40 kg/m²). Posterior cervical patients were categorized into two groups based on the basis of BMI: nonobese (18.5–29.9 kg/m²) and obese (≥30 kg/m²) due to the smaller sample size. Patients in the obese categories were compared with patients in the nonobese categories by the use of χ², Fisher's exact test, Student t test, and analysis of variance. Multivariate linear/logistic regression models were used to adjust for preoperative comorbidities. The authors report no sources of funding or conflicts of interest related to this study.ResultsData were available for 3,671 and 400 patients who underwent anterior or posterior cervical fusion, respectively. Obese class III patients only showed a greater incidence of deep-vein thrombosis after anterior fusions on univariate analysis. Obese patients only showed longer mean surgical times and total operating room times after posterior fusions on univariate analysis. On multivariate analyses, these differences did not remain significant. There were also no differences in multivariate analyses for overall and system-specific complication rates, lengths of hospital stay, reoperation rates, and mortality among the obesity groups when compared with the nonobese groups with anterior or posterior cervical fusions.ConclusionsHigh BMI, regardless of obesity class, does not appear to be associated with increased complications after cervical fusion in the 30-day postoperative period.     

Changes of Inflammatory Mediators in Obese Patients After Laparoscopic Cholecystectomy

Background

Obesity is associated with the impairment of immunological functions. The aim of this study was to analyze some inflammatory mediators in obese subjects who underwent laparoscopic cholecystectomy.

Methods

Seventeen consecutive female patients with a BMI ranging from 35 to 45 kg/m² (obese) and 17 consecutive female patients with BMI ranging from 20 to 25 kg/m² (nonobese) were included in the study. All patients were affected by symptomatic gallbladder stone disease and underwent laparoscopic cholecystectomy. Changes in levels of leukocytes, neutrophils, IL-6, IL-10, leptin, and adiponectin were evaluated.

Results

We observed a significant increase in leukocyte and neutrophil levels in the obese subjects compared to the nonobese subjects. The serum levels of leptin and IL-6 were higher in the postoperative period (compared to the baseline values in both groups), and always higher in the obese. Both adiponectin and IL-10 increased in the postoperative period in nonobese subjects and was always higher than in the obese.

Conclusions

Obese patients have a stronger acute inflammatory response than do nonobese subjects in reaction to surgical stress.     

Laparoscopic surgery for colon cancer in obese patients: a case-matched control study

Purpose

This study compared the results of laparoscopic surgery for colon cancer in obese patients with a body-mass index (BMI) of 25 kg/m² or higher with those in nonobese patients (BMI <25 kg/m²) who were matched for clinicohistopathological factors.

Methods

The oncologic outcomes were compared between 140 patients with a BMI of 25 kg/m² or higher (obese group) and 140 patients with a BMI of <25 kg/m² (nonobese group) that were matched for sex, tumor location, date of operation, and pTNM stage.

Results

The proportion of patients with postoperative complications was significantly higher in the obese group (15 %) than in the nonobese group (6 %). The disease-free survival rate and overall survival rate in patients with stage I or II disease were similar in the obese group (98.6 and 98.8 %, respectively) and the nonobese group (97.8 and 97.8 %, respectively). The disease-free survival rate and overall survival rate in patients with stage III disease also did not differ significantly between the obese group (77.2 and 79.4 %, respectively) and the nonobese group (83.4 and 84.9 %, respectively).

Conclusions

Postoperative complications and long-term oncologic outcomes were similar in obese and nonobese patients who underwent laparoscopic colectomy for colon cancer in this hospital.     

Enoxaparin thromboprophylaxis in gastric bypass patients: extended duration,dose stratification,and antifactor Xa activity

BackgroundMorbidly obese patients undergoing gastric bypass surgery are at risk for postoperative venous thromboembolism. Evidence-based recommendations regarding the dosing and duration of thromboprophylaxis are lacking for morbidly obese surgical patients. The aims of this study were to evaluate the safety and efficacy of an extended duration, body mass index (BMI)–stratified enoxaparin thromboprophylaxis regimen in patients undergoing Roux-en-Y gastric bypass and to determine the resultant antifactor Xa (AFXa) activity in morbidly obese surgical patients.MethodsIn this prospective open trial, 223 patients (75% female, mean BMI 50.4 kg/m²) undergoing Roux-en-Y gastric bypass were assigned to receive enoxaparin 40 mg (BMI ≤50 kg/m², n = 124) or 60 mg (BMI >50 kg/m², n = 99) every 12 hours during hospitalization and once daily for 10 days after discharge. The AFXa levels were monitored serially, and dose adjustments were made for results outside the target prophylactic range (.2–.4 IU/mL ± 10%) after the third dose. The safety and efficacy outcomes were major bleeding and venous thromboembolism.ResultsRoux-en-Y gastric bypass was performed laparoscopically in 208 subjects (93%). The duration of surgery averaged 99.5 ± 31 minutes, and the median length of hospitalization was 3 days. Target prophylactic AFXa concentration was achieved by 74% of patients after the third enoxaparin dose; none reached the full anticoagulation concentration. One patient developed nonfatal venous thromboembolism (.45%). Four patients required transfusion (1.79%). Bleeding was not associated with a high AFXa concentration.ConclusionThis BMI-stratified, extended enoxaparin dosing regimen provided well-tolerated, effective prophylaxis against venous thromboembolism in patients undergoing gastric bypass surgery.     

After 3 Years of Starvation: Duodenum Swallowed Remaining Stomach

A 42-year-old morbidly obese patient (BMI 44.1 kg/m²) was admitted to our emergency room with upper abdominal pain, nausea, and cholestasis. Nine years ago, a vertical banded gastroplasty had been performed (former BMI 53.5 kg/m²) with a subsequent weight loss to BMI 33.0 kg/m². After regaining weight up to a BMI of 47.6 kg/m², 5 years ago a conversion to a gastric bypass was realized. A computed tomography of the abdomen showed an invagination of the remaining stomach into the duodenum causing obstruction of the orifice of common bile duct. The patient underwent an open desinvagination of the intussusception and resection of the remaining stomach. Gastroduodenal intussusception is rare and mostly secondary to gastric lipoma. To prevent this rare but serious complication, the remaining stomach could be fixed at the crura of the diaphragm, tagged to the anterior abdominal wall by temporary gastrostomy tube, or resected. The authors have no commercial interests.     

Does obesity affect long-term outcomes of extreme lateral interbody fusion with posterior stabilization?

Background ContextObese patients can pose significant challenges to spine surgeons in lumbar fusion procedures. The increased risk of complications has led surgeons to be wary in pursing operative interventions in these patients. Since the advent of minimally-invasive techniques in lumbar fusion, surgeons are turning to these procedures in an attempt to minimize operative time, blood loss and overall cost. With an increased proportion of obese patients in the population, it is imperative to understand the long-term outcomes in these minimally-invasive approaches.PurposeThe purpose of this study was to evaluate the long-term safety and efficacy of extreme lateral interbody fusion (XLIF) in the obese.Study Design/SettingRetrospective cohort study.Patient SampleA total of 115 patients (53 nonobese and 62 obese) who underwent XLIF with a minimum of 5-year follow-up.Outcome Measures(1) Patient reported outcome scores: Visual Analog Scale (VAS) for back pain, Oswestry Disability Index (ODI), (2) Reoperation rate, (3) Pelvic incidence (PI)- Lumbar lordosis (LL) mismatch correction, (4) Graft subsidence and fusion rateMethodsA retrospective review was performed to identify patients who underwent XLIF with percutaneous posterior stabilization since 2007 with a minimum follow-up of 5 years. Demographics including BMI were recorded and patients were subdivided into 2 cohorts: nonobese (BMI <30 kg/m²) and obese (BMI ≥30 kg/m²). Functional outcomes were assessed by comparing pre- and postoperative VAS and ODI scores. Reoperation rates were compared between cohorts. PI-LL mismatch was calculated from both pre- and postoperative radiographs. Rates of graft subsidence and fusion were measured at final follow-up.ResultsA total of 115 consecutive patients were included (53 nonobese and 62 obese) with a mean follow up of 95.3 months. Mean BMI was 25.3 in the nonobese group and 35.3 in the obese group (p<.001). There were more females in nonobese cohort. VAS scores decreased by a mean of 5.7 in the nonobese cohort, and 5.4 in the obese cohort (p=.213). ODI improvement was also similar between the groups. 5.6% of nonobese patients required reoperation compared to 9.6% of obese patients (p=.503). Graft subsidence rates at final follow-up were 5.66% and 8.06% for the nonobese and obese groups, respectively (p=.613). Rates of successful fusion were 96.23% and 98.39% for the nonobese and obese groups, respectively (p=.469). Both cohorts achieved a similar proportion of PI-LL mismatch correction, 85% in obese versus 78% in nonobese patients (p=.526).ConclusionObese patients have similar surgical outcomes to nonobese patients with respect to functional outcome scores, reoperation rates, graft subsidence and correction of PI-LL mismatch after long-term follow-up. With similar outcome and reoperation profiles, minimally-invasive approaches to the spine, such as XLIF, may be an acceptable alternative to traditional open procedures in obese patients.     

Gastric Emptying is not Affected by Sleeve Gastrectomy—Scintigraphic Evaluation of Gastric Emptying after Sleeve Gastrectomy without Removal of the Gastric Antrum

Background  The aim of this study is to clarify whether laparoscopic sleeve gastrectomy (LSG) to treat morbid obesity causes changes in gastric emptying. Methods  Gastric emptying scintigraphy was performed before and 3 months after LSG, in 21 consecutive morbidly obese patients. After an overnight fast, subjects consumed a standard semi-solid meal, to which 0.5 mCi Tc⁹⁹-labeled sulfur colloid had been added. The meal was consumed within 10 min. Scintigraphic imaging was performed with a gamma camera immediately after the completion of the meal as well as after 30, 60, 120, 180, and 240 min. Quantitative and qualitative analysis was performed by drawing a region of interest (ROI) enclosing the stomach on the anterior and the posterior images. Time 0 was considered the time of meal completion (all the ingested activity) and was defined as 100% retention. The same ROI was used on all consecutive images of the same projection for the same patient. The geometric mean of the anterior and the posterior counts for each time point is calculated and corrected for Tc^99m decay. Gastric emptying curves were constructed. T 1/2 is the time interval between completion of the meal and the point at which half of the meal (by radioactivity counts) has left the stomach. Retention is expressed as the percent remaining in the stomach at each time point (half, 1, 2, 3, 4 h). Results  The mean T 1/2 raw data was 62.39 ± 19.83 and 56.79 ± 18.72 min (p = 0.36, t = −0.92, NS) before and 3 months after LSG, respectively. The T 1/2 linear was 103.64 ± 9.82 and 106.92 ± 14.55, (p = 0.43, t = −0.43, NS), and the linear fit slope 0.48 ± 0.04 and 0.47 ± 0.05 (p = 0.48, t = 0.7, NS). Conclusions  LSG with antrum preservation as performed in this series has no effect on gastric emptying. This work was performed in partial fulfillment of the requirements for a MSc degree of Ronit Tzioni Yehoshua, Sackler Faculty of Medicine, Tel Aviv University, Israel.     

Perioperative outcomes after lower extremity bypass and peripheral vascular interventions in patients with morbid obesity and superobesity

ObjectiveAlthough the effect of body mass index (BMI) on the treatment of infrainguinal peripheral artery disease has been reported, outcomes of patients on the upper end of the obesity spectrum, including morbid obesity (MO) and superobesity (SO), are unclear. Our goal was to analyze perioperative outcomes after lower extremity bypass (LEB) and peripheral vascular interventions (PVIs) in this population of patients.MethodsThe Vascular Quality Initiative was reviewed for all infrainguinal peripheral artery disease interventions from 2010 to 2017. All patients were categorized into four groups: nonobese (BMI 18.5-29.9 kg/m²), obese (BMI 30-39.9 kg/m²), morbidly obese (BMI 40-49.9 kg/m²), and superobese (BMI ≥50 kg/m²). Patient and case details were recorded. Multivariable analysis was used to analyze outcomes. For statistical analysis, MO and SO groups were combined.ResultsWe identified 29,138 LEB cases (68.5% nonobese, 28.3% obese, 2.9% morbidly obese, 0.3% superobese) and 81,405 PVI cases (66.6% nonobese, 29.2% obese, 3.6% morbidly obese, 0.5% superobese). For both LEB and PVI, patients with MO and SO were more likely to be younger, female, nonsmokers, and ambulatory (P < .05). They also more often had diabetes, end-stage renal disease, congestive heart failure, and fewer previous inflow procedures (P < .05). LEB and PVI interventions in patients with MO and SO were less often elective and more often performed for tissue loss. Multivariable analysis showed that LEB in patients with MO and SO was not significantly associated with increased perioperative cardiac complications, return to the operating room, or mortality. Patients with MO and SO were significantly associated with increased surgical site infection (odds ratio, 1.43; 95% confidence interval, 1.02-1.98; P = .03) and increased respiratory complications (odds ratio, 1.6; 95% confidence interval, 1.11-2.31; P = .01). Multivariable analysis showed that MO and SO were not significantly associated with periprocedural access site hematoma, access site stenosis or occlusion, or mortality after PVI.ConclusionsMO and SO were significantly associated with increased incidence of wound infections and respiratory complications after LEB but were not significantly associated with increased incidence after PVI. Overall, patients with MO and SO have more comorbidities and more advanced presentation of vascular disease at the time of intervention, but MO and SO alone should not deter necessary and appropriate revascularization.     

Robotic-Assisted Laparoscopic Hysterectomy: Outcomes in Obese and Morbidly Obese Patients

Objective:

To describe patient characteristics and perioperative outcomes among women undergoing robotic-assisted laparoscopic hysterectomy and to evaluate the characteristics of nonobese, obese, and morbidly obese patients.

Methods:

A retrospective review was conducted of 442 cases of women who underwent robotic-assisted laparoscopic hysterectomy for benign and malignant conditions over a 4-y period at an academic and community teaching hospital. Patient demographics, surgical indications, operative outcomes, and complications were evaluated for patients with a body mass index (BMI) <30 kg/m², 30 kg/m² to 39.9 kg/m², and ≥40 kg/m².

Results:

Of the 442 patients, 257 (58%) were obese or morbidly obese, with a BMI of ≥30 kg/m². Overall, the median estimated blood loss was 100 mL (range, 10 to 800), the operative time was 135 min (range, 40 to 436), and the length of stay was 1 d (range, 0 to 22). These did not differ significantly by BMI group. Overall, 11.9% of patients experienced complications (7.9% minor, 4.1% major), and this did not differ significantly across BMI groups.

Conclusion:

Robotic hysterectomy can be performed safely in obese and morbidly obese patients, with surgical outcomes and complications similar to those in nonobese patients.     

Prospective controlled study of effect of laparoscopic sleeve gastrectomy on small bowel transit time and gastric emptying half-time in morbidly obese patients with type 2 diabetes mellitus

BackgroundPublished data on sleeve gastrectomy (SG) have indicated better remission of type 2 diabetes mellitus (T2DM) and improvement in satiety compared with other restrictive procedures. Mechanisms in addition to rapid, extensive weight loss are responsible for the restoration of the euglycemic state. To prospectively evaluate the role of laparoscopic SG on gastric emptying half-time and small bowel transit time (SBTT) and effect of these on weight loss, satiety, and improvement in T2DM.MethodsA total of 67 subjects were studied. Of these 67 subjects, 24 were lean controls (body mass index 22.2 ± 2.84 kg/m²), 20 were severely and morbidly obese patients with T2DM who had not undergone SG (body mass index 37.73 ± 5.35 kg/m²), and 23 were severely and morbidly obese patients with T2DM after SG (body mass index 40.71 ± 6.59 kg/m²). All 67 patients were evaluated for gastric emptying half-time and SBTT using scintigraphic imaging. Imaging was performed every 15 minutes up to the ileocecal region. The Three-Factor Eating Questionnaire was administered simultaneously. Fasting blood sugar, postprandial blood sugar, and glycated hemoglobin were assessed. Nonparametric analysis of variance and the Mann-Whitney U test were applied.ResultsThe mean SBTT was significantly lower (P <.05) in the post-SG group (199 ± 65.7 minutes) than in the non-SG group (281.5 ± 46.2 minutes) or control group (298.1 ± 9.2 minutes). The gastric emptying half-time values were also significantly shorter (P <.05) in the post-SG (52.8 ± 13.5 minutes) than in the non-SG (73.7 ± 29.0 minutes) and control (72.8 ± 29.6 minutes) groups. The glycated hemoglobin, fasting blood sugar, and postprandial sugar were all significantly lower after SG. The Three-Factor Eating Questionnaire findings revealed significantly earlier satiety (29.0 ± 7.2) for the post-SG patients (P <.05) compared with the non-SG (45.8 ± 9.0) and control (37.9 ± 6.2) subjects.ConclusionA decreased gastric emptying half-time and SBTT after SG can possibly contribute to better glucose homeostasis in patients with T2DM.     

A modified laparoscopic sleeve gastrectomy for the treatment of diabetes mellitus type 2 and metabolic syndrome in obesity

BackgroundGhrelin is a gastrointestinal peptide hormone (a 28–amino acid peptide) produced primarily by X/A cells in the oxyntic glands of the stomach fundus and cells lining the duodenum cavern. It suppresses insulin secretion and action and commands a significant role in regulating food intake. The aim of the present study was to show that modified laparoscopic sleeve gastrectomy (MLSG), in which a significant part of the gastric fundus and body of the stomach is removed up to 1 inch from the pylorus vein, may contribute to decreasing circulating ghrelin levels.MethodsA study population consisting of 150 individuals was monitored after undergoing a MLSG, with individuals chosen based on a documented history of diabetes mellitus type 2 and metabolic syndrome, clinical results determining a body mass index (BMI) of 35 to 60 kg/m², peptide C level greater than 1, negative anti-glutamic acid decarboxylase, negative anti-insulin, and confirmed stability of drug/insulin treatment and glycosylated hemoglobin greater than 6.5% for at least 24 and 3 months, respectively, before enrollment.ResultsTwenty-four months after surgery, 150 patients (86.6%) presented with normal glycemic levels between 77 and 99 mg/dL. All patients improved average serum insulin levels by 9 mU/L and average glycosylated hemoglobin levels by 5.1% (normal range, 4%–6%). All patients tested negative for Helicobacter pylori and stopped using insulin, with 3 patients prescribed twice-daily use of an oral hypoglycemiant. In 14% of cases, patients experienced partial hair loss with low serum zinc levels and were prescribed oral zinc reposition and topical hair stimulants. The average weight loss recorded was 44.6% for patients with a BMI less than 45 kg/m² and 58% for patients with a BMI greater than 50 kg/m².ConclusionsThe MLSG is a safe procedure with a low morbidity rate (2.7%) (4 cases of fistula and 2 of bleeding) and no surgical mortality in this study. This surgery can promote control of diabetes mellitus type 2 and aid the treatment of exogenous overweight and morbidly obese individuals. The results of this study show that only through resection of the ghrelin-producing gastric area can most obesity cases and diabetes type II conditions be reverted to nonobese and controlled diabetes.     

Outcome of hand-assisted laparoscopic gastric bypass in super obese patients

BackgroundThe optimal surgical treatment for super obese patients (body mass index [BMI] ≥50 kg/m²) has been a challenge and debate for most bariatric surgeons. To compare the outcomes of hand-assisted laparoscopic Roux-en-Y gastric bypass (HALGB) in super obese patients (BMI ≥50 kg/m²) to morbidly obese patients (BMI <50 kg/m²).MethodsA total of 295 patients who underwent HALGB from October 2003 to December 2005 were studied. These patients included 177 with a BMI of ≤49 kg/m² (morbidly obese) and 118 with a BMI of ≥50 kg/m² (super-obese). The patient demographics, complications, and outcomes were examined. Additionally, the 12-month postoperative outcomes included the percentage of excess weight loss and improvement of co-morbidities.ResultsThe patient age and gender were similar between the 2 groups. The super-obese patients had significantly more co-morbidities and required a greater number of medications. A significant difference was found in 3 early postoperative complications, with super-obese patients experiencing more wound infections (P = .039), nausea/vomiting (P = .003), and pulmonary failure (P = .010). Logistic regression analysis found, after controlling for significant risk factors, that the difference in the incidence of nausea/vomiting was still significant (odds ratio 14.33, 95% confidence interval 1.73–118.60, P = .01). Morbidly obese patients had a significantly greater percentage of excess weight loss at 12 months postoperatively compared with the super-obese patients (80% versus 55%, respectively, P <.001).ConclusionHALGB is a safe and effective procedure in the super obese but with less favorable outcomes compared with those for morbidly obese patients regarding the percentage of excess weight loss.     

Gastric emptying of solids in normal children--a preliminary report

Objective

The physiological range of gastric emptying in healthy children has not previously been documented. The aim of this study was to establish the range of normal gastric emptying in children aged between 5 and 10 years with a Tc 99m-labelled solid meal acceptable to most of the children.

Methods

A list of 7 child-friendly foods was compiled. Thirty-one children aged 5 to 10 years completed a questionnaire, ranking their favourite food choices. A volume survey, to decide the weight of solid meal for the study, was carried out in 20 children.After ethical approval, gastric emptying was monitored in healthy children aged 5 to 10 years with a ^99mTc-labelled solid meal selected by the methodology given hereinabove. Geometric mean counts were obtained from anterior and posterior gamma camera images, and data were used to produce normal emptying curves. In each case, a T_1/2 gastric emptying time (time taken to empty half the stomach contents) was calculated.

Results

The overall preference was a chocolate Technecrispy cake, and the volume survey suggested a 30-g weight for the study. Twenty-four subjects consumed the meal and completed the study. The mean T_1/2 gastric emptying time was 107.2 minutes (2 SD; range, 54.6-159.8 minutes).

Conclusions

Chocolate Technecrispy cake was acceptable to most healthy children between 5 and 10 years of age and gave mean T_1/2 gastric emptying time of 107.2 minutes. This meal can now be used for paediatric patients with transit problems.     

Erythromycin accelerates delayed gastric emptying of solids in patients after truncal vagotomy and pyloroplasty.

OBJECTIVE--To find out if erythromycin (a motilin agonist) accelerated gastric emptying after vagotomy and in normal subjects. DESIGN--Double blind controlled study. SETTING--Two referral centres. SUBJECTS--15 patients who had previously undergone vagotomy and who did (n = 8) or did not (n = 7) have symptoms of gastric stasis and 10 normal controls. INTERVENTIONS--A standard meal containing 185 x 10(5) Bq -99mTc was eaten after either erythromycin 200 mg or 40 ml placebo (normal saline) had been given intravenously. Subjects were then scanned by gamma camera. MAIN OUTCOME MEASURES--Measurement of: the length of time from completion of the meal to the onset of gastric emptying; the length of time from completion of the meal until half of the meal had left the stomach; the length of the time from the onset of gastric emptying until half of the meal had left the stomach; and the percentage of the meal that was left in the stomach at 60 and 120 min after the end of the meal. RESULTS--Gastric emptying was significantly delayed in those patients with symptoms compared with normal subjects and patients without symptoms. Erythromycin accelerated the first two phases of gastric emptying in all patients and normal subjects, but did not affect the length of time from the onset of gastric emptying until half the meal had left the stomach. CONCLUSION--Erythromycin could be a useful gastrokinetic agent in patients with symptoms of gastric stasis after vagotomy.     

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.     

Roux-en-Y gastric bypass compared with aggressive diet and exercise therapy for morbidly obese patients awaiting renal transplant: a decision analysis

BackgroundThe optimal management of morbidly obese patients awaiting renal transplant is controversial and unknown. The objective of this study was to compare the impact of Roux-en-Y gastric bypass (RYGB) versus diet and exercise on the survival of morbidly obese patients with end-stage renal disease awaiting renal transplant.MethodsA decision analytic Markov state transition model was designed to simulate the life of morbidly obese patients with end-stage renal disease awaiting transplant. Life expectancy after RYGB and after 1 and 2 years of diet and exercise was estimated and compared in the framework of 2 clinical scenarios in which patients above a body mass index (BMI) of 35 kg/m² or above a BMI of 40 kg/m² were ineligible for transplantation, reflecting the BMI restrictions of many transplant centers. In addition to base case analysis (45 kg/m² BMI preintervention), sensitivity analysis of initial BMI was completed. Markov model parameters were extracted from the literature.ResultsRYGB improved survival compared with diet and exercise. Patients who underwent RYGB received transplants sooner and in higher frequency. Using 40 kg/m² as the upper limit for transplant eligibility, base case patients who underwent RYGB gained 5.4 years of life, whereas patients who underwent 1 and 2 years of diet and exercise gained 1.5 and 2.8 years of life, respectively. Using 35 kg/m² as the upper limit, RYGB base case patients gained 5.3 years of life, whereas patients who underwent 1 and 2 years of diet and exercise gained .7 and 1.5 years of life, respectively.ConclusionsIn morbidly obese patients with end-stage renal disease, RYGB may be more effective than optimistic weight loss outcomes after diet and exercise, thereby improving access to renal transplantation.     

Sleeve Gastrectomy — A Restrictive Procedure?

Background Diet and surgically-induced weight loss have been shown to lead to alterations in motor and sensory function of the stomach.We investigated the clinical outcome and gastric emptying of solid foods in morbidly obese (MO) patients following sleeve gastrectomy (SG). Methods We studied 23 MO patients [(7 males, 16 females), mean age 38.9 ± 11.0 years (range 20–64 years), mean weight 135.1 ± 19.0 kg (range 97–167 kg), mean BMI 47.2 ± 4.8 kg/m2 (range 39.6–56.0 kg/m2)] who each underwent a sleeve gastrectomy (SG) for weight reduction. At the monthly follow-up visits, variations in weight and BMI changes, postoperative meal size and frequency, and presence of gastrointestinal symptoms were recorded. 11 patients underwent scintigraphic measurement of the gastric emptying of a solid meal pre- and 6 months postoperatively. Results A significant reduction in patients’ weight was evidenced at 6 and 12 months postoperatively [98.6 ± 11.8 kg and 87.0 ± 10.7 kg respectively (P = 0.001)]. BMI decreased to 35.2 ± 4.3 kg/m² at 6 months and to 31.1 ± 4.5 kg/m² at 12 months, respectively (P = 0.001). Although meal size was drastically reduced, meal frequency increased postoperatively in 12 patients (52.2%). Only 5 patients (21.8%) reported occasional vomiting after meals following SG. The gastric emptying half-time (T1/2) accelerated (47.6 ± 23.2 vs. 94.3 ± 15.4, P < 0.01) and the T-lag phase duration decreased (9.5 ± 2 min vs. 19.2 ± 2 min, P < 0.05) postoperatively. The percentage of the meal emptied from the stomach 90 min after consumption increased significantly after SG (75.4 ± 14.9% vs. 49.2 ± 8.7%, P < 0.01). Conclusions This study indicates that following SG, the stomach empties its contents rapidly into the small intestine and symptoms of vomiting after eating (characteristic of restrictive procedures) are either absent or very mild. Therefore, the term ‘restrictive’ is possibly ill-advised for this new bariatric operation. It remains for other mechanisms of energy intake reduction, such as intestinal distension and satiety signals through gut hormones to be investigated, to comprehensively explain precisely how this ‘food limiting’ procedure results in weight loss.     

Gastric Emptying of Solids and Semi-solids in Morbidly Obese and Non-obese Subjects: An Assessment Using the <Superscript>13</Superscript>C-Octanoic Acid and <Superscript>13</Superscript>C-Acetic Acid Breath Tests

Background It has been suggested that obesity is associated with an altered rate of gastric emptying. The objective of the present study was to determine whether the rates of solid and semi-solid gastric emptying differ between morbidly obese patients and lean subjects. Methods The Gastric-emptying time (GET) of solid and semi-solid meals were compared between lean healthy subjects and morbidly obese patients enrolled in two previously published studies. GET of solid and semi-solid meals was measured using the ¹³C-octanoic acid breath test and ¹³C-acetic acid breath test, respectively, in 24 lean and 14 morbidly obese individuals of both sexes. Student t-test was used to compare the mean data between the lean and morbidly obese groups. The influence of sex, gender, BMI and morbid obesity on the GET of solid meals was verified by linear regression analysis. Results Mean t(1/2) values of solid GET (± standard deviation) were 203.6 ±  76.0 min and 143.5 ± 19.1 min for lean and obese subjects, respectively (P = 0.0010). Mean t(lag) values of solid GET were 127.3 ± 42.7 min and 98.4 ± 13.0 min for lean and obese subjects, respectively (P = 0.0044). No significant difference in semi-solid GET was observed between the lean and morbidly obese groups. Conclusion The present study demonstrated a significantly enhanced gastric emptying of the solid meal test in morbidly obese patients when compared to lean subjects. This finding is compatible with the hypothesis that rapid gastric emptying in morbidly obese subjects increases caloric intake due to a more rapid loss of satiety.     

Elevated Body Mass Index Is a Risk Factor for Failure to Achieve the Knee Disability and Osteoarthritis Outcome Score-Physical Function Short Form Minimal Clinically Important Difference Following Total Knee Arthroplasty

BackgroundThe aims of this study are (1) to assess the association between body mass index (BMI) and failure to achieve the 1-year Knee Disability and Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS) minimal clinically important difference (MCID) for total knee arthroplasty (TKA) patients and (2) to determine if there is a BMI threshold beyond which the risk of failing to achieve the MCID is significantly increased.MethodsA regional arthroplasty registry was queried for TKA patients from 2016 to 2019 with completion of preoperative and 1-year postoperative KOOS-PS. The MCID threshold was derived using a distribution-based approach. Demographic and patient-reported outcome measure variables were collected. BMI was analyzed continuously and categorically using cutoffs defined by the Centers for Disease Control and Prevention. The association between failure to achieve 1-year MCID and BMI was analyzed using multiple logistic regression. A BMI threshold was determined using the Youden index and receiver operating characteristic curve.ResultsIn total, 1059 TKAs were analyzed. BMI assessed continuously was significantly associated with failure to achieve the KOOS-PS MCID (odds ratio 1.03, 95% confidence interval 1.00-1.05, P = .025). Analysis of BMI categorically revealed that “overweight” (25-30 kg/m²), “obese class I” (30-35 kg/m²), “obese class II” (35-40 kg/m²), and “obese class III” (>40 kg/m²) patients faced 77%, 76%, 83%, and 106% greater risk, respectively, of failing to achieve the KOOS-PS MCID compared to “normal BMI” (<25 kg/m²) patients.ConclusionElevated BMI was associated with an increased risk of failure to achieve the 1-year KOOS-PS MCID following TKA.