Response to catecholamine stimulation of polymorphisms of the Beta-1 and Beta-2 adrenergic receptors

Previous studies have demonstrated that β-adrenergic receptor polymorphisms affect outcomes in patients with heart failure or after an acute coronary syndrome. Whether β-adrenergic polymorphisms influence catecholamine responses in patients with cardiovascular disease is not known. Cardiovascular responses to the β1-receptor agonist dobutamine and the β2-receptor agonist terbutaline were studied using gated blood pool scintigraphy in 21 patients on long-term β-blocker therapy. Heart rate (HR), stroke volume (SV), and cardiac output (CO) increased, and end-systolic volume decreased with dobutamine and terbutaline. Changes in HR and CO with dobutamine were higher for those with ≥1 β1 Arg389 allele than those homozygous for the Gly389 allele (change in HR 15 vs 1 beat/min, p = 0.02; change in CO 2.4 vs 1.0 L/min, p = 0.02). Increases in HR, CO, and SV with terbutaline were greater for those homozygous for the β2 Glu27 allele than those with ≥1 Gln27 allele (change in HR 13.7 vs 4.8 beats/min, p = 0.048; change in CO 3.1 vs 1.6 L/min, p = 0.034; change in SV 28.3 vs 14.8 ml, p = 0.045). Changes in CO and volume with terbutaline were greater in those with an ejection fraction <40% than in those with an ejection fraction ≥40%. In conclusion, β-receptor gene variants significantly influence inotropic and chronotropic responses to β-agonist exposure in patients on β-blocker therapy.     

Revisional Bariatric Surgery for Unsuccessful Weight Loss and Complications

Background

There are growing numbers of patients who require revisional bariatric surgery due to the undesirable results of their primary procedures. The aim of this study was to review our experience with bariatric patients undergoing revisional surgery.

Methods

We conducted a retrospective analysis to review the indications for revisional bariatric procedures and assess their postoperative outcomes.

Results

From 04/04 to 01/11, 2,918 patients underwent bariatric surgery at our institution. A total of 154 patients (5.3 %) of these cases were coded as revisional procedures. The mean age at revision was 49.1?±?11.3 and the mean BMI was 44.0?±?13.7 kg/m². Revisional surgery was performed laparoscopically in 121 patients (78.6 %). Laparoscopic revisions had less blood loss, shorter length of hospital stay, and fewer complications compared to open revisions. Two groups (A and B) were defined by the indication for revision: patients with unsuccessful weight loss (group A, n?=?106) and patients with complications of their primary procedures (group B, n?=?48). In group A, 74.5 % of the patients were revised to a bypass procedure and 25.5 % to a restrictive procedure. Mean excess weight loss was 53.7?±?29.3 % after revision of primary restrictive procedures and 37.6?±?35.1 % after revision of bypass procedures at >1-year follow-up (p?<?0.05). In group B, the complications prompting revision were effectively treated by revisional surgery.

Conclusions

Revisional bariatric surgery effectively treated the undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed after both failed open and laparoscopic bariatric procedures without a prohibitive complication rate. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss.     

Surgical management of early small bowel obstruction after laparoscopic Roux-en-Y gastric bypass

BackgroundLimited data are available regarding early postoperative small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of the present study was to review our experience with early SBO after LRYGB. The setting was a tertiary referral bariatric center.MethodsWe reviewed a prospectively maintained database to assess the diagnosis, management, and outcomes of patients who underwent surgery for SBO within 30 days of LRYGB.ResultsFrom April 2004 to December 2011, 2126 patients underwent LRYGB. Of these patients, 11 (.5%) required surgical management for early SBO. Of the 11 patients, 9 were women and 2 were men. with a mean age of 53 years (range 35–70) and mean body mass index of 45 kg/m² (range 38–65). The average interval from LRYGB to the presentation of SBO was 5.0 days (range 2–15). All early SBOs were diagnosed by computed tomography with oral contrast. The causes of early SBO included kinking at the jejunojejunostomy in 4, an intraluminal blood clot near the jejunojejunostomy in 2, angulation of the Roux limb in 1, mesenteric hematoma in 1, intra-abdominal hematoma in 1, obstruction of common channel in 1, and pelvic adhesions from previous surgery in 1. Diagnostic laparoscopy was attempted in all patients. Four patients required conversion to open surgery. Postoperative complications developed in 5 patients; no patient died. Laparoscopic management of early SBO resulted in fewer complications than the open approach.ConclusionEarly SBO after LRYGB is uncommon; however, a prompt diagnosis and surgical intervention are important to prevent additional morbidity. The ability to complete the reoperation laparoscopically varies with the etiology and location of the obstruction.     

Bariatric surgery in patients with liver cirrhosis

BackgroundData regarding the management of bariatric patients with cirrhosis are scarce, and there is no strong evidence that supports a specific approach for this group of patients. The aim of this study was to review our experience with cirrhotic patients undergoing bariatric surgery.MethodsA prospectively maintained database was reviewed to assess the outcomes of bariatric surgery for patients with known cirrhosis and for patients with cirrhosis discovered at surgery (unknown cirrhosis).ResultsFrom April 2004 to September 2011, 23 patients (12 with known cirrhosis and 11 with unknown cirrhosis) met inclusion criteria. There were 14 females and 9 males with a mean age of 51.5±8.3 and a mean body mass index of 48.2±8.6 kg/m2. Child-Pugh classes were A (n = 22) and B (n = 1). Patients had a high frequency of diabetes (83%), dyslipidemia (61%), and hypertension (83%). Procedures performed were laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 14), laparoscopic sleeve gastrectomy (LSG) (n = 8), and laparoscopic adjustable gastric banding (n = 1). Two patients underwent LSG successfully after transjugular intrahepatic portosystemic shunt. Mean length of hospital stay was 4.3±2.7 days. Complications developed in 8 patients. One patient died of unknown cause 9 months after surgery. No patients had liver decompensation after surgery. The patients lost 67.4%±30.9% of their excess weight at 12 months follow-up and 67.7%±24.8% at 37 months follow-up.ConclusionLRYGB and LSG can be performed without prohibitive complication rates in carefully selected patients with cirrhosis. In our experience, bariatric patients with cirrhosis achieved excellent weight loss and improvement in obesity-related co-morbidities.     

Which dyskinesia scale best detects treatment response?

Numerous scales assess dyskinesia in Parkinson's disease (PD), variably focusing on anatomical distribution, phenomenology, time, severity, and disability. No study has compared these scales and their relative ability to detect change related to an established treatment. We conducted a randomized placebo‐controlled trial of amantadine, assessing dyskinesia at baseline and at 4 and 8 weeks using the following scales: Unified Dyskinesia Rating Scale (UDysRS), Lang‐Fahn Activities of Daily Living Dyskinesia Rating Scale (LF), 26‐Item Parkinson's Disease Dyskinesia scale (PDD‐26), patient diaries, modified Abnormal Involuntary Movements Scale (AIMS), Rush Dyskinesia Rating Scale (RDRS), dyskinesia items from the Movement Disorder Society–sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS‐UPDRS), and Clinical Global Impression (severity and change: CGI‐S, CGI‐C). Scale order was randomized at each visit, but raters were aware of each scale as it was administered. Sensitivity to treatment was assessed using effect size. Sixty‐one randomized dyskinetic PD subjects (31 amantadine, 30 placebo) completed the study. Four of the 8 scales (CGI‐C, LF, PDD‐26, and UDysRS) detected a significant treatment. The UDysRS Total Score showed the highest effect size (η² = 0.138) for detecting treatment‐related change, with all other scales having effect sizes < 0.1. No scale was resistant to placebo effects. This study resolves 2 major issues useful for future testing of new antidyskinesia treatments: among tested scales, the UDysRS, having both subjective and objective dyskinesia ratings, is superior for detecting treatment effects; and the magnitude of the UDysRS effect size from amantadine sets a clear standard for comparison for new agents. © 2012 Movement Disorder Society