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BACKGROUND: A National institutes of Health Consensus Conference in 1991 established gastric surgery as accepted therapy for the treatment of severe obesity. The increasing prevalence of obesity in the United States, and the increasing numbers of patients undergoing gastric surgery for severe obesity, result in substantial numbers of patients being considered for revisional surgery. The indications and efficacy of revisional surgery remain controversial. METHODS: Sixty-three patients were followed prospectively after undergoing revisional surgery for obesity between 1981 and 1994. All patients had previously undergone obesity operations. Weight data were recorded at the time of original obesity surgery, at revisional surgery, and at most current follow-up. Complications following revisional surgery were monitored. RESULTS: The follow-up in the group is 98%. Revisional surgery after obesity surgery was associated with a 0% mortality rate and a serious complication rate of 16%. Body mass index (BMI) at the time of original surgery was associated revisional surgery after obesity surgery was 50 + 10 kg/[m.sup.2], at follow-up 34 [+ OR -] 10 kg/[m.sup.2] (P. 50 kg/[m.sup.2] lost significantly more weight (P

Severe obesity affects the health and quality of life of 4 moon Americans. The major cost of treating severe obesity and its associated comorbidities of hypertension, diabetes, cardiovascular disease, pulmonary insufficiency, cancer, and degenerative arthritis as well as the poor long-term results of medical, drug, and behavioral therapy has increased the numbers of patients being referred for surgical treatment. Gastric bypass and vertical banded gastroplasty are the two procedures recommended for severely obese patients. These operations currently have low morbidity and mortality. Surgery should he considered adjuvant therapy and must be part of a multidisciplinary approach. The significant long-term weight control resulting from the surgical therapy is associated with improvement and, often, resolution of comorbidities, including diabetes, hypertension, hyperlipidemia, and pulmonary insufficiency.

Objective: To describe the hemodynamic and oxygen transport patterns in survivors and nonsurvivors following liver transplantation (LT) and to assess their relationship to organ failure and mortality. Design: Retrospective cohort. [...]

In only two areas of colorectal cancer recurrence does surgery provide benefit. For a minority of patients with liver metastases that can be resected completely, cure is possible. Recent data from a prospective liver surgery protocol provide a perspective on the outcome, morbidity, and mortality of the procedure and confirm many of the suggestions in previous retrospective reviews. For patients with isolated pelvic or perineal recurrence, surgical removal of recurrent tumor provides palliation, but only if in-hospital convalescence is minimal and if recently introduced reconstructive techniques allow early rehabilitation. Cancer 1992; 70:1409-1413.

Hypertension is a major health risk factor in patients who are morbidly obese. Two hundred eighty-nine morbidly obese patients undergoing gastric restrictive surgery were evaluated for the presence of hypertension (blood pressure greater than or equal to 160/90 mm Hg or currently undergoing antihypertensive therapy) pre- and post-operatively. Of 74 (26%) preoperatively hypertensive patients, 67 (91%) were available for follow-up. Preoperative hypertension resolved in 66% (44 of 67) of patients following gastric restrictive surgery. Superobese and morbidly obese patients had similar reductions in hypertension after surgery (69% versus 63%). Patients not receiving antihypertensive preoperatively had a greater reduction of hypertension than those medically treated preoperatively (78% versus 58%). The amount of weight loss significantly predicted the reduction of hypertension, whereas follow-up weight achieved did not. The amount of weight loss for patients with resolved and persistent hypertension were 89.3% [+ or -] 5.6 lbs ( mean [+ or -] standard error of the mean [SEM]) and 66.0 [+ or -] 8.3 lbs, respectively (p < 0.02). For patients with resolved hypertension, follow-up weights for the morbidly obese and superobese were 162.0 [+ or -] 10.8 lbs (133% [+ or -] 4% ideal body weight [IBW]) and 220.4 [+ or -] 9.5 lbs (170% [+ or -] 7% IBW). Gastric restrictive surgery is effective therapy for hypertension in morbidly obese patients. Patients need not achieve weights approaching IBW to enjoy the benefits of gastric restrictive surgery on hypertension.

Severe obesity is associated with abnormalities of cardiac structure and function. These include an increased cardiac workload and ventricular hypertrophy. Hypertension in combination with severe obesity seriously burdens the heart because the increased preload and afterload compound cardiac work. Weight reduction induced by gastric operations for severe obesity is associated with resolution of hypertension, reduction in ventricular wall thickness and cardiac chamber size, as well as improved systolic function. Additional data are needed to predict when in the course of development of obese cardiomyopathy the changes in contractile function become irreversible. Additionally, the impact of coronary artery disease on the progression of obese cardiomyopathy and the effects of surgical weight reduction on cardiac structure and function need to be further clarified. Studies of the association between obesity, its treatment, and modification of cardiovascular risk are a major focus of preventive cardiology today. Am J Clin Nutr 1992;55:586S-90S.

Indexes of left ventricular (LV) diastolic filling were measured by pulse Doppler echocardiography in 16 asymptomatic morbidly obese patients presenting for bariatric surgery and were compared with an age- and sex-matched lean control population. No patient had concomitant disorders known to affect diastolic function. All patients had normal systolic function. LV wall thickness and internal dimension were measured in order to calculate LV mass. Fifty percent of morbidly obese patients had LV diastolic filling abnormalities as assessed by the presence of [equal to or greater than] 2 abnormal variables of mitral inflow velocity. The ratio of peak early to peak late (atrial) filling velocity was significantly decreased in obese compared with control patients (1.16 [+ or -] 0.26 vs 1.66 [+ or -] 0.30, p [is not greater than] 0.00 1). The peak velocity of early LV diastolic filling was significantly reduced in obese patients (75 [+ or -] 15 vs 98 [+ or -] 19 cm/s, p [is not greater than] 0.001). The atrial contribution to stroke velocity as assessed by the time-velocity integral of late compared with total LV diastolic filling was significantly increased in obese patients (36 [+ or -] 7 vs 27 [+ or -] 4%, p [is not greater than] 0.001). Obese patients had significantly increased LV mass (214 [+ or -] 45 vs 138 [+ or -] 37 g, p [is not greater than] 0.001), even when corrected for bUy surface area (95 [+ or -] 16 vs 76 [+ or -] 16 g/m[sup. 2], p [is not greater than] 0.002). However, increased LV mass did not correlate with indexes of abnormal diastolic filling in obese patients. These data suggest that abnormalities of diastolic function occur frequently in asymptomatic morbidly obese patients and may represent a subclinical form of cardiomyopathy in the obese patient. (Am J Cardiol 1991;68:377-381), Extreme obesity is linked to cardiomyopathy (disease of heart muscle tissue), and many morbidly obese patients die of congestive heart failure. Whether the condition is linked to other conditions such as diabetes or atherosclerosis, which commonly occur in the obese, or whether it is independent of these is unclear as heart function in the obese has been infrequently studied. Echocardiography (ultrasound imaging) was used to study heart function in 16 morbidly obese patients (13 female) who had no known complicating diseases and results were compared with those from 21 healthy control subjects. Velocity of filling of the left ventricle (the main pumping chamber of the heart) during diastole (resting phase of the heartbeat) and the proportion of filling occurring during diastole were significantly different in half of the obese patients. These changes could not be attributed to other conditions that are known to affect diastolic filling and were not associated with high blood pressure. The study suggests that obese patients may benefit from screening with echocardiography to identify those possibly at risk for cardiomyopathy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Hypoalbuminemia (low blood levels of albumin, a protein to which many substances in blood are bound) is thought to be associated with a poor prognosis for patients who are seriously ill. Several important roles have been postulated for this protein, including maintenance of proper water balance and binding to toxic agents to remove them from the circulation. For these reasons, administration of albumin (albumin replacement therapy) to seriously ill patients has been advocated. This treatment, however, is costly, and its effects have not been proven in a randomized, prospective study. To investigate this issue, 40 hypoalbuminemic, critically ill patients who had been referred for nutritional assessment and total parenteral nutrition (nutrition delivered directly into a large vein, bypassing the digestive system) were randomly assigned to either a treatment (18 patients) or a nontreatment group (22 patients). Those in the treatment group received albumin, in addition to their total nutritional support, until their blood levels had reached 25 grams per liter. They were then maintained at that level. Data were obtained regarding mortality, the rate of major complications, length of hospital stay, intensive care (ICU) stay, length of time patients were dependent on a ventilator (breathing machine), and their tolerance for enteral feeding (food delivered into the digestive tract). In addition, an APACHE II (acute physiology and chronic health evaluation) score was recorded for each patient before and after treatment, and nutritional status was observed. Results showed that blood albumin levels reached 25 grams per liter sooner for the treatment group than the nontreatment group (four days vs nine days, respectively). However, no differences were found in mortality or major complication rates, or in any other variables measured. The cost of albumin was approximately $1,000 per patient. Albumin levels in the nontreatment group in this study increased with time, while those in the treatment group declined, indicating that improved health results in higher levels, and that albumin supplementation has, at best, a transitory effect. In general, it appears that albumin supplementation in critically ill patients is not warranted. (Consumer Summary produced by Reliance Medical Information, Inc.)

The drug warfarin, or coumadin, is used to prevent thrombosis, or blood clot formation, but it can cause hemorrhage. Studies show that the use of low doses of warfarin reduce the risk of hemorrhage without affecting the antithrombotic action of warfarin. Low-dose warfarin was shown to be effective in reducing the incidence of thrombosis in veins after surgery and after the insertion of a catheter into a vein to deliver nutrient-containing fluids and medications to patients. The usefulness of low doses of this anticoagulant for preventing thrombosis was studied in patients with a central venous catheter, which was used to deliver chemotherapeutic agents. Some patients received a small dose of warfarin (one milligram) three days before catheter insertion and for the next 90 days. Another group of patients with central venous catheters did not receive warfarin. X-rays were performed on the vein with the catheter at the onset of thrombosis symptoms or at the end of 90 days. Of 42 patients receiving warfarin, four developed thrombosis with symptoms. Of 40 patients not receiving the anticoagulant, 15 patients developed thrombosis, and 10 showed symptoms of blood clotting disorders. The results demonstrate that very low doses of warfarin can protect against thrombosis without causing hemorrhage. (Consumer Summary produced by Reliance Medical Information, Inc.)

Iron deficiency is a well-known and common nutritional complication of metabolic surgery. In addition to the known adverse effects of metabolic surgery on iron absorption, recent evidence suggests that the chronic low-grade systemic inflammation which commonly accompanies severe obesity alters iron availability and absorption, rendering patients with severe obesity at increased risk for iron deficiency and explains the high prevalence of iron deficiency among candidates for metabolic surgery. Awareness of the physiology of the inflammatory response, its effects on iron homeostasis, and its complicating effects on the diagnosis and management iron deficiency should be a priority for those providing nutritional care for metabolic surgery patients. [ABSTRACT FROM AUTHOR]

Background:Adipokines mediate many metabolic effects of adipose tissue. While regional body composition is associated with metabolic risk, it is unclear if metabolic risk associations differ for adipokine expression in visceral and subcutaneous tissue and adipokine concentrations in the circulation.Methods:We obtained visceral and subcutaneous fat samples, and pre-surgical serum samples from Geisinger Obesity Registry patients undergoing bariatric surgery. We used real-time PCR to quantify mRNA expression of adipokines (adiponectin, leptin, leptin/adiponectin ratio) in fat samples, and targeted assays (ELISA) to measure serum adipokines. Using multivariable linear regression, we evaluated the individual and combined associations of visceral, subcutaneous and serum adipokines (per-1-SD and tertiles) with a metabolic syndrome (MetS) severity Z-score.Results:181 participants (mean age 45 years, mean BMI 47 kg/m2, 85% female) with available fat and serum samples were included. Visceral, subcutaneous and serum adipokines were all weakly correlated (all ρ<0.15). Each 1-SD higher visceral adipokine expression and serum adipokine concentrations were significantly associated with MetS z-score, whereas no associations with MetS z-score were seen for subcutaneous adipokine expression (Table). Individuals in the top tertile of leptin/adiponectin ratio in serum only (ß=0.29, 95%CI: 0.01, 0.57) or in visceral fat only (ß=0.37, 95%CI: 0.08, 0.66) had higher metabolic risk than those in the top tertile in neither visceral fat nor serum (Figure). However, those in the top leptin/adiponectin tertile in both in visceral fat and serum had the greatest metabolic risk (ß=0.78, 95%CI: 0.46, 1.11).Conclusion:Visceral, but not subcutaneous, adipokine expression provides complementary information to serum adipokines on metabolic risk. This indicates significant differences in the physiologic impact of regional adipose tissue and highlights adipokines as a potential target for modifying cardiometabolic risk.

IMPORTANCE: Weight loss after bariatric surgery varies, yet preoperative clinical factors associated with long-term suboptimal outcomes are not well understood. OBJECTIVE: To evaluate the association between preoperative clinical factors and long-term weight loss after Roux-en-Y gastric bypass (RYGB). DESIGN, SETTING, AND PARTICIPANTS: From June 2001 to September 2007, this retrospective cohort study followed up RYGB patients before surgery to 7 to 12 years after surgery. The setting was a large rural integrated health system. Of 1033 eligible RYGB patients who consented to participate in longitudinal research and completed surgery before October 2007, a total of 726 (70.3%) had a weight entered in the electronic medical record 7 or more years after surgery and were included in the analyses after exclusions for pregnancy and mortality. Date of the long-term weight measurement was recorded between August 2010 and January 2016. MAIN OUTCOMES AND MEASURES: The primary outcome was percentage weight loss (%WL) at 7 to 12 years after surgery. Preoperative clinical factors (>200) extracted from the electronic medical record included medications, comorbidities, laboratory test results, and demographics, among others. RESULTS: Among the 726 study participants, 83.1% (n = 603) were female and 97.4% (n = 707) were of white race, with a mean (SD) preoperative body mass index (calculated as weight in kilograms divided by height in meters squared) of 47.5 (7.4). From the time of surgery to long-term follow-up (median, 9.3 postoperative years), the mean (SD) %WL was 22.5% (13.1%). Preoperative insulin use, history of smoking, and use of 12 or more medications before surgery were associated with greater long-term postoperative %WL (6.8%, 2.8%, and 3.1%, respectively). Preoperative hyperlipidemia, older age, and higher body mass index were associated with poorer long-term postoperative %WL (−2.8%, −8.8%, and −4.1%, respectively). CONCLUSIONS AND RELEVANCE: Few preoperative clinical factors associated with long-term weight loss after RYGB were identified. Preoperative insulin use was strongly associated with better long-term %WL, while preoperative hyperlipidemia, higher body mass index, and older age were associated with poorer %WL. Our findings provide additional insight into preoperative identification of RYGB patients at higher risk for long-term suboptimal outcomes.

Introduction:There is varied metabolic dysfunction among persons with obesity. We assessed differences in visceral adipose tissue transcriptome between persons with metabolically healthy and metabolically unhealthy obesity.Methods:We studied 40 patients with obesity (mean age 46; median body mass index 46 kg/m2) undergoing bariatric surgery at Geisinger Medical Center. Three obesity groups were defined. Two (metabolically unhealthy) had metabolic syndrome (MetS) with diabetes (DM) (MUOD; n=16) or without DM (MUO; n=8). The third (metabolically healthy) had no MetS or DM (MHO, n=16). Omental adipose tissue obtained at bariatric surgery was snap frozen. Total RNA was extracted and RNA sequencing performed using an Illumina platform. Differential gene expression between the 3 groups was analyzed using DESeq2 software and pathway enrichment analysis performed using Gene Ontology.Results:Using an adjusted P-value <0.05, 134 genes were upregulated and 114 genes downregulated in patients with MUOD versus MHO. Genes with the highest amplitude of transcriptional differences included lipopolysaccharide binding protein with log2 fold change (l2fc) of 2.2 and Padj= 1.6 10-7, osteopontin (l2fc= 1.9, Padj=1.6 10-7), chitinase 3 L1 (l2fc= 2.4 Padj= 1.7 10-4), carbonic anhydrase 3 (l2fc= -2.6 Padj= 4.8 10-8) and perilipin 5 (l2fc= -1.2 Padj= 0.003). GO upregulated pathways were enriched for pro-inflammatory pathways including leukocyte migration, responses to lipopolysaccharide and interleukin-1, and T cell activation (Padj= 1.7 10-13, 9.89 10-11, 4.9 10-09, 1.1 10-08respectively). Downregulated pathways were enriched in organic acid catabolic process, fatty acid oxidation and oxidative phosphorylation (Padj= 7.7 10-20, 8.6 10-20, 1.5 10-09respectively). An inflammatory signature was also present in MUO compared to MHO, whereas oxidative processes were not downregulated in those with MUO relative to MHO.Conclusion:In patients with class III obesity, we found a heterogeneous visceral adipose tissue transcriptome. A pro-inflammatory signature in visceral fat was found across the metabolic syndrome spectrum. A metabolic signature with decreased oxidative phosphorylation was linked to metabolic syndrome with concomitant diabetes.

Severe obesity is a well-known risk factor for atherosclerosis and cardiovascular disease. Obesity is also a defining characteristic of the metabolic syndrome, a group of conditions associated with metabolic dysfunction and cardiovascular risk. The cardiovascular abnormalities that occur as a consequence of extreme obesity and its associated conditions contribute to an increase in all-cause mortality and morbidity as will as reduced life expectancy. This article will summarize the available information regarding the pathophysiology of cardiovascular disease in obesity, the impact of obesity on cardiac structure and function, and the major benefits afforded by surgical weight loss. [ABSTRACT FROM AUTHOR]

About 60% of patients with type 2 diabetes achieve remission after Roux-en-Y gastric bypass (RYGB) surgery. No accurate method is available to preoperatively predict the probability of remission. Our goal was to develop a way to predict probability of diabetes remission after RYGB surgery on the basis of preoperative clinical criteria.

HYPOTHESIS Preoperative weight loss reduces the frequency of surgical complications in patients undergoing bariatric surgery. DESIGN Review of records of patients undergoing open or laparoscopic gastric bypass. SETTING A comprehensive, multidisciplinary obesity treatment center at a tertiary referral center that serves central Pennsylvania. PATIENTS A total of 881 patients undergoing open or laparoscopic gastric bypass from May 31, 2002, through February 24, 2006. INTERVENTION All preoperative patients completed a 6-month multidisciplinary program that encouraged a 10% preoperative weight loss. MAIN OUTCOME MEASURES Loss of excess body weight (EBW) and total and major complication rates. RESULTS Of the 881 patients, 592 (67.2%) lost 5% or more EBW and 423 (48.0%) lost more than 10% EBW. Patients referred for open gastric bypass (n = 466) were generally older (P &lt; .001), had a higher body mass index (P &lt; .001), and were more often men (P &lt; .001) than those undergoing laparoscopic gastric bypass (n = 415). Total and major complication rates were higher in patients undergoing open gastric bypass (P &lt; .001 and P = .03, respectively). Univariate analysis revealed that increasing preoperative weight loss is associated with reduced complication frequencies for the entire group for total complications (P =.004) and most likely for major complications (P = .06). Controlling for age, sex, baseline body mass index, and type of surgery in a multiple logistic regression model, increased preoperative weight loss was a predictor of reduced complications for any (P =.004) and major (P = .03) complications. CONCLUSION Preoperative weight loss is associated with fewer complications after gastric bypass surgery.Arch Surg. 2009;144(12):1150-1155--

Taste-signaling proteins, which are expressed in the oral cavity and the gastrointestinal tract, may be involved in regulating metabolism and immunity via oral-gut-brain circuit. This study aimed to determine if these genes are expressed and altered in the jejunum of patients with extreme obesity after bariatric surgery. Reverse transcription polymerase chain reaction revealed that phospholipase C beta 2 and transient receptor potential channel M5 expressions were downregulated whereas Gustducins expression level remained unchained in the jejunum of patients with a body mass index >50. Our data suggest that taste-signaling dysregulation might contribute to obesity.

OBJECTIVE To determine whether 2 single nucleotide polymorphisms (SNPs) in the obesity genes the fat mass and obesity associated gene (FTO) and the insulin induced gene 2 (INSIG2) are associated with class III, or morbid, obesity in patients undergoing bariatric weight loss operations. DESIGN Retrospective analysis of genotype and clinical data. SETTING Large rural tertiary care health system. PATIENTS A total of 707 adult patients with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of at least 40 undergoing open or laparoscopic Roux-en-Y gastric bypass operations for morbid obesity or its comorbid medical problems at Geisinger Medical Center, Danville, Pennsylvania. RESULTS The mean BMI in the predominantly white female cohort was 51.2. Approximately 21% of patients were homozygous for the FTO obesity SNP variant, 13% were homozygous for the INSIG2 obesity SNP variant, and 3.4% were homozygous for both. Mean BMIs in the groups homozygous for each of these genes were not significantly different from nonhomozygotes. However, FTO/INSIG2 double homozygotes and homozygote/heterozygote pairs had significantly higher BMIs than the other groups. CONCLUSION Increased BMI in morbid obesity is associated with a combination of FTO and INSIG2 SNPs.Arch Surg. 2008;143(3):235-240--

HYPOTHESIS Modest, preoperative weight loss will improve perioperative outcomes among high-risk, morbidly obese patients undergoing Roux-en-Y gastric bypass. DESIGN A prospective, longitudinal assessment of characteristics and outcomes of gastric bypass patients. SETTING All patients undergoing open or laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity or its comorbid medical problems at Geisinger Medical Center in Danville, Pennsylvania, during a 3-year period from May 31, 2002, to February 24, 2006, were included in this analysis. Patients were required to participate in a standardized multidisciplinary preoperative program that encompasses medical, psychological, nutritional, and surgical interventions and education. In addition, patients were encouraged to achieve a 10% loss of excess body weight prior to surgical intervention. RESULTS Of the 884 subjects, 425 (48%) lost more than 10% of their excess body weight prior to the operation. After surgery (mean follow-up, 12 months), this group was more likely to achieve 70% loss of excess body weight (P &lt; .001). Those who lost more than 5% of excess body weight prior to surgery were statistically less likely to have a length of stay of greater than 4 days (P = .03). CONCLUSIONS This study shows that high-risk morbidly obese candidates for bariatric surgery who are able to achieve a loss of 5% to 10% excess body weight prior to surgery have a higher probability of a shorter length of hospital stay and more rapid postoperative weight loss.Arch Surg. 2007;142(10):994-998--

Background: Laparoscopic bariatric surgery has experienced a rapid expansion of interest over the past 5 years, with a 470% increase. This rapid expansion has markedly increased overall cost, reducing surgical access. Many surgeons believe that the traditional open approach is a cheaper, safer, equally effective alternative. Methods: 16 highly experienced "open" bariatric surgeons with a combined total of 25,759 cases representing >200 surgeon years of experience, pooled their open Roux-en-Y gastric bypass (ORYGBP) data, and compared their results to the leading laparoscopic (LRYGBP) papers in the literature. Results: In the overall series, the incisional hernia rate was 6.4% using the standard midline incision. Utilizing the left subcostal incision (LSI), it was only 0.3%. Return to surgery in <30 days was 0.7%, deaths 0.25%, and leaks 0.4%. Average length of stay was 3.4 days, and return to usual activity 21 days. Small bowel obstruction was significantly higher with the LRYGBP. Surgical equipment costs averaged ∼$3,000 less for "open" cases. LRYGBP had an added expense for longer operative time. This more than made up for the shorter length of stay with the laparoscopic approach. Conclusions: The higher cost, higher leak rate, higher rate of small bowel obstruction, and similar long-term weight loss results make the "open" RYGBP our preferred operation. If the incision is taken out of the equation (i.e. use of the LSI), the significant advantages of the open technique become even more obvious.

Patients with a recent myocardial infarction, congestive heart failure, severe angina, or uncorrected multivessel coronary artery disease are at increased risk of cardiac complications after major noncardiac surgery. Although invasive hemodynamic monitoring and preoperative optimization of cardiac status may lead to some reduction in the rate of perioperative cardiac events, the mortality from such events remains high. We report our experience with the use of perioperative intra-aortic balloon counterpulsation in eight patients with unstable coronary syndromes or severe coronary artery disease who underwent urgent noncardiac surgery. There were no perioperative cardiac events while the intra-aortic balloon pump (IABP) was in place. There were two postoperative cardiac events (nonfatal myocardial infarction, congestive heart failure) in the first postoperative week after the IABP was removed. One patient required emergent femoral thrombectomy as a result of intra-aortic balloon counterpulsation and subsequently died of a gastrointestinal hemorrhage. Intra-aortic balloon counterpulsation should be considered as an adjunct to maintain hemodynamic stability for the high-risk cardiac patient about to undergo urgent or emergent noncardiac surgery.

OBJECTIVE: To examine the safety and efficacy of multiple doses of PGG-glucan (poly- [ 1-6]-B-Dglucopyranosyl-[ 1-3]-B-D-glucopyranose) in high-risk patients undergoing major thoracic or abdominal surgery. DESIGN: An interventional, multicenter, double-blind, randomized, placebo-controlled study. SETTING: Four university-affiliated medical centers. PATIENTS: Sixty-seven high-risk patients undergoing major thoracic or abdominal surgery. INTERVENTION: Patients were randomized in a 1:1:1:1 ratio to receive saline placebo or PGG-glucan at a dose of 0.1 mg/kg, 0.5 mg/kg, and 1.0 mg/kg or 2.0 mg/kg. One dose was administered before surgery and three doses were administered after surgery. MAIN OUTCOME MEASURES: To examine the safety and efficacy of PGG-glucan infusion and to identify potentially important factors for a planned phase III study. RESULTS: A dose-response trend with regard to infection incidence among patients who received PGG-glucan was observed. Serious infections occurred in four patients who received placebo and in three patients who received PGG-glucan at a dose of 0.1 mg/kg. However, only one patient who received PGG-glucan at a high dose had a serious infection. The incidence and severity of adverse events was comparable in all groups. CONCLUSIONS: PGG-glucan was generally safe and well tolerated, may decrease postoperative infection rates, and warrants further investigation in a planned phase III trial.(Arch Surg. 1994;129:1204-1210)

OBJECTIVE: To compare the respiratory rate to tidal volume ratio with the oxygen cost of breathing to see which could more accurately predict the outcome of ventilator weaning for surgical patients. DESIGN: Prospective comparison of two modalities used to predict the likelihood of successful ventilator weaning. PATIENTS: Twenty-eight consecutive patiens with chronic respiratory insufficiency requiring long-term mechanical ventilation in the surgical intensive care unit at New England Deaconess Hospital, Boston, Mass, were studied. MAIN OUTCOME MEASURES: The oxygen cost of breathing and the respiratory rate to tidal volume ratio were measured during spontaneous breathing. Patients extubated within 2 weeks of being studied were designated as extubated while patients not extubated within this period or requiring reintubation were recorded as not extubated. RESULTS: The oxygen cost of breathing predicted succesful extubation in all five patients who were extubated, and failure in 20 of 23 patients who could not be extubated (sensitivity, 100%; specificity, 87%). In contrast, the respiratory rate to tidal volume ratio predicted extubation for only two of five patients who were extubated and predicted failure in only 12 of 23 patients who could not be extubated (sensitivity, 40%; specificity, 52%). CONCLUSION: For this group of patients requiring prolonged ventilation, the oxygen cost of breathing proved to be a more reliable predictor of both successful extubation and failure.(Arch Surg. 1994;129:269-274)

Liver replacement has become a viable treatment option for select patients with severe acute or chronic hepatic failure. Evaluation of potential candidates is discussed along with current techniques for donor organ retrieval, recipient implantation, and postoperative immunosuppression.

The health risks to the morbidly obese are such that first conservative (dietary) and then aggressive (surgical) treatment must be undertaken to restore and maintain health. This paper discusses state-of-the-art aggressive treatment in which patients have an average loss of 55 of their excess weight, mortality no greater than that of normal weight population and experience both physical and psychological benefits. Patients must be carefully selected and monitored before and after surgery.

As the practical uses of parenteral feeding have increased, so too have the possibilities for complications. By following certain guidelines involving catheter placement, placement technique, and patient positioning, one can minimize the chance for complications, thus allowing for more effective utilization of parenteral nutritional support.

Pulmonary complications following orthotopic liver transplantation (OLT) were prospectively evaluated in 18 indivduals transplanted at the New England Deaconess Hosptial. Of sixteen patients who survived the immediate postoperation period, 12 (75) sustained a pulmonary complication. Of these comlications, 64 were noninfectious—whereas 22 were infectious, and 14 probably infectous. Six of eight documented infections were caused by viruses of the herpes group. In four cases of viral penumonitis other pulmonary pathogens were isolated (fungi-3, protozoan-1, bacteria-1). Unlike noninfectous complications, pumonary infections were associated with a fatal outcome in five of six patients who died after OLT. Pulmonary complications are frequent and serious occurrences after OLT, and contribute to both the morbidity and mortality of this procedure. Compared with pulmonary complications seen after transplantation of other organs, OLT was associated with a higher proportion of noninfectious complications but a similar spectrum of pulmonary infections.

• We present our experience from 1982 to the present in treating 33 patients with recurrent cancers (colorectal, 22; gynecologic, six; breast, two; melanoma, two; and lung, one) secondarily involving the genitourinary tract. All patients had severe symptoms that required palliation. Endoscopically placed stents relieved ureteral obstruction in 18 (75%) of 24 patients with widespread metastatic disease. Two patients required percutaneous nephrostomy tubes, and five required open operations. Good to excellent palliation was achieved in 23 of 24 patients. Mean survival in the group with diffuse metastases was 13 months (range, six to 29 months). Nine patients with localized recurrences underwent surgical procedures. For localized pelvic recurrences, total exenteration (with or without intraoperative radiotherapy) provided excellent palliation with low morbidity. At the time of this report, five of six such patients had no evidence of disease, and one had a small asymptomatic pelvic recurrence, with a mean follow-up of 13 months (range, five to 19 months).(Arch Surg 1987;122:493-498)

• The management of regional tumor recurrence in the pelvis traditionally has been a difficult problem for surgeons and oncologists. The only meaningful therapy for these patients is a potentially curative re-resection. The records and operative reports of 29 patients with regional pelvic tumor recurrence treated between 1981 and 1986 were reviewed. The operative procedures performed included three bowel resections, six abdominoperineal resections, eight pelvic exenterations, eight resections of tumor recurrence, and four conservative procedures. There was one operative death in this group. Significant morbidity was noted in the group but was clustered in a small number of patients operated on early in the series. The median follow-up in this series was 13 months (range, two to 51 months). Nineteen (65%) of the patients are surviving at a median follow-up of ten months (range, two to 51 months). The median survival (following resection) in the ten patients (35%) who died was 18 months. In 15 (52%) of the patients, a complete resection was performed. In this group, the survival is 80% with a median follow-up of 11 months. Seven (37%) are surviving with no evidence of disease. Palliation of symptoms occurred in 23 (79%) of the 29 patients. Radical resection of tumor recurrence in the pelvis can be performed with acceptable mortality and complication rates. This therapy should be considered for further clinical trials combining surgical and adjuvant therapy in patients with regional pelvic tumor recurrence.(Arch Surg 1987;122:457-460)

Liver resection is an increasingly common procedure. Despite the wide variety of indications, the preoperative and postoperative care are similar. Recent work has brought to light the significant alterations in fluid and electrolytes, hemostasis, metabolism, and pulmonary function that may occur, and a thorough understanding of these changes is required to minimize the morbidity and mortality rates. Postoperative hepatic failure is a devastating complication, and careful patient selection is required to avoid this. Better methods of evaluating functional hepatic reserve are needed.

Pulmonary hypertension has recently been indentified as a risk factor for adverse events and mortality after gastric bypass surgery. This condition can be present in association with obstructive sleep apnea, obesity hypoventilation, obese cardiomyopathy, and chronic thromboembolism. Since this is a modifiable risk factor and may be overlooked in the evaluation of bariatric candidates, bariatric surgeons and team members should become more familiar with guidelines for current diagnosis, prognosis assessment, and treatment. Improved diagnosis and severity assessment will enhance the patient selection and optimization process in bariatric surgery. [ABSTRACT FROM AUTHOR]

Catheter sepsis rates related to total parenteral nutrition are variable and depend on several patient-specific factors. These factors include the presence of immunosuppression or critical illness, the use of multiple intravascular catheters, and bacterial translocation. Catheter-related sepsis may present in the patient as fever, chills, change in mental status, hypotension, and leukocytosis. In patients with suspected catheter-related infection whose peripheral blood cultures do not grow the same organism as a blood culture drawn from the catheter, a guidewire exchange of the catheter has been shown to be effective. This technique should be considered a surgical procedure. Complications that are associated with guidewire exchange of central venous catheters are catheter malposition, embolism of air or septic thrombi, and cardiac arrhythmias.

There is no uniform data regarding prophylactic cholecystectomy in patients undergoing renal transplantation with gallbladder disease. Data analyses suggest that posttransplant patients on cyclosporine have a higher incidence of gallbladder calcifications compared with nonimmunosuppressed patients. Laparoscopic cholecystectomy is a relatively safe procedure in modern-day surgery. Taking these facts into consideration, we attempted to compare risks and complications associated with gallbladder disease and eventual cholecystectomy in pretransplant versuspost-transplant patients. Between June 1999 and December 2005, 210 renal transplants were performed at our institution. One hundred four patients who had transplants before April 2003 were not screened for gallbladder disease and nine of these patients developed gallbladder disease. These patients form our control group. One hundred six patients who had transplants after April 2003 had pretransplant screening for gallbladder disease and 11 patients were identified with gallbladder disease. These patients form our study group. Nine patients who developed gallbladder disease after renal transplant underwent laparoscopic cholecystectomy with three resulting morbidities (33%), two graft losses (22%), and one mortality (11%). There was one mortality (11%) in this group. One patient in the study group died of acute gallstone pancreatitis. Of the 11 patients who were found to have gallbladder disease on screening, nine patients underwent laparoscopic cholecystectomy with one morbidity and no mortality or graft loss. Given the relative rarity of the critical events in this study (morbidity, mortality, and graft loss), the definitive statistical value of prescreening for gallbladder disease cannot be established. However, our results are suggestive of clinical value and thus we tentatively recommend ultrasound screening for gallbladder disease for all pretransplant patients and laparoscopic cholecystectomy for those identified to have gallbladder disease.