Why do not we talk about MIS fellowship? A short review of the short literature.

BACKGROUND: The minimally invasive surgery (MIS) fellowship has existed for three decades and has steadily grown in both number of positions available and variety of techniques practiced. Despite continued popularity, growth, and wide breadth of surgical techniques of the MIS fellowship, publication rates in medical journals regarding these fellowships have not been as robust as one may expect. Our goal was to review the available literature on MIS fellowship. METHODS: We reviewed PubMed to search for articles pertinent for MIS fellowship. The initial search included "MIS fellowship" "minimally invasive surgery fellowship" and "laparoscopy fellowship." Articles pertaining to MIS fellowship were then reviewed by title and abstract for content. Articles were excluded from subsequent analysis if they focused on disciplines that were not direct extensions of general surgery (such as urology, gynecology, oncology). Using similar search techniques, we tabulated unfiltered publications rates specific to other major surgical fellowship disciplines. The metric articles per position was created by dividing the total number articles for each discipline by the annual fellowship positions RESULTS: An initial review of available literature produced 134 articles pertinent to MIS fellowship. Further analysis for direct relevance to MIS yielded only 58 published articles. MIS had the fewest number of publications and smallest APP, 0.7, of any of the major fellowship disciplines. CONCLUSIONS: There is a surprising dearth of material on MIS fellowship. While, MIS fellowship is a one-year experience, we have the opportunity to build on three decades of clinical experience to continue optimize the fellow experience and improve subspecialized surgical training and patient outcomes. This could be facilitated through broadened focus of inquiry and publication of findings.

What is MIS fellowship? Community and academic program experience.

INTRODUCTION: Minimally invasive surgery (MIS) fellowship is one of the most popular fellowship programs, but little is known about the individual fellow's clinical experience. Our goal was to determine the differences in case volume and case type in academic and community programs. METHODS: A retrospective review of advanced gastrointestinal, MIS, foregut, or bariatric fellowship cases logged into the Fellowship Council directory of fellowships during the 2020 and 2021 academic years included for analysis. The final cohort included 57,324 cases from all fellowship programs, that list data on the Fellowship Council website, including 58 academic programs and 62 community-based programs. All comparisons between groups were completed using Student's t-test. RESULTS: The mean number of cases logged during a fellowship year was 477.7 ± 149.9 with similar case numbers in academic and community programs, 462.5 ± 115.0 and 491.9 ± 176.2 respectively (p = 0.28). The mean data is illustrated in Fig. 1. The most common performed cases were in the following categories: bariatric surgery (149.8 ± 86.9 cases), endoscopy (111.1 ± 86.4 cases), hernia (68.0 ± 57.7 cases) and foregut (62.8 ± 37.3 cases). In these case-type categories, no significant differences in case volume were found between academic and community-based MIS fellowship programs. However, community-based programs had significantly more case experience compared to academic programs in all of the less commonly performed case-type categories: appendix 7.8 ± 12.8 vs 4.6 ± 5.1 cases (p = 0.08), colon 16.1 ± 20.7 vs 6.8 ± 11.7 cases (p = 0.003), hepato-pancreatic-biliary 46.9 ± 50.8 vs 32.5 ± 18.5 cases (p = 0.04), peritoneum 11.7 ± 16.0 vs 7.0 ± 7.6 cases (p = 0.04), and small bowel 11.9 ± 9.6 vs 8.8 ± 5.9 cases (p = 0.03). CONCLUSION: MIS fellowship has been a well-established fellowship program under the Fellowship Council guideline. In our study, we aimed to identify the categories of fellowship training and the perspective case volumes in academic vs community setting. We conclude that fellowship training experience is similar in case volumes of commonly performed cases when comparing academic and community programs. However, there is substantial variability in the operative experience among MIS fellowship programs. Further study is necessary to identify the quality of fellowship training experience.

Monitoring performance in laparoscopic gastric bypass surgery using risk-adjusted cumulative sum at 2 high-volume centers.

BACKGROUND: Traditional surgical outcomes are measured retrospectively and intermittently, limiting opportunities for early intervention. OBJECTIVES: The objective of this study was to use risk-adjusted cumulative sum (RA-CUSUM) to track perioperative surgical outcomes for laparoscopic gastric bypass. We hypothesized that RA-CUSUM could identify performance variations between surgeons. SETTING: Two mid-Atlantic quaternary care academic centers. METHODS: Patient-level data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) were abstracted for laparoscopic gastric bypasses performed by 3 surgeons at 2 high-volume centers from 2014 to 2021. Estimated probabilities of serious complications, reoperation, and readmission were derived from the MBSAQIP risk calculator. RA-CUSUM curves were generated to signal observed-to-expected odds ratios (ORs) of 1.5 (poor performance) and .5 (superior performance). Control limits were set based on a false positive rate of 5% (α = .05). RESULTS: We included 1192 patients: Surgeon A = 767, Surgeon B = 188, and Surgeon C = 237. Overall rates of serious complications, 30-day reoperations, and 30-day readmissions were 3.9%, 2.5%, and 5.2% respectively, with expected rates of 4.7%, 2.2%, and 5.8%. RA-CUSUM signaled lower-than-expected (OR < .5) rates of readmission and serious complication in Surgeon A, and higher-than-expected (OR > 1.5) readmission rate in Surgeon C. Surgeon A further demonstrated an early period of higher-than-expected (OR > 1.5) reoperation rate before April 2015, followed by superior performance thereafter (OR < .5). Surgeon B's performance generally reflected expected standards throughout the study period. CONCLUSIONS: RA-CUSUM adjusts for clinical risk factors and identifies performance outliers in real-time. This approach to analyzing surgical outcomes is applicable to quality improvement, root-cause analysis, and surgeon incentivization.

Insurance Coverage of Pediatric Bariatric Surgery: a Cross-Sectional Analysis of the USA.

PURPOSE: Pediatric bariatric surgery is increasingly recognized as a safe and effective option for the management of obesity and obesity-related conditions. However, insurance coverage is a key barrier to accessing these procedures. Criteria are variable and often not evidence-based. In an effort to characterize common patterns in insurance coverage, we report coverage criteria for adolescents relative to adults. MATERIALS AND METHODS: We surveyed medical policies of the 50 highest market share health insurance providers in the USA. Private insurer coverage criteria included age, Tanner staging, skeletal maturity, body mass index, procedures covered, medical weight management requirements, co-morbidities, and multidisciplinary team criteria. These were then compared to the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. RESULTS: Two thirds (n = 33, 66%) of companies provided inclusion criteria for adolescents. All policies covered RYGB (n = 33), most covered sleeve gastrectomy (n = 32, 97.0%). Obstructive sleep apnea (OSA) (n = 32, 97%), hypertension (HTN) (n = 27, 81.8%), and gastroesophageal reflux disease (GERD) (n = 11, 33.3%) were the three most commonly cited co-morbidities used as inclusion criteria. Tanner staging or skeletal maturity were most commonly used (n = 10, 30.3%). Similarly, twenty (60.6%) insurers required medical weight management programs. Multi-disciplinary teams were required by 81.8% of adolescent policies (n = 27) as described by the ASMBS. Seventeen (51.5%) policies defined providers for these teams, and 10 (30.3%) provided other defined criteria. CONCLUSION: Contrary to ASMBS guidelines, companies commonly require Tanner staging and/or skeletal maturity criteria as well as participation in medical weight management programs. Also, multi-disciplinary team are frequently required but not well defined.

Ten Year Trends in Minimally Invasive Surgery Fellowship.

BACKGROUND: Minimally Invasive Surgery (MIS) is one of the more recently established surgical fellowships, with many candidates applying due to a perception of inadequate exposure to advanced MIS during residency. The desire for advanced training should be reflected in increased competitiveness for fellowship positions. The aim of this study is to determine the desirability of MIS fellowships over time through review of national application data. METHODS: We reviewed the fellowship match statistics obtained from The Fellowship Council, the organizing body behind the MIS fellowship match. Data from January 1, 2008 - December 31, 2019 were included. We compared match rates to other specialties using the National Resident Matching Program, a nonprofit organization established for US residency and some fellowship programs. RESULTS: In the period of 2008 to 2019, the number of certified MIS fellowship programs increased from 124 to 141. While this program expansion was associated with a 19% increase in available positions, the number of applications increased 36%. As a result, the number of positions filled increased from 83% to 97%, but the match rate among US applicants fell from 82% to 71% during this interval. In comparison, the match rates for pediatric surgery, surgical oncology, vascular surgery, and surgical critical care fellowships remained largely unchanged, most recently 50%, 56%, 99%, and 100% respectively. CONCLUSION: Over the last decade, US residents have shown an increased interest in pursuing MIS fellowship positions. As a consequence, the match process for MIS fellowships is becoming increasingly competitive.

Panniculectomy at the time of bariatric surgery: a propensity score-matched analysis of outcomes in the MBSAQIP database.

BACKGROUND: Body contouring in the postbariatric surgery patient improves quality of life and daily function. OBJECTIVES: To determine the risk profile of panniculectomy when performed in select patients at the time of bariatric surgery. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating centers. METHODS: We examined the MBSAQIP database (2016-2017), in which data on 379,544 bariatric surgeries are reported. Concurrent panniculectomy procedures were identified by Current Procedural Technology (CPT) codes. Patient characteristics and in-hospital as well as 30-day complications were compared between the body contouring group and propensity score-matched bariatric surgery controls. RESULTS: One hundred twenty-four patients met inclusion criteria and were matched to 248 controls. An infra-umbilical panniculectomy was performed in the majority of patients (n = 94, 75.8%). Most patients received an open rather than laparoscopic bariatric surgery (n = 87, 70.2%). There were no statistically significant differences between 30-day mortality (1.9%), wound complications (11.5%), readmission (12.5%) and reoperation (5.8%) between the 2 groups (P > .05). Wound complications occurred in 11.5% of patients and were associated with prolonged hospital stay (odds ratio 4.65, 95% confidence interval 1.99-10.86, P < .001) and a body mass index (BMI) > 50 (odds ratio 3.19, 95% confidence interval 1.02-9.96, P = .046). CONCLUSION: In select patients, panniculectomy at the time of bariatric surgery was not associated with increased in-hospital or 30-day adverse outcomes compared with matched bariatric surgery controls. This procedure may be performed in select patients, with awareness that revision surgery may be needed once weight loss stabilizes.

Operative approach to intestinal malrotation encountered during laparoscopic gastric bypass.

Congenital anomalies of midgut rotation are uncommon with a 0.2-0.5% incidence. Intestinal malrotation (IM) presents a unique challenge in bariatric surgery during laparoscopic gastric bypass (LRYGB), and familiarity with alternatives allows for safe laparoscopic intervention. IM was encountered in 5 of 1183 (0.4%) patients undergoing surgery. Once IM was suspected, a standardized approach was applied: rightward shift of ports, confirmation of IM by the absence of the ligament of Treitz, identification of the duodenojejunal junction, lysis of Ladd's bands, mirror-image construction of the Roux limb and construction of the gastrojejunal anastomosis. Forty percent were male, age 33 ± 8 years, with body mass index 50 kg/m2 (37-75 kg/m2). IM was identified preoperatively in two patients (40%). All operations were completed laparoscopically. Despite the finding of IM, successful laparoscopic completion of gastric bypass can be anticipated if the surgeon has an understanding of the anatomic alterations and a strategy for intraoperative management.

Review of Insurance Coverage for Abdominal Contouring Procedures in the Postbariatric Population.

BACKGROUND: Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population. METHODS: The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage. RESULTS: Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415). CONCLUSIONS: For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.

A Cross-sectional Analysis of Insurance Coverage of Extremity Contouring After Massive Weight Loss.

INTRODUCTION: After bariatric surgery, patients often experience redundant skin in the upper arms and medial thighs as sequelae of massive weight loss. Insurance companies have unpredictable criteria to determine the medical necessity of brachioplasty and thighplasty, which are often ascribed as cosmetic procedures. We evaluated current insurance coverage and characterized policy criteria for extremity contouring in the postbariatric population. METHODS: We conducted a cross-sectional analysis of insurance policies for coverage of brachioplasty and thighplasty in January 2019. Insurance companies were selected based on their state enrolment data and market share. A web-based search and direct calls were conducted to identify policies. A comprehensive list of standard criteria was compiled based on the policies that offered coverage. RESULTS: Of the 56 insurance companies assessed, half did not provide coverage for either procedure (n = 28). No single criterion featured universally across brachioplasty and thighplasty policies. Functional impairment was the most commonly cited condition for preapproval of brachioplasty and/or thighplasty (94%). Conversely, minimum weight loss was the least frequent criterion within the insurance policies (6%). Only 5% of the insurance companies (n = 3) would consider coverage of liposuction-assisted lipectomy as a modality for brachioplasty or thighplasty. CONCLUSIONS: We propose a comprehensive list of reporting recommendations to help optimize authorization of extremity contouring in the postbariatric population. There is great intercompany variation in preapproval criteria for brachioplasty and thighplasty, illustrating an absence of established recommendations or guidelines. High-level evidence and investigations are needed to ascertain validity of the limited coverage criteria in current use.

Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies.

BACKGROUND: Bariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies. METHODS: We surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation. RESULTS: Sixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%). CONCLUSIONS: A majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.

A Review of National Insurance Coverage of Post-bariatric Upper Body Lift.

INTRODUCTION: Recent years have seen an increased utilisation of upper body lift following massive weight loss. Although it is typically considered cosmetic, the recurrent skin conditions and decline in quality of life may warrant medical necessity. We evaluated current insurance coverage and characterised policy criteria for upper body lift in the post-bariatric population. METHODS: We defined upper body lift as a combination of mastopexy and upper back excision (UBE) and conducted a cross-sectional analysis of US insurance policies. Insurance companies were selected based on their enrolment data and market share. A web-based search and telephone interviews were conducted to identify the policy. Criteria were abstracted from the publicly available policies that offered coverage. RESULTS: Of the 56 insurance companies assessed, 5% would consider coverage of both procedures. Although fewer companies held established policies for UBE than mastopexy in the post-bariatric population (79% vs 96%, p = 0.0081), there were significantly more policies that offered pre-approval for UBE than for mastopexy (30% vs 5%, p = 0.0017). Three medical necessity criteria were common to both procedures: evidence of functional impairment, secondary skin conditions, and medical photographs. CONCLUSION: Policy criteria for coverage of mastopexy or UBE differ greatly between companies. Further evaluation of medical necessity criteria for post-bariatric mastopexy and UBE with the establishment of a standardised guideline is needed. We propose a comprehensive list of reporting recommendations to help optimise authorisation of upper body lift in the post-bariatric population, and we urge plastic surgeons to challenge current definition of "cosmetic" by insurance companies. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Exponential decay modeling can define parameters of weight loss trajectory after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) produces durable and clinically significant weight loss. We aim to characterize the trajectory of weight loss, and demonstrate the predictive ability of three-month performance on final weight loss. METHODS: Retrospective analysis of 1097 consecutive LRYGB patients allowed for assessment of conformity of various weight loss trajectory models. Establishing exponential decay as the optimal fit, initial, three-month and final BMI values were used to determine empiric rate constants (λ3). Empirically derived weight loss curves and associated rate constants (λ) were generated. RESULTS: Exponential decay optimally characterizes post-LRYGB weight loss trajectory. Final weight loss can be characterized by λ3, as well as by the demographics black race (P = 0.008) and initial BMI (P < 0.001). Stratification by three-month weight loss allowed derivation of weight loss trajectory curves to predict weight at any point until and including plateau. CONCLUSIONS: Weight loss after LRYGB conforms well to exponential decay, and postoperative trajectory can thus be predicted early. This allows the clinician early identification and intervention upon patients at risk of poor performance.

Red cell distribution width is a novel biomarker that predicts excess body-mass index loss 1 year after laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: Bariatric surgery is the most effective method for producing sustained weight loss, improving obesity-associated comorbidities and reducing inflammation in the morbidly obese population. The red cell distribution width (RDW) is a novel marker of inflammation that is usually reported as part of a complete blood count. In this study, we tested our hypothesis that red cell distribution width might represent a novel biomarker predictive of excess body-mass index loss (EBMIL) following laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: Five hundred and forty-seven LRYGB patients included from a single institution were individually reviewed, noting both preoperative RDW and percent excess BMI loss at 6 months and 1 year post-LRYGB (%EBMIL180 and %EBMIL365, respectively). Bivariate and multivariate linear regression analysis was conducted between age, gender, initial body-mass index (BMI0) and RDW and each of the two endpoints, to assess the independence of RDW as a predictor of postoperative success. RESULTS: The median RDW was 13.9 (13.3-14.6) %, and median EBMIL180 and EBMIL365 were 55.4 (45.2-66.7) % and 71.3 (58.9-87.8) %, respectively. After controlling for age, gender and BMI0, RDW was associated with %EBMIL365 (B = -1.4 [-2.8 to -0.002] %, P = .05), but not %EBMIL180 (B = -0.6 [-1.6 to 0.5] %, P = .30. Upon Kruskal-Wallis analysis, patients with a preoperative RDW > 15.0 % had significantly lower %EBMIL than those in the <13.0 % (P < .001) and 13.0-15.0 % (P < .01) strata. CONCLUSIONS: RDW is predictive of EBMIL at 1 year following LRYGB. This represents a novel preoperative biomarker that may provide clinically useful prognostic information.

Inhibiting CARD11 translation during BCR activation by targeting the eIF4A RNA helicase.

Human diffuse large B-cell lymphomas (DLBCLs) often aberrantly express oncogenes that generally contain complex secondary structures in their 5' untranslated region (UTR). Oncogenes with complex 5'UTRs require enhanced eIF4A RNA helicase activity for translation. PDCD4 inhibits eIF4A, and PDCD4 knockout mice have a high penetrance for B-cell lymphomas. Here, we show that on B-cell receptor (BCR)-mediated p70s6K activation, PDCD4 is degraded, and eIF4A activity is greatly enhanced. We identified a subset of genes involved in BCR signaling, including CARD11, BCL10, and MALT1, that have complex 5'UTRs and encode proteins with short half-lives. Expression of these known oncogenic proteins is enhanced on BCR activation and is attenuated by the eIF4A inhibitor Silvestrol. Antigen-experienced immunoglobulin (Ig)G(+) splenic B cells, from which most DLBCLs are derived, have higher levels of eIF4A cap-binding activity and protein translation than IgM(+) B cells. Our results suggest that eIF4A-mediated enhancement of oncogene translation may be a critical component for lymphoma progression, and specific targeting of eIF4A may be an attractive therapeutic approach in the management of human B-cell lymphomas.

Internal hernia due to adjustable gastric band tubing: review of the literature and illustrative case video.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is a commonly performed bariatric procedure. Device-related morbidity is typically associated with the subcutaneous port or the band itself. Complications related to band tubing are unusual. Small bowel obstruction (SBO) after LAGB is a unique and serious complication; there is the potential of delayed diagnosis and the risk of closed-loop bowel obstruction. SBO secondary to internal hernia caused by band tubing is very rare, with only five cases reported in the literature. METHODS: In this article, we describe our experience and provide an illustrative video of a case of SBO related to band tubing. We also provide a detailed review of the few previously published case reports. RESULTS: Based on the common features of our case and other published case reports, we hypothesize some risk factors that might lead to this unique morbidity of adjustable gastric band tubing and provide potential solutions to prevent this problem. CONCLUSION: Tubing-related SBO is a serious complication with the risk of closed-loop bowel obstruction. Urgent operative exploration is required to avoid bowel strangulation. To prevent recurrence we advise functionally shortening the tubing by tucking it to the right upper quadrant above the liver and also provide some omental coverage between the bowel and band tubing if possible.

Platelet-dense granule deficiency causes postoperative hemorrhage in patients receiving enoxaparin: a novel observation with dramatic clinical implications.

BACKGROUND: Inherent hemorrhage risk has impeded the universal adoption of low-molecular-weight heparin (LMWH) for venous thromboembolic prophylaxis in surgical patients. Coagulation pathway parameters and platelet numbers routinely are evaluated preoperatively; scant attention has been directed toward evaluation of platelet function. We hypothesized that administration of LMWH may unmask latent platelet dysfunction and result in postoperative hemorrhage. METHODS: Postoperative hemorrhage occurred in 15 (3.5%) of 423 consecutive patients undergoing laparoscopic gastric bypass. All patients received LMWH (enoxaparin, 40 mg) preoperatively. Hematologic evaluation included measurement of von Willebrand's factor level and activity, factor VIII level, and electron microscopic enumeration of platelet-dense granules. RESULTS: All patients had normal preoperative platelet counts and coagulation profiles. Ten patients underwent hematologic evaluation: coagulation pathway parameters were normal in all; however, all patients had a markedly decreased number of platelet-dense granules. CONCLUSIONS: Platelet-dense granule deficiency may cause postoperative hemorrhage in patients receiving LMWH.

New-onset orthostatic intolerance following bariatric surgery.

BACKGROUND: As bariatric surgery has become an increasingly popular treatment for obesity, we have seen an increasing number of patients present after bariatric surgery with new-onset syncope, near-syncope, and lightheadedness. METHODS: We retrospectively reviewed patients who had had bariatric surgery referred to our institution for evaluation of orthostatic intolerance. We reviewed history, physical examination, type of bariatric surgery procedure, and tilt table test results in these patients. There were 14 women and one man with mean age 42 +/- 6 years, preoperative body mass index was 49.3 +/- 6.0 kg/m(2), and mean postoperative weight loss was 55.9 kg. Mean onset of symptoms was 5.2 +/- 3.9 months after surgery. Presenting symptoms were lightheadedness in 15 (100%), near-syncope in 11 (73%), and syncope in nine (60%). All but one patient had a positive tilt table test with eight (53%) having a neurocardiogenic response, three (20%) having a dysautonomic response, and (20%) having a postural tachycardia response. The likely mechanism of orthostatic intolerance is autonomic insufficiency in combination with reverse course of obesity-related hypertension. The majority of the patients (12 out of 15) responded to standard therapy for autonomic insufficiency. CONCLUSION: Some patients may develop significant orthostatic intolerance due to autonomic insufficiency following bariatric surgery, and awareness of the potential association between bariatric surgery and new orthostatic intolerance is important for providing timely care.

Shrinking cardiovascular risk through bariatric surgery: application of Framingham risk score in gastric bypass.

BACKGROUND: The Framingham risk score estimates 10-year coronary heart disease (CHD) risk based on gender, age, smoking status, blood pressure, TC, HDL-C, and diabetes mellitus status. It was designed to be independent of weight, and as such it is the ideal model to estimate the impact of bariatric surgery on the change in this risk. Our study evaluates the effect of gastric bypass on the prevalence of CHD risk factors and then utilizes the Framingham risk score to estimate the postoperative reduction in 10-year CHD risk. METHODS: Retrospectively, 101 consecutive patients who underwent laparoscopic Roux-en-Y gastric bypass were reviewed. The 10-year CHD risk was calculated using historic, biometric, and laboratory data. RESULTS: The mean body mass index decreased from 46.9 +/- 5.8 kg/m(2) preoperatively to 28.7 +/- 4.0 kg/m(2) one year postoperatively. All physical and biochemical markers of cardiac risk improved significantly. Systolic blood pressure fell from 143 +/- 20 mmHg to 123 +/- 18 mmHg (14%) and diastolic blood pressure fell from 81 +/- 10 mmHg to 71 +/- 11 mmHg (12%). Total cholesterol declined from 202 to 165 (18%); LDL-C declined from 118 to 97 (18%); and HDL-C increased from 45 to 51 (14%). The overall 10-year CHD risk decreased from 6.7 +/- 5.5% to 3.2 +/- 3.1%, representing an absolute risk reduction of 3.3% or relative risk reduction of 52%. This risk reduction was similar in subgroups based on preoperative CHD risk or on initial BMI. CONCLUSIONS: Using the Framingham risk score we show that gastric bypass surgery reduces 10-year coronary risk by more than half. Additionally, to the increasing evidence of the salutary effect gastric bypass surgery has on CHD risk, we contribute assessment of 10-year risk in subjects at stable weight loss and within the Framingham model's validated parameters.

A novel approach for Roux limb construction via the lesser sac.

Exposure of the ligament of Treitz for Roux limb construction during laparoscopic gastric bypass requires either division or displacement of the omentum. Factors compromising this exposure include: (1) a bulky omentum, (2) hepatomegaly, (3) adhesions between the omentum and lower abdominal wall or pelvic contents and (4) inability to identify the transverse colon because of overlying adipose tissue. The lesser sac approach is an alternative method for Roux limb construction during laparoscopic gastric bypass when access to the inframesocolic abdomen is difficult. In this technique the lesser sac is entered through the gastrocolic ligament. The transverse mesocolon is then opened and the ligament of Treitz is identified. The jejunum is pulled into the lesser sac and the Roux limb is constructed. The jejunojejunostomy is reduced into the inframesocolic compartment, the mesenteric defects are closed, and the remaining portion of the procedure is completed. This technique provides an alternative method for completion of a laparoscopic gastric bypass in patients who would otherwise require more extensive surgery.