Effect of sitagliptin on glucose control in type 2 diabetes mellitus after Roux-en-Y gastric bypass surgery.

The present study was a 4-week randomized trial to assess the efficacy and safety of sitagliptin, a dipeptidyl-peptidase-4 inhibitor, in persistent or recurring type 2 diabetes after Roux-en-Y gastric bypass surgery (RYGB). Participants (n = 32) completed a mixed meal test (MMT) and self-monitoring of plasma glucose (SMPG) before and 4 weeks after randomization to either sitagliptin 100 mg daily or placebo daily. Questionnaires were administered to assess gastrointestinal discomfort. Outcome variables were glucose, active glucagon-like peptide-1 and ß-cell function during the MMT, and glucose levels during SMPG. Age (56.3 ± 8.2 years), body mass index (34.4 ± 6.7 kg/m2 ), glycated haemoglobin (7.21 ± 0.77%), diabetes duration (12.9 ± 10.0 years), years since RYGB (5.6 ± 3.3 years) and ß-cell function did not differ between the placebo and sitagliptin groups at pre-intervention. Sitagliptin was well tolerated, decreased postprandial glucose levels during the MMT (from 8.31 ± 1.92 mmol/L to 7.67 ± 1.59 mmol/L, P = 0.03) and mean SMPG levels, but had no effect on ß-cell function. In patients with diabetes and mild hyperglycemia after RYGB, a short course of sitagliptin provided a small but significant glucose-lowering effect, with no identified improvement in ß-cell function.

Glucose Metabolism After Gastric Banding and Gastric Bypass in Individuals With Type 2 Diabetes: Weight Loss Effect.

OBJECTIVE: The superior effect of Roux-en-Y gastric bypass (RYGB) on glucose control compared with laparoscopic adjustable gastric banding (LAGB) is confounded by the greater weight loss after RYGB. We therefore examined the effect of these two surgeries on metabolic parameters matched on small and large amounts of weight loss. RESEARCH DESIGN AND METHODS: Severely obese individuals with type 2 diabetes were tested for glucose metabolism, ß-cell function, and insulin sensitivity after oral and intravenous glucose stimuli, before and 1 year after RYGB and LAGB, and at 10% and 20% weight loss after each surgery. RESULTS: RYGB resulted in greater glucagon-like peptide 1 release and incretin effect, compared with LAGB, at any level of weight loss. RYGB decreased glucose levels (120 min and area under the curve for glucose) more than LAGB at 10% weight loss. However, the improvement in glucose metabolism, the rate of diabetes remission and use of diabetes medications, insulin sensitivity, and ß-cell function were similar after the two types of surgery after 20% equivalent weight loss. CONCLUSIONS: Although RYGB retained its unique effect on incretins, the superiority of the effect of RYGB over that of LAGB on glucose metabolism, which is apparent after 10% weight loss, was attenuated after larger weight loss.

Robotically Assisted Thoracic Surgery: Proposed Guidelines for Privileging and Credentialing.

OBJECTIVE: Increased use of robotically assisted thoracic surgery (RATS) necessitates effective credentialing guidelines to ensure safe outcomes. We provide a stepwise algorithm for granting privileges and credentials in RATS. This algorithm reflects graduated responsibility and complexity of the surgical procedures performed. Furthermore, it takes into account volume, outcomes, surgeon's competency, and appropriateness of robot usage. METHODS: We performed a literature review for available strategies to grant privileges and credentials for implementing robotic surgery. The following terms were queried: robot, robotic, surgery, and credentialing. We provide this algorithm on the basis of review of the literature, our institutional experience, and the experience of other medical centers around the United States. RESULTS: Currently, two pathways for robotic training exist: residency and nonresidency-trained. In the United Sates, Joint Commission: Accreditation, Health Care, Certification requires hospitals to credential and privilege physicians on their medical staff. In the proposed algorithm, a credentialing designee oversees and reviews all requests. Residency-trained surgeons must fulfill 20 cases with program directors' attestation to obtain full privileges. Nonresidency-trained surgeons are required to fulfill simulation, didactics including online modules, wet laboratories (cadaver or animal), and observation of at least two cases before provisional privileges can be granted. A minimum number of cases (10 per year) are required to maintain privileges. All procedures are monitored via departmental QA/QI committee review. Investigational uses of the robot require institutional review board approval, and complex operations may require additional proctoring and QA/QI review. CONCLUSIONS: Safety concerns with the introduction of novel and complex technologies such as RATS must be paramount. Our algorithm takes into consideration appropriate use and serves as a basic guideline for institutions that wish to implement a RATS program.

Internal mammary silicone lymphadenopathy diagnosed by robotic thoracoscopic lymphadenectomy.

Internal mammary lymphadenopathy can be caused by a variety of disease processes and is a difficult diagnostic dilemma. We report a case of internal mammary lymphadenopathy, in a patient with a significant history of malignancy, requiring a tissue diagnosis. Robotic thoracoscopic lymphadenectomy was used to facilitate excisional biopsy. Pathology was significant for silicone granulomatous lymphadenitis secondary to silicone breast implants inserted after mastectomy for breast cancer.

Surgical residents' perception of the 16-hour work day restriction: concern for negative impact on resident education and patient care.

BACKGROUND: Effective July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted a 16-hour duty period limitation for postgraduate year I (PGY I) residents. Our aim was to assess the attitudes and perception of general surgery residents regarding the new duty hour limitation as well as the transfer of care process under the new guidelines. STUDY DESIGN: An anonymous, web-based survey was conducted nationally 7 months after the institution of the 16-hour duty limitation. RESULTS: A total of 464 completed surveys were analyzed. Overall, 75% of residents expressed dissatisfaction with the new duty hour limitation. PGY II to V residents reported a higher level of dissatisfaction compared with PGY I residents (87% vs 54%, p < 0.01). Eighty-nine percent of PGY II to V residents responded that there has been a shift of responsibilities from the PGY I class to PGY II to V residents, with 73% reporting increased fatigue as a result. Seventy-five percent of PGY I and 94% of PGY II to V residents expressed concerns about the adverse impact of the restrictions on the education of PGY I residents (p < 0.01). Residents at all PGY training levels reported encountering problems due to inadequate sign-outs (PGY I, 59%; PGY II to V, 85%; p < 0.01). Sixty-two percent of PGY I residents and 54% of PGY II to V residents believed that the new 16-hour duty restriction contributes to inadequate sign-outs (p = NS). Most PGY II to V residents (86%) believe there is a decreased level of patient ownership due to the work hour restrictions. CONCLUSIONS: The results of the survey suggest that the majority of general surgery residents are concerned over the potential negative impact of the duty limitation on resident education and patient care. Further research is needed to address these concerns.

Dietary flaxseed protects against lung ischemia reperfusion injury via inhibition of apoptosis and inflammation in a murine model.

BACKGROUND: The hallmark of lung ischemia-reperfusion injury (IRI) is the production of reactive oxygen species (ROS), and the resultant oxidant stress has been implicated in apoptotic cell death as well as subsequent development of inflammation. Dietary flaxseed (FS) is a rich source of naturally occurring antioxidants and has been shown to reduce lung IRI in mice. However, the mechanisms underlying the protective effects of FS in IRI remain to be determined. METHODS: We used a mouse model of IRI with 60 min of ischemia followed by 180 min of reperfusion and evaluated the anti-apoptotic and anti-inflammatory effects of 10% FS dietary supplementation. RESULTS: Mice fed 10% FS undergoing lung IRI had significantly lower levels of caspases and decreased apoptotic activity compared with mice fed 0% FS. Lung homogenates and bronchoalveolar lavage fluid analysis demonstrated significantly reduced inflammatory infiltrate in mice fed with 10% FS diet. Additionally, 10% FS treated mice showed significantly increased expression of antioxidant enzymes and decreased markers of lung injury. CONCLUSIONS: We conclude that dietary FS is protective against lung IRI in a clinically relevant murine model, and this protective effect may in part be mediated by the inhibition of apoptosis and inflammation.

Timely airway stenting improves survival in patients with malignant central airway obstruction.

BACKGROUND: The survival of patients with malignant central airway obstruction is very limited. Although airway stenting results in significant palliation of symptoms, data regarding improved survival after stenting for advanced thoracic cancer with central airway obstruction are lacking. METHODS: Fifty patients received a total of 72 airway stents for malignant central airway obstruction over a two-year period at a single institution. The Medical Research Council (MRC) dyspnea scale and Eastern Cooperative Oncology Group (ECOG) performance status were used to divide patients into a poor performance group (MRC = 5, ECOG = 4) and an intermediate performance group (MRC ≤ 4, ECOG ≤ 3). The SPSS version 16.0 (SPSS Inc, Chicago, IL) and Microsoft Excel (Microsoft, Redmond, WA) were used to analyze the data. Survival curves were constructed using the Kaplan-Meier survival analysis method and a log-rank test was used to compare the survival distributions among different groups. RESULTS: Successful patency of the airway was achieved in all patients with no procedure-related mortality. Stenting resulted in significant improvement in MRC and ECOG performance scores (p < 0.01). Significantly improved survival was observed only in patients in the intermediate performance group compared with patients in the poor performance group (p < 0.05). CONCLUSIONS: Airway stenting resulted in significant palliation of symptoms in both groups as evaluated by MRC dyspnea scale and ECOG performance status. Compared with historic controls, a significant survival advantage was seen only in the intermediate performance group. We postulate that timely stenting of the airway, before the morbid complications of malignant central airway obstruction have set in, results in improved survival.

Robotic brachytherapy and sublobar resection for T1 non-small cell lung cancer in high-risk patients.

BACKGROUND: Sublobar lung resection and brachytherapy seed placement is gaining acceptance for T1 non-small cell lung cancer (NSCLC) in select patients with comorbidities precluding lobectomy. Our institution first reported utilization of the da Vinci system for robotic brachytherapy developed experimentally in swine and applied to high-risk patients 5 years ago. We now report seed dosimetrics and midterm follow-up. METHODS: Eleven high-risk patients with stage IA NSCLC who were not candidates for conventional lobectomy underwent limited resection of 12 primary tumors. To reduce locoregional recurrence, (125)I brachytherapy seeds were robotically sutured intracorporeally over resection margins to deliver 14,400 cGy 1 cm from the implant plane. Patients were followed with dosimetric computed tomography scans at 30 +/- 16 days. Survival and sites of recurrence were documented. RESULTS: Resected tumor size averaged 1.48 +/- 0.38 cm (range, 1.1 to 2.1 cm). Perioperative mortality was 0% and recurrence was 9% (1 of 11 [margin recurrence at 6 months with resultant mortality at 1 year]). Follow-up duration was 31.82 +/- 17.35 months. Dosimetrics confirmed 14,400 cGy delivery using 24.21 +/- 4.6 (125)I seeds (range, 17 to 30 seeds) over a planning target volume of 10.29 +/- 2.39 cc(3). Overall, 84.1% of the planning target volume was covered by 100% of the prescription dose (V100), and 88.2% was covered by 87% of the prescription dose (V87), comparable to open dosimetric data at our institution. Follow-up imaging confirmed seed stability in all patients. CONCLUSIONS: Robotic (125)I brachytherapy seed placement is a feasible adjuvant procedure to reduce the incidence of recurrence after sublobar resection in medically compromised patients. Tailored robotic seed placement delivers an exact dosing regimen in a minimally invasive fashion with equivalent precision to open surgery.

Endoscopic tracheoplasty: segmental tracheal ring resection in a porcine model.

Endoscopic tracheoplasty is used for the relief of airway obstruction because of several benign conditions such as postintubation stenosis, inflammatory disorders such as Wegener granulomatosis, and benign neoplastic processes. Several endoscopic treatment modalities exist for these conditions, all with good initial results. However, recurrence is common and often requires frequent reintervention. Endoscopic segmental tracheal ring resection is a novel therapeutic approach that could potentially provide a durable solution. Endoscopic segmental tracheal ring resection was performed in 3 Yorkshire pigs under general anesthesia. A combination of bipolar cautery and sharp dissection was used to resect 25% to 33% of the circumference of a single tracheal ring. Technical success was achieved in all 3 animals with no intraoperative complications. Full-thickness excision, including the anterior perichondrium, was performed in 1 animal without violation of the pretracheal fascia, with no subcutaneous emphysema or clinically apparent pneumothorax. Average operative time was 31 minutes and estimated blood loss was minimal. Heart rate, oxygen saturation, and peak airway pressures were maintained within normal ranges during the procedure and for the 60-minute postoperative period. Histologic analysis of the resected specimen confirmed complete thickness excision of the segment of tracheal cartilage. Endoscopic tracheoplasty by segmental tracheal ring resection is a safe and feasible technique in a porcine model. Long-term durability could potentially outlast other endoscopic techniques for the treatment of bening tracheal stenosis. Survival studies in a porcine model of tracheal stenosis must be performed to assess the long-term outcomes of this approach.

Single-incision laparoscopic cholecystectomy using a flexible endoscope.

OBJECTIVE: To describe our experience with a single-incision laparoscopic cholecystectomy (SILC) performed using a flexible endoscope as the means of visualization and surgical dissection. The use of flexible endoscopy in intra-abdominal surgery has never been described. DESIGN: Prospective observational case series. PATIENTS: Eleven patients with symptomatic cholelithiasis were selected based on age, clinical presentation, body habitus, and history of previous abdominal surgery. Patients with acute or chronic cholecystitis were excluded. RESULTS: All procedures were completed laparoscopically via the single umbilical incision without the need to convert to an open operation and without introduction of any additional laparoscopic instruments or trocars. The mean operative time was 149.5 minutes (range, 99-240 minutes). The mean length of hospital stay was 0.36 days. There were no associated intraoperative or postoperative complications. CONCLUSIONS: In our experience, SILC performed with a flexible endoscope is feasible and safe. Further studies are needed to determine its advantages in reference to postoperative pain and complication rate in juxtaposition with the current standard laparoscopic cholecystectomy.

One-year readmission rates at a high volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and vertical banded gastroplasty-Roux-en-Y gastric bypass.

BACKGROUND: An increasing importance has been placed on a bariatric program's readmission rates. Despite the importance of such data, there have been few studies that document 1-year readmission rates. There have been even fewer studies that delineate the causes of readmission. The objective of this study is to delineate the rates and causes of readmissions within 1 year of bariatric operations performed in a high-volume center. METHODS: Records for all patients undergoing bariatric operations during a 31-month period were harvested from the hospital electronic medical database. Readmissions for these patients were then identified within the hospital database for the year following the index operation. The electronic medical records of all readmitted patients were reviewed. RESULTS: The overall 1-year readmission rate for 1,939 consecutive bariatric operations was 18.8%. The laparoscopic adjustable gastric band (LAGB) had the lowest readmission rate of 12.69%. Next was the vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RYGB) with a rate of 15.4%. The laparoscopic Roux-en-Y gastric bypass (LRYGB) had the highest readmission rate of 24.2%. Leading causes of readmission were abdominal pain with normal radiographic studies and elective operations. Independent factors predicting readmission were found to be LOS > 3 days (odds ratio 1.69 p = 0.004) and having a LRYGB (odds ratio of 1.49 p = 0.003). The previously reported reoperation rate for bowel obstruction of 9.7% had decreased to 3.7% due to changes in operative technique. CONCLUSION: Rates of readmissions for patients undergoing bariatric surgery center at our high-volume center decreased over time and are comparable to other major abdominal operations.

Bariatric surgery: low mortality at a high-volume center.

BACKGROUND: The American Society of Bariatric Surgery has initiated a Bariatric Surgery Center of Excellence Program and the American College of Surgeons has followed with their Bariatric Surgery Center Network Accreditation Program. These programs postulate that concentration of weight loss operations in high-volume centers will decrease surgical mortality and improve outcomes. METHODS: The purpose of this study was to calculate the in-hospital mortality for bariatric operations accomplished at the highest volume bariatric surgery center in the state of New Jersey. After receiving Institutional Revew Board approval, the revised surgical schedule was used to identify all patients undergoing weight loss surgery (WLS) at Hackensack University Medical Center from 1998 through June, 2006. Data for these patients were then harvested from the hospital's electronic medical record. Step-wise and univariate logistic regression analysis tested the impact of various factors on hospital length of stay and in-hospital mortality. RESULTS: Between 1998 and June, 2006, 5,365 patients underwent WLS surgery: 2,099 open vertical banded gastroplasty-Roux en Y gastric bypass (VBG-RYGB); 2,177 laparoscopic Roux en Y gastric bypass (LRYGB); and 1,089 laparoscopic adjustable gastric banding (LAGB). 75.5% of patients were women. Median age was 41 years old (13-79), median weight 128 kg (81.2-290.3), and median body mass index 46.1 kg/m2 (35.0-92.6). Median total operating room time for VBG-RYGB was 115 min (33-328); LRYGB 155 min (53-493), and LAGB 92 min (33-274). Median length of stay for VBG-RYGB was 3 days (1-39 days), LRYGB 2 days (1-46 days), and LAGB 1 day (1-20). Seven patients died in hospital after the 5,365 WLS operations (0.13%): four after VBG-RYGB (0.19%); three after LRYGB (0.14%); and none after LAGB (0%). The characteristics of the patients who died did not significantly differ from the group as a whole. CONCLUSION: Surgeons at Hackensack University Medical Center, a high volume, accredited 1A American College of Surgeons Bariatric Surgery Center, achieved a 0.13% mortality among 5,365 patients undergoing weight loss operations between 1998 and June, 2006. This study supports the concept that high-volume centers perform bariatric operations with low mortalities.

Short-term outcomes for super-super obese (BMI > or =60 kg/m2) patients undergoing weight loss surgery at a high-volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass.

BACKGROUND: We previously reported significantly longer operating room times and a trend toward increased complications and mortality in the super-super obese (body mass index [BMI] > or =60 kg/m(2)) early in our experience with laparoscopic Roux-en-Y gastric bypass. The goal of this study was to re-examine the short-term outcomes for super-super obese patients undergoing weight loss surgery at our high-volume bariatric surgery center well beyond our learning curve. METHODS: The records for all patients who had undergone weight loss surgery at Hackensack University Medical Center from 2002 to June 2006 were harvested from the hospital's electronic medical database. This population was analyzed as 2 groups (those with a BMI <60 kg/m(2) and those with a BMI > or =60 kg/m(2)), as well as by type of operation. Step-wise and univariate logistic regression analyses assessed the effect of BMI on the outcome variables, including mortality, length of surgery, length of hospital stay, and disposition at discharge. RESULTS: A total of 3692 patients were studied. Of these patients, 3401 had a BMI <60 kg/m(2) and 291 had a BMI > or =60 kg/m(2). Of the 291 super-super obese patients, 130 underwent vertical banded gastroplasty-Roux-en-Y gastric bypass, 116 laparoscopic Roux-en-Y gastric bypass, and 45 laparoscopic adjustable gastric banding. The proportion of male patients, black patients, and patients with sleep apnea was increased in the BMI > or =60 kg/m(2) group. The number of co-morbid diseases per patient correlated with age but not BMI. The BMI > or =60 kg/m(2) group required a significantly longer total operating room time (136 versus 120 min). Hospital length of stay was significantly longer only in the laparoscopic Roux-en-Y gastric bypass patients (3 d for the BMI > or =60 kg/m(2) group versus 2 d for the BMI <60 kg/m(2) group). A significantly greater percentage of patients in the super-super obese group were discharged to chronic care facilities. The overall in-hospital mortality rate was 0.15% (5 of 3692) but did not significantly differ between the 2 groups: BMI <60 kg/m(2), rate of 0.12% (4 of 3401 patients), and BMI > or =60 kg/m(2), rate of 0.34% (1 of 291 patients). The type of operation did not significantly affect the disposition at discharge or in-hospital mortality. CONCLUSION: Super-super obese patients required longer total operating room times, a longer hospital length of stay, and were more likely to be discharged to chronic care facilities than were patients with a BMI <60 kg/m(2); however, the in-hospital mortality was similar for both groups.

30-day readmission rates at a high volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and vertical banded gastroplasty-Roux-en-Y gastric bypass.

BACKGROUND: Recent studies suggest that weight loss operations may actually increase the costs to society due to increased hospital readmission rates. The purpose of this study was to determine the 30-day readmission rates following bariatric operations at a high volume bariatric surgery program. METHODS: Records for all patients undergoing bariatric operations during a 3-year period were harvested from the hospital electronic medical database. All hospital readmissions within 30 days of surgery were reviewed to determine the cause, demographics, and patient characteristics. Logistic regression analysis assessed the impact of various factors on the risk of readmission. RESULTS: 2,823 consecutive patients were identified using the corrected operative log. Of these patients, 165 (5.8%) patients required 184 (6.5%) readmissions within 30 days of their index bariatric operation. Laparoscopic adjustable gastric banding (LAGB) had the lowest patient readmission rate of 3.1%; vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RYGBP) 6.8% and Laparoscopic Roux-en-Y gastric bypass (LRYGBP) 7.3%. Technical considerations were the most common cause for readmission (41% of readmissions). White race and undergoing LAGB decreased the odds for readmission, while total operating-room time >120 minutes, initial hospital stay of >3 days and deep venous thrombosis increased the odds for readmission. CONCLUSION: This study found an overall 30-day readmission rate of 6.5% following bariatric operations at a high volume bariatric surgery program. This study supports the concept of bariatric surgery Centers of Excellence and accreditation of Bariatric Surgery Programs based on hospital volume of bariatric operations.

Factors affecting morbidity and mortality of Roux-en-Y gastric bypass for clinically severe obesity: an analysis of 1,000 consecutive open cases by a single surgeon.

INTRODUCTION: Determinants of perioperative risk for RYGB are not well defined. METHODS: Retrospective analysis of comorbidities was used to evaluate predictors of perioperative risk in 1,000 consecutive patients having open RYGB by univariate analyses and logistic regression. RESULTS: One hundred forty-six men, 854 women; average age 38.3+/-11.2 years; mean BMI 51.8+/-10.5 (range 24-116) were evaluated. Average hospital stay (LOS) was 3.8 days; 87%<3 days. 91.3% of procedures were without major complication. The most common complications were incisional hernia 3.5%, intestinal obstruction 1.9%, and leak 1.6%. 31 patients required reoperation within 30 days (3.1%). A 30-day mortality was 1.2%. Logistic regression evaluating predictors of operative mortality correlated strongly with coronary artery disease (CAD) (p<0.01), sleep apnea (p=0.03), and age (p=0.042). BMI>50 (0.6 vs 2.3%, p=0.03) and male sex were associated with increased mortality (1.3 vs. 4.0%, p=0.02). Sex-specific logistic regression demonstrated males with angiographically proven CAD were more likely to die (p=0.028) than matched cohorts. Age (p=0.033) and sleep apnea (p=0.040) were significant predictors of death for women. CONCLUSION: Perioperative mortality after RYGB appears to be affected by sex, BMI, age, CAD, and sleep apnea. Strategies employing risk stratification should be developed for bariatric surgery.

Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity.

Few data exist concerning preoperative nutritional status in patients undergoing bariatric surgery. We retrospectively analyzed the preoperative values of serum albumin, calcium, 25-OH vitamin D, iron, ferritin, hemoglobin, vitamin B12, and thiamine in 379 consecutive patients (320 women and 59 men; mean body mass index 51.8 +/- 10.6 kg/m2; 25.8% white, 28.4% African American, 45.8% Hispanic) undergoing bariatric surgery between 2002 and 2004. Preoperative deficiencies were noted for iron (43.9%), ferritin (8.4%), hemoglobin (22%; women 19.1%, men 40.7%), thiamine (29%), and 25-OH vitamin D (68.1%). Low ferritin levels were more prevalent in females (9.9% vs. 0%; P = 0.01); however, anemia was more prevalent in males (19.1% vs. 40.7%; P < 0.005). Patients younger than 25 years were more likely to be anemic than patients over 60 years (46% vs. 15%; P < 0.005). This correlated with iron deficiency, which was more prevalent in younger patients (79.2% vs. 41.7%; P < 0.005). Whites (78.8%) and African Americans (70.4%) had a higher prevalence of vitamin D deficiency than Hispanics (56.4%), P = 0.01. Whites were the least likely group to be thiamine deficient (6.8% vs 31.0% African Americans and 47.2% Hispanics; P < 0.005). Nutritional deficiencies are common in patients undergoing Roux-en-Y gastric bypass, and these deficiencies should be detected and corrected early to avoid postoperative complications.

Preoperative prediction of long-term survival after coronary artery bypass grafting in patients with low left ventricular ejection fraction.

OBJECTIVE: We aimed to develop multivariable models of preoperative risk factors that predict long-term survival after coronary artery bypass grafting in patients with ejection fraction 25% or less. METHODS: We retrospectively evaluated 544 consecutive patients with ejection fraction 25% or less who underwent coronary artery bypass grafting from 1992 to 2002 at a single institution. Long-term survival data (mean follow-up 4.1 years) were obtained from the National Death Index. Multivariable Cox regression analysis was performed to construct a predictive score for long-term mortality. A split-sample approach was also used building a model on a training group (n = 360); this model was then tested on a separate validation group (n = 184). RESULTS: From the entire database, the predictive score was calculated according to the following equation: 0.430(if past congestive heart failure) + 0.049(age in years) + 0.507(if peripheral vascular disease) + 0.580(if emergency operation) + 0.366(if chronic obstructive pulmonary disease). The 5-year survivals of the predictive score quartiles were 82.3%, 78.2%, 65.5%, and 45.5% (P < .0001). The model based on the training group had four independent predictors for long-term mortality (the same as the listed equation except for past congestive heart failure). The 5-year survival rates of the quartiles were 90.1%, 75.4%, 64.3%, and 49.2% in the training group (P < .0001) and 77.4%, 71.2%, 65.8%, and 45.5% in the validation group (P = .0001). CONCLUSION: Coronary artery bypass grafting in patients with severe ischemic cardiomyopathy achieves satisfactory midterm and long-term survival in selected patients. This new score, which is based on long-term data from a large number of patients, may aid clinicians in selecting therapeutic interventions for patients with ischemic cardiomyopathy.

Initial experience with bariatric surgery in asymptomatic human immunodeficiency virus-infected patients.

BACKGROUND: Performance of bariatric surgery in patients with human immunodeficiency virus (HIV) infection is controversial. The advent of highly active antiretroviral treatment (HAART) has dramatically reduced the progression of HIV/AIDS, so that these individuals live longer, with nearly undetectable viral loads, and thus may develop obesity and similar obesity-related comorbidity as occurs in the general population. However, HAART also causes lipodystrophy, placing these patients at increased risk for coronary artery disease. METHODS: This was a retrospective study of 6 patients from a prospectively maintained database of 892 patients (0.71%) undergoing bariatric surgery between June 1999 and December 2003. RESULTS: Six HIV-infected patients (4 women, 2 men; mean age, 43 years [range, 28-56 years]; mean preoperative weight, 142 kg [range, 110-174 kg]; mean preoperative body mass index, 50 [range, 42-59) underwent Roux-en-Y gastric bypass (RYGB). The mean duration of HIV infection was 9 years; 33% were receiving HAART at the time of surgery, which was discontinued perioperatively for 2-3 days. Average CD4 cell count was 619 cells/mm3 (range, 361-1096 cells/mm3). Preoperative comorbidities included type 2 diabetes mellitus/impaired glucose tolerance (3 cases), hypertension (2 cases), dyslipidemia (2 cases), coronary artery disease/chronic heart failure (1 case), sleep apnea (4 cases), asthma (2 cases), gastroesophageal reflux disease (3 cases), arthritis (5 cases), and depression (3 cases). Average preoperative length of hospital stay was 4.2 days (range, 3-5 days). There were no deaths or postoperative infectious complications. Mean percent excess body weight loss was 33% at 3 months, 47% at 6 months, and 61% at 12 months. Mean percent initial body weight lost was 19% at 3 months, 26% at 6 months, and 33% at 12 months. CONCLUSION: RYGB can be safely performed in HIV-infected individuals. Initial results appear to be comparable to those in noninfected controls. Well-controlled HIV infection should not be an absolute contraindication to bariatric surgery.

Placement of 125I implants with the da Vinci robotic system after video-assisted thoracoscopic wedge resection: a feasibility study.

PURPOSE: To evaluate the feasibility of using the da Vinci robotic system for radioactive seed placement in the wedge resection margin of pigs' lungs. METHODS AND MATERIALS: Video-assisted thoracoscopic wedge resection was performed in the upper and lower lobes in pigs. Dummy (125)I seeds embedded in absorbable sutures were sewn into the resection margin with the aid of the da Vinci robotic system without complications. In the "loop technique," the seeds were placed in a cylindrical pattern; in the "longitudinal," they were above and lateral to the resection margin. Orthogonal radiographs were taken in the operating room. For dose calculation, Variseed 66.7 (Build 11312) software was used. RESULTS: With looping seed placement, in the coronal view, the dose at 1 cm from the source was 97.0 Gy; in the lateral view it was 107.3 Gy. For longitudinal seed placement, the numbers were 89.5 Gy and 70.0 Gy, respectively. CONCLUSION: Robotic technology allows direct placement of radioactive seeds into the resection margin by endoscopic surgery. It overcomes the technical difficulties of manipulating in the narrow chest cavity. With the advent of robotic technology, new options in the treatment of lung cancer, as well as other malignant tumors, will become available.