Chronic and Sustained High-Dose Opioid Use in an Integrated Health System.

INTRODUCTION: The Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain released in 2016 had led to decreases in opioid prescribing. This study sought to examine chronic and sustained high-dose prescription opioid use in an integrated health system. METHODS: A serial cross-sectional study was conducted in 2021 to estimate the annual age-adjusted prevalence and incidence of chronic and high-dose opioid use among demographically diverse noncancer adults in an integrated health system in Southern California during 2013-2020. Interrupted time-series analysis with segmented regression was conducted to estimate changes in the trends in annual rates before (2013-2015) and after (2017-2020) the 2016 guideline, treating 2016 as a wash-out period. RESULTS: Prevalence and incidence of chronic use and sustained high-dose use had started to decrease after a health system intervention program before the 2016 Centers for Disease Control and Prevention guideline release and continued to decline after the guideline. Among those with sustained high-dose use, there was a substantial decrease in persons with an average daily dosage ≥90 morphine milligram equivalent and concurrent benzodiazepine use. An accelerated decrease in prevalent chronic use after the guideline was observed (slope change: -11.1 [95% CI= -20.3, -1.9] users/10,000 person-years, p=0.03). The incidence of chronic use and sustained high-dose use continued to decrease after the guideline release but at a slower pace. CONCLUSIONS: Implementing evidence-based prescribing guidelines was associated with a decrease in chronic and sustained high-dose prescription opioid use.

Laparoscopic Hiatal Hernia Repair in 221 Patients: Outcomes and Experience.

BACKGROUND AND OBJECTIVES: Hiatal hernia is a common condition often associated with symptomatic gastroesophageal reflux disease (GERD). The objectives of this study were to examine the efficacy and safety of laparoscopic hiatal hernia repair (LHHR) with biologic mesh to reduce and/or alleviate GERD symptoms and associated hiatal hernia recurrence. METHODS: We retrospectively reviewed consecutive LHHR procedures with biologic mesh performed by a single surgeon from July 2009 to October 2014. The primary efficacy outcome measures were relief from GERD symptoms, as measured according to the GERD-health-related quality-of-life (GERD-HRQL) scale and hiatal hernia recurrence. A secondary outcome measure was overall safety of the procedure. RESULTS: A total of 221 patients underwent LHHR with biologic mesh during the study period, and pre- and postoperative GERD-HRQL studies were available for 172 of them. At baseline (preoperative), the mean GERD-HRQL score for all procedures was 18.5 ± 14.4. At follow-up (mean, 14.5 ± 11.0 months [range, 2.0-56.0]), the score showed a statistically significant decline to a mean of 4.4 ± 7.5 (P < .0001). To date, 8 patients (3.6%, 8/221) have had a documented anatomic hiatal hernia recurrence. However, a secondary hiatal hernia repair reoperation was necessary in only 1 patient. Most complications were minor (dysphagia, nausea and vomiting). However, there was 1 death caused by a hemorrhage that occurred 1 week after surgery. CONCLUSIONS: Laparoscopic hiatal hernia repair using biologic mesh, both with and without a simultaneous bariatric or antireflux procedure, is an efficacious and safe therapeutic option for management of hiatal hernia, prevention of recurrence, and relief of symptomatic GERD.

Randomized, Prospective Comparison of Ursodeoxycholic Acid for the Prevention of Gallstones after Sleeve Gastrectomy.

BACKGROUND: Several studies have examined the role of ursodeoxycholic acid (UDCA) for the prevention of cholelithiasis (gallstones) following rapid weight loss from restrictive diets, vertical band gastroplasty, and Roux-en-Y gastric bypass. However, to date, there have been no prospective, controlled studies examining the role of UDCA for the prevention of gallstones following sleeve gastrectomy (SG). This study was conducted to identify the effectiveness of UDCA for prevention of gallstones after SG. METHODS: Following SG, eligible patients were randomized to a control group who did not receive UDCA treatment or to a group who were prescribed 300 mg UDCA twice daily for 6 months. Gallbladder ultrasounds were performed preoperatively and at 6 and 12 months postoperatively. Patients with positive findings preoperatively were excluded from the study. Compliance with UDCA was assessed. RESULTS: Between December 2011 and April 2013, 37 patients were randomized to the UDCA treatment arm and 38 patients were randomized to no treatment. At baseline, the two groups were similar. At 6 months, the UDCA group had a statistically significant lower incidence of gallstones (p = 0.032). Analysis revealed no significant difference in gallstones between the two groups at 1 year (p = 0.553 and p = 0.962, respectively). The overall gallstone formation rate was 29.8%. CONCLUSIONS: The incidence of gallstones is higher than previously estimated in SG patients. UDCA significantly lowers the gallstone formation rate at 6 months postoperatively.

Case reports--resolution of Barrett's disease and esophageal epithelial atypia after gastric bypass and LAP-BAND.

Gastroesophageal reflux is a well-recognized complication of obesity. Long-term reflux is associated with the progression from esophageal injury to Barrett's esophagus then to carcinoma. Bariatric surgery may prevent reflux and the progression of esophageal injury. We present two cases that had remission of their esophageal problems after differing bariatric operations.

Focal motor seizures induced by alerting stimuli in critically ill patients.

PURPOSE: We have previously demonstrated that it is common for alerting stimuli to induce electrographic seizures and other periodic or rhythmic patterns in the critically ill; however, only 1 of the first 33 patients we reported with this phenomenon had a detectable clinical correlate. METHODS: Review of charts and video EEG findings in critically ill patients in a neurological ICU at a tertiary care medical center in Manhattan. RESULTS: We identified nine patients who had focal motor seizures repeatedly induced by alerting stimuli. All patients were comatose, and 8/9 had nonconvulsive status epilepticus at some point during their acute illness. Imaging abnormalities involved bilateral thalami in three patients, upper brainstem in one, and the perirolandic region in five. DISCUSSION: We hypothesize that in encephalopathic patients, alerting stimuli activate the arousal circuitry, and, when combined with hyperexcitable cortex, result in epileptiform activity or seizures. This activity can be focal or generalized, and is usually nonconvulsive, as is true of seizures in general in the critically ill. However, when the cortex is hyperexcitable in a specific region only, focal EEG findings arise. If the electrographic seizure activity is adequately synchronized and involves motor pathways, this can present as focal motor seizures, as seen in these nine patients. Alerting can induce seizures in encephalopathic/comatose patients. The observation of clear focal clinical seizures removes the last remaining doubt that these stimulus-induced patterns are indeed seizures by any definition, not simply abnormal arousal patterns.

Metabolic syndrome phenotype in very obese women.

Severe obesity is increasingly common in the United States. Very obese persons are at increased risk for the metabolic consequences of obesity. A common multidimensional risk condition associated with obesity is the metabolic syndrome. It is accompanied by increased risk for cardiovascular disease and type 2 diabetes. Clinical manifestations of the metabolic syndrome can vary among obese individuals depending on ethnicity and gender. This study was carried out to determine the pattern of metabolic risk factors in very obese women who were considered candidates for bariatric surgery. Twenty-eight women of this type were compared to 28 nonobese women. Among the former, 11 had categorical hyperglycemia (type 2 diabetes), and 26 had metabolic syndrome by current criteria. Both those with and without diabetes had higher triglycerides and lower high-density lipoprotein (HDL) cholesterol levels than nonobese, but their levels were not categorically abnormal. These changes may have been related to observed lower postheparin lipoprotein lipase activities and higher hepatic lipase activities. In spite of lipid changes, apolipoprotein B levels were only marginally higher in very obese women. In contrast to small changes in lipoprotein metabolism, the obese women were severely insulin resistant, as indicated by hyperglycemia and elevated insulin levels. In addition, they had very high C-reactive protein levels. Thus, the metabolic syndrome, which appears to be typical of very obese women, is characterized by insulin resistance, glucose intolerance and a proinflammatory state. Atherogenic dyslipidemia as a metabolic risk factor in contrast is relatively mild. This pattern is more likely to lead to type 2 diabetes prior to development of clinically evident cardiovascular disease.

Pit viper envenomation in pregnancy: a case report and literature review.

Pit viper bites are very rare in pregnant patients and there is no consensus for treatment. This case report describes the treatment of a 28-year-old woman at 26 weeks gestation who suffered a pit viper envenomation.

Laparoscopic choledochojejunostomy via PTFE-covered stent successfully achieves internal drainage of common bile duct obstruction.

The purpose of this study was to develop a method of laparoscopic biliary bypass utilizing a PTFE-covered biliary stent. An animal model of common bile duct obstruction was developed. Three days before the planned choledochojejunostomy, the common duct in 10 female pigs was ligated using mini-laparoscopy instrumentation (2 mm) to create an obstruction model. A laparoscopic choledochojejunostomy was then performed using intracorporal suturing (n=5) or stented (n=5) techniques. In the sutured group, a side-to-side two-layer anastomosis was performed. In the stented group, a Seldinger technique was used to deliver the stent into the abdomen through the small bowel and into the anterior wall of the common bile duct for deployment across both the duct and bowel to create an anastomosis (under fluoroscopic guidance). After the surgery, the animals were followed for 7 days, and then sacrificed to examine the anastomosis grossly and histologically. Statistical analysis was used to compare the two groups. Although the difference was not statistically significant, the mean anastomosis time in minutes was shorter for the stented group (37.8; range 15-74 minutes) than in the sutured group (52.8; range 28-70 minutes). All animals survived for 7 days after the procedure with no detectable biliary leaks or biliary obstruction at autopsy. These gross findings were confirmed by pathologic examination of the anastomoses. Laparoscopic choledochojejunostomy using a PTFE-covered metallic biliary stent can be performed to relieve common bile duct obstruction. In addition, the stent method was as safe and effective as sutured laparoscopic choledochojejunostomy.

Abdominal wall neurofibroma presenting as an inguinal hernia.

Inguinal hernias are a common cause of abdominal wall pain and are the most common abdominal wall abnormality. They can usually be differentiated from other abnormalities by history and physical examination. Occasionally, the diagnosis may be difficult with very small or very large lesions. The following case report describes an abdominal wall neurofibroma presenting as an inguinal hernia in a young, active duty, male soldier with previously undiagnosed neurofibromatosis.

Acute post-gastric reduction surgery (APGARS) neuropathy.

BACKGROUND: A variety of neurologic complications have been reported after weight loss surgery. Recently, a new term was introduced to describe cases of postoperative polyneuropathy - acute post-gastric reduction surgery (APGARS) neuropathy, a polynutritional, multisystem disorder characterized by protracted postoperative vomiting, hyporeflexia, and muscular weakness. The incidence, associations, and prognosis of this disorder have not been precisely defined. METHODS: A questionnaire about features of APGARS was mailed to all members of the ASBS. Surgeons were asked about their surgical and bariatric experience. Respondents were asked to report on specific cases where APGARS may have been present. They were also asked to report the patient's diagnosis and which operation the patient had undergone. RESULTS: Of the 808 questionnaires, 257 were returned for a response-rate of 31.8%. The mean years in general surgical practice and in bariatric surgery were 15.3 +/- 10.3 and 7.5 +/- 7.4. A total of 168010 bariatric cases were performed by all respondents. 109 cases of neuropathy were described. 99 cases were believed to represent APGARS (weakness with hyporeflexia and/or vomiting). Vitamin B and/or thi12 amine deficiency were present in 40 (40%); 18 cases resolved. 9 of 17 cases with B(12) deficiency resolved; 12 of 29 cases with thiamine deficiency resolved; and 3 of 6 cases with both deficiencies resolved. Vitamin deficiencies were not noted in 59 (60%), of which 30 resolved. The most common diagnoses were Wernicke's encephalopathy, thiamine deficiency, and Guillain-Barré Syndrome. The most common operation performed was gastric bypass. CONCLUSIONS: The incidence of APGARS in this survey was 5.9 cases per 10000 operations. Given the potentially reversible nature of APGARS, surgeons should be aware of the findings and treatment.

Is routine cholecystectomy required during laparoscopic gastric bypass?

BACKGROUND: Routine cholecystectomy is often performed at the time of gastric bypass for morbid obesity. The aim of our study was to determine the incidence of gallstone formation requiring cholecystectomy following a laparoscopic Roux-en-Y gastric bypass (LRYGBP). METHODS: 289 LRYGBP were performed between November 1999 and May 2002. 60 patients (21%) who had prior cholecystectomy were excluded. If gallstones were identified by intra-operative ultrasound (IOUS), simultaneous cholecystectomy was performed. Patients without gallstones were prescribed ursodiol for 6 months and scheduled for follow-up with transabdominal ultrasound. RESULTS: During LRYGBP, gallstones were detected in 40 patients using IOUS (14%) and simultaneous cholecystectomy was performed. Of 189 patients with no stones identified by IOUS, 151 patients (80%) had a postoperative ultrasound after 6 months. 39 patients developed gallstones (22%) and 12 developed sludge (8%), as demonstrated by ultrasound at the time of follow-up. 11 patients had gallstone-related symptoms and subsequently underwent cholecystectomy (7%). 106 patients (70%) were gallstone-free at the time of ultrasound follow-up. Ursodiol compliance was found to be significantly lower for patients developing stones than for gallstone-free patients (38.9% vs 58.3%, z =-2.00, P = 0.045). CONCLUSIONS: There is a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGBP. Prophylactic ursodiol is protective. Routine IOUS and selective cholecystectomy with close patient follow-up is a rational approach in the era of laparoscopy.

Is routine cholecystectomy required during laparoscopic gastric bypass?

BACKGROUND: Routine cholecystectomy is often performed at the time of gastric bypass for morbid obesity. The aim of this study was to determine the incidence of gallstone formation requiring cholecystectomy following a laparoscopic Roux-en-Y gastric bypass (LRYGBP). METHODS: 289 LRYGBP were performed between November 1999 and May 2002. 60 patients (21%) who had prior cholecystectomy were excluded. If gallstones were identified by intra-operative ultrasound (IOUS), simultaneous cholecystectomy was performed. Patients without gallstones were prescribed ursodiol for 6 months and scheduled for follow-up with transabdominal ultrasound. RESULTS: During LRYGBP, gallstones were detected in 40 patients using IOUS (14%) and simultaneous cholecystectomy was performed. Of 189 patients with no stones identified by IOUS, 151 patients (80%) had a postoperative ultrasound after 6 months. 33 patients developed gallstones (22%) and 12 developed sludge (8%) as demonstrated by ultrasound at the time of follow-up. 11 patients had gallstone-related symptoms and subsequently underwent cholecystectomy (7%). 106 patients (70%) were gallstone-free at the time of ultrasound follow-up. Ursodiol compliance was found to be significantly lower for patients who developed stones than for gallstone-free patients (38.9% vs 58.3%, z =-2.00, P = 0.045). CONCLUSIONS: There is a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGBP. Prophylactic ursodiol is protective. Routine IOUS and selective cholecystectomy with close patient follow-up is a rational approach in the era of laparoscopy.

Gastro-clip gastroplasty: a very long-term complication.

For most surgeons, the gastro-clip gastroplasty is an unfamiliar operation. It was performed during the mid 1980s as an alternative to more complex bariatric operations. However, the device had problems. Because of its rigid nature, it occasionally eroded into the stomach and chest. Many of these devices required removal. However, patients may occasionally present with delayed complications. We present a patient with a Gastro-clip gastroplasty, who presented years after the procedure with a functional gastric outlet obstruction.

Gastric bypass: it pays to keep military hospitals busy.

This study was performed to review the surgical treatment of obesity at a community military hospital and compare costs to TRICARE reimbursement rates (the cost of sending a patient to a civilian surgeon for obesity surgery). The preoperative, operative, and postoperative phases are described in detail. The expenses of five consecutive patients were calculated and averaged. Each operation at our hospital cost 1,710 dollars, whereas the TRICARE cost was at least 6,950 dollars. A saving of 5,240 dollars per operation was achieved in our military hospital. These five patients subjectively graded their outcomes as very good to excellent at a mean of 7.9 months from surgery. These patients lost an average of 70% of their excess body weight. All patients with weight-related comorbidities reported resolution of at least one problem.

Weakness after gastric bypass.

Two patients underwent gastric bypasses and had uneventful hospital courses. In the early postoperative periods, both developed severe, protracted vomiting, weakness, and hyporeflexia. After thorough laboratory and clinical evaluations by neurologists, the patients were diagnosed with Guillain-Barré syndrome, although there were many atypical features. The clinical presentations of these patients are very similar to case reports of nutritional polyneuropathy associated with gastric partitioning. This paper addresses the difficulties of differentiating these two diagnoses.