Laparoscopic Roux-en-Y gastric bypass in morbidly obese patients > or =55 years old.

BACKGROUND: Advanced age is considered a relative contraindication to bariatric surgery at some institutions because of concerns about higher morbidity and less than optimal weight loss. The aim of our study was to evaluate the operative outcomes, length of stay, weight loss, and improvement of comorbidities in patients > or =55 years old who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery in our institution. METHODS: Retrospective data on 33 patients (26 women and 7 men) > or =55 years of age who underwent LRYGB from January 2003 to December 2006 were reviewed. RESULTS: Average patient age was 59 years (range 55-68 years), and the mean preoperative body mass index was 47 kg/m2 (range 41.1-55.8 kg/m2). The median length of hospital stay was 3 days. There were no intraoperative or postoperative deaths. Early complications were one anastomotic leak, two upper gastrointestinal bleedings, and two readmissions for intractable vomiting. Late complications included four anastomotic strictures and one small bowel obstruction. Patients were followed for a mean 13 months (range 3-24 months). The mean excess body weight (EBW) loss was 13.5 kg (23%), 23.3 kg (39.8%), 33.3 kg (58.1%), 39.8 kg (66.8%), 40.1 kg (69.5%), and 40.8 kg (75.3%) at 1, 3, 6, 9, 12 and 24 months, respectively. Diabetes mellitus improved in 19 (100%) patients and completely resolved in 10 (53%). Hypertension improved in 18 (64%) patients, completely resolved in 9 (32%) and was unchanged in 10 (36%). CONCLUSIONS: LRYGB is safe and effective in morbidly obese patients > or =55 years of age.

Laparoscopic Roux-en-Y gastric bypass surgery on morbidly obese patients with hypothyroidism.

BACKGROUND: It is well known that obesity is accompanied by changes in thyroid function. Hypothyroidism is associated with increased body weight. The aim of this study was to evaluate the operative outcomes, weight loss, and the effect of weight loss on thyroid function in morbidly obese patients with hypothyroidism who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. METHODS: A retrospective review of 20 morbidly obese female patients with hypothyroidism and on thyroid replacement therapy who underwent LRYGB between January 2003 and August 2006. RESULTS: Mean preoperative body mass index (BMI) was 47.6 kg/m2 (range 38-58.5 kg/m2). Average patient age was 44.5 years (range 21-66 years). There was one early complication (pneumonia). Late complications included one death, three anastomotic strictures, and one small bowel obstruction. The patients were followed for a mean of 13.5 months (range 3-24 months). Their mean excess body weight loss was 13 kg (22%), 24.4 kg (39.4%), 33.2 kg (63.3%), 38.4 kg (65%), 41.7 kg (70%), and 43 kg (73%) at 1, 3, 6, 9, 12, and 24 months, respectively. Change in a mean BMI was the same regardless of the patient preoperative and postoperative thyroxine dose. Hypothyroidism resolved in 5(25%) patients, improved in 2(10%) patients, unchanged in 8(40%) patients, and worsened in 5 (25%) patients. Most of the five whose hypothyroidism worsened had thyroid autoimmune disease. CONCLUSIONS: Hypothyroidism appears to improve in the vast majority of morbidly obese patients who undergo LRYGB, except for those whose thyroid disease is autoimmune in nature.

Cystic teratoma of the pancreas: presentation, evaluation and management.

CONTEXT: Congenital cystic lesions of the pancreas are rare findings. Furthermore, a dermoid cyst of the pancreas is exceptionally uncommon. A review of the world literature shows 18 documented cases. The pre-operative evaluation of this lesion is rather questionable, with definitive diagnosis taking place intra-operatively. CASE REPORT: A 52-year-old male with a symptomatic, 3-cm cystic-type mass in the pancreas. CONCLUSIONS: From our case presentation and review of the world literature, we hope to establish an increased awareness in the diagnostic evaluation of these patients.

Association of super-super-obesity and male gender with elevated mortality in patients undergoing the duodenal switch procedure.

BACKGROUND: Previous studies have reported that risk factors for elevated mortality after Roux-en-Y gastric bypass include male gender, as well as a very elevated BMI. The present study was aimed at determining whether these same risk factors applied to patients undergoing the duodenal switch (DS) operation. MATERIALS AND METHODS: A retrospective chart review was performed of a cohort of 385 patients who underwent DS. The 30-day mortality of super-superobese (SSO) patients [BMI > or =60 kg/m2 (n=102)] was compared with the mortality of the super- and morbidly obese (SMO) patients [35 or =60 kg/m2.

Beneficial effects of humidified, warmed carbon dioxide insufflation during laparoscopic bariatric surgery: a randomized clinical trial.

BACKGROUND: Recent data has shown that the use of warmed, humidified carbon dioxide (CO2) insufflation during laparoscopic surgery may be associated with better outcomes. METHODS: We performed a randomized, doubleblind, prospective controlled clinical trial of 30 patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Patients were randomized into 2 groups. The first group (group 1, n=15) received standard (dry, room temperature) CO2 for insufflation during the surgery, while the second group (group 2, n=15) received warmed (35 degrees C) and humidified (95%) CO2. Patients received postoperative analgesia from morphine delivered via a patient-controlled analgesia (PCA) pump. Pain scores (on a scale of 0 to 10, 0 being no pain and 10 being the worst pain) were measured postoperatively at 3 h, 6 h, 1 day and 2 days. The amount of morphine that was delivered through the PCA was also measured at the same time intervals. Operating-room (OR) time, core temperature, and total hospital length of stay were documented. RESULTS: Postoperative pain as documented by pain scores and narcotic usage were not statistically different in the 2 groups. We demonstrated a statistically significant difference (mean+/-SD) in OR time (76+/-16 min vs 101+/-34 min, P=0.02), total hospital length of stay (3.2+/-.4 days vs 4.0+/-.9 days, P=0.01) and end-of-case core temperature (36.2+/-.5 degrees C vs 35.7+/-.6 degrees C, P=0.02) in group 2 compared with group 1. CONCLUSION: The use of warmed, humidified CO2 insufflation in bariatric patients undergoing LRYGBP was not associated with any significant benefit with regards to postoperative pain.

Open heart surgery in patients 85 years and older.

BACKGROUND: There has been an increase in the number of elderly patients considered for cardiac surgery. Several reports have documented acceptable morbidity and mortality in patients 80 years and older. The results from surgical patients 85 years and older were analyzed. METHODS: The records of 89 consecutive patients 85 years and older having cardiac operations between June 1993 and May 1999 were retrospectively reviewed. For purposes of statistical analysis follow-up was considered as a minimum of one office visit to the surgeon, cardiologist, or internist at least 1 month postoperatively. RESULTS: Eighty-seven patients underwent coronary artery grafting and two patients had mitral valve replacement. Follow-up was 100% complete. The operative mortality rate was 12.3%; probability of in-hospital death was 8.2%; risk-adjusted mortality rate was 3.2%. The complication rate was 31.5%. The actuarial 1-, 3-, and 5-year survivals were as follows: 75%, 67%, and 40%. Multivariate predictors of 30-day mortality were preoperative EF, less than 30% (p = 0.029) and postoperative renal failure (p = 0.0039). CONCLUSIONS: Cardiac surgery can be performed in patients 85 years and older with good results. There is an associated prolonged hospital stay for elderly patients. Consistent successful outcomes can be expected in this patient population with selective criteria identifying risk factors.

Telemetrically monitored arrhythmogenic effects of doxorubicin in a dog model of heart failure.

A model of chronic heart failure has been induced in dogs by repeated intracoronary infusion of doxorubicin, which is an antineoplastic medication that has dose-limiting cardiotoxic side effects. Although many of the dogs receiving doxorubicin develop typical signs of dilated cardiomypathy over 4-6 weeks, some of them suddenly die before completing the four weekly infusions of the drug. The present study was undertaken to determine whether such sudden death may be caused by the development of fatal arrhythmias during doxorubicin treatment. This was assessed by telemetrically monitoring the EKG of seven dogs, which received intracoronary infusion of 1 mg/kg doxorubicin given in four divided weekly doses. The recordings were obtained for 8-10 h on alternate days up to 4 weeks. Echo-cardiographic recordings were obtained once a week. The acute effects with each infusion of doxorubicin included a significant increase in heart rate, and no significant change in QRS complex. The cumulative prolonged effects of doxorubicin included slight reduction in QRS amplitude and duration, and marked arrhythmic changes. Four out of seven dogs showed a spectrum of arrhythmic events such as single or groups of premature ventricular complexes (PVCs), bigeminy, ventricular tachycardia (VTAC), ventricular fibrillations (VFIB), and asystole. All dogs did not show each of the events listed above and the same dog did not show all the events all the time. One of these four dogs developed VFIB for 25 min and then asystole leading to sudden death. These studies conclusively showed that fatal arrhythmias develop in some of the dogs receiving doxorubicin treatment accounting for the sporadic incidence of sudden death. Prophylactic treatment with antiarrhythmic agents may prevent such adverse events.