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Virtual Reality Allows Patient-Specific Surgery Simulation
Physicians and patients heading into the operating room have to hope that the surgeon or proceduralist does the job right the first time. Generally, needing a do-over is not a good thing.
Soon, however, vascular and cardiac surgeons at Cleveland Clinic will be able to take several consequences-free do-overs that should lower risk for the patient. Some of the latest advances in imaging and technology are being incorporated into new simulation rooms built adjacent to a few new ORs. In these rooms physicians can rehearse the procedure they’re about to do on a three-dimensional simulation of the patient, who is being prepared for surgery next door.
For example, “fusion” imaging can help in the repair of aortic aneurysms. The results of an angiogram taken at the time of the procedure are superimposed on a preoperative CT scan of the patient to create three-dimensional imaging studies “telling us where all the arteries are without using any contrast,” Dr. Roy K. Greenberg said at the annual meeting of the Southern Association for Vascular Surgery. Not having to use catheters and wires to figure that out makes the procedure much easier, said Dr. Greenberg of the Cleveland Clinic Foundation.
His talk on “Aortic Care for the 21st Century” at the meeting was the first Jesse E. Thompson, M.D. Distinguished Guest Lecture.
“The imaging can be loaded in patient-specific simulators, providing a means to ‘test’ the procedures in virtual reality, train the team, and problem-solve `off-line’ ” with less risk to the patient, he said.
The Cleveland Clinic is no slouch when it comes to simulation. Their doctors-in-training practice on mannequins, robots, and other virtual stand-ins for patients. There is an Anesthesia Simulation Lab. The Clinic is even building an entire Center for Multidisciplinary Simulation.
The two new ORs that Dr. Greenberg described take simulation to the next level. The simulators are not in a remote room, they’re not in a separate building, and they’re not at a course that physicians go to for two or three days before the surgery. “I think they have to be integrated into the actual work flow and case,” he said.
The ORs should be finished in the fourth quarter of 2012, and will feature a control room behind each OR. Behind each control room will be a simulator room.
Dr. Greenberg described the work flow for a fenestrated endovascular aneurysm repair as something like this: The preoperative CT scan is used for patient selection and device design, and is imported into the OR and the simulator before the patient arrives. The CT scan and fluoroscopic imaging studies are used in fusion imaging in the OR, minimizing the use of contrast agents and radiation.
Standard clinic procedures required team sign-ins when the patient is on the table. Each team members signs in, introduces themselves, and makes sure they're operating on the correct anatomic part. Then “we have that obligatory 2.5 hours while anesthesia gets everything else ready,” during which the operative team goes to the simulator room. Residents, fellows, and the rest of the team get to practice the procedure using the repair device on a simulation of that particular patient.
“So there’s no question about what steps are next” during the live surgery, he said. If something doesn’t seem right during rehearsal, “you can say, `Why not?’ Is that a problem with the simulator, or is it going to be a problem with the procedure?”
Dr. Greenberg said he doesn’t know of any other institutions doing patient-specific simulations like this, but “I hope they will.”
Dr. Greenberg disclosed receiving royalties for intellectual property licensed to Cook, Inc. and funds for research and travel from Cook.
Physicians and patients heading into the operating room have to hope that the surgeon or proceduralist does the job right the first time. Generally, needing a do-over is not a good thing.
Soon, however, vascular and cardiac surgeons at Cleveland Clinic will be able to take several consequences-free do-overs that should lower risk for the patient. Some of the latest advances in imaging and technology are being incorporated into new simulation rooms built adjacent to a few new ORs. In these rooms physicians can rehearse the procedure they’re about to do on a three-dimensional simulation of the patient, who is being prepared for surgery next door.
For example, “fusion” imaging can help in the repair of aortic aneurysms. The results of an angiogram taken at the time of the procedure are superimposed on a preoperative CT scan of the patient to create three-dimensional imaging studies “telling us where all the arteries are without using any contrast,” Dr. Roy K. Greenberg said at the annual meeting of the Southern Association for Vascular Surgery. Not having to use catheters and wires to figure that out makes the procedure much easier, said Dr. Greenberg of the Cleveland Clinic Foundation.
His talk on “Aortic Care for the 21st Century” at the meeting was the first Jesse E. Thompson, M.D. Distinguished Guest Lecture.
“The imaging can be loaded in patient-specific simulators, providing a means to ‘test’ the procedures in virtual reality, train the team, and problem-solve `off-line’ ” with less risk to the patient, he said.
The Cleveland Clinic is no slouch when it comes to simulation. Their doctors-in-training practice on mannequins, robots, and other virtual stand-ins for patients. There is an Anesthesia Simulation Lab. The Clinic is even building an entire Center for Multidisciplinary Simulation.
The two new ORs that Dr. Greenberg described take simulation to the next level. The simulators are not in a remote room, they’re not in a separate building, and they’re not at a course that physicians go to for two or three days before the surgery. “I think they have to be integrated into the actual work flow and case,” he said.
The ORs should be finished in the fourth quarter of 2012, and will feature a control room behind each OR. Behind each control room will be a simulator room.
Dr. Greenberg described the work flow for a fenestrated endovascular aneurysm repair as something like this: The preoperative CT scan is used for patient selection and device design, and is imported into the OR and the simulator before the patient arrives. The CT scan and fluoroscopic imaging studies are used in fusion imaging in the OR, minimizing the use of contrast agents and radiation.
Standard clinic procedures required team sign-ins when the patient is on the table. Each team members signs in, introduces themselves, and makes sure they're operating on the correct anatomic part. Then “we have that obligatory 2.5 hours while anesthesia gets everything else ready,” during which the operative team goes to the simulator room. Residents, fellows, and the rest of the team get to practice the procedure using the repair device on a simulation of that particular patient.
“So there’s no question about what steps are next” during the live surgery, he said. If something doesn’t seem right during rehearsal, “you can say, `Why not?’ Is that a problem with the simulator, or is it going to be a problem with the procedure?”
Dr. Greenberg said he doesn’t know of any other institutions doing patient-specific simulations like this, but “I hope they will.”
Dr. Greenberg disclosed receiving royalties for intellectual property licensed to Cook, Inc. and funds for research and travel from Cook.
Physicians and patients heading into the operating room have to hope that the surgeon or proceduralist does the job right the first time. Generally, needing a do-over is not a good thing.
Soon, however, vascular and cardiac surgeons at Cleveland Clinic will be able to take several consequences-free do-overs that should lower risk for the patient. Some of the latest advances in imaging and technology are being incorporated into new simulation rooms built adjacent to a few new ORs. In these rooms physicians can rehearse the procedure they’re about to do on a three-dimensional simulation of the patient, who is being prepared for surgery next door.
For example, “fusion” imaging can help in the repair of aortic aneurysms. The results of an angiogram taken at the time of the procedure are superimposed on a preoperative CT scan of the patient to create three-dimensional imaging studies “telling us where all the arteries are without using any contrast,” Dr. Roy K. Greenberg said at the annual meeting of the Southern Association for Vascular Surgery. Not having to use catheters and wires to figure that out makes the procedure much easier, said Dr. Greenberg of the Cleveland Clinic Foundation.
His talk on “Aortic Care for the 21st Century” at the meeting was the first Jesse E. Thompson, M.D. Distinguished Guest Lecture.
“The imaging can be loaded in patient-specific simulators, providing a means to ‘test’ the procedures in virtual reality, train the team, and problem-solve `off-line’ ” with less risk to the patient, he said.
The Cleveland Clinic is no slouch when it comes to simulation. Their doctors-in-training practice on mannequins, robots, and other virtual stand-ins for patients. There is an Anesthesia Simulation Lab. The Clinic is even building an entire Center for Multidisciplinary Simulation.
The two new ORs that Dr. Greenberg described take simulation to the next level. The simulators are not in a remote room, they’re not in a separate building, and they’re not at a course that physicians go to for two or three days before the surgery. “I think they have to be integrated into the actual work flow and case,” he said.
The ORs should be finished in the fourth quarter of 2012, and will feature a control room behind each OR. Behind each control room will be a simulator room.
Dr. Greenberg described the work flow for a fenestrated endovascular aneurysm repair as something like this: The preoperative CT scan is used for patient selection and device design, and is imported into the OR and the simulator before the patient arrives. The CT scan and fluoroscopic imaging studies are used in fusion imaging in the OR, minimizing the use of contrast agents and radiation.
Standard clinic procedures required team sign-ins when the patient is on the table. Each team members signs in, introduces themselves, and makes sure they're operating on the correct anatomic part. Then “we have that obligatory 2.5 hours while anesthesia gets everything else ready,” during which the operative team goes to the simulator room. Residents, fellows, and the rest of the team get to practice the procedure using the repair device on a simulation of that particular patient.
“So there’s no question about what steps are next” during the live surgery, he said. If something doesn’t seem right during rehearsal, “you can say, `Why not?’ Is that a problem with the simulator, or is it going to be a problem with the procedure?”
Dr. Greenberg said he doesn’t know of any other institutions doing patient-specific simulations like this, but “I hope they will.”
Dr. Greenberg disclosed receiving royalties for intellectual property licensed to Cook, Inc. and funds for research and travel from Cook.
Weight Loss Higher After Roux-en-Y vs. Gastric Banding
Major Finding: Patients lost 78.5% of excess weight after Roux-en-Y gastric bypass vs. 64.8% after gastric banding; the treatment failure rate after 6 years was 2.5% vs. 38.9%, respectively.
Data Source: A retrospective matched-pair study of 221 Roux-en-Y gastric bypass patients and 221 gastric banding patients at a single center who were followed for at least 6 years.
Disclosures: No financial conflicts of interest were reported.
Roux-en-Y gastric bypass surgery resulted in greater, more rapid, and more sustained weight loss compared with gastric banding, but also a higher number of complications in a matched-pair study.
The weight loss advantage achieved with Roux-en-Y leads to better correction of the comorbidities that accompany obesity, such as adverse lipid profiles and high fasting glucose levels, said Dr. Sébastein Romy of the department of visceral surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland, and his associates.
Although there are more early complications with the Roux-en-Y procedure, they are outweighed by “the much higher long-term major morbidity seen after gastric banding, leading to a large number of major reoperations and their risks,” the investigators noted.
The sharp rise in bariatric surgeries performed in recent years in the United States has occurred predominantly in gastric banding procedures. “This is probably because gastric banding is perceived both by doctors and patients as a simple, safe, and reversible operation but also because of a huge industry-driven marketing campaign,” they said.
Dr. Romy and his colleagues performed a matched-pair analysis of patients who underwent the two procedures in 1998–2005. The study subjects, who had failed to lose weight with more conservative approaches, all had a body mass index of 40 or more, or a BMI of 35 plus at least one severe comorbidity. A total of 221 patients who underwent Roux-en-Y gastric bypass were matched for age, sex, and BMI with 221 who underwent gastric banding. Follow-up rates after 6 years were about 92% in both groups. The same team performed the operations at the same two hospitals.
Maximal weight loss was achieved at a mean of 18 months after Roux-en-Y gastric bypass, compared with 36 months after gastric banding. The percentage of excess weight lost was significantly higher after Roux-en-Y (78.5%) than after gastric banding (64.8%), and the mean nadir in BMI was significantly lower (26.7 vs. 29.4, respectively). After 6 years, only 5 patients (2.4%) in the Roux-en-Y group had a BMI greater than 40, compared with 21 patients (13.8%) in the gastric banding group.
As a result, significantly more patients who had Roux-en-Y surgery were rated as having excellent or acceptable results at all time points during follow-up, Dr. Romy and his associates said (Arch. Surg. 2012 Jan. 16 [doi:10. 1001/archsurg.2011.1708]).
Treatment failures were defined as a weight loss of less than 25% of baseline weight or the need to reverse the surgery or convert to a different bariatric procedure. At the 3-year mark, there were no treatment failures among Roux-en-Y patients, compared with 39 treatment failures (18.2%) among gastric banding patients. After 6 years, failure rates were 2.5% and 38.9%, respectively, in Roux-en-Y and gastric banding patients.
Improvement in lipid profiles was significantly greater after Roux-en-Y than after gastric banding. Total cholesterol, LDL cholesterol, and triglyceride levels decreased after Roux-en-Y but not after gastric banding. Fasting glucose levels also were lower after Roux-en-Y (89.55 mg/dL vs. 92.79 mg/dL).
There were significantly more early complications after Roux-en-Y (17.2%) than after gastric banding (5.4%), most of which required only conservative treatment. In contrast, gastric banding was associated with significantly more long-term complications than was Roux-en-Y (41.6% vs. 19%) and required more than twice as many reoperations (26.7% vs. 12.7%).
View on the News
Still a Few Caveats for Roux-en-Y
“I personally agree” with Romy et al. that Roux-en-Y gastric bypass is the better procedure, but “before we make from this conclusion a paradigm, a few caveats remain,” said Dr. Jacques Himpens.
A case-control study such as this one may be biased. Even though a prospective randomized trial comparing the two surgeries isn't feasible, a prospective rather than retrospective comparison of matched patients would yield better evidence, as would a multicenter rather than a single-center study.
In addition, a growing number of Roux-en-Y patients are showing neuroglycopenia and diabetes recurrence several years after surgery, which is concerning.
DR. HIMPENS is at the European School of Laparoscopy at Saint Pierre University Hospital, Brussels. He reported being a consultant for Ethicon Endo-Surgery, Covidien, and Gore. These remarks were taken from his invited critique that accompanied Dr. Romy's article (Arch. Surg. 2012 Jan. 16 [doi:10.1001/archsurg.2011.1855]).
Major Finding: Patients lost 78.5% of excess weight after Roux-en-Y gastric bypass vs. 64.8% after gastric banding; the treatment failure rate after 6 years was 2.5% vs. 38.9%, respectively.
Data Source: A retrospective matched-pair study of 221 Roux-en-Y gastric bypass patients and 221 gastric banding patients at a single center who were followed for at least 6 years.
Disclosures: No financial conflicts of interest were reported.
Roux-en-Y gastric bypass surgery resulted in greater, more rapid, and more sustained weight loss compared with gastric banding, but also a higher number of complications in a matched-pair study.
The weight loss advantage achieved with Roux-en-Y leads to better correction of the comorbidities that accompany obesity, such as adverse lipid profiles and high fasting glucose levels, said Dr. Sébastein Romy of the department of visceral surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland, and his associates.
Although there are more early complications with the Roux-en-Y procedure, they are outweighed by “the much higher long-term major morbidity seen after gastric banding, leading to a large number of major reoperations and their risks,” the investigators noted.
The sharp rise in bariatric surgeries performed in recent years in the United States has occurred predominantly in gastric banding procedures. “This is probably because gastric banding is perceived both by doctors and patients as a simple, safe, and reversible operation but also because of a huge industry-driven marketing campaign,” they said.
Dr. Romy and his colleagues performed a matched-pair analysis of patients who underwent the two procedures in 1998–2005. The study subjects, who had failed to lose weight with more conservative approaches, all had a body mass index of 40 or more, or a BMI of 35 plus at least one severe comorbidity. A total of 221 patients who underwent Roux-en-Y gastric bypass were matched for age, sex, and BMI with 221 who underwent gastric banding. Follow-up rates after 6 years were about 92% in both groups. The same team performed the operations at the same two hospitals.
Maximal weight loss was achieved at a mean of 18 months after Roux-en-Y gastric bypass, compared with 36 months after gastric banding. The percentage of excess weight lost was significantly higher after Roux-en-Y (78.5%) than after gastric banding (64.8%), and the mean nadir in BMI was significantly lower (26.7 vs. 29.4, respectively). After 6 years, only 5 patients (2.4%) in the Roux-en-Y group had a BMI greater than 40, compared with 21 patients (13.8%) in the gastric banding group.
As a result, significantly more patients who had Roux-en-Y surgery were rated as having excellent or acceptable results at all time points during follow-up, Dr. Romy and his associates said (Arch. Surg. 2012 Jan. 16 [doi:10. 1001/archsurg.2011.1708]).
Treatment failures were defined as a weight loss of less than 25% of baseline weight or the need to reverse the surgery or convert to a different bariatric procedure. At the 3-year mark, there were no treatment failures among Roux-en-Y patients, compared with 39 treatment failures (18.2%) among gastric banding patients. After 6 years, failure rates were 2.5% and 38.9%, respectively, in Roux-en-Y and gastric banding patients.
Improvement in lipid profiles was significantly greater after Roux-en-Y than after gastric banding. Total cholesterol, LDL cholesterol, and triglyceride levels decreased after Roux-en-Y but not after gastric banding. Fasting glucose levels also were lower after Roux-en-Y (89.55 mg/dL vs. 92.79 mg/dL).
There were significantly more early complications after Roux-en-Y (17.2%) than after gastric banding (5.4%), most of which required only conservative treatment. In contrast, gastric banding was associated with significantly more long-term complications than was Roux-en-Y (41.6% vs. 19%) and required more than twice as many reoperations (26.7% vs. 12.7%).
View on the News
Still a Few Caveats for Roux-en-Y
“I personally agree” with Romy et al. that Roux-en-Y gastric bypass is the better procedure, but “before we make from this conclusion a paradigm, a few caveats remain,” said Dr. Jacques Himpens.
A case-control study such as this one may be biased. Even though a prospective randomized trial comparing the two surgeries isn't feasible, a prospective rather than retrospective comparison of matched patients would yield better evidence, as would a multicenter rather than a single-center study.
In addition, a growing number of Roux-en-Y patients are showing neuroglycopenia and diabetes recurrence several years after surgery, which is concerning.
DR. HIMPENS is at the European School of Laparoscopy at Saint Pierre University Hospital, Brussels. He reported being a consultant for Ethicon Endo-Surgery, Covidien, and Gore. These remarks were taken from his invited critique that accompanied Dr. Romy's article (Arch. Surg. 2012 Jan. 16 [doi:10.1001/archsurg.2011.1855]).
Major Finding: Patients lost 78.5% of excess weight after Roux-en-Y gastric bypass vs. 64.8% after gastric banding; the treatment failure rate after 6 years was 2.5% vs. 38.9%, respectively.
Data Source: A retrospective matched-pair study of 221 Roux-en-Y gastric bypass patients and 221 gastric banding patients at a single center who were followed for at least 6 years.
Disclosures: No financial conflicts of interest were reported.
Roux-en-Y gastric bypass surgery resulted in greater, more rapid, and more sustained weight loss compared with gastric banding, but also a higher number of complications in a matched-pair study.
The weight loss advantage achieved with Roux-en-Y leads to better correction of the comorbidities that accompany obesity, such as adverse lipid profiles and high fasting glucose levels, said Dr. Sébastein Romy of the department of visceral surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland, and his associates.
Although there are more early complications with the Roux-en-Y procedure, they are outweighed by “the much higher long-term major morbidity seen after gastric banding, leading to a large number of major reoperations and their risks,” the investigators noted.
The sharp rise in bariatric surgeries performed in recent years in the United States has occurred predominantly in gastric banding procedures. “This is probably because gastric banding is perceived both by doctors and patients as a simple, safe, and reversible operation but also because of a huge industry-driven marketing campaign,” they said.
Dr. Romy and his colleagues performed a matched-pair analysis of patients who underwent the two procedures in 1998–2005. The study subjects, who had failed to lose weight with more conservative approaches, all had a body mass index of 40 or more, or a BMI of 35 plus at least one severe comorbidity. A total of 221 patients who underwent Roux-en-Y gastric bypass were matched for age, sex, and BMI with 221 who underwent gastric banding. Follow-up rates after 6 years were about 92% in both groups. The same team performed the operations at the same two hospitals.
Maximal weight loss was achieved at a mean of 18 months after Roux-en-Y gastric bypass, compared with 36 months after gastric banding. The percentage of excess weight lost was significantly higher after Roux-en-Y (78.5%) than after gastric banding (64.8%), and the mean nadir in BMI was significantly lower (26.7 vs. 29.4, respectively). After 6 years, only 5 patients (2.4%) in the Roux-en-Y group had a BMI greater than 40, compared with 21 patients (13.8%) in the gastric banding group.
As a result, significantly more patients who had Roux-en-Y surgery were rated as having excellent or acceptable results at all time points during follow-up, Dr. Romy and his associates said (Arch. Surg. 2012 Jan. 16 [doi:10. 1001/archsurg.2011.1708]).
Treatment failures were defined as a weight loss of less than 25% of baseline weight or the need to reverse the surgery or convert to a different bariatric procedure. At the 3-year mark, there were no treatment failures among Roux-en-Y patients, compared with 39 treatment failures (18.2%) among gastric banding patients. After 6 years, failure rates were 2.5% and 38.9%, respectively, in Roux-en-Y and gastric banding patients.
Improvement in lipid profiles was significantly greater after Roux-en-Y than after gastric banding. Total cholesterol, LDL cholesterol, and triglyceride levels decreased after Roux-en-Y but not after gastric banding. Fasting glucose levels also were lower after Roux-en-Y (89.55 mg/dL vs. 92.79 mg/dL).
There were significantly more early complications after Roux-en-Y (17.2%) than after gastric banding (5.4%), most of which required only conservative treatment. In contrast, gastric banding was associated with significantly more long-term complications than was Roux-en-Y (41.6% vs. 19%) and required more than twice as many reoperations (26.7% vs. 12.7%).
View on the News
Still a Few Caveats for Roux-en-Y
“I personally agree” with Romy et al. that Roux-en-Y gastric bypass is the better procedure, but “before we make from this conclusion a paradigm, a few caveats remain,” said Dr. Jacques Himpens.
A case-control study such as this one may be biased. Even though a prospective randomized trial comparing the two surgeries isn't feasible, a prospective rather than retrospective comparison of matched patients would yield better evidence, as would a multicenter rather than a single-center study.
In addition, a growing number of Roux-en-Y patients are showing neuroglycopenia and diabetes recurrence several years after surgery, which is concerning.
DR. HIMPENS is at the European School of Laparoscopy at Saint Pierre University Hospital, Brussels. He reported being a consultant for Ethicon Endo-Surgery, Covidien, and Gore. These remarks were taken from his invited critique that accompanied Dr. Romy's article (Arch. Surg. 2012 Jan. 16 [doi:10.1001/archsurg.2011.1855]).
From Archives of Surgery
IV Anesthetics During Surgery May Speed Postop Recovery
An hour of intravenous anesthetic during surgery can shave a day off the hospital stay and decrease the risk of postoperative complications for some patients, according to Dr. Marcel Durieux.
Intravenous anesthetics (for example, lidocaine) exert surprising effects on recovery from some – but not all – major abdominal surgeries. They’re associated with decreased postoperative pain, quicker return of bowel function, and a shorter length of stay. But they don’t help in all surgeries – not even in all abdominal surgeries – and the way they work is still something of a mystery, he said.
The well-documented systemic benefits of surgical epidurals got anesthesiologists thinking about intravenous agents, said Dr. Durieux, professor of anesthesiology at the University of Virginia, Charlottesville. Epidurals provide excellent postoperative pain control, but it was obvious that their effects spread much farther.
"Even if the local anesthetic goes away, its beneficial effect does not."
"They do much more than just help pain," he said in an interview. "They have significant effects on surgical outcomes that can’t be explained simply by blocking sodium channels in nerves."
Because the effects span several systems, they are probably due to systemic absorption of the anesthetic agent, he said. "If improved outcomes have little to do with blocking nerves, there is no special reason to give an anesthetic near those nerves. You should be able to give it intravenously at doses that lead to blood levels similar to what we get with an epidural."
Researchers have been looking at the issue for more than a decade, and are now honing in on inflammation as the root of these postoperative problems.
A hyperinflammatory response to surgical trauma is probably the root of many postoperative problems, including pain and thrombosis, Dr. Durieux said. "The response develops during the case and lasts into the postoperative period. If it continues, it can lead to a lot of negative effects – increased cardiac strain, impaired respiratory function that can lead to respiratory distress syndrome, nausea and ileus, and a procoagulatory state."
Intravenous local anesthetics seem to suppress that response before it explodes. The drugs likely target neutrophils and the two pathways in which they respond to a bodily injury: priming and activation.
In normal activation, a neutrophil senses bacteria and generates superoxide that kills the invader, leading to the normal inflammatory response seen with an illness. But a wound, including a surgical wound, primes the neutrophils for a superresponse. "Subsequently, when they encounter bacteria, they generate 10 times the amount of superoxide, actually damaging the body," Dr. Durieux said.
In some yet-unknown way, local anesthetics appear to inhibit neutrophilic priming. "There is no other drug around that selectively blocks priming. And if you don’t prime these neutrophils during surgery, you won’t have them there 2 days after surgery causing problems. Even if the local anesthetic goes away, its beneficial effect does not."
Recognition of this prolonged anti-inflammatory effect may eventually shape the administration of intraoperative local anesthetics. Because there is no data-driven protocol, some anesthesiologists give the drug for an hour during surgery, some continue it in the recovery room, and a few want to continue it on the surgical floor.
"This is still a matter of debate. Most of the data show that the vast majority of the benefit can be achieved by giving the drug just for the duration of the case. You can leave it on in the recovery room and turn it off when the patient is ready to go to the floor."
Unfortunately, the agents seem rather selective in their benefit. A 2010 meta-analysis found it most effective in open and laparoscopic bowel surgeries, but unhelpful in small studies on tonsillectomy, arthroscopic surgery, or coronary artery bypass. Another 2010 study found the drugs didn’t have much effect in abdominal hysterectomy, but a 1998 study found it had good effect in prostatectomy.
"I can’t explain that," Dr. Durieux said. "I’m impressed by the data we have but frustrated that the benefit has been shown in just a subset of surgeries."
Although more research is necessary – and in the offing – the drugs are cheap, safe, and easy to use.
"But I’m selective in how I use it. If someone is having an open colectomy and faces prolonged painful ileus, I would consider it, for example. And for people who can’t or won’t accept an epidural, I think this is a reasonable way to go."
He disclosed that he serves on the steering committee of a clinical trial investigating a novel system for delivering local anesthetics to surgical wounds for postoperative pain relief.
An hour of intravenous anesthetic during surgery can shave a day off the hospital stay and decrease the risk of postoperative complications for some patients, according to Dr. Marcel Durieux.
Intravenous anesthetics (for example, lidocaine) exert surprising effects on recovery from some – but not all – major abdominal surgeries. They’re associated with decreased postoperative pain, quicker return of bowel function, and a shorter length of stay. But they don’t help in all surgeries – not even in all abdominal surgeries – and the way they work is still something of a mystery, he said.
The well-documented systemic benefits of surgical epidurals got anesthesiologists thinking about intravenous agents, said Dr. Durieux, professor of anesthesiology at the University of Virginia, Charlottesville. Epidurals provide excellent postoperative pain control, but it was obvious that their effects spread much farther.
"Even if the local anesthetic goes away, its beneficial effect does not."
"They do much more than just help pain," he said in an interview. "They have significant effects on surgical outcomes that can’t be explained simply by blocking sodium channels in nerves."
Because the effects span several systems, they are probably due to systemic absorption of the anesthetic agent, he said. "If improved outcomes have little to do with blocking nerves, there is no special reason to give an anesthetic near those nerves. You should be able to give it intravenously at doses that lead to blood levels similar to what we get with an epidural."
Researchers have been looking at the issue for more than a decade, and are now honing in on inflammation as the root of these postoperative problems.
A hyperinflammatory response to surgical trauma is probably the root of many postoperative problems, including pain and thrombosis, Dr. Durieux said. "The response develops during the case and lasts into the postoperative period. If it continues, it can lead to a lot of negative effects – increased cardiac strain, impaired respiratory function that can lead to respiratory distress syndrome, nausea and ileus, and a procoagulatory state."
Intravenous local anesthetics seem to suppress that response before it explodes. The drugs likely target neutrophils and the two pathways in which they respond to a bodily injury: priming and activation.
In normal activation, a neutrophil senses bacteria and generates superoxide that kills the invader, leading to the normal inflammatory response seen with an illness. But a wound, including a surgical wound, primes the neutrophils for a superresponse. "Subsequently, when they encounter bacteria, they generate 10 times the amount of superoxide, actually damaging the body," Dr. Durieux said.
In some yet-unknown way, local anesthetics appear to inhibit neutrophilic priming. "There is no other drug around that selectively blocks priming. And if you don’t prime these neutrophils during surgery, you won’t have them there 2 days after surgery causing problems. Even if the local anesthetic goes away, its beneficial effect does not."
Recognition of this prolonged anti-inflammatory effect may eventually shape the administration of intraoperative local anesthetics. Because there is no data-driven protocol, some anesthesiologists give the drug for an hour during surgery, some continue it in the recovery room, and a few want to continue it on the surgical floor.
"This is still a matter of debate. Most of the data show that the vast majority of the benefit can be achieved by giving the drug just for the duration of the case. You can leave it on in the recovery room and turn it off when the patient is ready to go to the floor."
Unfortunately, the agents seem rather selective in their benefit. A 2010 meta-analysis found it most effective in open and laparoscopic bowel surgeries, but unhelpful in small studies on tonsillectomy, arthroscopic surgery, or coronary artery bypass. Another 2010 study found the drugs didn’t have much effect in abdominal hysterectomy, but a 1998 study found it had good effect in prostatectomy.
"I can’t explain that," Dr. Durieux said. "I’m impressed by the data we have but frustrated that the benefit has been shown in just a subset of surgeries."
Although more research is necessary – and in the offing – the drugs are cheap, safe, and easy to use.
"But I’m selective in how I use it. If someone is having an open colectomy and faces prolonged painful ileus, I would consider it, for example. And for people who can’t or won’t accept an epidural, I think this is a reasonable way to go."
He disclosed that he serves on the steering committee of a clinical trial investigating a novel system for delivering local anesthetics to surgical wounds for postoperative pain relief.
An hour of intravenous anesthetic during surgery can shave a day off the hospital stay and decrease the risk of postoperative complications for some patients, according to Dr. Marcel Durieux.
Intravenous anesthetics (for example, lidocaine) exert surprising effects on recovery from some – but not all – major abdominal surgeries. They’re associated with decreased postoperative pain, quicker return of bowel function, and a shorter length of stay. But they don’t help in all surgeries – not even in all abdominal surgeries – and the way they work is still something of a mystery, he said.
The well-documented systemic benefits of surgical epidurals got anesthesiologists thinking about intravenous agents, said Dr. Durieux, professor of anesthesiology at the University of Virginia, Charlottesville. Epidurals provide excellent postoperative pain control, but it was obvious that their effects spread much farther.
"Even if the local anesthetic goes away, its beneficial effect does not."
"They do much more than just help pain," he said in an interview. "They have significant effects on surgical outcomes that can’t be explained simply by blocking sodium channels in nerves."
Because the effects span several systems, they are probably due to systemic absorption of the anesthetic agent, he said. "If improved outcomes have little to do with blocking nerves, there is no special reason to give an anesthetic near those nerves. You should be able to give it intravenously at doses that lead to blood levels similar to what we get with an epidural."
Researchers have been looking at the issue for more than a decade, and are now honing in on inflammation as the root of these postoperative problems.
A hyperinflammatory response to surgical trauma is probably the root of many postoperative problems, including pain and thrombosis, Dr. Durieux said. "The response develops during the case and lasts into the postoperative period. If it continues, it can lead to a lot of negative effects – increased cardiac strain, impaired respiratory function that can lead to respiratory distress syndrome, nausea and ileus, and a procoagulatory state."
Intravenous local anesthetics seem to suppress that response before it explodes. The drugs likely target neutrophils and the two pathways in which they respond to a bodily injury: priming and activation.
In normal activation, a neutrophil senses bacteria and generates superoxide that kills the invader, leading to the normal inflammatory response seen with an illness. But a wound, including a surgical wound, primes the neutrophils for a superresponse. "Subsequently, when they encounter bacteria, they generate 10 times the amount of superoxide, actually damaging the body," Dr. Durieux said.
In some yet-unknown way, local anesthetics appear to inhibit neutrophilic priming. "There is no other drug around that selectively blocks priming. And if you don’t prime these neutrophils during surgery, you won’t have them there 2 days after surgery causing problems. Even if the local anesthetic goes away, its beneficial effect does not."
Recognition of this prolonged anti-inflammatory effect may eventually shape the administration of intraoperative local anesthetics. Because there is no data-driven protocol, some anesthesiologists give the drug for an hour during surgery, some continue it in the recovery room, and a few want to continue it on the surgical floor.
"This is still a matter of debate. Most of the data show that the vast majority of the benefit can be achieved by giving the drug just for the duration of the case. You can leave it on in the recovery room and turn it off when the patient is ready to go to the floor."
Unfortunately, the agents seem rather selective in their benefit. A 2010 meta-analysis found it most effective in open and laparoscopic bowel surgeries, but unhelpful in small studies on tonsillectomy, arthroscopic surgery, or coronary artery bypass. Another 2010 study found the drugs didn’t have much effect in abdominal hysterectomy, but a 1998 study found it had good effect in prostatectomy.
"I can’t explain that," Dr. Durieux said. "I’m impressed by the data we have but frustrated that the benefit has been shown in just a subset of surgeries."
Although more research is necessary – and in the offing – the drugs are cheap, safe, and easy to use.
"But I’m selective in how I use it. If someone is having an open colectomy and faces prolonged painful ileus, I would consider it, for example. And for people who can’t or won’t accept an epidural, I think this is a reasonable way to go."
He disclosed that he serves on the steering committee of a clinical trial investigating a novel system for delivering local anesthetics to surgical wounds for postoperative pain relief.
Heparin Bridging Associated With Increased Bleeding Risk
SAN DIEGO – Patients who receive heparin bridging during an interruption of oral anticoagulation appear to be at a 5.4-fold increased risk of overall bleeding and a 3.6-fold increased risk of major bleeding, without a reduction in risk of thromboembolic events.
Those are key findings from a systematic review and meta-analysis of recently published medical literature presented by Dr. Jovana Yudin at the annual meeting of the American Society of Hematology.
Antithrombotic and thrombolytic therapy guidelines published by the American College of Chest Physicians in 2008 recommended bridging according to an individualized approach (Chest 2008;133[suppl. 6]:299S-339S).
"They suggested bridging according to patients’ bleeding and thromboembolic risk," said Dr. Yudin, a fellow in the hematology residency program at McMaster University, Hamilton, Ont. "Within the last decade, several new studies have been published using periprocedural bridging. In these studies, low-molecular-weight heparin has been used with increased frequency. However, optimal strategies for bridging remain unclear. Our objective was to do a systematic review and meta-analysis of bridging trials published in the last decade to look at thromboembolic risk as well as bleeding risk."
Dr. Yudin and her associates searched the MEDLINE, EMBASE, and Cochrane Collaboration databases for systematic reviews and meta-analyses of studies published between Jan. 1, 2001, and July 31, 2010, that examined bleeding and thromboembolic events in patients receiving bridging therapy during temporary oral anticoagulation interruption for elective surgical or invasive procedures. Studies were excluded if the reporting of thromboembolic or bleeding outcomes was unclear, or if they focused exclusively on patients with renal failure (ASH 2011; abstract 545). All studies were reviewed by two independent investigators.
The researchers identified and screened 1,164 studies for review. Of these, 35 studies that included 7,169 bridged patients were selected for the final review. Most of the studies (33) were observational, and only two were randomized. The median follow-up was 30 days.
The most common indication for anticoagulation was atrial fibrillation (44%), followed by mechanical valve (24%), prior venous thromboembolism (22%), and other (10%).
The most common preoperative strategy was to discontinue oral anticoagulation more than 3 days in advance. Low-molecular-weight heparin was most commonly used, both preoperatively and postoperatively.
Dr. Yudin reported that thromboembolic events, which were primarily arterial in nature, occurred in 73 of the 7,169 patients (mean rate, 0.96%). The mean rate of overall bleeding was 13.01%, whereas the mean rate of major bleeding was 4.32%.
Eight of the studies included in the final analysis had control groups from which the researchers were able to pull data to determine an odds ratio for thromboembolism with bridging vs. no bridging. These studies included 1,691 bridged patients and 3,493 nonbridged patients. The odds ratio for thromboembolic events was 0.80, with a 95% confidence interval (CI) of 0.42-1.54, "suggesting no risk reduction for thromboembolic events with heparin or low-molecular-weight bridging," Dr. Yudin said. "There was also no difference between these two groups in the risk for arterial or venous thromboembolism."
To determine the risk of overall bleeding, the researchers pulled data from 13 studies that included control groups. These studies included 1,935 bridged patients and 5,160 nonbridged patients. The odds ratio for overall bleeding with bridging was 5.40 (95% CI, 3.00-9.74). "This suggested an increased risk of overall bleeding with bridging anticoagulation, but there was significant heterogeneity noted across these studies."
For major bleeding, five studies with control groups were assessed. These included 1,397 bridged patients and 2,104 nonbridged patients. The odds ratio for major bleeding was 3.60 (95% CI, 1.52-8.50), "again suggesting an increased risk in major bleeding with bridging," she said. "There was significant heterogeneity noted across studies."
Dr. Yudin acknowledged that the review had certain limitations: Most of the studies included in the analysis were observational, and only about a third had control groups. "Our control groups consisted largely of low-thromboembolic-risk patients, or patients who were not chronically on vitamin K antagonists, suggesting that they had a different risk profile for thromboembolism than many of the bridged patients," she said.
The findings "underline the need for studies of higher [methodological] quality in periprocedural bridging," she concluded. "It also tells us that there is a need for standardized definitions in terms of outcomes. We suspect that much of our heterogeneity had to do with varying definitions for outcomes such as major bleeding."
Dr. Yudin said that she had no relevant financial conflicts to disclose.
SAN DIEGO – Patients who receive heparin bridging during an interruption of oral anticoagulation appear to be at a 5.4-fold increased risk of overall bleeding and a 3.6-fold increased risk of major bleeding, without a reduction in risk of thromboembolic events.
Those are key findings from a systematic review and meta-analysis of recently published medical literature presented by Dr. Jovana Yudin at the annual meeting of the American Society of Hematology.
Antithrombotic and thrombolytic therapy guidelines published by the American College of Chest Physicians in 2008 recommended bridging according to an individualized approach (Chest 2008;133[suppl. 6]:299S-339S).
"They suggested bridging according to patients’ bleeding and thromboembolic risk," said Dr. Yudin, a fellow in the hematology residency program at McMaster University, Hamilton, Ont. "Within the last decade, several new studies have been published using periprocedural bridging. In these studies, low-molecular-weight heparin has been used with increased frequency. However, optimal strategies for bridging remain unclear. Our objective was to do a systematic review and meta-analysis of bridging trials published in the last decade to look at thromboembolic risk as well as bleeding risk."
Dr. Yudin and her associates searched the MEDLINE, EMBASE, and Cochrane Collaboration databases for systematic reviews and meta-analyses of studies published between Jan. 1, 2001, and July 31, 2010, that examined bleeding and thromboembolic events in patients receiving bridging therapy during temporary oral anticoagulation interruption for elective surgical or invasive procedures. Studies were excluded if the reporting of thromboembolic or bleeding outcomes was unclear, or if they focused exclusively on patients with renal failure (ASH 2011; abstract 545). All studies were reviewed by two independent investigators.
The researchers identified and screened 1,164 studies for review. Of these, 35 studies that included 7,169 bridged patients were selected for the final review. Most of the studies (33) were observational, and only two were randomized. The median follow-up was 30 days.
The most common indication for anticoagulation was atrial fibrillation (44%), followed by mechanical valve (24%), prior venous thromboembolism (22%), and other (10%).
The most common preoperative strategy was to discontinue oral anticoagulation more than 3 days in advance. Low-molecular-weight heparin was most commonly used, both preoperatively and postoperatively.
Dr. Yudin reported that thromboembolic events, which were primarily arterial in nature, occurred in 73 of the 7,169 patients (mean rate, 0.96%). The mean rate of overall bleeding was 13.01%, whereas the mean rate of major bleeding was 4.32%.
Eight of the studies included in the final analysis had control groups from which the researchers were able to pull data to determine an odds ratio for thromboembolism with bridging vs. no bridging. These studies included 1,691 bridged patients and 3,493 nonbridged patients. The odds ratio for thromboembolic events was 0.80, with a 95% confidence interval (CI) of 0.42-1.54, "suggesting no risk reduction for thromboembolic events with heparin or low-molecular-weight bridging," Dr. Yudin said. "There was also no difference between these two groups in the risk for arterial or venous thromboembolism."
To determine the risk of overall bleeding, the researchers pulled data from 13 studies that included control groups. These studies included 1,935 bridged patients and 5,160 nonbridged patients. The odds ratio for overall bleeding with bridging was 5.40 (95% CI, 3.00-9.74). "This suggested an increased risk of overall bleeding with bridging anticoagulation, but there was significant heterogeneity noted across these studies."
For major bleeding, five studies with control groups were assessed. These included 1,397 bridged patients and 2,104 nonbridged patients. The odds ratio for major bleeding was 3.60 (95% CI, 1.52-8.50), "again suggesting an increased risk in major bleeding with bridging," she said. "There was significant heterogeneity noted across studies."
Dr. Yudin acknowledged that the review had certain limitations: Most of the studies included in the analysis were observational, and only about a third had control groups. "Our control groups consisted largely of low-thromboembolic-risk patients, or patients who were not chronically on vitamin K antagonists, suggesting that they had a different risk profile for thromboembolism than many of the bridged patients," she said.
The findings "underline the need for studies of higher [methodological] quality in periprocedural bridging," she concluded. "It also tells us that there is a need for standardized definitions in terms of outcomes. We suspect that much of our heterogeneity had to do with varying definitions for outcomes such as major bleeding."
Dr. Yudin said that she had no relevant financial conflicts to disclose.
SAN DIEGO – Patients who receive heparin bridging during an interruption of oral anticoagulation appear to be at a 5.4-fold increased risk of overall bleeding and a 3.6-fold increased risk of major bleeding, without a reduction in risk of thromboembolic events.
Those are key findings from a systematic review and meta-analysis of recently published medical literature presented by Dr. Jovana Yudin at the annual meeting of the American Society of Hematology.
Antithrombotic and thrombolytic therapy guidelines published by the American College of Chest Physicians in 2008 recommended bridging according to an individualized approach (Chest 2008;133[suppl. 6]:299S-339S).
"They suggested bridging according to patients’ bleeding and thromboembolic risk," said Dr. Yudin, a fellow in the hematology residency program at McMaster University, Hamilton, Ont. "Within the last decade, several new studies have been published using periprocedural bridging. In these studies, low-molecular-weight heparin has been used with increased frequency. However, optimal strategies for bridging remain unclear. Our objective was to do a systematic review and meta-analysis of bridging trials published in the last decade to look at thromboembolic risk as well as bleeding risk."
Dr. Yudin and her associates searched the MEDLINE, EMBASE, and Cochrane Collaboration databases for systematic reviews and meta-analyses of studies published between Jan. 1, 2001, and July 31, 2010, that examined bleeding and thromboembolic events in patients receiving bridging therapy during temporary oral anticoagulation interruption for elective surgical or invasive procedures. Studies were excluded if the reporting of thromboembolic or bleeding outcomes was unclear, or if they focused exclusively on patients with renal failure (ASH 2011; abstract 545). All studies were reviewed by two independent investigators.
The researchers identified and screened 1,164 studies for review. Of these, 35 studies that included 7,169 bridged patients were selected for the final review. Most of the studies (33) were observational, and only two were randomized. The median follow-up was 30 days.
The most common indication for anticoagulation was atrial fibrillation (44%), followed by mechanical valve (24%), prior venous thromboembolism (22%), and other (10%).
The most common preoperative strategy was to discontinue oral anticoagulation more than 3 days in advance. Low-molecular-weight heparin was most commonly used, both preoperatively and postoperatively.
Dr. Yudin reported that thromboembolic events, which were primarily arterial in nature, occurred in 73 of the 7,169 patients (mean rate, 0.96%). The mean rate of overall bleeding was 13.01%, whereas the mean rate of major bleeding was 4.32%.
Eight of the studies included in the final analysis had control groups from which the researchers were able to pull data to determine an odds ratio for thromboembolism with bridging vs. no bridging. These studies included 1,691 bridged patients and 3,493 nonbridged patients. The odds ratio for thromboembolic events was 0.80, with a 95% confidence interval (CI) of 0.42-1.54, "suggesting no risk reduction for thromboembolic events with heparin or low-molecular-weight bridging," Dr. Yudin said. "There was also no difference between these two groups in the risk for arterial or venous thromboembolism."
To determine the risk of overall bleeding, the researchers pulled data from 13 studies that included control groups. These studies included 1,935 bridged patients and 5,160 nonbridged patients. The odds ratio for overall bleeding with bridging was 5.40 (95% CI, 3.00-9.74). "This suggested an increased risk of overall bleeding with bridging anticoagulation, but there was significant heterogeneity noted across these studies."
For major bleeding, five studies with control groups were assessed. These included 1,397 bridged patients and 2,104 nonbridged patients. The odds ratio for major bleeding was 3.60 (95% CI, 1.52-8.50), "again suggesting an increased risk in major bleeding with bridging," she said. "There was significant heterogeneity noted across studies."
Dr. Yudin acknowledged that the review had certain limitations: Most of the studies included in the analysis were observational, and only about a third had control groups. "Our control groups consisted largely of low-thromboembolic-risk patients, or patients who were not chronically on vitamin K antagonists, suggesting that they had a different risk profile for thromboembolism than many of the bridged patients," she said.
The findings "underline the need for studies of higher [methodological] quality in periprocedural bridging," she concluded. "It also tells us that there is a need for standardized definitions in terms of outcomes. We suspect that much of our heterogeneity had to do with varying definitions for outcomes such as major bleeding."
Dr. Yudin said that she had no relevant financial conflicts to disclose.
FROM THE ANNUAL MEETING OF THE AMERICAN SOCIETY OF HEMATOLOGY
Major Finding: Patients who received heparin bridging during interruption of oral anticoagulation had a significantly increased risk of overall bleeding (odds ratio 5.4) and major bleeding (OR 3.6), compared with nonbridged patients.
Data Source: A meta-analysis of 35 studies that examined bleeding and thromboembolic events in patients receiving bridging therapy during temporary interruption of oral anticoagulants for elective procedures.
Disclosures: Dr. Yudin said that she had no relevant financial conflicts to disclose.
Iron Deficiency 'Unintended Consequence' of Gastric Bypass
SAN DIEGO – About one-quarter of patients referred to a group hematology practice had iron deficiency associated with gastric bypass surgery, a study has shown.
In addition, 57% demonstrated symptoms of pica syndrome – a craving for and compulsive eating of nonfood substances such as ice and starch.
“As morbid obesity has become a large problem in this country and more and more people are undergoing gastric bypass surgery, iron deficiency anemia is an unintended consequence,” Dr. Thomas A. Bensinger said at the meeting “Some of these patients get very severely anemic.”
Dr. Bensinger and his associates at a group practice in Greenbelt reviewed the medical records of 300 adults referred to the practice between March and November of 2010 with a diagnosis of anemia.
Of the total, 130 demonstrated iron deficiency anemia after undergoing laboratory studies that included a complete blood count, a ferritin level, an iron/total iron-binding capacity, a reticulocyte count, and a review of the peripheral blood film.
Of the 130 patients, 122 (94%) were women, 4 of whom were pregnant. Heavy menstrual bleeding was the most common cause of iron deficiency anemia (62%), followed by gastric bypass surgery (24%), gastrointestinal abnormalities (6%), and heavy menstrual bleeding associated with the presence of uterine fibroid (5%). In addition, 12% of patients had heavy menstrual bleeding and had undergone gastric bypass surgery. The remaining 3% of patients were male.
More than half of the patients (57%) demonstrated symptoms of pica syndrome, primarily the urge to eat ice. Two patients reported an urge to eat toilet paper while one patient reported eating leaves that were stripped from a plant in her garden. Such symptoms “were often not reported by the patient unless the patient was questioned in detail, with the exception of a small subset of patients who had performed an Internet search and found pica for ice to be associated with iron deficiency anemia,” Dr. Bensinger said.
Pica syndrome symptoms typically resolved within 7-21 days of intravenous iron administration. “I speculate that the craving for ice is related to enzymes that are in the oral cavity in the mucosa,” he said.
“They get iron depleted and somehow the ice makes them feel better. When you give them the iron, those enzymes get repleted. It's a very interesting phenomenon. Some of our patients know when they start to get iron deficient again, because they realize they're eating ice.”
The study's overall findings underscore the importance of paying close attention to key indicators of iron deficiency anemia, including low mean corpuscular volume and various forms of pica syndrome.
“You have to keep paying attention to the causes of anemia,” he said.
Dr. Bensinger reported having no relevant financial disclosures.
It is important to pay attention to key indicators of iron deficiency anemia, including various forms of pica syndrome.
Source DR. BENSINGER
SAN DIEGO – About one-quarter of patients referred to a group hematology practice had iron deficiency associated with gastric bypass surgery, a study has shown.
In addition, 57% demonstrated symptoms of pica syndrome – a craving for and compulsive eating of nonfood substances such as ice and starch.
“As morbid obesity has become a large problem in this country and more and more people are undergoing gastric bypass surgery, iron deficiency anemia is an unintended consequence,” Dr. Thomas A. Bensinger said at the meeting “Some of these patients get very severely anemic.”
Dr. Bensinger and his associates at a group practice in Greenbelt reviewed the medical records of 300 adults referred to the practice between March and November of 2010 with a diagnosis of anemia.
Of the total, 130 demonstrated iron deficiency anemia after undergoing laboratory studies that included a complete blood count, a ferritin level, an iron/total iron-binding capacity, a reticulocyte count, and a review of the peripheral blood film.
Of the 130 patients, 122 (94%) were women, 4 of whom were pregnant. Heavy menstrual bleeding was the most common cause of iron deficiency anemia (62%), followed by gastric bypass surgery (24%), gastrointestinal abnormalities (6%), and heavy menstrual bleeding associated with the presence of uterine fibroid (5%). In addition, 12% of patients had heavy menstrual bleeding and had undergone gastric bypass surgery. The remaining 3% of patients were male.
More than half of the patients (57%) demonstrated symptoms of pica syndrome, primarily the urge to eat ice. Two patients reported an urge to eat toilet paper while one patient reported eating leaves that were stripped from a plant in her garden. Such symptoms “were often not reported by the patient unless the patient was questioned in detail, with the exception of a small subset of patients who had performed an Internet search and found pica for ice to be associated with iron deficiency anemia,” Dr. Bensinger said.
Pica syndrome symptoms typically resolved within 7-21 days of intravenous iron administration. “I speculate that the craving for ice is related to enzymes that are in the oral cavity in the mucosa,” he said.
“They get iron depleted and somehow the ice makes them feel better. When you give them the iron, those enzymes get repleted. It's a very interesting phenomenon. Some of our patients know when they start to get iron deficient again, because they realize they're eating ice.”
The study's overall findings underscore the importance of paying close attention to key indicators of iron deficiency anemia, including low mean corpuscular volume and various forms of pica syndrome.
“You have to keep paying attention to the causes of anemia,” he said.
Dr. Bensinger reported having no relevant financial disclosures.
It is important to pay attention to key indicators of iron deficiency anemia, including various forms of pica syndrome.
Source DR. BENSINGER
SAN DIEGO – About one-quarter of patients referred to a group hematology practice had iron deficiency associated with gastric bypass surgery, a study has shown.
In addition, 57% demonstrated symptoms of pica syndrome – a craving for and compulsive eating of nonfood substances such as ice and starch.
“As morbid obesity has become a large problem in this country and more and more people are undergoing gastric bypass surgery, iron deficiency anemia is an unintended consequence,” Dr. Thomas A. Bensinger said at the meeting “Some of these patients get very severely anemic.”
Dr. Bensinger and his associates at a group practice in Greenbelt reviewed the medical records of 300 adults referred to the practice between March and November of 2010 with a diagnosis of anemia.
Of the total, 130 demonstrated iron deficiency anemia after undergoing laboratory studies that included a complete blood count, a ferritin level, an iron/total iron-binding capacity, a reticulocyte count, and a review of the peripheral blood film.
Of the 130 patients, 122 (94%) were women, 4 of whom were pregnant. Heavy menstrual bleeding was the most common cause of iron deficiency anemia (62%), followed by gastric bypass surgery (24%), gastrointestinal abnormalities (6%), and heavy menstrual bleeding associated with the presence of uterine fibroid (5%). In addition, 12% of patients had heavy menstrual bleeding and had undergone gastric bypass surgery. The remaining 3% of patients were male.
More than half of the patients (57%) demonstrated symptoms of pica syndrome, primarily the urge to eat ice. Two patients reported an urge to eat toilet paper while one patient reported eating leaves that were stripped from a plant in her garden. Such symptoms “were often not reported by the patient unless the patient was questioned in detail, with the exception of a small subset of patients who had performed an Internet search and found pica for ice to be associated with iron deficiency anemia,” Dr. Bensinger said.
Pica syndrome symptoms typically resolved within 7-21 days of intravenous iron administration. “I speculate that the craving for ice is related to enzymes that are in the oral cavity in the mucosa,” he said.
“They get iron depleted and somehow the ice makes them feel better. When you give them the iron, those enzymes get repleted. It's a very interesting phenomenon. Some of our patients know when they start to get iron deficient again, because they realize they're eating ice.”
The study's overall findings underscore the importance of paying close attention to key indicators of iron deficiency anemia, including low mean corpuscular volume and various forms of pica syndrome.
“You have to keep paying attention to the causes of anemia,” he said.
Dr. Bensinger reported having no relevant financial disclosures.
It is important to pay attention to key indicators of iron deficiency anemia, including various forms of pica syndrome.
Source DR. BENSINGER
From the Annual Meeting of the American Society of Hematologysan
Weigh Surgical Options for Metabolic Syndrome
HOT SPRINGS, VA. – An analysis of a large database of bariatric surgery patients has found that those with metabolic syndrome had dramatic improvements in comorbidities but a slightly higher rate of adverse events after 90 days.
Overall, patients with metabolic syndrome tend to be sicker and to have a greater incidence of adverse outcomes and higher mortality than do obese patients who don't have the syndrome, said Dr. William B. Inabnet III, professor of surgery at Mount Sinai School of Medicine in New York.
He and his colleagues at Mount Sinai also determined that the reduction in weight was procedure dependent. “A careful assessment of risk-benefit ratio is warranted to develop the optimal clinical pathway for treating these patients,” said Dr. Inabnet at the meeting.
The researchers examined BOLD (Bariatric Outcomes Longitudinal Database) to identify patients who had undergone bariatric surgery from June 2007 to November 2010 and had metabolic syndrome.
BOLD is maintained by the American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Center of Excellence program, and includes 1,157 surgeons at 884 hospitals. The data are self-reported, but some data are verified by on-site inspections. The surgical interventions covered in the registry include gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.
A modified scoring system (0-5) was used to assess comorbidities. For the purposes of the study, metabolic syndrome was defined as a hypertension score greater than 3, a diabetes score greater than 2, a dyslipidemia score greater than 2, and a sleep apnea score greater than 3. (Sleep apnea is not usually included in the definition of metabolic syndrome, but the researchers were interested in the condition as a comorbidity, said Dr. Inabnet.)
Overall, there were 186,567 patients in BOLD, including 23,106 patients who had metabolic syndrome. Those with metabolic syndrome were more likely than other obese patients to be male, older, and white, and to have sleep apnea and an ASA (American Society of Anesthesiologists) classification of 3 or greater. Body mass index was similar for both groups at 47 kg/m
Gastric bypass was the most commonly performed procedure, and was the preferred method in patients with metabolic syndrome, followed by gastric banding, sleeve gastrectomy, and duodenal switch. And, said Dr. Inabnet, the researchers “were truly amazed to see that the vast majority of these cases were performed with laparoscopic approaches.”
At 30 days, those with metabolic syndrome had increases in mortality, serious complications, readmissions, and reoperations, compared with other obese patients. The increases continued as time went on, and became more pronounced at 90 days post surgery, said Dr. Inabnet.
Overall mortality was very low (0.1%) for the entire cohort of 186,567 patients.
Mortality rates differed by procedure, however. The gastric band patients had the lowest rate (0.1%), followed by 1.2% for duodenal switch, 0.3% for sleeve gastrectomy, and 0.4% for gastric bypass. The serious complications, readmissions, and reoperations at 90 days were also lowest for gastric band patients, followed by duodenal switch, sleeve gastrectomy, and gastric bypass patients.
Metabolic syndrome was associated with the greatest risk for serious complications, according to the authors' regression model. Those who received the gastric band had a 2.79-fold increase in risk at 90 days, compared with bypass patients, who had a 1.34-fold increased risk.
Follow-up data at 1 year were available for a little more than half of those with metabolic syndrome (12,144 patients). The data show that the decrease in BMI was procedure dependent. The greatest decrease in mean BMI (from 51 to 32) was seen in those who had a biliopancreatic diversion. Mean BMI dropped from 46 to 39 in gastric band patients, from 49 to 36 in those who had a sleeve gastrectomy, and from 48 to 32 in those who had the bypass.
Reduction of comorbidities was also greatest in the duodenal switch group, followed by the bypass, sleeve, and gastric band procedures. For instance, diabetes resolved in 74% of patients who had the duodenal switch, compared with only 28% of those who received the band. There were big reductions in hyperlipidemia and sleep apnea for all the procedures.
The data are limited in that they are self-reported, noted Dr. Inabnet. Even so, the “study confirms the previously held hypothesis that metabolic syndrome confers increased morbidity,” said Dr. Bruce Schirmer, vice-chair of the department of surgery at the University of Virginia, Charlottesville. In discussing the paper, Dr. Schirmer noted that BOLD also seemed to show lower overall weight loss and resolution of comorbidities than was previously reported by individual institutions.
The database, however, has its advantages, said another discussant, Dr. William O. Richards, chair of the department of surgery and director of the surgical weight loss center at the University of South Alabama, Mobile. “This paper is important because it's another one of the studies emanating from prospective [collections of data across the United States] from hundreds of surgeons, and convinces me we are ever more confident in reporting results not just from a single surgeon but from actual practice,” said Dr. Richards.
He questioned whether the low mortality rate was a reflection of surgeons' opting to avoid procedures in high-risk, older obese patients, or whether it was a reflection of the success of the centers of excellence system.
Dr. Inabnet said that there were 200 patients older than age 75, and although the data are currently too young to allow the measurement of any trends, it does not seem that older patients are being operated on less often than are younger patients.
“What is the best operation? That really is the million dollar question,” he said. The data show that the Roux-en-Y procedure provides the best overall risk profile, but he added that the sleeve gastrectomy is increasing in prevalence and may eventually prove to be a good choice.
Dr. Inabnet, Dr. Schirmer, and Dr. Richards reported no conflicts.
Roux-en-Y has the best risk profile, but sleeve gastrectomy may prove to be a good choice.
Source DR. INABNET
HOT SPRINGS, VA. – An analysis of a large database of bariatric surgery patients has found that those with metabolic syndrome had dramatic improvements in comorbidities but a slightly higher rate of adverse events after 90 days.
Overall, patients with metabolic syndrome tend to be sicker and to have a greater incidence of adverse outcomes and higher mortality than do obese patients who don't have the syndrome, said Dr. William B. Inabnet III, professor of surgery at Mount Sinai School of Medicine in New York.
He and his colleagues at Mount Sinai also determined that the reduction in weight was procedure dependent. “A careful assessment of risk-benefit ratio is warranted to develop the optimal clinical pathway for treating these patients,” said Dr. Inabnet at the meeting.
The researchers examined BOLD (Bariatric Outcomes Longitudinal Database) to identify patients who had undergone bariatric surgery from June 2007 to November 2010 and had metabolic syndrome.
BOLD is maintained by the American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Center of Excellence program, and includes 1,157 surgeons at 884 hospitals. The data are self-reported, but some data are verified by on-site inspections. The surgical interventions covered in the registry include gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.
A modified scoring system (0-5) was used to assess comorbidities. For the purposes of the study, metabolic syndrome was defined as a hypertension score greater than 3, a diabetes score greater than 2, a dyslipidemia score greater than 2, and a sleep apnea score greater than 3. (Sleep apnea is not usually included in the definition of metabolic syndrome, but the researchers were interested in the condition as a comorbidity, said Dr. Inabnet.)
Overall, there were 186,567 patients in BOLD, including 23,106 patients who had metabolic syndrome. Those with metabolic syndrome were more likely than other obese patients to be male, older, and white, and to have sleep apnea and an ASA (American Society of Anesthesiologists) classification of 3 or greater. Body mass index was similar for both groups at 47 kg/m
Gastric bypass was the most commonly performed procedure, and was the preferred method in patients with metabolic syndrome, followed by gastric banding, sleeve gastrectomy, and duodenal switch. And, said Dr. Inabnet, the researchers “were truly amazed to see that the vast majority of these cases were performed with laparoscopic approaches.”
At 30 days, those with metabolic syndrome had increases in mortality, serious complications, readmissions, and reoperations, compared with other obese patients. The increases continued as time went on, and became more pronounced at 90 days post surgery, said Dr. Inabnet.
Overall mortality was very low (0.1%) for the entire cohort of 186,567 patients.
Mortality rates differed by procedure, however. The gastric band patients had the lowest rate (0.1%), followed by 1.2% for duodenal switch, 0.3% for sleeve gastrectomy, and 0.4% for gastric bypass. The serious complications, readmissions, and reoperations at 90 days were also lowest for gastric band patients, followed by duodenal switch, sleeve gastrectomy, and gastric bypass patients.
Metabolic syndrome was associated with the greatest risk for serious complications, according to the authors' regression model. Those who received the gastric band had a 2.79-fold increase in risk at 90 days, compared with bypass patients, who had a 1.34-fold increased risk.
Follow-up data at 1 year were available for a little more than half of those with metabolic syndrome (12,144 patients). The data show that the decrease in BMI was procedure dependent. The greatest decrease in mean BMI (from 51 to 32) was seen in those who had a biliopancreatic diversion. Mean BMI dropped from 46 to 39 in gastric band patients, from 49 to 36 in those who had a sleeve gastrectomy, and from 48 to 32 in those who had the bypass.
Reduction of comorbidities was also greatest in the duodenal switch group, followed by the bypass, sleeve, and gastric band procedures. For instance, diabetes resolved in 74% of patients who had the duodenal switch, compared with only 28% of those who received the band. There were big reductions in hyperlipidemia and sleep apnea for all the procedures.
The data are limited in that they are self-reported, noted Dr. Inabnet. Even so, the “study confirms the previously held hypothesis that metabolic syndrome confers increased morbidity,” said Dr. Bruce Schirmer, vice-chair of the department of surgery at the University of Virginia, Charlottesville. In discussing the paper, Dr. Schirmer noted that BOLD also seemed to show lower overall weight loss and resolution of comorbidities than was previously reported by individual institutions.
The database, however, has its advantages, said another discussant, Dr. William O. Richards, chair of the department of surgery and director of the surgical weight loss center at the University of South Alabama, Mobile. “This paper is important because it's another one of the studies emanating from prospective [collections of data across the United States] from hundreds of surgeons, and convinces me we are ever more confident in reporting results not just from a single surgeon but from actual practice,” said Dr. Richards.
He questioned whether the low mortality rate was a reflection of surgeons' opting to avoid procedures in high-risk, older obese patients, or whether it was a reflection of the success of the centers of excellence system.
Dr. Inabnet said that there were 200 patients older than age 75, and although the data are currently too young to allow the measurement of any trends, it does not seem that older patients are being operated on less often than are younger patients.
“What is the best operation? That really is the million dollar question,” he said. The data show that the Roux-en-Y procedure provides the best overall risk profile, but he added that the sleeve gastrectomy is increasing in prevalence and may eventually prove to be a good choice.
Dr. Inabnet, Dr. Schirmer, and Dr. Richards reported no conflicts.
Roux-en-Y has the best risk profile, but sleeve gastrectomy may prove to be a good choice.
Source DR. INABNET
HOT SPRINGS, VA. – An analysis of a large database of bariatric surgery patients has found that those with metabolic syndrome had dramatic improvements in comorbidities but a slightly higher rate of adverse events after 90 days.
Overall, patients with metabolic syndrome tend to be sicker and to have a greater incidence of adverse outcomes and higher mortality than do obese patients who don't have the syndrome, said Dr. William B. Inabnet III, professor of surgery at Mount Sinai School of Medicine in New York.
He and his colleagues at Mount Sinai also determined that the reduction in weight was procedure dependent. “A careful assessment of risk-benefit ratio is warranted to develop the optimal clinical pathway for treating these patients,” said Dr. Inabnet at the meeting.
The researchers examined BOLD (Bariatric Outcomes Longitudinal Database) to identify patients who had undergone bariatric surgery from June 2007 to November 2010 and had metabolic syndrome.
BOLD is maintained by the American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Center of Excellence program, and includes 1,157 surgeons at 884 hospitals. The data are self-reported, but some data are verified by on-site inspections. The surgical interventions covered in the registry include gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.
A modified scoring system (0-5) was used to assess comorbidities. For the purposes of the study, metabolic syndrome was defined as a hypertension score greater than 3, a diabetes score greater than 2, a dyslipidemia score greater than 2, and a sleep apnea score greater than 3. (Sleep apnea is not usually included in the definition of metabolic syndrome, but the researchers were interested in the condition as a comorbidity, said Dr. Inabnet.)
Overall, there were 186,567 patients in BOLD, including 23,106 patients who had metabolic syndrome. Those with metabolic syndrome were more likely than other obese patients to be male, older, and white, and to have sleep apnea and an ASA (American Society of Anesthesiologists) classification of 3 or greater. Body mass index was similar for both groups at 47 kg/m
Gastric bypass was the most commonly performed procedure, and was the preferred method in patients with metabolic syndrome, followed by gastric banding, sleeve gastrectomy, and duodenal switch. And, said Dr. Inabnet, the researchers “were truly amazed to see that the vast majority of these cases were performed with laparoscopic approaches.”
At 30 days, those with metabolic syndrome had increases in mortality, serious complications, readmissions, and reoperations, compared with other obese patients. The increases continued as time went on, and became more pronounced at 90 days post surgery, said Dr. Inabnet.
Overall mortality was very low (0.1%) for the entire cohort of 186,567 patients.
Mortality rates differed by procedure, however. The gastric band patients had the lowest rate (0.1%), followed by 1.2% for duodenal switch, 0.3% for sleeve gastrectomy, and 0.4% for gastric bypass. The serious complications, readmissions, and reoperations at 90 days were also lowest for gastric band patients, followed by duodenal switch, sleeve gastrectomy, and gastric bypass patients.
Metabolic syndrome was associated with the greatest risk for serious complications, according to the authors' regression model. Those who received the gastric band had a 2.79-fold increase in risk at 90 days, compared with bypass patients, who had a 1.34-fold increased risk.
Follow-up data at 1 year were available for a little more than half of those with metabolic syndrome (12,144 patients). The data show that the decrease in BMI was procedure dependent. The greatest decrease in mean BMI (from 51 to 32) was seen in those who had a biliopancreatic diversion. Mean BMI dropped from 46 to 39 in gastric band patients, from 49 to 36 in those who had a sleeve gastrectomy, and from 48 to 32 in those who had the bypass.
Reduction of comorbidities was also greatest in the duodenal switch group, followed by the bypass, sleeve, and gastric band procedures. For instance, diabetes resolved in 74% of patients who had the duodenal switch, compared with only 28% of those who received the band. There were big reductions in hyperlipidemia and sleep apnea for all the procedures.
The data are limited in that they are self-reported, noted Dr. Inabnet. Even so, the “study confirms the previously held hypothesis that metabolic syndrome confers increased morbidity,” said Dr. Bruce Schirmer, vice-chair of the department of surgery at the University of Virginia, Charlottesville. In discussing the paper, Dr. Schirmer noted that BOLD also seemed to show lower overall weight loss and resolution of comorbidities than was previously reported by individual institutions.
The database, however, has its advantages, said another discussant, Dr. William O. Richards, chair of the department of surgery and director of the surgical weight loss center at the University of South Alabama, Mobile. “This paper is important because it's another one of the studies emanating from prospective [collections of data across the United States] from hundreds of surgeons, and convinces me we are ever more confident in reporting results not just from a single surgeon but from actual practice,” said Dr. Richards.
He questioned whether the low mortality rate was a reflection of surgeons' opting to avoid procedures in high-risk, older obese patients, or whether it was a reflection of the success of the centers of excellence system.
Dr. Inabnet said that there were 200 patients older than age 75, and although the data are currently too young to allow the measurement of any trends, it does not seem that older patients are being operated on less often than are younger patients.
“What is the best operation? That really is the million dollar question,” he said. The data show that the Roux-en-Y procedure provides the best overall risk profile, but he added that the sleeve gastrectomy is increasing in prevalence and may eventually prove to be a good choice.
Dr. Inabnet, Dr. Schirmer, and Dr. Richards reported no conflicts.
Roux-en-Y has the best risk profile, but sleeve gastrectomy may prove to be a good choice.
Source DR. INABNET
From the Annual Meeting of the Southern Surgical Association
Tennessee Hospitals Cut Costs While Improving Outcomes
HOT SPRINGS, VA. – A collaboration among 10 hospitals in Tennessee has produced a boost in quality of care while also saving millions of dollars.
The collaboration first got started in 2005, when the three initial participants – Erlanger Medical Center in Chattanooga, Vanderbilt University Medical Center in Nashville, and St. Francis Hospital–Memphis – took inspiration from the rollout of the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP), said Dr. Joseph B. Cofer, a professor of surgery at the University of Tennessee, Chattanooga.
A successful run so far has led BlueCross Blue Shield of Tennessee (which has bankrolled the operation) to extend its funding through 2012 for the 10 hospitals that are currently participating, said Dr. Cofer. And it made funds available for an additional 11 hospitals to join, which would bring the total to 21.
With data now complete for 2009 and 2010, the Tennessee Surgical Quality Collaborative reported that postoperative mortality was not statistically significantly different from the first year (2.32%, or 232/10,000) to the second year (2.38%, or 237/10,000).
However, significant declines in postoperative complications in five areas – acute renal failure (25% drop), graft/flap failure (60% drop), ventilation for more than 48 hours (15% drop), superficial incisional surgical-site infection (19% drop), and wound disruption (34% drop) – resulted in total savings of $4.47 million.
At the same time, increases in postoperative complications in three areas – urinary tract infection (42% rise), pneumonia (23% rise), and deep vein thrombosis (35% rise) – cost $2.1 million.
Overall, the savings were at least $2 million for the 10 participating hospitals, said Dr. Cofer. But that number reflects only a sampling of cases from the 10 hospitals; if all the cases had been included, "we can reliably say we probably avoided about $8 million in costs over this year," Dr. Cofer said.
"Why this happened, we don’t know," he added. It’s possible that just being part of the NSQIP process improves monitoring and outcomes.
The Tennessee collaborative is now identifying exemplar hospitals and "sending out teams to dissect how they did it so well," Dr. Cofer said. Then, those best practices will be disseminated to other hospitals in the collaborative.
The collaboration would not likely have been possible without the participation of BlueCross BlueShield of Tennessee. Dr. Cofer spearheaded the talks with the insurer, which began in 2006 and culminated in a three-way partnership among the Blues, the Tennessee chapter of the ACS, and the Tennessee Hospital Association. In 2008, the Blues announced that it was giving the collaboration $2.5 million over the next 3 years to fund the collaborative.
Another crucial element was the leadership committee, said Dr. Cofer. Of the seven committee members, four are surgeons, two are hospital CEOs, and one is a staff person from the Tennessee Hospital Association. Data cannot be released without permission of the committee, and, so far, specific data are not being shared.
Dr. J. David Richardson, a discussant and chairman of the NSQIP committee at ACS, said, "it takes a tremendous effort to put a group like this together," adding that "within the ACS, I think we’ve all been heartened by the initiative taken by the Tennessee chapter in developing this program." The ACS is looking to expand the program, particularly beyond Veterans Affairs hospitals, said Dr. Richardson, professor and vice chairman of surgery at the University of Louisville (Ky.). The collaborative model is a way to spread the cost, so it may entice more participants, he said.
"This is a provocative paper because it should provoke us to follow suit," Dr. Joseph J. Tepas III, professor of surgery at the University of Florida, Jacksonville, said in his discussion of the paper. "This report demonstrates that this engine of quality, fueled by real-time clinical data, produces results that are understandable to the nonphysician public."
He added that just participating in NSQIP likely improved the hospitals’ quality. "The power of NSQIP is, first, in its surveillance, and this is what’s so well demonstrated here," he said.
Dr. Tepas, Dr. Richardson, and several other discussants asked why there had been improvement in some clinical areas but not in others. Was this perhaps a change in surgical leadership, or – as Dr. Cofer suggested – the Hawthorne effect (that is, the tendency of outcomes to improve when participants – in this case, hospitals and surgeons – know they are being monitored)?
Lead author Dr. Oscar Guillamondegui had an answer: "There have been no real changes in leadership at any of these hospitals, but if you think about the cost of putting together a NSQIP program – other than for the large hospitals – for many of these hospitals, it’s a bottom-line item that’s not insubstantial," he said. "Most hospitals will push to have improvement of care just based on the fact they’re putting that kind of funding into a system," said Dr. Guillamondegui of the division of trauma and surgical critical care at Vanderbilt University Medical Center. He also surmised that the Hawthorne effect may have played a part.
Some outcomes got worse, likely because of natural variations, but also because NSQIP definitions are strict and include a 30-day window, he said. For instance, more than half of urinary tract infections happen outside the hospital, but if they occur within 30 days of admission, they fall within the NSQIP 30-day morbidity outcome window.
Going forward, sustaining such collaboratives could be difficult, said Dr. Guillamondegui. "If you have a weak surgeon champion, then the program does nothing," especially if data are not being shared with other surgeons or the hospital administration. "If your culture isn’t capable of sustaining this, it will fail."
Dr. Cofer, Dr. Tepas, and Dr. Guillamondegui reported no conflicts. Dr. Richardson chairs the ACS NSQIP committee.
HOT SPRINGS, VA. – A collaboration among 10 hospitals in Tennessee has produced a boost in quality of care while also saving millions of dollars.
The collaboration first got started in 2005, when the three initial participants – Erlanger Medical Center in Chattanooga, Vanderbilt University Medical Center in Nashville, and St. Francis Hospital–Memphis – took inspiration from the rollout of the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP), said Dr. Joseph B. Cofer, a professor of surgery at the University of Tennessee, Chattanooga.
A successful run so far has led BlueCross Blue Shield of Tennessee (which has bankrolled the operation) to extend its funding through 2012 for the 10 hospitals that are currently participating, said Dr. Cofer. And it made funds available for an additional 11 hospitals to join, which would bring the total to 21.
With data now complete for 2009 and 2010, the Tennessee Surgical Quality Collaborative reported that postoperative mortality was not statistically significantly different from the first year (2.32%, or 232/10,000) to the second year (2.38%, or 237/10,000).
However, significant declines in postoperative complications in five areas – acute renal failure (25% drop), graft/flap failure (60% drop), ventilation for more than 48 hours (15% drop), superficial incisional surgical-site infection (19% drop), and wound disruption (34% drop) – resulted in total savings of $4.47 million.
At the same time, increases in postoperative complications in three areas – urinary tract infection (42% rise), pneumonia (23% rise), and deep vein thrombosis (35% rise) – cost $2.1 million.
Overall, the savings were at least $2 million for the 10 participating hospitals, said Dr. Cofer. But that number reflects only a sampling of cases from the 10 hospitals; if all the cases had been included, "we can reliably say we probably avoided about $8 million in costs over this year," Dr. Cofer said.
"Why this happened, we don’t know," he added. It’s possible that just being part of the NSQIP process improves monitoring and outcomes.
The Tennessee collaborative is now identifying exemplar hospitals and "sending out teams to dissect how they did it so well," Dr. Cofer said. Then, those best practices will be disseminated to other hospitals in the collaborative.
The collaboration would not likely have been possible without the participation of BlueCross BlueShield of Tennessee. Dr. Cofer spearheaded the talks with the insurer, which began in 2006 and culminated in a three-way partnership among the Blues, the Tennessee chapter of the ACS, and the Tennessee Hospital Association. In 2008, the Blues announced that it was giving the collaboration $2.5 million over the next 3 years to fund the collaborative.
Another crucial element was the leadership committee, said Dr. Cofer. Of the seven committee members, four are surgeons, two are hospital CEOs, and one is a staff person from the Tennessee Hospital Association. Data cannot be released without permission of the committee, and, so far, specific data are not being shared.
Dr. J. David Richardson, a discussant and chairman of the NSQIP committee at ACS, said, "it takes a tremendous effort to put a group like this together," adding that "within the ACS, I think we’ve all been heartened by the initiative taken by the Tennessee chapter in developing this program." The ACS is looking to expand the program, particularly beyond Veterans Affairs hospitals, said Dr. Richardson, professor and vice chairman of surgery at the University of Louisville (Ky.). The collaborative model is a way to spread the cost, so it may entice more participants, he said.
"This is a provocative paper because it should provoke us to follow suit," Dr. Joseph J. Tepas III, professor of surgery at the University of Florida, Jacksonville, said in his discussion of the paper. "This report demonstrates that this engine of quality, fueled by real-time clinical data, produces results that are understandable to the nonphysician public."
He added that just participating in NSQIP likely improved the hospitals’ quality. "The power of NSQIP is, first, in its surveillance, and this is what’s so well demonstrated here," he said.
Dr. Tepas, Dr. Richardson, and several other discussants asked why there had been improvement in some clinical areas but not in others. Was this perhaps a change in surgical leadership, or – as Dr. Cofer suggested – the Hawthorne effect (that is, the tendency of outcomes to improve when participants – in this case, hospitals and surgeons – know they are being monitored)?
Lead author Dr. Oscar Guillamondegui had an answer: "There have been no real changes in leadership at any of these hospitals, but if you think about the cost of putting together a NSQIP program – other than for the large hospitals – for many of these hospitals, it’s a bottom-line item that’s not insubstantial," he said. "Most hospitals will push to have improvement of care just based on the fact they’re putting that kind of funding into a system," said Dr. Guillamondegui of the division of trauma and surgical critical care at Vanderbilt University Medical Center. He also surmised that the Hawthorne effect may have played a part.
Some outcomes got worse, likely because of natural variations, but also because NSQIP definitions are strict and include a 30-day window, he said. For instance, more than half of urinary tract infections happen outside the hospital, but if they occur within 30 days of admission, they fall within the NSQIP 30-day morbidity outcome window.
Going forward, sustaining such collaboratives could be difficult, said Dr. Guillamondegui. "If you have a weak surgeon champion, then the program does nothing," especially if data are not being shared with other surgeons or the hospital administration. "If your culture isn’t capable of sustaining this, it will fail."
Dr. Cofer, Dr. Tepas, and Dr. Guillamondegui reported no conflicts. Dr. Richardson chairs the ACS NSQIP committee.
HOT SPRINGS, VA. – A collaboration among 10 hospitals in Tennessee has produced a boost in quality of care while also saving millions of dollars.
The collaboration first got started in 2005, when the three initial participants – Erlanger Medical Center in Chattanooga, Vanderbilt University Medical Center in Nashville, and St. Francis Hospital–Memphis – took inspiration from the rollout of the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP), said Dr. Joseph B. Cofer, a professor of surgery at the University of Tennessee, Chattanooga.
A successful run so far has led BlueCross Blue Shield of Tennessee (which has bankrolled the operation) to extend its funding through 2012 for the 10 hospitals that are currently participating, said Dr. Cofer. And it made funds available for an additional 11 hospitals to join, which would bring the total to 21.
With data now complete for 2009 and 2010, the Tennessee Surgical Quality Collaborative reported that postoperative mortality was not statistically significantly different from the first year (2.32%, or 232/10,000) to the second year (2.38%, or 237/10,000).
However, significant declines in postoperative complications in five areas – acute renal failure (25% drop), graft/flap failure (60% drop), ventilation for more than 48 hours (15% drop), superficial incisional surgical-site infection (19% drop), and wound disruption (34% drop) – resulted in total savings of $4.47 million.
At the same time, increases in postoperative complications in three areas – urinary tract infection (42% rise), pneumonia (23% rise), and deep vein thrombosis (35% rise) – cost $2.1 million.
Overall, the savings were at least $2 million for the 10 participating hospitals, said Dr. Cofer. But that number reflects only a sampling of cases from the 10 hospitals; if all the cases had been included, "we can reliably say we probably avoided about $8 million in costs over this year," Dr. Cofer said.
"Why this happened, we don’t know," he added. It’s possible that just being part of the NSQIP process improves monitoring and outcomes.
The Tennessee collaborative is now identifying exemplar hospitals and "sending out teams to dissect how they did it so well," Dr. Cofer said. Then, those best practices will be disseminated to other hospitals in the collaborative.
The collaboration would not likely have been possible without the participation of BlueCross BlueShield of Tennessee. Dr. Cofer spearheaded the talks with the insurer, which began in 2006 and culminated in a three-way partnership among the Blues, the Tennessee chapter of the ACS, and the Tennessee Hospital Association. In 2008, the Blues announced that it was giving the collaboration $2.5 million over the next 3 years to fund the collaborative.
Another crucial element was the leadership committee, said Dr. Cofer. Of the seven committee members, four are surgeons, two are hospital CEOs, and one is a staff person from the Tennessee Hospital Association. Data cannot be released without permission of the committee, and, so far, specific data are not being shared.
Dr. J. David Richardson, a discussant and chairman of the NSQIP committee at ACS, said, "it takes a tremendous effort to put a group like this together," adding that "within the ACS, I think we’ve all been heartened by the initiative taken by the Tennessee chapter in developing this program." The ACS is looking to expand the program, particularly beyond Veterans Affairs hospitals, said Dr. Richardson, professor and vice chairman of surgery at the University of Louisville (Ky.). The collaborative model is a way to spread the cost, so it may entice more participants, he said.
"This is a provocative paper because it should provoke us to follow suit," Dr. Joseph J. Tepas III, professor of surgery at the University of Florida, Jacksonville, said in his discussion of the paper. "This report demonstrates that this engine of quality, fueled by real-time clinical data, produces results that are understandable to the nonphysician public."
He added that just participating in NSQIP likely improved the hospitals’ quality. "The power of NSQIP is, first, in its surveillance, and this is what’s so well demonstrated here," he said.
Dr. Tepas, Dr. Richardson, and several other discussants asked why there had been improvement in some clinical areas but not in others. Was this perhaps a change in surgical leadership, or – as Dr. Cofer suggested – the Hawthorne effect (that is, the tendency of outcomes to improve when participants – in this case, hospitals and surgeons – know they are being monitored)?
Lead author Dr. Oscar Guillamondegui had an answer: "There have been no real changes in leadership at any of these hospitals, but if you think about the cost of putting together a NSQIP program – other than for the large hospitals – for many of these hospitals, it’s a bottom-line item that’s not insubstantial," he said. "Most hospitals will push to have improvement of care just based on the fact they’re putting that kind of funding into a system," said Dr. Guillamondegui of the division of trauma and surgical critical care at Vanderbilt University Medical Center. He also surmised that the Hawthorne effect may have played a part.
Some outcomes got worse, likely because of natural variations, but also because NSQIP definitions are strict and include a 30-day window, he said. For instance, more than half of urinary tract infections happen outside the hospital, but if they occur within 30 days of admission, they fall within the NSQIP 30-day morbidity outcome window.
Going forward, sustaining such collaboratives could be difficult, said Dr. Guillamondegui. "If you have a weak surgeon champion, then the program does nothing," especially if data are not being shared with other surgeons or the hospital administration. "If your culture isn’t capable of sustaining this, it will fail."
Dr. Cofer, Dr. Tepas, and Dr. Guillamondegui reported no conflicts. Dr. Richardson chairs the ACS NSQIP committee.
FROM THE ANNUAL MEETING OF THE SOUTHERN SURGICAL ASSOCIATION
Major Finding: The Tennessee Surgical Quality Collaborative saw significant improvements in some patient outcomes, and saved as much as $8 million in its first year.
Data Source: Data collected from the 10 hospitals participating in the collaborative.
Disclosures: Dr. Cofer, Dr. Tepas, and Dr. Guillamondegui reported no conflicts. Dr. Richardson chairs the ACS NSQIP committee.
Impaired Cognition in Elderly Impacts Postoperative Outcomes
Impaired cognition among older adults who undergo elective surgery is significantly associated with adverse postoperative outcomes, including increased complications, length of stay, and long-term mortality, results from a single-center study showed.
In addition, delirium was found to be an effect modifier in the relationship between impaired cognition and adverse postoperative outcomes.
"The most striking finding is that delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality," lead investigator Dr. Thomas N. Robinson said in an interview before the annual meeting of the Western Surgical Association, where the work was presented.
In what he said is the first study of its kind, Dr. Robinson, of the department of surgery at the University of Colorado, Denver, and his associates prospectively evaluated 186 adults aged 65 and older who underwent an elective operation requiring postoperative ICU admission.
To assess preoperative baseline cognitive function, they used the validated Mini-Cog test, which combines an uncued three-item recall test with a clock drawing task. Impaired cognition was defined as a Mini-Cog score of 3 or less.
To assess delirium, the researchers used the Confusion Assessment Method for the ICU, a validated tool that evaluates delirium based on fluctuation in mental status, inattention, disorganized thinking, and altered level of consciousness.
"Delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality."
To determine adverse outcomes, they used definitions from the Veterans Affairs Surgical Quality Improvement Program.
Dr. Robinson, who also holds an appointment in the department of surgery at the Denver Veterans Affairs Medical Center, reported that the mean age of the 186 patients was 73 years and 96% were male. Nearly half (44%) had impaired cognition.
Compared with their counterparts who had normal cognition at baseline, those with impaired cognition had a higher rate of one or more complications (41% vs. 24%, respectively), a higher incidence of delirium (78% vs. 37%), longer hospital stays (a mean of 15 vs. 9 days), a higher rate of discharge to an institutional care facility (42% vs. 18%), a higher 30-day readmission rate (21% vs. 10%), and a higher 6-month mortality (11% vs. 5%). All differences were statistically significant.
Dr. Robinson also reported that the hazard ratio for death was 2.77 higher among patients with impaired cognition and delirium at baseline compared with patients with normal cognition and delirium. On the other hand, the hazard ratio for death was 1.86 times higher among patients who had impaired cognitive function but no delirium at baseline.
In their abstract, the researchers noted certain limitations of the study, including the fact that nearly all patients were male and that a wide variety of operations were included, which "leads to large variability in measurements such as blood loss, operating room time, and length of stay."
They went on to conclude that "recognition of the brain’s function as a relevant marker of postoperative events has implications on the clinician’s ability to counsel their older patients about the anticipated postoperative course. In the future, preoperative risk stratification will likely not be based on physiologic compromise of a single organ system alone. Instead, the sum of compromise across multiple health-related domains (e.g., cognition, function, nutrition, disease burden) will likely be used to forecast postoperative outcomes."
The study received financial support from the National Institute on Aging and the American Geriatrics Society. Dr. Robinson said that he had no relevant financial disclosures.
This study further corroborates what we already know, in that patients with baseline cognitive dysfunction are at significant risk of delirium when hospitalized, with increased morbidity and mortality that can extend several months beyond the hospital stay. Because persons over age 65 comprise the fastest-growing population, this is going to be an increasing issue as time goes on.
|
| Dr. Stacie Levine |
This also highlights the importance of a global assessment when conducting preoperative assessments on older adults. We are skilled at medical clearance with regards to cardiac status, but also need to consider the brain as being another “at-risk” organ. The identification of persons with underlying cognitive dysfunction should lead to thoughtful decisions regarding perioperiative risk-reduction, such as route/type of anesthesia, type of surgical procedure, and delirium prevention strategies. By doing a risk-benefit calculation we can consider the best route of care for each patient, including whether they are a good candidate for surgery at all. In summary, preoperative assessment of older adults requires a global evaluation that includes not only cardiac risk assessment, but also standardized cognitive and functional assessments.
The next question is how to effectively risk-stratify and make clinical decisions based on patients’ level of cognitive dysfunction. For example, at what level of cognitive impairment do we decide a person is not a good candidate for surgery? Or, which surgical patients should be placed on more resource-intensive delirium risk prevention protocols? As a geriatrician, I identify and attempt to modify all potential factors that can put any older adult at risk for delirium such as sensory impairment, dehydration, and certain medications. Dr. Sharon Inouye’s Hospital Elder Life Program (HELP) is an example of a successful program in reducing incidence of delirium by proactively using preventative strategies. Ideally every hospital should have some version of this model in place for all older adults, but at the very least targeting medical and surgical patients deemed to be at highest risk.
STACIE LEVINE, M.D., is an associate professor of medicine in the section of geriatrics and palliative medicine at University of Chicago. She was core faculty in the development and implementation of the Curriculum for the Hospitalized Aging Medical Patient.
This study further corroborates what we already know, in that patients with baseline cognitive dysfunction are at significant risk of delirium when hospitalized, with increased morbidity and mortality that can extend several months beyond the hospital stay. Because persons over age 65 comprise the fastest-growing population, this is going to be an increasing issue as time goes on.
|
|
| Dr. Stacie Levine |
This also highlights the importance of a global assessment when conducting preoperative assessments on older adults. We are skilled at medical clearance with regards to cardiac status, but also need to consider the brain as being another “at-risk” organ. The identification of persons with underlying cognitive dysfunction should lead to thoughtful decisions regarding perioperiative risk-reduction, such as route/type of anesthesia, type of surgical procedure, and delirium prevention strategies. By doing a risk-benefit calculation we can consider the best route of care for each patient, including whether they are a good candidate for surgery at all. In summary, preoperative assessment of older adults requires a global evaluation that includes not only cardiac risk assessment, but also standardized cognitive and functional assessments.
The next question is how to effectively risk-stratify and make clinical decisions based on patients’ level of cognitive dysfunction. For example, at what level of cognitive impairment do we decide a person is not a good candidate for surgery? Or, which surgical patients should be placed on more resource-intensive delirium risk prevention protocols? As a geriatrician, I identify and attempt to modify all potential factors that can put any older adult at risk for delirium such as sensory impairment, dehydration, and certain medications. Dr. Sharon Inouye’s Hospital Elder Life Program (HELP) is an example of a successful program in reducing incidence of delirium by proactively using preventative strategies. Ideally every hospital should have some version of this model in place for all older adults, but at the very least targeting medical and surgical patients deemed to be at highest risk.
STACIE LEVINE, M.D., is an associate professor of medicine in the section of geriatrics and palliative medicine at University of Chicago. She was core faculty in the development and implementation of the Curriculum for the Hospitalized Aging Medical Patient.
This study further corroborates what we already know, in that patients with baseline cognitive dysfunction are at significant risk of delirium when hospitalized, with increased morbidity and mortality that can extend several months beyond the hospital stay. Because persons over age 65 comprise the fastest-growing population, this is going to be an increasing issue as time goes on.
|
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| Dr. Stacie Levine |
This also highlights the importance of a global assessment when conducting preoperative assessments on older adults. We are skilled at medical clearance with regards to cardiac status, but also need to consider the brain as being another “at-risk” organ. The identification of persons with underlying cognitive dysfunction should lead to thoughtful decisions regarding perioperiative risk-reduction, such as route/type of anesthesia, type of surgical procedure, and delirium prevention strategies. By doing a risk-benefit calculation we can consider the best route of care for each patient, including whether they are a good candidate for surgery at all. In summary, preoperative assessment of older adults requires a global evaluation that includes not only cardiac risk assessment, but also standardized cognitive and functional assessments.
The next question is how to effectively risk-stratify and make clinical decisions based on patients’ level of cognitive dysfunction. For example, at what level of cognitive impairment do we decide a person is not a good candidate for surgery? Or, which surgical patients should be placed on more resource-intensive delirium risk prevention protocols? As a geriatrician, I identify and attempt to modify all potential factors that can put any older adult at risk for delirium such as sensory impairment, dehydration, and certain medications. Dr. Sharon Inouye’s Hospital Elder Life Program (HELP) is an example of a successful program in reducing incidence of delirium by proactively using preventative strategies. Ideally every hospital should have some version of this model in place for all older adults, but at the very least targeting medical and surgical patients deemed to be at highest risk.
STACIE LEVINE, M.D., is an associate professor of medicine in the section of geriatrics and palliative medicine at University of Chicago. She was core faculty in the development and implementation of the Curriculum for the Hospitalized Aging Medical Patient.
Impaired cognition among older adults who undergo elective surgery is significantly associated with adverse postoperative outcomes, including increased complications, length of stay, and long-term mortality, results from a single-center study showed.
In addition, delirium was found to be an effect modifier in the relationship between impaired cognition and adverse postoperative outcomes.
"The most striking finding is that delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality," lead investigator Dr. Thomas N. Robinson said in an interview before the annual meeting of the Western Surgical Association, where the work was presented.
In what he said is the first study of its kind, Dr. Robinson, of the department of surgery at the University of Colorado, Denver, and his associates prospectively evaluated 186 adults aged 65 and older who underwent an elective operation requiring postoperative ICU admission.
To assess preoperative baseline cognitive function, they used the validated Mini-Cog test, which combines an uncued three-item recall test with a clock drawing task. Impaired cognition was defined as a Mini-Cog score of 3 or less.
To assess delirium, the researchers used the Confusion Assessment Method for the ICU, a validated tool that evaluates delirium based on fluctuation in mental status, inattention, disorganized thinking, and altered level of consciousness.
"Delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality."
To determine adverse outcomes, they used definitions from the Veterans Affairs Surgical Quality Improvement Program.
Dr. Robinson, who also holds an appointment in the department of surgery at the Denver Veterans Affairs Medical Center, reported that the mean age of the 186 patients was 73 years and 96% were male. Nearly half (44%) had impaired cognition.
Compared with their counterparts who had normal cognition at baseline, those with impaired cognition had a higher rate of one or more complications (41% vs. 24%, respectively), a higher incidence of delirium (78% vs. 37%), longer hospital stays (a mean of 15 vs. 9 days), a higher rate of discharge to an institutional care facility (42% vs. 18%), a higher 30-day readmission rate (21% vs. 10%), and a higher 6-month mortality (11% vs. 5%). All differences were statistically significant.
Dr. Robinson also reported that the hazard ratio for death was 2.77 higher among patients with impaired cognition and delirium at baseline compared with patients with normal cognition and delirium. On the other hand, the hazard ratio for death was 1.86 times higher among patients who had impaired cognitive function but no delirium at baseline.
In their abstract, the researchers noted certain limitations of the study, including the fact that nearly all patients were male and that a wide variety of operations were included, which "leads to large variability in measurements such as blood loss, operating room time, and length of stay."
They went on to conclude that "recognition of the brain’s function as a relevant marker of postoperative events has implications on the clinician’s ability to counsel their older patients about the anticipated postoperative course. In the future, preoperative risk stratification will likely not be based on physiologic compromise of a single organ system alone. Instead, the sum of compromise across multiple health-related domains (e.g., cognition, function, nutrition, disease burden) will likely be used to forecast postoperative outcomes."
The study received financial support from the National Institute on Aging and the American Geriatrics Society. Dr. Robinson said that he had no relevant financial disclosures.
Impaired cognition among older adults who undergo elective surgery is significantly associated with adverse postoperative outcomes, including increased complications, length of stay, and long-term mortality, results from a single-center study showed.
In addition, delirium was found to be an effect modifier in the relationship between impaired cognition and adverse postoperative outcomes.
"The most striking finding is that delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality," lead investigator Dr. Thomas N. Robinson said in an interview before the annual meeting of the Western Surgical Association, where the work was presented.
In what he said is the first study of its kind, Dr. Robinson, of the department of surgery at the University of Colorado, Denver, and his associates prospectively evaluated 186 adults aged 65 and older who underwent an elective operation requiring postoperative ICU admission.
To assess preoperative baseline cognitive function, they used the validated Mini-Cog test, which combines an uncued three-item recall test with a clock drawing task. Impaired cognition was defined as a Mini-Cog score of 3 or less.
To assess delirium, the researchers used the Confusion Assessment Method for the ICU, a validated tool that evaluates delirium based on fluctuation in mental status, inattention, disorganized thinking, and altered level of consciousness.
"Delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality."
To determine adverse outcomes, they used definitions from the Veterans Affairs Surgical Quality Improvement Program.
Dr. Robinson, who also holds an appointment in the department of surgery at the Denver Veterans Affairs Medical Center, reported that the mean age of the 186 patients was 73 years and 96% were male. Nearly half (44%) had impaired cognition.
Compared with their counterparts who had normal cognition at baseline, those with impaired cognition had a higher rate of one or more complications (41% vs. 24%, respectively), a higher incidence of delirium (78% vs. 37%), longer hospital stays (a mean of 15 vs. 9 days), a higher rate of discharge to an institutional care facility (42% vs. 18%), a higher 30-day readmission rate (21% vs. 10%), and a higher 6-month mortality (11% vs. 5%). All differences were statistically significant.
Dr. Robinson also reported that the hazard ratio for death was 2.77 higher among patients with impaired cognition and delirium at baseline compared with patients with normal cognition and delirium. On the other hand, the hazard ratio for death was 1.86 times higher among patients who had impaired cognitive function but no delirium at baseline.
In their abstract, the researchers noted certain limitations of the study, including the fact that nearly all patients were male and that a wide variety of operations were included, which "leads to large variability in measurements such as blood loss, operating room time, and length of stay."
They went on to conclude that "recognition of the brain’s function as a relevant marker of postoperative events has implications on the clinician’s ability to counsel their older patients about the anticipated postoperative course. In the future, preoperative risk stratification will likely not be based on physiologic compromise of a single organ system alone. Instead, the sum of compromise across multiple health-related domains (e.g., cognition, function, nutrition, disease burden) will likely be used to forecast postoperative outcomes."
The study received financial support from the National Institute on Aging and the American Geriatrics Society. Dr. Robinson said that he had no relevant financial disclosures.
Major Finding: Compared with their counterparts who had normal cognition at baseline, those who had impaired cognition had a higher rate of one or more postoperative complications (41% vs. 24%, respectively), a higher incidence of delirium (78% vs. 37%), longer hospital stays (a mean of 15 vs. 9 days), and a higher 6-month mortality (11% vs. 5%). All differences were statistically significant.
Data Source: A prospective study of 186 adults aged 65 and older who underwent an elective operation that required postoperative ICU admission.
Disclosures: Dr. Robinson said that he had no relevant financial disclosures. The study received financial support from the National Institute on Aging and the American Geriatrics Society.
Bariatric Surgery Recipients' Family Members Slim Down
Major Finding: Obese adults and children residing with bariatric surgery patients showed significant reductions in weight, BMI, and waist circumference; improved eating habits; and increased physical activity during the year following the procedure.
Data Source: A prospective, 1-year study of weight and lifestyle changes among 35 bariatric surgery patients, 26 spouses, 3 grandparents, 6 adult children, and 15 children younger than age 18 years.
Disclosures: This study was supported by the Medical Scholars Program at Stanford University. No financial conflicts of interest were reported.
Bariatric surgery appears to exert a favorable influence on family members of the recipient, leading to weight loss, healthier eating habits, and greater activity levels among adults and children residing with the patient, according to the results of a prospective, longitudinal study.
“Previous studies have shown that obesity may be a social contagion and that by associating with obese individuals, a person is more likely to become obese. Our study may demonstrate that bariatric surgery in selected populations can provide a reverse corollary and induce weight loss and healthy behaviors in people surrounding the patient,” according to Dr. Gavitt A. Woodard and her associates at Stanford (Calif.) University.
The investigators assessed weight and lifestyle changes in spouses, parents, and children who were residing with patients during the year after the patients underwent Roux-en-Y gastric bypass surgery. They enrolled 35 families, including 35 patients, 26 spouses, 3 grandparents, 6 adult children, and 15 children younger than age 18 years during a 2-year period.
Both patients and family members were required to attend three preoperative educational sessions and five postoperative visits in which lifestyle modification was emphasized.
A high-protein, high-fiber, low-fat, low-sugar diet was recommended for the patients, which advised six small daily meals comprising 200-300 calories and including 4-6 ounces of protein.
Lifestyle modification included daily goals of increased physical activity (10,000 steps per day), 8 hours of sleep, moderation of alcohol intake, and avoidance of watching more than 2 hours of television.
After 1 year, the study subjects were evaluated by a physical examination as well as a battery of validated questionnaires assessing overall health, physical activity, sleep, risk behaviors, television viewing, alcohol consumption, and quality of life.
The gastric bypass patients lost weight as expected.
The mean weight of adult family members declined from 220 to 198 pounds, which was not statistically significant. However, when the family members were categorized by their own baseline weight, significant differences emerged.
Obese adult family members showed significant weight loss, from a mean of 234 to 226 pounds. Nonobese adult family members showed a nonsignificant weight loss from 180 to 176 pounds. This pattern held true for decreases in body mass index as well, Dr. Woodard and her associates wrote.
The pattern also was the same for waist circumference, with obese adult family members showing a significant decrease from a mean of 119 cm to 111 cm and nonobese adult family members showing no change in waist circumference.
According to these findings, obese adult family members lost 3% of their total weight in 1 year, which falls within the range of a 2%-5% weight loss reported for people following the Atkins, Zone, Ornish, or LEARN diets. “Living with a gastric bypass patient and undertaking a structured diet plan along with the patient may have an equivalent effect on weight,” the investigators said (Arch. Surg. 2011;146:1185-90).
Children were analyzed separately because of the expectation that their weight and waist circumference would increase because of natural growth.
Given the growth trajectories documented in their medical charts, obese children actually showed a smaller increase in BMI (29.6) than was expected (31.2). Nonobese children showed a slightly larger increase in BMI (19.8) than was expected (18.8).
As with the adult family members, children who were obese showed a significant reduction in waist circumference, from 119 cm to 111 cm, but nonobese children did not show any change in waist circumference.
Patients and their adult family members showed significant changes in their eating habits. Both groups had marked decreases in “uncontrolled eating” and in “emotional eating.” In addition, patients, but not their relatives, showed significantly increased “cognitive control of eating,” Dr. Woodard and her associates said.
However, children showed no changes in these measures. And neither adult family members nor children changed their food choices or decreased their intake of carbohydrates or junk food, while patients did achieve these goals, they reported.
Yet there was a significant increase in the percentage of children who reported that they were “on a diet,” from 25% at baseline to 50% at 1 year.
Patients and their adult family members reported significant declines in alcohol consumption, from 5 to 0.2 drinks per month among patients and from 11 to 0.8 drinks per month among adult family members.
Patients, adult relatives, and children all showed significant gains in daily activity levels. Children also decreased the amount of time they spent watching TV or using a computer every day, although this reduction did not reach statistical significance.
Overall, the study findings indicate that “bariatric surgery provides an opportunity for intervention for many individuals beyond the patient,” Dr. Woodard and her associates said.
Major Finding: Obese adults and children residing with bariatric surgery patients showed significant reductions in weight, BMI, and waist circumference; improved eating habits; and increased physical activity during the year following the procedure.
Data Source: A prospective, 1-year study of weight and lifestyle changes among 35 bariatric surgery patients, 26 spouses, 3 grandparents, 6 adult children, and 15 children younger than age 18 years.
Disclosures: This study was supported by the Medical Scholars Program at Stanford University. No financial conflicts of interest were reported.
Bariatric surgery appears to exert a favorable influence on family members of the recipient, leading to weight loss, healthier eating habits, and greater activity levels among adults and children residing with the patient, according to the results of a prospective, longitudinal study.
“Previous studies have shown that obesity may be a social contagion and that by associating with obese individuals, a person is more likely to become obese. Our study may demonstrate that bariatric surgery in selected populations can provide a reverse corollary and induce weight loss and healthy behaviors in people surrounding the patient,” according to Dr. Gavitt A. Woodard and her associates at Stanford (Calif.) University.
The investigators assessed weight and lifestyle changes in spouses, parents, and children who were residing with patients during the year after the patients underwent Roux-en-Y gastric bypass surgery. They enrolled 35 families, including 35 patients, 26 spouses, 3 grandparents, 6 adult children, and 15 children younger than age 18 years during a 2-year period.
Both patients and family members were required to attend three preoperative educational sessions and five postoperative visits in which lifestyle modification was emphasized.
A high-protein, high-fiber, low-fat, low-sugar diet was recommended for the patients, which advised six small daily meals comprising 200-300 calories and including 4-6 ounces of protein.
Lifestyle modification included daily goals of increased physical activity (10,000 steps per day), 8 hours of sleep, moderation of alcohol intake, and avoidance of watching more than 2 hours of television.
After 1 year, the study subjects were evaluated by a physical examination as well as a battery of validated questionnaires assessing overall health, physical activity, sleep, risk behaviors, television viewing, alcohol consumption, and quality of life.
The gastric bypass patients lost weight as expected.
The mean weight of adult family members declined from 220 to 198 pounds, which was not statistically significant. However, when the family members were categorized by their own baseline weight, significant differences emerged.
Obese adult family members showed significant weight loss, from a mean of 234 to 226 pounds. Nonobese adult family members showed a nonsignificant weight loss from 180 to 176 pounds. This pattern held true for decreases in body mass index as well, Dr. Woodard and her associates wrote.
The pattern also was the same for waist circumference, with obese adult family members showing a significant decrease from a mean of 119 cm to 111 cm and nonobese adult family members showing no change in waist circumference.
According to these findings, obese adult family members lost 3% of their total weight in 1 year, which falls within the range of a 2%-5% weight loss reported for people following the Atkins, Zone, Ornish, or LEARN diets. “Living with a gastric bypass patient and undertaking a structured diet plan along with the patient may have an equivalent effect on weight,” the investigators said (Arch. Surg. 2011;146:1185-90).
Children were analyzed separately because of the expectation that their weight and waist circumference would increase because of natural growth.
Given the growth trajectories documented in their medical charts, obese children actually showed a smaller increase in BMI (29.6) than was expected (31.2). Nonobese children showed a slightly larger increase in BMI (19.8) than was expected (18.8).
As with the adult family members, children who were obese showed a significant reduction in waist circumference, from 119 cm to 111 cm, but nonobese children did not show any change in waist circumference.
Patients and their adult family members showed significant changes in their eating habits. Both groups had marked decreases in “uncontrolled eating” and in “emotional eating.” In addition, patients, but not their relatives, showed significantly increased “cognitive control of eating,” Dr. Woodard and her associates said.
However, children showed no changes in these measures. And neither adult family members nor children changed their food choices or decreased their intake of carbohydrates or junk food, while patients did achieve these goals, they reported.
Yet there was a significant increase in the percentage of children who reported that they were “on a diet,” from 25% at baseline to 50% at 1 year.
Patients and their adult family members reported significant declines in alcohol consumption, from 5 to 0.2 drinks per month among patients and from 11 to 0.8 drinks per month among adult family members.
Patients, adult relatives, and children all showed significant gains in daily activity levels. Children also decreased the amount of time they spent watching TV or using a computer every day, although this reduction did not reach statistical significance.
Overall, the study findings indicate that “bariatric surgery provides an opportunity for intervention for many individuals beyond the patient,” Dr. Woodard and her associates said.
Major Finding: Obese adults and children residing with bariatric surgery patients showed significant reductions in weight, BMI, and waist circumference; improved eating habits; and increased physical activity during the year following the procedure.
Data Source: A prospective, 1-year study of weight and lifestyle changes among 35 bariatric surgery patients, 26 spouses, 3 grandparents, 6 adult children, and 15 children younger than age 18 years.
Disclosures: This study was supported by the Medical Scholars Program at Stanford University. No financial conflicts of interest were reported.
Bariatric surgery appears to exert a favorable influence on family members of the recipient, leading to weight loss, healthier eating habits, and greater activity levels among adults and children residing with the patient, according to the results of a prospective, longitudinal study.
“Previous studies have shown that obesity may be a social contagion and that by associating with obese individuals, a person is more likely to become obese. Our study may demonstrate that bariatric surgery in selected populations can provide a reverse corollary and induce weight loss and healthy behaviors in people surrounding the patient,” according to Dr. Gavitt A. Woodard and her associates at Stanford (Calif.) University.
The investigators assessed weight and lifestyle changes in spouses, parents, and children who were residing with patients during the year after the patients underwent Roux-en-Y gastric bypass surgery. They enrolled 35 families, including 35 patients, 26 spouses, 3 grandparents, 6 adult children, and 15 children younger than age 18 years during a 2-year period.
Both patients and family members were required to attend three preoperative educational sessions and five postoperative visits in which lifestyle modification was emphasized.
A high-protein, high-fiber, low-fat, low-sugar diet was recommended for the patients, which advised six small daily meals comprising 200-300 calories and including 4-6 ounces of protein.
Lifestyle modification included daily goals of increased physical activity (10,000 steps per day), 8 hours of sleep, moderation of alcohol intake, and avoidance of watching more than 2 hours of television.
After 1 year, the study subjects were evaluated by a physical examination as well as a battery of validated questionnaires assessing overall health, physical activity, sleep, risk behaviors, television viewing, alcohol consumption, and quality of life.
The gastric bypass patients lost weight as expected.
The mean weight of adult family members declined from 220 to 198 pounds, which was not statistically significant. However, when the family members were categorized by their own baseline weight, significant differences emerged.
Obese adult family members showed significant weight loss, from a mean of 234 to 226 pounds. Nonobese adult family members showed a nonsignificant weight loss from 180 to 176 pounds. This pattern held true for decreases in body mass index as well, Dr. Woodard and her associates wrote.
The pattern also was the same for waist circumference, with obese adult family members showing a significant decrease from a mean of 119 cm to 111 cm and nonobese adult family members showing no change in waist circumference.
According to these findings, obese adult family members lost 3% of their total weight in 1 year, which falls within the range of a 2%-5% weight loss reported for people following the Atkins, Zone, Ornish, or LEARN diets. “Living with a gastric bypass patient and undertaking a structured diet plan along with the patient may have an equivalent effect on weight,” the investigators said (Arch. Surg. 2011;146:1185-90).
Children were analyzed separately because of the expectation that their weight and waist circumference would increase because of natural growth.
Given the growth trajectories documented in their medical charts, obese children actually showed a smaller increase in BMI (29.6) than was expected (31.2). Nonobese children showed a slightly larger increase in BMI (19.8) than was expected (18.8).
As with the adult family members, children who were obese showed a significant reduction in waist circumference, from 119 cm to 111 cm, but nonobese children did not show any change in waist circumference.
Patients and their adult family members showed significant changes in their eating habits. Both groups had marked decreases in “uncontrolled eating” and in “emotional eating.” In addition, patients, but not their relatives, showed significantly increased “cognitive control of eating,” Dr. Woodard and her associates said.
However, children showed no changes in these measures. And neither adult family members nor children changed their food choices or decreased their intake of carbohydrates or junk food, while patients did achieve these goals, they reported.
Yet there was a significant increase in the percentage of children who reported that they were “on a diet,” from 25% at baseline to 50% at 1 year.
Patients and their adult family members reported significant declines in alcohol consumption, from 5 to 0.2 drinks per month among patients and from 11 to 0.8 drinks per month among adult family members.
Patients, adult relatives, and children all showed significant gains in daily activity levels. Children also decreased the amount of time they spent watching TV or using a computer every day, although this reduction did not reach statistical significance.
Overall, the study findings indicate that “bariatric surgery provides an opportunity for intervention for many individuals beyond the patient,” Dr. Woodard and her associates said.
From Archives of Surgery
Gastric Bypass' Metabolic Gains Persist at 6 Years : Rate of diabetes remission was 75% in surgical group, 1% among controls.
Major Finding: Six years after gastric bypass surgery, the rate of diabetes remission in a cohort of morbidly obese patients was 75%, compared with 1% among those who did not undergo the procedure. The average weight loss from baseline was 28%.
Data Source: Longitudinal controlled prospective study evaluating the long-term weight and health outcomes of gastric bypass surgery in 418 morbidly obese patients.
Disclosures: Dr. Adams had no financial conflicts of interest to disclose.
ORLANDO – Cardiometabolic improvements following gastric bypass surgery persist over time, according to findings from the first prospective, long-term controlled trial to focus on gastric bypass patients.
After 6 years of follow-up, patients in the Utah Obesity Study who underwent the bariatric procedure maintained significant total weight loss and significant improvements in cardiovascular and metabolic measures and other disease end points relative to severely obese patients in the control group who did not undergo the surgery, according to Dr. Ted D. Adams of the University of Utah in Salt Lake City.
Of the 1,156 morbidly obese subjects enrolled in the study, 418 underwent gastric bypass surgery; 417 sought the procedure but were unable to have it, primarily because of lack of health insurance; and 321 were randomly selected as community controls from the Utah Health Family Tree program.
All of the participants underwent physical examinations and health evaluations at baseline, 2 years, and 6 years, including a physician interview and detailed medical history; resting electro- and echocardiograms; a submaximal exercise treadmill test and electrocardiogram; pulmonary function; limited polysomnography; resting metabolic rate; anthropometry; resting and exercise blood pressure; comprehensive blood chemistry; urinalysis; and dietary, quality of life, and physical activity questionnaires, Dr. Adams stated, noting that the 6-year follow-up was “excellent,” at 97%.
“In the surgical group, nearly all of the clinical measures improved significantly between the baseline and 2-year exams, and they remained significantly improved, compared with baseline at 6 years,” Dr. Adams said. In contrast, he noted, “the clinical variables in the combined control groups changed minimally if at all over the 6-year period.”
With respect to weight loss, the total weight reduction from baseline in the surgery group was 35% at 2 years and 28% at 6 years, while the average weight loss in the nonsurgical control subjects was negligible, Dr. Adams reported.
Further, the rate of diabetes remission at 6 years was 75% in the surgical group and 1% in the combined controls, and the incidence of diabetes in the surgical and control groups at 6 years was 2% and 16%, respectively, he said.
Cardiac morphology measures were also significantly improved at 6 months in the surgical group, Dr. Adams said. Echocardiography showed reduced left atrial volume and left ventricular mass, improvements that could potentially lead to reduction in obesity-related heart failure over time, he pointed out. The left atrial volume increased in the control group. Significant reductions in waist circumference, systolic blood pressure, heart rate, triglycerides, low-density lipoprotein cholesterol, and insulin resistance were maintained at 6 years in the surgical group, as were higher levels of high-density lipoprotein cholesterol, he said.
The findings complement other cohort studies in bariatric surgery, Dr. Adams stated.
The cohort will continue to be followed to provide additional insight in the long-term durability of the improvements, he said.
Major Finding: Six years after gastric bypass surgery, the rate of diabetes remission in a cohort of morbidly obese patients was 75%, compared with 1% among those who did not undergo the procedure. The average weight loss from baseline was 28%.
Data Source: Longitudinal controlled prospective study evaluating the long-term weight and health outcomes of gastric bypass surgery in 418 morbidly obese patients.
Disclosures: Dr. Adams had no financial conflicts of interest to disclose.
ORLANDO – Cardiometabolic improvements following gastric bypass surgery persist over time, according to findings from the first prospective, long-term controlled trial to focus on gastric bypass patients.
After 6 years of follow-up, patients in the Utah Obesity Study who underwent the bariatric procedure maintained significant total weight loss and significant improvements in cardiovascular and metabolic measures and other disease end points relative to severely obese patients in the control group who did not undergo the surgery, according to Dr. Ted D. Adams of the University of Utah in Salt Lake City.
Of the 1,156 morbidly obese subjects enrolled in the study, 418 underwent gastric bypass surgery; 417 sought the procedure but were unable to have it, primarily because of lack of health insurance; and 321 were randomly selected as community controls from the Utah Health Family Tree program.
All of the participants underwent physical examinations and health evaluations at baseline, 2 years, and 6 years, including a physician interview and detailed medical history; resting electro- and echocardiograms; a submaximal exercise treadmill test and electrocardiogram; pulmonary function; limited polysomnography; resting metabolic rate; anthropometry; resting and exercise blood pressure; comprehensive blood chemistry; urinalysis; and dietary, quality of life, and physical activity questionnaires, Dr. Adams stated, noting that the 6-year follow-up was “excellent,” at 97%.
“In the surgical group, nearly all of the clinical measures improved significantly between the baseline and 2-year exams, and they remained significantly improved, compared with baseline at 6 years,” Dr. Adams said. In contrast, he noted, “the clinical variables in the combined control groups changed minimally if at all over the 6-year period.”
With respect to weight loss, the total weight reduction from baseline in the surgery group was 35% at 2 years and 28% at 6 years, while the average weight loss in the nonsurgical control subjects was negligible, Dr. Adams reported.
Further, the rate of diabetes remission at 6 years was 75% in the surgical group and 1% in the combined controls, and the incidence of diabetes in the surgical and control groups at 6 years was 2% and 16%, respectively, he said.
Cardiac morphology measures were also significantly improved at 6 months in the surgical group, Dr. Adams said. Echocardiography showed reduced left atrial volume and left ventricular mass, improvements that could potentially lead to reduction in obesity-related heart failure over time, he pointed out. The left atrial volume increased in the control group. Significant reductions in waist circumference, systolic blood pressure, heart rate, triglycerides, low-density lipoprotein cholesterol, and insulin resistance were maintained at 6 years in the surgical group, as were higher levels of high-density lipoprotein cholesterol, he said.
The findings complement other cohort studies in bariatric surgery, Dr. Adams stated.
The cohort will continue to be followed to provide additional insight in the long-term durability of the improvements, he said.
Major Finding: Six years after gastric bypass surgery, the rate of diabetes remission in a cohort of morbidly obese patients was 75%, compared with 1% among those who did not undergo the procedure. The average weight loss from baseline was 28%.
Data Source: Longitudinal controlled prospective study evaluating the long-term weight and health outcomes of gastric bypass surgery in 418 morbidly obese patients.
Disclosures: Dr. Adams had no financial conflicts of interest to disclose.
ORLANDO – Cardiometabolic improvements following gastric bypass surgery persist over time, according to findings from the first prospective, long-term controlled trial to focus on gastric bypass patients.
After 6 years of follow-up, patients in the Utah Obesity Study who underwent the bariatric procedure maintained significant total weight loss and significant improvements in cardiovascular and metabolic measures and other disease end points relative to severely obese patients in the control group who did not undergo the surgery, according to Dr. Ted D. Adams of the University of Utah in Salt Lake City.
Of the 1,156 morbidly obese subjects enrolled in the study, 418 underwent gastric bypass surgery; 417 sought the procedure but were unable to have it, primarily because of lack of health insurance; and 321 were randomly selected as community controls from the Utah Health Family Tree program.
All of the participants underwent physical examinations and health evaluations at baseline, 2 years, and 6 years, including a physician interview and detailed medical history; resting electro- and echocardiograms; a submaximal exercise treadmill test and electrocardiogram; pulmonary function; limited polysomnography; resting metabolic rate; anthropometry; resting and exercise blood pressure; comprehensive blood chemistry; urinalysis; and dietary, quality of life, and physical activity questionnaires, Dr. Adams stated, noting that the 6-year follow-up was “excellent,” at 97%.
“In the surgical group, nearly all of the clinical measures improved significantly between the baseline and 2-year exams, and they remained significantly improved, compared with baseline at 6 years,” Dr. Adams said. In contrast, he noted, “the clinical variables in the combined control groups changed minimally if at all over the 6-year period.”
With respect to weight loss, the total weight reduction from baseline in the surgery group was 35% at 2 years and 28% at 6 years, while the average weight loss in the nonsurgical control subjects was negligible, Dr. Adams reported.
Further, the rate of diabetes remission at 6 years was 75% in the surgical group and 1% in the combined controls, and the incidence of diabetes in the surgical and control groups at 6 years was 2% and 16%, respectively, he said.
Cardiac morphology measures were also significantly improved at 6 months in the surgical group, Dr. Adams said. Echocardiography showed reduced left atrial volume and left ventricular mass, improvements that could potentially lead to reduction in obesity-related heart failure over time, he pointed out. The left atrial volume increased in the control group. Significant reductions in waist circumference, systolic blood pressure, heart rate, triglycerides, low-density lipoprotein cholesterol, and insulin resistance were maintained at 6 years in the surgical group, as were higher levels of high-density lipoprotein cholesterol, he said.
The findings complement other cohort studies in bariatric surgery, Dr. Adams stated.
The cohort will continue to be followed to provide additional insight in the long-term durability of the improvements, he said.
From the Annual Meeting of the Obesity Society