Faculty Bibliography

Background: Hiatal hernia repair at the time of bariatric surgery improves patient outcome, decreases GERD symptoms and reduces the need for reoperation. The aim of this report is twofold: first, to compare the sensitivity of esophagram with surgical findings at the time of bariatric surgery, and second, to compare the sensitivities of upright versus right anterior oblique (RAO) recumbent esophagram in predicting the presence of hiatal hernia intraoperatively. Methods: Between 2008 and 2010, 389 patients undergoing bariatric surgery were prospectively evaluated for hiatal hernia by barium esophagram. 70 (18%) were performed only in the upright position and 319 (82%) only in the RAO recumbent position. Esophagram technique was changed from upright to recumbent because we hypothesized that we would be able to better detect hiatal hernia utilizing RAO recumbent technique. Hiatal hernia was assessed intraoperatively by laxity/dimpling of the phrenoesophageal ligament and, when present, was repaired posteriorly with permanent sutures. Results: Compared with the surgical findings, the sensitivity and specificity for upright esophagram was 50% and 97%, respectively. For recumbent esophagram, sensitivity was 70% and specificity was 77%. Recumbent esophagram had a lower percentage of false negatives than upright esophagram (11% vs. 21%). Conclusions: Use of a recumbent technique for preoperative esophagram has a higher sensitivity for diagnosis of hiatal hernia than upright esophagram. Routine use of recumbent esophagram results in increased preoperative detection of hiatal hernia and facilitates planning of crural closure

OBJECTIVE:To describe clinical associations of delirium in hospitalized patients and relationships to on admission presentation. DESIGN/METHODS:Retrospective analysis of an administrative hospitalization database 1998-2007. SETTING/METHODS:Acute care hospitalizations in the New York State (NYS). MEASUREMENTS/METHODS:Four categories of diagnosis related group (DRG) hospitalizations were extracted from a NYS administrative database: pneumonia, congestive heart failure, urinary tract/kidney infection (UTI), and lower extremity orthopedic surgery (LEOS) DRGs. These hospitalizations were examined for clinical associations with delirium coding both on and after admission. RESULTS:Delirium was coded in 0.8% of the cohort, of which an on admission diagnosis was present in 59%. On admission delirium was strongly associated with dementia (adjusted odds ratio 0, 95%CI 5.8-6.3) and with adverse drug effects (ADEs) (adjusted odds ratio 4.6, 95%CI 4.3, 5.0). After admission delirium was even more highly associated with ADEs (adjusted odds ratio 22.2, 95%CI 20.7-23.7). The UTI DRG category had the greatest proportion of on admission delirium. However after admission delirium was more common in the LEOS DRG category. Over time, there was a greater increase in delirium proportions in the UTI DRG category, and an overall increase in coding for encephalopathy states (potential alternative delirium descriptors). CONCLUSION/CONCLUSIONS:ADEs play an important role in delirium regardless of whether or not it is present on admission. While the finding that most delirium hospitalizations presented on admission suggests that delirium impacts more as a clinical admitting determinant, in-hospital prevention strategies may still have benefit in targeted settings where after admission delirium is more frequent, such as patients with LEOS.

BACKGROUND: Improvement in quality of life (QOL) is 1 of the goals of bariatric procedures. We hypothesized that greater impairment of QOL would encourage the choice of more invasive surgical procedures. Our study was performed at a university hospital weight loss surgical center in the United States. METHODS: Patients qualifying for weight loss surgery, who at their surgical consultation had chosen their surgical option and signed an informed consent form, were asked to complete 3 QOL forms--the Medical Outcomes Study Short Form 36-item Health Survey, the Beck Depression Inventory, and the Impact of Weight on Quality of Life-Lite. Analysis of variance was used to compare the surgery types with the demographics, QOL, and depression. RESULTS: A total of 367 patients, 114 men (31.1%) and 253 women (68.75), completed the QOL forms at their surgical consultation. Of these 367 patients, 68.9% elected gastric bypass (GB), 15% chose biliopancreatic diversion/duodenal switch (BPD/DS), and 16.1% chose adjustable gastric banding (AGB). The mean patient age was 42.5 +/- 10.7 years (P = NS), with no differences in gender distribution. The body mass index was 51.9 kg/m(2) for the BPD/DS group, greater than that for the GB group (45.9 kg/m(2)) or AGB group (44.3 kg/m(2); P < .0001). No significant differences were found in the Beck Depression Inventory score among the 3 groups (GB 14.6 +/- 9.6, AGB 10.8 +/- 8.2, and BPD/DS 13.5 +/- 7.3). For the Short Form 36-item Health Survey, only the physical component score was different for the AGB group compared with the BPD/DS group (GB 49.2 +/- 25.1, BPD/DS 42.8 +/- 26.4, and AGB 52.3 +/- 31.7; P = .05). For the Impact of Weight on Quality of Life-Lite, all differences were nonsignificant. The total score was 44.1 +/- 20.7, 44.4 +/- 21.1, and 52.2 +/- 19.6 for the GB, BPD/DS, and AGB groups, respectively. CONCLUSION: Patients requesting a weight loss procedure reported moderate to severe impairments in QOL and mood dysphoria compared with the community norms. However, the patients choosing from the 3 procedures studied scored similarly on the health-related QOL assessments.

BACKGROUND:The incidence and pattern of delirium recorded in a broad spectrum of American hospitalizations has not been well described. The National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project is an administrative database of hospitalizations in the US that affords an opportunity to examine for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes relating to delirium. OBJECTIVE:To examine the prevalence of delirium diagnoses and associated clinical factors, including adverse drug effects, in a broad spectrum of hospitalizations in the US. Delirium was grouped into three categories: drug-induced delirium, dementia-associated delirium, and non-dementia, non-drug (NDND). METHODS:Hospitalizations during the years 1998-2005 in the NIS databases were examined. These databases represent samples of hospitalizations that allow for national prevalence estimates. ICD-9 codes for drug-induced, dementia-associated and NDND delirium were identified in the hospitalizations for each year. Delirium tremens was not considered in this classification, and paediatric and psychiatric admissions were excluded. Yearly prevalence for drug-induced, dementia-associated and NDND delirium were tabulated, and time trends were analysed with negative binomial regression. A hospitalization subset cohort with urinary tract/kidney infection, pneumonia, heart failure and lower extremity orthopaedic surgery diagnosis-related group categories was also analysed for clinical associations with the presence of the three categories of delirium using multinomial logistic regression. ICD-9 E codes (external causes of injury) constituting adverse drug effects were identified and considered as clinical predictors. RESULTS:Delirium was recorded in 1 269 185 (0.54%) non-psychiatric adult hospitalizations during the study years. Whereas the overall prevalence of dementia-associated delirium and NDND delirium decreased over time, drug-induced delirium prevalence increased (p < 0.0001). As expected, the presence of dementia and adverse drug effects had the strongest associations with dementia-associated and drug-induced delirium, respectively, in the cohort hospitalizations. CONCLUSIONS:Drug-induced delirium and NDND delirium had the strongest associations with lower extremity orthopaedic surgery hospitalizations and urinary tract/kidney infection hospitalizations, respectively. Among the NDND co-morbid conditions, volume depletion and sodium imbalance had the strongest, albeit modest, associations with delirium. The association between decade of age and delirium was strongest for NDND delirium (adjusted odds ratio 1.53; 95% CI 1.52, 1.53), but age had significant associations with drug-induced and dementia-associated delirium as well. In the cohort, the most frequent adverse effects codes were for opioids and for benzodiazepines or other sedatives, which were noted in 21.3% and 15.2% of drug-induced delirium hospitalizations, respectively. Drug-induced delirium is being increasingly identified in hospitalized patients. Administrative hospitalization databases constitute a resource to explore factors and trends associated with delirium. The findings suggest that interventions focusing on adverse drug effects have the greatest potential for preventing delirium.

BACKGROUND: A paucity of information is available on the comparative body composition changes after bariatric procedures. The present study reports on the body mass index (BMI) and body composition changes after 4 procedures by a single group. METHODS: At the initial consultation, the weight and body composition of the patients undergoing 4 different bariatric procedures were measured by bioimpedance (Tanita 310). Follow-up examinations were performed at 1 year and at subsequent visits after surgery. Analysis of variance was used to compare the postprocedure BMI and body composition. Analysis of covariance was used to adjust for baseline differences. RESULTS: A total of 101 gastric bypass (GB) patients were evaluated at 19.1 + or - 10.6 months, 49 biliopancreatic diversion with the duodenal switch (BPD/DS) patients at 27.5 + or - 16.3 months, 41 adjustable gastric band (AGB) patients at 21.4 + or - 9.2 months, and 30 sleeve gastrectomy (SG) patients at 16.7 + or - 5.6 months (P <.0001). No differences were found in patient age or gender among the 4 groups. The mean preoperative BMI was significantly different among the 4 groups (P <.0001): 61.4 kg/m(2), 53.2, 46.7, and 44.3 kg/m(2) for the SG, BPD/DS, GB, and AGB group, respectively. The postoperative BMI adjusted for baseline differences was 27.8 (difference 23.6 + or - 8.3), 32.5 (difference 15.6 + or - 5.0), 37.2 (difference 18.2 + or - 8.2), and 39.5 kg/m(2) (difference 7.5 + or - 4.3) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The percentage of excess weight loss was 84%, 70%, 49%, and 38% for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The postoperative percentage of body fat adjusted for baseline differences was 25.7% (23.9% + or - 7.0%) 32.7% (16.1% + or - 10.5%) 37.7% (16.7% + or - 5.6%), and 42% (6.0% + or - 6.8%) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The lean body mass changes were reciprocal. CONCLUSION: Although the BPD/DS procedure reduced the BMI the most effectively and promoted fat loss, all the procedures produced weight loss. The AGB procedure resulted in less body fat loss within 21.5 months than SG within 16.7 months. Longer term observation is indicated.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has been increasingly offered to high-risk bariatric patients as the first-stage procedure before gastric bypass or biliopancreatic diversion or as the primary weight loss procedure. The bougie size has varied by surgeon during LSG. The aim of this study was to determine whether short-term weight loss correlates with the bougie size used during creation of the sleeve. METHODS: We retrospectively reviewed the data from all patients who had undergone LSG at our institution between 2003 and 2006. Revision LSG for failed bariatric procedures was excluded. The data analyzed included preoperative age, body mass index (BMI), bougie size, and percentage of excess weight loss (%EWL). RESULTS: A total of 135 patients underwent LSG during the 4-year period. Most of these patients (79%) underwent LSG as part of a 2-stage operation (either gastric bypass or duodenal switch within a mean of 11 months). The mean preoperative age and BMI was 43.5 years and 60.1 kg/m(2), respectively. The mean BMI and %EWL at 6 months was 47.1 kg/m(2) and 37.9%, respectively. The mean BMI and %EWL at 12 months was 44.3 kg/m(2) and 47.3%, respectively. When stratifying the %EWL by bougie size (40F versus 60F), we did not find a significant difference at 6 months (38.8% versus 40.6%, P = NS) or 12 months (51.9% versus 45.4%, P = NS). CONCLUSION: LSG results in significant weight loss in the short term. When stratifying outcomes by bougie size, our results suggested that a bougie size of 40F compared with 60F does not result in significantly greater weight loss in the short term. However, longer follow-up of the primary LSG group is required to determine whether a difference becomes evident over time.