Biomedical subjects

Atul K Madan

Publications and source records attributed to Atul K Madan.

At least 19 recordsLinked to original sources

PubMed2006

Safety and efficacy of initial trocar placement in morbidly obese patients.

HYPOTHESIS: The use of a nonbladed trocar with an optical view is a safe and effective method for initial trocar placement for laparoscopic bariatric surgery. DESIGN: Retrospective review of consecutive patients. SETTING: University-associated hospital. PATIENTS: All patients who underwent laparoscopic bariatric surgery from December 2002 to November 2003. INTERVENTION: Initial trocar placement. MAIN OUTCOME MEASURES: Injury and bleeding during initial trocar placement, trocar placement time, and insufflation time. Trocar placement time was defined as the time to place the trocar into the peritoneal cavity (including infiltration of local anesthesia and incision). Insufflation time was defined as time to insufflate the abdomen to a pressure of 10 to 15 mm Hg (including time to place tubing on trocar). RESULTS: There were 228 patients who had no evidence of any bowel or vessel injury during initial trocar placement. In the last 50 patients, average body mass index (calculated as weight in kilograms divided by the square of height in meters) was 47 (range, 35-63). Average trocar placement time was 25 seconds (range, 10-60 seconds), and average insufflation time was 16 seconds (range, 5-25 seconds). In almost all cases, appropriate pneumoperitoneum was established in less than a minute. No correlation was seen between times and body mass index (trocar, P = .56; insufflation, P = .95) or waist-hip circumference (trocar, P = .74; insufflation, P=.48). CONCLUSIONS: Initial trocar placement using a nonbladed trocar with an optical view without prior abdominal insufflation is safe and effective in morbidly obese patients. This method can be applied even in the super obese.

Body Mass Index↗

PubMed2006

Outcome of a clinical pathway for discharge within 48 hours after laparoscopic gastric bypass.

BACKGROUND: The benefits of laparoscopic gastric bypass (LGB) include decreased pain, quicker recovery, and shorter hospital stay. Our hypothesis was that a clinical pathway for 48-hour discharge after LGB can be implemented safely. METHODS: Charts of patients undergoing LGB were retrospectively reviewed to assess our prospectively placed clinical pathway. Patients were discharged within 48 hours if they met the criteria of the pathway. RESULTS: There were 104 patients who underwent LGB with no intraoperative conversions. Complications included 5 leaks, 5 reoperations, and no mortality. In our series, 76% (n=79) of patients were discharged within 48 hours. Gender and body mass index (BMI) did not differ between those who were discharged in 48 hours and those who were not (P=not significant). No patient who was discharged in 48 hours required return before their scheduled appointment. CONCLUSIONS: A majority of patients after LGB can be discharged safely in 48 hours. A formal clinical pathway helps decrease hospital stay without adverse patient outcome.

Adolescent↗

PubMed2006

Emerging endoluminal therapies for gastroesophageal reflux disease: adverse events.

BACKGROUND: Endoluminal therapies are emerging as a new therapeutic option for the treatment of gastroesophageal reflux disease (GERD). Many of these endoluminal therapies are touted as short outpatient procedures with minimal complications. It is thought that these complications are uncommon and minor. This investigation sought to summarize the adverse events of these endoluminal therapies for the treatment of GERD. METHODS: The Manufacturer and User Facility Device Experience Database for the U.S. Food and Drug Administration's Center for Devices and Radiological Health Web site was searched to examine all voluntary adverse events reported on emerging endoluminal therapies. The adverse events can be divided into 3 categories: (1) radiofrequency ablation based, (2) injection based, and (3) suture based. RESULTS: There were a total of 50 adverse events reported on 4 specific therapies. Half of the complications were found to result from injection-based therapy and 44% of the complications were found to result from radiofrequency ablation-based therapy. There were 8 deaths reported (5 in the injection-based group and 3 in the radiofrequency ablation-based group). Sixty-four percent of the adverse events resulted in hospitalizations and 10% of these patients required surgery. CONCLUSIONS: Physicians must be aware that no endoluminal therapy is truly noninvasive. Complications and even deaths are associated with these treatments for GERD. Patients must be informed of all the potential risks and complications of these new technologies.

Catheter Ablation↗

PubMed2006

Most of the interleukin 1 receptor antagonist, cathepsin S, macrophage migration inhibitory factor, nerve growth factor, and interleukin 18 release by explants of human adipose tissue is by the non-fat cells, not by the adipocytes.

The present studies were designed to compare the relative release of interleukin 1 receptor antagonist (IL-1Ra), cathepsin S, macrophage migration inhibitory factor (MIF), nerve growth factor (NGF), and interleukin 18 (IL-18) by adipocytes as compared with the non-fat cells present in subcutaneous and omental adipose tissue from morbidly obese gastric bypass patients as compared with obese abdominoplasty patients. The release of IL-1Ra, cathepsin S, and MIF by explants of human adipose tissue incubated for 48 hours averaged 6, 9, and 19 pmol/g, respectively, and was far greater than the release of NGF (0.05 pmol/g) or IL-18 (0.006 pmol/g). The release by human adipocytes of IL-1Ra, cathepsin S, and MIF was 0.13, 0.32, and 2.6 pmol/g, respectively, over 48 hours, whereas NGF release was 0.003 and IL-18 0.001 pmol/g. Only the total release of MIF by human adipose tissue explants was enhanced, whereas that of IL-18 was significantly reduced in explants from morbidly obese women. Most of (55%-73%) the release of IL-1Ra, cathepsin S, MIF, NGF, and IL-18 was by the adipose tissue matrix, whereas release by stromal-vascular (SV) cells was 3% to 28% of total release over 48 hours by the adipose tissue matrix, SV cells and adipocytes. The release of NGF by adipocytes was 42%, that of MIF was 27%, and for the other factors 15% or less of release over 48 hours by the adipose tissue matrix, SV cells, and adipocytes. Our results suggest that the non-fat cells in human adipose tissue contribute to most of the release of NGF, IL-18, IL-1Ra, cathepsin S, and MIF seen during primary culture of adipose tissue explants from obese women.

Abdominal Fat↗

PubMed2006

Laparoscopic repair of congenital duodenal obstruction.

CHARGE syndrome (or association) refers to a group of physical abnormalities occurring together: coloboma, heart defect, atresia choanae, retarded growth and development, genital hypoplasia, and ear anomalies/deafness. We report the successful use of laparoscopy in a patient with CHARGE syndrome and congenital duodenal obstruction.

Abnormalities, Multiple↗

PubMed2006

Survey of minimally invasive surgery fellowship programs.

INTRODUCTION: Since there was no accrediting body for minimally invasive surgery fellowships, this investigation was performed to characterize minimally invasive surgery fellowships. MATERIALS AND METHODS: All minimally invasive surgery fellowships that were noted on the Society of American Gastrointestinal Endoscopic Surgeons website in July 2002 were sent a survey. Only those fellowships that had fellow(s) for the year 2001-2002 were included in the survey. All programs were contacted a second time if the survey was not returned. Incomplete responses were not included in the data. RESULTS: There were 78 fellowships listed, of which 16 had no fellow in 2001-2002, one which was not a minimally invasive surgery fellowship, and one which was listed twice. Of the 19 (32%) programs that responded, there was an average of 1.3 clinical fellows per program (range, 1-3). All clinical fellowships were of one year duration. There was an average of 3.2 attendings for each program. Thirty-two percent of program directors had attended a laparoscopic fellowship. The average program received 50 applications and interviewed 12 applicants for the year 2001-2002. The average fellow had 14 (range, 0-42) manuscripts, abstracts, and/or presentations either completed or in progress. Average minimally invasive cases performed was bariatric 95, colon 33, solid organ (liver, spleen, kidney, adrenal) 32, antireflux 36, hernia 54, and endoscopy 48. However, the range of these cases varied and the lowest number of cases for each category was bariatric 5, colon 3, solid organ 8, antireflux 1, hernia 6, and endoscopy 0. CONCLUSION: Minimally invasive surgery fellowships seem to be competitive for surgical residents. These fellowships vary in both research and clinical experience.

Education, Medical, Graduate↗

PubMed2006

Why would laparoscopic gastric bypass patients choose open instead?

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to be comparable to open Roux-en-Y gastric bypass (ORYGBP) surgery in randomized studies. Although a steep learning curve exists, laparoscopic bariatric surgery offers advantages if performed by an experienced bariatric surgeon. Despite these facts, some patients still choose to undergo ORYGBP. This investigation explored the reasons why patients who have had LRYGBP would decide to undergo the laparoscopic operation. METHODS: A survey was given to patients who had undergone LRYGBP. The survey was designed to ascertain what factors would influence them to have LRYGBP versus ORYGBP. Incomplete responses were not included in the data analysis. RESULTS: There were 41 patients who filled out the survey. Over 90% of the patients felt LRYGBP is better than open gastric bypass. There were 4 patients who had seen another surgeon who recommended ORYGBP. Approximately 61% (23/38) of the patients would have stayed with their surgeon even if their surgeon did not offer LRYGBP. In addition, 79% of patients (31/39) would have ORYGBP if their insurance did not cover LRYGBP. Most patients (67%) would have ORYGBP if their surgeon thought LRYGBP was experimental. If they were told that LRYGBP was too risky for them, 77% of patients (30/39) would have undergone ORYGBP. Only 15% of patients (6/40) would not have had surgery if LRYGBP did not exist. CONCLUSIONS: Patients are willing to undergo ORYGBP even if they believe that LRYGBP is better. Non-medical factors and/or surgeon recommendations instead of scientific data influence patient decision-making when choosing ORYGBP over LRYGBP.

Adult↗

PubMed2006

Does laparoscopic gastric bypass result in a healthier body composition? An affirmative answer.

BACKGROUND: Bariatric surgery results in sustained weight loss. While weight loss is the goal of bariatric surgery, fat loss and muscle conservation are germaine goals. This study investigated the hypothesis that body composition would significantly change after laparoscopic Roux-en-Y gastric bypass (LRYGBP). METHODS: Patients undergoing LRYGBP were studied. Percent fat and percent water were calculated via bioelectrical impedance analysis (BIA). Waist and hip circumference were measured in all patients as well. Measurements were taken preoperatively, and at 1 month, 3 months, 6 months, and 1 year. Non-parametric ANOVA was utilized for statistical analysis. RESULTS: There were 151 patients included in this study. Fat percentage (48.6 +/- 10.0 vs 34.6 +/- 10.8; P<0.001), total fat mass (141 +/- 37 vs 67 +/- 30; P<0.0001) and total water mass (108 +/- 27 vs 93 +/- 23; P<0.0001) decreased postoperatively at 1 year. Water percentage increased postoperatively at 1 year (37.0 +/- 6.6 vs 52.5 +/- 3.3; P<0.001). Waist:hip ratio improved from preoperatively to 1 year postoperatively (0.895 +/- 0.115 vs 0.811 +/- 0.076; P<0.001). CONCLUSIONS: Bariatric surgery results not only in fat loss but also in a change in body composition. Improved waist:hip ratio, fat percentage decreases, and water percentage increases all indicate an overall healthy body composition. While weight loss is important, improvement in body composition should be another recognized benefit of bariatric surgery.

Adipose Tissue↗

PubMed2006

Vitamin and trace mineral levels after laparoscopic gastric bypass.

BACKGROUND: Nutritional deficiencies are a concern after any bariatric surgery procedure. Restriction of oral intake and/or decreased absorption may cause vitamin abnormalities. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. An investigation was undertaken to examine preoperative and short-term (1-year) postoperative levels of vitamins/trace minerals in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). METHODS: Serum preoperative and postoperative vitamin/trace element levels of LRYGBP patients were recorded in a retrospective chart review (n = 100). Unavailable and undrawn levels were not included in the results. RESULTS: Preoperative and 1-year postoperative percentage of abnormal levels were: vitamin A 11% and 17%, vitamin B(12) 13% and 3%, vitamin D-25 40% and 21%, zinc 30% and 36%, iron 16% and 6%, ferritin 9% and 3%, selenium 58% and 3%, and folate 6% and 11%. CONCLUSIONS: Abnormal vitamin and trace mineral values are common both preoperatively and postoperatively in a bariatric surgery patient population. Routine evaluation of serum levels should be performed in this specific patient population.

Anastomosis, Roux-en-Y↗

PubMed2006

Preoperative carbohydrate "addiction" does not predict weight loss after laparoscopic gastric bypass.

BACKGROUND: Weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies. Dietary habits that exist preoperatively may continue after surgery and affect weight loss. This study investigated the hypothesis that preoperative carbohydrate addiction would predict weight loss after laparoscopic gastric bypass. METHODS: 104 consecutive patients in our LRYGBP program were included in the study. A preoperative survey was used to determine level of carbohydrate craving. This survey was scored from 0 to 60. A higher score indicated a higher level of carbohydrate addiction. Percentage of excess weight loss (%EWL) was determined after at least 1 year postoperatively in all patients. RESULTS: Data were available in 95 (91%) of the patients. There was no correlation seen between level of carbohydrate addiction and %EWL at 1 year (r=0.02; P=NS). In addition, we looked at patients with successful weight loss (>50% %EWL; n=83) versus those patients who were considered unsuccessful (<50% EWL; n=12). There was no statistical difference in the level of preoperative carbohydrate craving between these 2 groups (36+/-13 vs 33+/-15; P=NS). CONCLUSIONS: Consistently large carbohydrate intake preoperatively does not predict weight loss after LRYGBP. High level of carbohydrate addiction is not a contraindication to LRYGBP.

Adolescent↗

PubMed2006

Comparison of IL-8, IL-6 and PGE(2) formation by visceral (omental) adipose tissue of obese Caucasian compared to African-American women.

BACKGROUND: One of the key consequences of obesity is an enhanced release of cytokines such as IL-8 and IL-6 by adipose tissue. There may be differences in adiposity, inflammatory markers, and medical co-morbidity between morbidly obese African-American (AA) and Caucasian (CA) women. We hypothesized that there are ethnic differences in inflammatory markers and medical co-morbidities. METHODS: We compared the mRNA content in omental fat and the release of IL-8, IL-6 and PGE(2) after a 4-hour incubation of explants of adipose tissue in women undergoing bariatric surgery. In addition, medical co-morbidities and fat measurements were examined and compared. RESULTS: Medication usage differed, with CA women being three times more likely to report taking medication for depression compared to AA women (P< or =0.001). IL-8 and PGE(2) release over 4 hours by omental fat in vitro was the same in CA and AA women. Similar results were seen with respect to the COX-2 mRNA and IL-8 mRNA values at the start and at the end of the incubation. In CA and AA women, the IL-6 mRNA content in fat immediately after removal from the patients was the same. CONCLUSIONS: In morbidly obese women seeking bariatric surgery, there are little ethnic differences between cytokine release by omental adipose tissue explants in vitro, or the mRNA content in omental adipose tissue of IL-6, IL-8 or COX-2. The only noted difference between AA and CA morbidly obese women was the greater use of antidepressants by CA women.

Abdominal Fat↗

PubMed2006

Nonalcoholic fatty liver disease of obesity.

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are part of the same continuum. They are a major, under-recognized cause of chronic liver disease. Good medical treatment options do not exist to date. The mainstay of treatment is weight loss. Bariatric surgery offers weight loss and improvement of NAFLD and NASH.

Fatty Liver↗

PubMed2006

Laparoscopic revision of the gastrojejunostomy for recurrent bleeding ulcers after past open revision gastric bypass.

Late complications of open gastric bypass can include malnutrition, weight gain, stomal stenosis, and recurrent bleeding ulcers. Herein, we describe the case of a woman who had recurrent bleeding ulcers, after an open revision of a stenotic gastric bypass. She now underwent an uneventful laparoscopic revision of her gastrojejunostomy and was discharged within 72 hours. Laparoscopic revision of a gastrojejunostomy, even after an open revision following an open gastric bypass, can be done safely.

Female↗

PubMed2006

Poor knowledge of basic cancer facts of physicians-in-training.

PURPOSE: Since many physicians-in-training will play an important role in cancer screening, their understanding of cancer screening and basic cancer facts is paramount. This investigation was undertaken to determine their baseline knowledge in basic cancer facts. METHOD: A questionnaire was used to assess the knowledge of basic cancer facts of medical students, medical residents and surgical residents. Participants were asked to rank five different malignancies in their correct order for both mortality and incidence. Physicians-in-training were given separate questions for male and female patients. The questions were considered correct if at least the first three malignancies were ranked in the appropriate order. RESULTS: One-hundred-twelve second-year medical students and 78 residents were assessed. Few physicians-in-training ranked the malignancies in correct order for mortality (21% for female patients and 18% for male patients). Even fewer physicians-in-training ranked the malignancies in correct order for incidence (2% for female patients and 9% for male patients). CONCLUSION: Most physicians-in-training lack an understanding of basic cancer facts. If this poor basic cancer fact knowledge represents an overall lack of cancer knowledge, educational efforts need to be focused on cancer care for all levels and specialties of physician training.

Adult↗

PubMed2006

Laparoscopic lumbar hernia repair.

Lumbar hernias are rare clinical entities that often pose a challenge for repair. Because of the surrounding anatomy, adequate surgical herniorraphy is often difficult. Minimally invasive surgery has become an option for these hernias. Herein, we describe two patients with lumbar hernias (one with a recurrent traumatic hernia and one with an incisional hernia). Both of these hernias were successfully repaired laparoscopically.

Adult↗

PubMed2006

Ageism in breast cancer surgical options by medical students.

INTRODUCTION: The similar long-term survival of breast conservation and modified radical mastectomy in treating early invasive breast cancer has been well established. Since doctors often find themselves in the position of making operative recommendations, characterization of factors that may influence their recommendations is important. Previous investigations have demonstrated the phenomenon of ageism (i.e., between patients aged 30 versus 60 years old) in doctors and doctors-in-training. Thus, this study was undertaken to investigate any possible economic bias of doctors-in-training in breast conserving procedures. METHODS: Medical students were instructed on the efficacy of breast conservation in treating breast cancer. Then, their opinions were assessed using a questionnaire about recommendations for breast conservation as well as breast reconstruction after mastectomies in similar patients. All patients were between the ages of 41-54 years old but differed by occupation. Chi squared tests were used for statistical analysis. RESULTS: Forty-eight students participated in the study. No differences were noted between "high income" occupations and "low income" occupations. However, subtle ageism was noted even in this similarly aged population. Modified radical mastectomy was recommended in 35 percent of the "older" age group (41-48 years old) versus 15 percent of "younger" patients (49-54 years old, p < 0.002). Further, breast reconstruction was recommended in 89 percent of younger patients versus only 72 percent of older patients (p < 0.004). CONCLUSIONS: Medical students still demonstrate an age bias against older women in their recommendations of breast conservation and breast reconstruction. Educational efforts should be instituted during the medical school training to decrease this age bias in treatment of breast cancer.

Adult↗

PubMed2006

Laparoscopic repair of gastrointestinal leaks after laparoscopic gastric bypass.

Gastrointestinal (GI) leak after gastric bypass is a cause of significant morbidity and a mortality that may exceed 50%. This study was performed to review our experience with laparoscopic repair of GI leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective chart review of all patients who underwent LRYGB over a 25-month period was performed. Patients who had any operation for a GI leak after LRYGB were included in this study. There were 300 patients who underwent LRYGB. No intraoperative conversions occurred. Eight (2.7%) patients underwent operative repair of a GI leak. Another patient had a gastrojejunostomy leak that was managed nonoperatively. The rate of GI leaks reduced from 5.3 per cent in the first 150 cases to 0.7 per cent in the last 150 cases (P < 0.05). One patient was converted to an open approach. Average operative time for the laparoscopic repairs was 133 minutes (range, 75-182 minutes). Sources of leak found at operation were gastrojejunostomy (3), enterotomy (3), jejunojejunostomy (2), gastric pouch (1), and cystic duct stump (1). Two patients had a GI leak from two sources. Average length of stay was 28 days (range, 4-78 days). Three patients whose stay was greater than a month were the result of sepsis and ventilator dependence. Further reoperations were required in two patients (laparoscopic) for abdominal washout and one patient (open) for enterotomy repair. One patient required computed tomography-guided drainage of an abscess. Mortality was 22 per cent (2) in patients who developed GI leaks. One patient died from sepsis-induced multiple organ failure and the other patient from a presumed pulmonary embolus. GI leaks cause significant morbidity and mortality. GI leak rates decrease with experience. Laparoscopic repair of GI leaks should be used judiciously. Conversions and further reoperations may be necessary.

Adult↗

PubMed2005

Mallory-Weiss tear after laparoscopic Roux-en-Y gastric bypass.

In the United States, the most common surgical procedure for morbid obesity is the Roux-en-Y gastric bypass. Pulmonary embolism, leak, bowel obstruction, and gastrointestinal bleeding are among the potential early fatal complications. Early postoperative bleeding after laparoscopic gastric bypass, although uncommon, presents a dilemma because of the danger of perforation from postoperative endoscopy and the inability to access the gastric remnant easily. We describe a case of a Mallory-Weiss tear causing massive upper gastrointestinal hemorrhage 1 week after laparoscopic Roux-en-Y gastric bypass. Bariatric surgeons should consider this diagnosis, especially when encountering a patient with a history of significant retching postoperatively.

Esophagus↗