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Biomedical subjects

Scott A Shikora

Publications and source records attributed to Scott A Shikora.

18 recordsLinked to original sources
PubMed2006

Morbid obesity is an independent determinant of death among surgical critically ill patients.

OBJECTIVE: To determine whether extreme obesity (morbid obesity; body mass index > or =40 kg/m(2)) is an independent risk factor for death among critically ill patients; this objective is most salient in the subset of patients who sustain a prolonged intensive care unit stay during which the burdens of care imposed by obesity and its consequences would become most apparent. DESIGN: Cohort analysis of data from the Project Impact database used to catalog admissions and outcomes to a surgical intensive care unit, with predetermined end point analyses of outcomes. SETTING: Surgical intensive care unit serving Tufts-New England Medical Center, a tertiary care and university medical center in Boston. PATIENTS: All critically ill surgical patients admitted to the Tufts-New England Medical Center surgical intensive care unit from January 1998 to March 2001. INTERVENTIONS: Intensive care unit and hospital mortality and lengths of stay were compared with body mass index subclassified into five groups: underweight, normal weight, overweight, obese, and extremely obese. Data were examined for all admissions during the study period and for a predetermined subgroup with a prolonged intensive care unit stay (> or =4 days). MEASUREMENTS AND MAIN RESULTS: The prevalence of obesity in the surgical intensive care unit was 26.7%; extreme obesity was observed in 6.8%. In the full cohort of patients (n = 1373), median length of stay was short (2 days) and there were no differences in mortality in patients among any of the body mass index classes. In the subgroup of prolonged stay patients (n = 406), intensive care unit and hospital mortality rates were significantly increased in extremely obese patients compared with all other patients (intensive care unit, 33.3% vs. 12.3%, p = .009; hospital, 33.3% vs. 16%, p = .045). Multivariate analysis showed that extreme obesity was an independent predictor of death in surgical critically ill patients with prolonged intensive care unit stay after controlling for age, gender, and severity of illness. The odds of death increased 7.4 times in patients with morbid obesity. CONCLUSIONS: Morbid obesity (body mass index > or =40 kg/m(2)) is an independent risk factor for death in surgical patients with catastrophic illness requiring prolonged intensive care. The prevalence of obesity is growing, both in the intensive care unit and in the general population. The increased risk of complications and death in this population mandates that we adapt customized processes of care to specifically address this unique and very challenging subset of patients.

Critical Care↗
PubMed2005

Laparoscopic Roux-en-Y gastric bypass: results and learning curve of a high-volume academic program.

HYPOTHESIS: Laparoscopic Roux-en-Y gastric bypass is a complex procedure performed on a high-risk patient population. Good results can be attained with experience and volume. DESIGN: Retrospective study. SETTING: Tertiary care academic hospital. PATIENTS: Seven hundred fifty consecutive morbidly obese patients undergoing surgery from March 1998 to April 2004. INTERVENTIONS: All patients underwent laparoscopic Roux-en-Y gastric bypass. MAIN OUTCOME MEASURES: Perioperative deaths and complications. RESULTS: The patient population was 85% women and had a mean body mass index of 47 kg/m2 (range, 32-86 kg/m2). The overall complication rate was 15% and the mortality was 0.3%. For the first 100 cases, the overall complication rate was 26% with a mortality of 1%. This complication rate decreased to approximately 13% and was stable for the next 650 patients. The incidence of major complications has also decreased since the first 100 cases. Leak decreased from 3% to 1.1%. Small-bowel obstruction decreased from 5% to 1.1%. Overall mean operating time was 138 minutes (range, 65-310 minutes). It decreased from 212 minutes for the first 100 cases to 132 minutes for the next 650 and 105 minutes (range, 65-200 minutes) for the last 100 cases. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is a technically difficult operation. This review of a large series in a high-volume program demonstrated that the morbidity and mortality could be reduced by 50% with experience. The results are similar to those reported from other major centers. In addition, as reported elsewhere, the learning curve for this procedure may be 100 cases.

Academic Medical Centers↗
PubMed2005

Pregnancy after gastric bypass surgery and internal hernia formation.

BACKGROUND: Gastric bypass is a surgical procedure that is increasingly performed in the United States to treat morbid obesity. Because of the changes associated with pregnancy, women with a history of gastric bypass surgery may be at an increased risk of gastrointestinal complications during the antepartum period, as demonstrated by these cases. CASES: The first patient presented at 12 weeks of gestation with abdominal pain. Computed tomography scan revealed rotation of the small bowel mesentery. In the operating room, a Petersen's internal hernia was observed. The second patient presented at 34 weeks of gestation with epigastric pain, nausea, and vomiting. An abdominal computed tomography scan suggested distention of the biliopancreatic limb, duodenum, and bypassed stomach. She underwent exploratory laparotomy with repair of an internal (mesenteric loop) hernia. CONCLUSION: As obstetricians, we should be aware of the potential for internal hernias in pregnant patients who have undergone bariatric surgery.

Abdominal Pain↗
PubMed2005

A comparison of burst pressure between buttressed versus non-buttressed staple-lines in an animal model.

BACKGROUND: The consequences of a staple-line leak or disruption can be devastating particularly in the bariatric surgery population. This study was designed to assess if gastrointestinal staple-lines buttressed with bovine pericardium could tolerate greater intraluminal pressures compared with non-reinforced staple-lines. METHODS: A laparoscopic linear cutting staple device was used to create divided staple-lines across the small intestine in a porcine model and the stomach in a rabbit model. 21 staple-lines were created with buttressing strips of bovine pericardium, and another 21 staple-lines were created without any reinforcement. All staple-lines were subjected to a constant rate increase in intraluminal pressure via intraluminal infusion of a dye solution. At the first sign of seam leak or failure, the burst pressure was recorded. RESULTS: In 19 of the 21 studies, the staple-lines buttressed with bovine pericardium sustained higher mean burst pressures than the conventional non-buttressed staple-lines. For the porcine intestinal segments, the mean intraluminal pressure at failure was 125 +/- 24 mmHg for buttressed staple-lines versus 58.4 +/- 28 mm Hg for conventional staple-lines (P <0.0001). For rabbit stomach segments, the mean intraluminal pressure at failure was also significantly higher for the buttressed segments (115 +/- 24 vs 75.6 +/- 23, P <0.0137). Most buttressed segments failed away from the staple-line, while the non-buttressed segments failed at the staple-line. CONCLUSIONS: Gastrointestinal staple-lines buttressed with bovine pericardium are able to maintain seam integrity at significantly higher intraluminal pressures when compared to non-buttressed GI staple-lines in animal models.

Anastomosis, Roux-en-Y↗
PubMed2004

Implantable Gastric Stimulation - the surgical procedure: combining safety with simplicity.

Implantable Gastric Stimulation is a safe and minimally invasive surgical therapy currently under investigation for the treatment for severe obesity. Over 500 patients have been implanted internationally, and thus far, there have been no major complications or mortalities. While this technology is proving to be the least morbid of the bariatric surgical procedures, it still has the potential to result in devastating complications because of the high-risk nature of operating on severely obese patients. Keeping the risk of a complication to a minimum requires careful attention to preoperative patient preparation, good operative technique, and comprehensive perioperative patient care. In addition, like for all bariatric procedures, the program must have the appropriate equipment and resources to serve this unique patient population. This review will highlight the most significant aspects of each issue.

Electric Stimulation Therapy↗
PubMed2004

"What are the yanks doing?" the U.S. experience with implantable gastric stimulation (IGS) for the treatment of obesity - update on the ongoing clinical trials.

BACKGROUND: The prevalence of obesity is growing worldwide. Medical therapies are often ineffective, and surgical treatments have significant risk. IGS(R) offers a novel approach to weight loss that was found to be safe and effective in European trials. In the U.S., 2 consecutive trials have been undertaken. METHODS: In 2000, a multicenter, prospective, randomized, placebo-controlled trial involving 103 morbidly obese patients (U.S. O-01) was undertaken. In 2002, a prospective, open label trial involving 30 morbidly obese patients was initiated (DIGEST). Patients were followed for complications, postoperative untoward events, and weight loss. RESULTS: In O-01, there were no significant perioperative complications. However, 20 patients were found to have had lead dislodgements. At 7 months, there was no significant difference in weight loss between the activated and non-activated groups. After 29 months, loss of excess weight (EWL) approached 20%. With DIGEST, there was 1 operative complication (a lost needle retrieved surgically). There were no untoward events or known lead dislodgements. EWL was 23% after only 16 months follow-up. With the introduction of a preoperative screening algorithm, almost 40% EWL was achieved for selected patients in both trials. CONCLUSIONS: In the U.S., the IGS system for the treatment of obesity has been shown to be safe. Technical improvements and better patient selection resulted in improved weight loss. The preliminary results of these trials suggest that IGS may be a suitable surgical option for selected patients.

Adult↗
PubMed2004

Energy expenditure is very high in extremely obese women.

To test the hypothesis that total energy expenditure (TEE) and resting energy expenditure (REE) are low in extremely obese individuals, factors that could contribute to maintenance of excess weight, a cross-sectional study was conducted in 30 weight stable, extremely obese women [BMI (mean +/- SEM) 48.9 +/- 1.7 kg/m(2)]. TEE was measured over 14 d using the doubly labeled water method, REE and the thermic effect of feeding (TEF) were measured using indirect calorimetry, and activity energy expenditure (AEE) was calculated as TEE - (REE + TEF). Body composition was determined using a 3-compartment model. Subjects were divided into tertiles of BMI (37.5-45.0; 45.1-52.0; and 52.1-77.0 kg/m(2)) for data analysis. TEE and REE increased with increasing BMI tertile: TEE, 12.80 +/- 0.5, 14.67 +/- 0.5, and 16.10 +/- 0.9 MJ/d (P < 0.01); REE, 7.87 +/- 0.2, 8.78 +/- 0.3, and 9.94 +/- 0.6 MJ/d (P < 0.001), and these values were 29-38% higher than published means of measured TEE in nonobese individuals. No significant differences were observed among BMI tertiles for AEE, TEF, or physical activity level (PAL = TEE/REE, overall mean 1.64 +/- 0.16). The Harris-Benedict and WHO equations provided the closest estimates of REE (within 3%), whereas the obese-specific equations of Ireton-Jones overpredicted (40%) and Bernstein underpredicted (21%) REE. Extremely obese individuals have high absolute values for TEE and REE, indicating that excess energy intake contributes to the maintenance of excess weight. Standard equations developed for nonobese populations provided the most accurate estimates of REE for the obese individuals studied here. REE was not accurately predicted by equations developed in obese populations.

Adult↗
PubMed2004

Implantable gastric stimulation for the treatment of severe obesity.

The prevalence of obesity is growing worldwide at an alarming rate. Current medical therapies are often ineffective and surgical treatments result in weight loss but have significant risk. Implantable Gastric Stimulation (IGS) offers a novel approach to weight loss. Simply stated, the IGS system electrically stimulates the stomach with a pacemaker-like device. The device is implanted in a brief minimally invasive procedure. Investigation in over 500 patients globally has proven it to be safe and seemly free of long-term sequelae. With refinements in patient selection and device application, the weight loss results have been steadily improving. The IGS may someday become a reliable and safe surgical option for weight loss.

Electric Stimulation Therapy↗
PubMed2003

Body composition assessment in extreme obesity and after massive weight loss induced by gastric bypass surgery.

Body composition methods were examined in 20 women [body mass index (BMI) 48.7 +/- 8.8 kg/m(2)] before and after weight loss [-44.8 +/- 14.6 (SD) kg] after gastric bypass (GBP) surgery. The reference method, a three-compartment (3C) model using body density by air displacement plethysmography and total body water (TBW) by H(2)18O dilution (3C-H(2)18O), showed a decrease in percent body fat (%BF) from 51.4 to 34.6%. Fat-free mass hydration was significantly higher than the reference value (0.738) in extreme obesity (0.756; P < 0.001) but not after weight reduction (0.747; P = 0.16). %BF by H(2)18O dilution and air displacement plethysmography differed significantly from %BF by 3C-H(2)18O in extreme obesity (P < 0.05) and 3C models using (2)H(2)O or bioelectrical impedance analysis (BIA) to determine TBW improved mean %BF estimates over most other methods at both time points. BIA results varied with the equation used, but BIA better predicted %BF than did BMI at both time points. All methods except BIA using the Segal equation were comparable to the reference method for determining changes over time. A simple 3C model utilizing air displacement plethysmography and BIA is useful for clinical evaluation in this population.

Adipose Tissue↗
PubMed2003

Long-term changes in energy expenditure and body composition after massive weight loss induced by gastric bypass surgery.

BACKGROUND: Little is known about the determinants of individual variability in body weight and fat loss after gastric bypass surgery or about the effects of massive weight loss induced by this surgery on energy requirements. OBJECTIVES: The objectives were to determine changes in energy expenditure and body composition with weight loss induced by gastric bypass surgery and to identify presurgery predictors of weight loss. DESIGN: Thirty extremely obese women and men with a mean (+/- SD) age of 39.0 +/- 9.6 y and a body mass index (BMI; in kg/m(2)) of 50.1 +/- 9.3 were tested longitudinally under weight-stable conditions before surgery and after weight loss and stabilization (14 +/- 2 mo). Total energy expenditure (TEE), resting energy expenditure (REE), body composition, and fasting leptin were measured. RESULTS: Subjects lost 53.2 +/- 22.2 kg body weight and had significant decreases in REE (-2.4 +/- 1.0 MJ/d; P < 0.001) and TEE (-3.6 +/- 2.5 MJ/d; P < 0.001). Changes in REE were predicted by changes in fat-free mass and fat mass. The average physical activity level (TEE/REE) was 1.61 at both baseline and follow-up (P = 0.98). Weight loss was predicted by baseline fat mass and BMI but not by any energy expenditure variable or leptin. Measured REE at follow-up was not significantly different from predicted REE. CONCLUSIONS: TEE and REE decreased by 25% on average after massive weight loss induced by gastric bypass surgery. REE changes were predicted by loss of body tissue; thus, there was no significant long-term change in energy efficiency that would independently promote weight regain.

Adult↗
PubMed2003

Reinforcing gastric staple-lines with bovine pericardial strips may decrease the likelihood of gastric leak after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Staple-line leakage is a potentially devastating complication of Roux-en-Y gastric bypass (RYGBP). Bovine pericardial strips (BPS) have been used to reinforce staple-lines in pulmonary resections and have been shown to decrease air-leaks. This study examined the use of BPS to decrease gastric staple-line leaks. METHODS: 250 consecutive patients undergoing laparoscopic RYGBP had BPS used for the gastric pouch. Ease of use, operative complications, and visual bleeding were recorded. In addition, the postoperative leak rate was compared to 100 consecutive patients operated on prior to the study when BPS was not used. RESULTS: Patient characteristics were the same for both groups and comparable with most published data. With the use of BPS, there were no operative complications and no meaningful increase in operating time. BPS reinforced staple-lines had no visual bleeding. In the 100 cases without BPS, there were 2 staple-line leaks (2%) both of which required emergency exploration. One additional patient was subsequently found to have a gastrogastric fistula. In the 250 patients who had BPS-reinforced staple-lines, there were no acute leaks. Three patients were subsequently found to have gastrogastric fistula. None required emergency surgery. CONCLUSION: In this non-randomized trial, BPS were found to be easy and safe to use. In addition, staple-line hemorrhage was essentially non-existent. Although the reduction in gastric staple-line leak rate may also be attributed to learning curve, there were no acute leaks in 250 patients with BPS, which is below the published norms.

Adult↗
PubMed2002

The development of the surgical treatment of morbid obesity.

Morbid obesity is defined as obesity with a body mass index >/=40, or >/=35 with secondary serious diseases. Conservative medical therapies in these individuals generally fail to sustain weight loss. Thus, surgical operations have evolved which are based on gastric restriction and/or malabsorption. Historically, the intestinal bypass operation was followed by the gastric bypass operation (in some instances combined with intestinal bypass) or by the gastric restriction operations (gastroplasty or gastric banding). Laparoscopic techniques are now being used for these operations, but require surgical expertise in both the bariatric operations and advanced laparoscopic skills. All operations may have complications, but these occur in a very small percent. Postoperative follow-up and nutritional surveillance are mandatory. The operations result in significant weight loss, and the current operations have a mean lasting weight loss of about 50 percent of excess body weight, with improvement or resolution of most obesity-associated conditions. There is evidence that even modest to moderate weight loss in these individuals has significant medical benefit.

Gastric Balloon↗
PubMedDate not supplied

Implantable gastric stimulation for weight loss.

With the epidemic of obesity worldwide, bariatric surgery has rapidly grown in popularity. Currently, a variety of surgical procedures are performed including Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, vertical banded gastroplasty, and biliopancreatic diversion. All of these procedures have been shown to succeed in achieving significant and sustainable weight loss for the majority of patients. However, these procedures also carry the potential for serious operative morbidity, altered gastrointestinal anatomy or function, or both. Electrical gastric stimulation via the implantable gastric stimulation (IGS) system is a relatively new and novel approach to treat obesity. The operative technique is relatively simple and the system does not alter gastrointestinal anatomy. Preliminary worldwide investigations have demonstrated safety and efficacy. This article will review the current experience with the IGS system.

Clinical Trials as Topic↗
PubMedDate not supplied

Severe obesity: a growing health concern A.S.P.E.N. should not ignore.

The definition of malnutrition in the published standards of the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) is any derangement in the normal nutrition status and includes overnutrition, commonly referred to as obesity. The incidence of obesity is increasing and reaching epidemic proportions in the United States and even worldwide. This has significant financial impact as our society spends billions of dollars on fad diets, commercial weight-loss programs, nutrition and dietary supplements, prescription and over-the-counter medications, and health clubs. Another approximately dollars 100 billion are spent to treat the medical consequences of obesity. Currently, for those patients with intractable morbid obesity, defined as having a body mass index >40 kg/m2, surgery offers the only option for achieving meaningful and sustainable weight loss. The resultant weight loss dramatically improves health and decreases the cost of health care for these patients. Years of refinement in technology and the introduction of safer and less invasive procedures have dramatically reduced the short-term morbidities and long-term metabolic consequences of these procedures. This address will review the field of weight loss (bariatric) surgery and will offer a compelling request for A.S.P.E.N. to include obesity in its fabric.

Bariatrics↗
PubMedDate not supplied

The use of staple-line reinforcement during laparoscopic gastric bypass.

Divided linear staple-lines are a mainstay of gastrointestinal surgery, and in particular, bariatric surgery. Staple-line failure, although uncommon, can result in significant morbidity and even mortality. Staple-line buttressing has been developed to improve staple-line strength, decrease bleeding and minimize the risk of leak. Many different products are currently available. However, most have not been proven in clinical trials. Bovine pericardial strips (BPS) are a buttressing material that fits onto the stapler device and gets "stapled" onto the tissue when the device is fired. The strips add thickness and potentially strength to the staple-line. Animal research has shown that staple-lines incorporated with BPS had higher burst pressures than those without. Human experience has suggested that BPS decreased the risk of acute staple-line failures in laparoscopic Roux-en-Y gastric bypass surgery. This report reviews the clinical and research experience with this product.

Anastomosis, Roux-en-Y↗