Nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, and bariatric surgery: a review.
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Bariatric Surgery↗
Biomedical subjects
Thomas S Helling
Publications and source records attributed to Thomas S Helling.
The liver and hemorrhagic shock.
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Apoptosis↗
Is trauma centre care helpful for less severely injured patients?
BACKGROUND: Trauma centres have been shown to reduce the number of preventable deaths from serious injuries. This is due largely to the rapid response of surgeons and health care teams to resuscitate, evaluate, and operate if necessary. Less is known about the effectiveness of trauma centre care on those patients who have not incurred immediate life-threatening problems and may not be as critically injured. The purpose of this study was to review the use of physician and hospital resources for this patient population to determine whether trauma team and trauma centre care is helpful or even needed. METHODS: This was a retrospective study of consecutive trauma patients (n=1592) admitted from 1998 to 2002 to the trauma service of an urban level I trauma centre and recorded in the hospital trauma registry. Patients were triaged in a tiered response to more or less severely injured. All patients' care was directed by trauma surgeons. RESULTS: Of the 1592 patients, 398 (25%) received a full trauma team response (Class I), 1194 were less seriously injured (Class II). The ISS for the Class I patients was 19+/-18 and for Class II patients 10+/-10. Nineteen percent of Class II patients had an ISS>15. Overall mortality in Class II patients was 2% including 20 unexpected deaths. Four hundred and three Class II patients (34%) had multisystem injuries. Of the Class II patients 423 (35%) were sent to the ICU or OR from the ED, 106 of whom required an immediate operation and 345 required an operation prior to discharge. Complications developed in 129 patients (11%), the majority of which were pulmonary. CONCLUSIONS: A large proportion of those patients thought initially to be less severely injured required resources available in a trauma centre, including specialty care, intensive care, and operating room accessibility. Over one-third of these patients had multisystem injuries and almost 20% were considered major trauma, needing prioritisation of care and expertise ideally found in a trauma centre environment. Complications developed in a sizable number of patients. This patient population, because of its heterogeneity and propensity for critical illness, deserves the resources of a trauma centre.
Adult↗
The lethality of obstructing hematoma at the jejunojejunostomy following Roux-en-Y gastric bypass.
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Adult↗
Operative experience and follow-up in a cohort of patients with a BMI > or =70 kg/m2.
BACKGROUND: Roux-en-Y gastric bypass (RYGBP) has been found to be a safe and effective operation for the morbidly obese whether performed open or laparoscopically. Weight loss has been substantial and sustained. Less is known about those at the extremes of obesity, with BMI > or =70 kg/m2 with regard to safety and efficacy. This study is a retrospective review of a cohort of such patients, to examine operative experience and response to surgical treatment. METHODS: A cohort of 34 patients who underwent open RYGBP at one institution was retrospectively reviewed. All operations were performed by a single surgeon. Operative outcome was examined, including early mortality, morbidity, need for intensive (ICU) care and hospital length of stay (LOS). Percent of excess weight lost (EWL) and percent reduction of BMI after at least 1 year of follow-up were determined. Late mortality was assessed. RESULTS: There were 22 females and 12 males with mean age 42.0 + 8.1 years and mean BMI 78.3 + 8.5 kg/m2. Obstructive sleep apnea (OSA) was found in 19/34 (58%) and hypoventilation syndrome of obesity (HSO) in 11/34 (32%). There was 1 early death (3 months) from renal failure. 7 patients (21%) developed complications, 3 major (pulmonary embolus, wound dehiscence) and 4 minor (wound infection). 16 patients (47%) required ICU, and 12 (35%) required extended mechanical ventilation. Hospital LOS was 10.3 +/- 10.4 days for all patients. There were 4 late deaths (12%) from 7 to 36 months after RYGBP. Mean percent EWL was 61 +/- 17 and mean percent reduction in BMI was 44 +/- 11. For those followed at least 36 months, weight loss was sustained in 12/14 patients. CONCLUSIONS: RYGBP can be performed safely, even at the extremes of weight. While technically challenging, there were no instances of intra-abdominal sepsis. Postoperative complications were few. Need for ICU and hospital LOS is greater, reflecting the incidence of pre-existing pulmonary problems. Weight loss is significant and appears to be sustained in most patients. Late deaths have been noted and deserve careful scrutiny.
Adult↗
Partial hepatectomy with or without endotoxin does not promote apoptosis in the rat liver.
BACKGROUND: Liver insufficiency and failure has been described following subtotal hepatectomy. The cause is poorly understood but may be because of attrition of hepatocytes through enhanced cell death pathways such as apoptosis. The trigger for this could be reduction beyond a critical mass of liver tissue or the influence of endotoxin (LPS) on cytokine activation. The experiment was designed to answer these questions. MATERIALS AND METHODS: Rats were subjected to either 30% or 70% hepatectomy. Sacrifice occurred on either postoperative day 2 or 4. At sacrifice remnant livers were examined for apoptosis through the direct Tunel immunoperoxidase method (apoptotic index) and soluble histone ELISA. A second group of rats underwent 30% or 70% hepatectomy and were given either saline or endotoxin (LPS). Sacrifice occurred on postoperative day 1, 2, or 4. Liver samples were analyzed for apoptosis by Tunel immunoperoxidase, histone-associated DNA, TNF-alpha, and caspase-3. Mitotic activity and evidence of hepatocellular necrosis were also determined. RESULTS: By comparison to prehepatectomy values, rats subjected to hepatectomy alone failed to disclose any effect of resection on apoptotic activity. By comparison to sham operated controls there was a modest but significant increase in apoptotic activity at day 4 in the 30% and 70% hepatectomized rates by apoptotic index but not the soluble histone ELISA. Injection of LPS without hepatectomy produced an increase in apoptotic activity by apoptotic index and soluble histone ELISA methods on day 1 and 2. The addition of 30% or 70% hepatectomy produced a sporadic, but not sustained, increase in apoptotic activity which may have been because of LPS injection alone. Tissue TNF-alpha levels increased with LPS but changed little with addition of hepatectomy. Mitotic activity remained essentially unchanged with or without LPS injection. No evidence of hepatocellular necrosis was detected with LPS and extended hepatectomy. CONCLUSIONS: Apoptosis does not appear to be a prominent feature in the posthepatectomy liver, with or without addition of LPS. Even with accelerated TNF-alpha production from LPS, the mitotic pathways continue to take precedent. Apoptosis, except for occasional sporadic bursts, is effectively suppressed. It is not likely that apoptosis contributes to depletion of functional hepatocytes and liver insufficiency.
Animals↗
Determinants of the need for intensive care and prolonged mechanical ventilation in patients undergoing bariatric surgery.
BACKGROUND: Bariatric surgery at the upper extremes of weight can be associated with serious postoperative complications. In many cases, these complications will require the availability of critical care resources. The purpose of this study is to examine factors that increase the likelihood for prolonged postoperative intensive care unit (ICU) and extended mechanical ventilation (MV) >24 hours. METHODS: A retrospective chart review was conducted of all patients undergoing bariatric surgery over a 7-year period at a tertiary care academic institution. There were 250 total patients undergoing either vertical banded gastroplasty (n=15) or Roux-en-Y gastric bypass (n=235). Age, Gender, BMI, pulmonary co-morbidity, revisional surgery (previous bariatric operations), and need for reoperation for suspected intra-abdominal complications were examined by univariate and multivariate analyses. RESULTS: Mean age was 43.6+/-10.6 years and mean BMI 56+/-10.6 kg/m2. Pulmonary co-morbidity was present in 123/250 patients (49%), 42/250 (17%) had revisional surgery, and 21/250 (8%) required reoperation. ICU care was required in 60 patients (24%). By univariate analysis, age >50 yrs (P=0.047), male gender (P=0.038), and need for reoperation (P <0.001) were associated with need for ICU. By multivariate analysis, BMI >60 kg/m2, odds ratio (OR) 2.25, 95% confidence Interval (CI) 1.11-4.60, P=0.04, and need for reoperation, OR 39.8, 95% CI 10.41-264.7, P <0.0001, were associated with need for ICU. MV >24 hrs was required in 44 patients (18%). By univariate analysis, BMI >60 kg/m2 (P=0.013), pulmonary co-morbidity (P=0.014), male gender (P =0.029), and reoperation (P <0.0001) were associated with need for MV. By multivariate analysis, BMI >60 kg/m2, OR 3.1, 95% CI 1.44-7.13, P=0.005, and need for reoperation, OR 22.3, 95% CI 7.4-79.2, P <0.0001, were associated with need for MV. CONCLUSIONS: Patients who are male, older (>50 yrs), heavier (BMI >60 kg/m2), and who have complications requiring reoperation will likely need intensive care. Additionally, males, heavier patients (BMI >60 kg/m2), pulmonary co-morbidity, and need for reoperation may warrant need for extended MV. Surgeons and hospitals should consider this when planning resources for bariatric surgery programs.
Adolescent↗
The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients.
BACKGROUND: The presence of a surgeon at the initial assessment and care of the trauma patient has been the focal point of trauma center designation. However, for Level I verification, the American College of Surgeons Committee on Trauma currently does not require the presence of an attending trauma surgeon in the hospital (IH), provided senior surgical residents are immediately available. Likewise, the state of Missouri does not mandate an IH presence of the attending trauma surgeon but requires senior (postgraduate year 4 or 5) level surgical residents to immediately respond, with a 20-minute response time mandated for the attending surgeon if IH or out of the hospital (OH). Nevertheless, some claim that IH coverage by attending surgeons provides better care for seriously injured patients. METHODS: This retrospective study assessed patient care parameters over the past 10 years on critically injured patients to detect any difference in outcome whether the surgeon was IH or OH at the time of the trauma team activation (cardiopulmonary instability, Glasgow Coma Scale [GCS] score < 9, penetrating truncal injury). Patients were subcategorized into blunt/penetrating, shock (systolic blood pressure < 90 mm Hg) on arrival, GCS score < 9, Injury Severity Score (ISS) > 15, or ISS > 25. Response was examined from 8 am to 6 pm weekdays (IH) or 6 pm to 8 am weekdays and all weekends (OH). Patient care parameters examined were mortality, complications, time in the emergency department, time to the operating room, time to computed tomographic scanning, intensive care unit length of stay (LOS), and hospital LOS. RESULTS: For all patients (n = 766), there was no significant difference in any parameters except intensive care unit LOS (IH, 4.90 +/- 7.96 days; OH, 3.58 +/- 7.69 days; p < 0.05). For blunt trauma (n = 369), emergency department time was shorter (99.71 +/- 88.26 minutes vs. 126.51 +/- 96.68 minutes, p < 0.01) and hospital LOS was shorter (8.04 +/- 1.02 days vs. 11.08 +/- 1.15 days, p < 0.05) for OH response. For penetrating trauma (n = 377), shock (n = 187), GCS score < 9 (n = 248), ISS > 15 (n = 363), and ISS > 25 (n = 230), there were no statistically significant differences in any patient care parameter between IH and OH response. For those in most need of urgent operation-penetrating injuries and shock-there were no differences in time to operating room or mortality for OH or IH response. CONCLUSION: As long as initial assessment and care is provided by senior level IH surgical residents and as long as the attending surgeon responds in a defined period of time (if OH) to guide critical decision-making, the IH presence of an attending surgeon has not been shown in this retrospective study to improve care of the critically injured patient.
Glasgow Coma Scale↗
Gastric bypass: it pays to keep military hospitals busy.
This study was performed to review the surgical treatment of obesity at a community military hospital and compare costs to TRICARE reimbursement rates (the cost of sending a patient to a civilian surgeon for obesity surgery). The preoperative, operative, and postoperative phases are described in detail. The expenses of five consecutive patients were calculated and averaged. Each operation at our hospital cost 1,710 dollars, whereas the TRICARE cost was at least 6,950 dollars. A saving of 5,240 dollars per operation was achieved in our military hospital. These five patients subjectively graded their outcomes as very good to excellent at a mean of 7.9 months from surgery. These patients lost an average of 70% of their excess body weight. All patients with weight-related comorbidities reported resolution of at least one problem.
Adult↗
Weakness after gastric bypass.
Two patients underwent gastric bypasses and had uneventful hospital courses. In the early postoperative periods, both developed severe, protracted vomiting, weakness, and hyporeflexia. After thorough laboratory and clinical evaluations by neurologists, the patients were diagnosed with Guillain-Barré syndrome, although there were many atypical features. The clinical presentations of these patients are very similar to case reports of nutritional polyneuropathy associated with gastric partitioning. This paper addresses the difficulties of differentiating these two diagnoses.
Adult↗
Minimal acceptable care as a vital component to Missouri's trauma system.
Immediate attention to life-threatening injuries and expeditious transfer of major and complex wounds to tertiary care trauma centers are the cornerstones of any trauma system. Rapid assessment and "minimalization" of care should be the buzz-word of rural (Level III) and suburban (Level II) trauma centers in order to provide quickest treatment of injuries by timely referral of patients for definitive attention. This concept is called minimal acceptable care and may serve to improve patient outcome by reducing the interval to ultimate treatment and avoidance of duplication of services.
Efficiency, Organizational↗
Bleeding and early obstruction after laparoscopic gastric bypass.
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Adult↗
Surgical management of chronic pancreatitis and the role of islet cell autotransplantation.
Chronic pancreatitis is a disease characterized by disabling pain, inability to eat, steatorrhea, and eventual malnutrition. This often results in repeated hospitalizations and attempts to control symptoms with various analgesic regimens. As a result, the medical treatment of chronic pancreatitis is one of symptomatic management. Eventually, in some, nutritional supplementation becomes a necessity. For a fortunate few, the disease apparently burns itself out in time, lessening pain and improving appetite. In many patients, frustration over pain management and repeated hospitalizations leads to surgical treatment. Various procedures have been devised but, generally, fall into 2 categories: operations to decompress dilated ducts and operations to resect diseased pancreas. Results with either approach are unpredictable and often unsuccessful. For those without dilated ducts or with recurrent pain after surgery, total pancreatectomy has been suggested to remove all inflammatory tissue. This can be coupled with islet cell autotransplantation to avoid the dangers of pancreatogenic diabetes. Appropriate care of the removed pancreas and islet cell separation and purification are critical to this procedure to produce viable cells. Dispersed islets have been shown to successfully engraft and function for indefinite periods of time. Although insulin independence may not be achieved, easier maintenance of blood glucose can usually be realized.
Chronic Disease↗
Ruminations of an ordinary hepatic surgeon: a journey through the pitfalls of major liver resections.
Historically, major hepatic resections have been fraught with voluminous blood losses and, at times, high mortality rates. Improvements in patient selection and operative technique over the past 20 years have resulted in marked reduction in death and complications and have given the impression that liver surgery can be relatively effortless. Contrary to this belief, the present review illustrates some of the pitfalls and dangers of major hepatectomy and may serve to alert ordinary surgeons to approach this operation with a degree of trepidation and careful planning. Over a 22-year period, 147 liver resections were performed by one surgeon for solid liver tumors (range 0 to 21/yr). Of these, 101 were major hepatectomies comprising at least three anatomic segments (63 right, 24 left, 11 extended right, and 3 extended left) and form the basis for this report. The major resections were performed for benign disease in 16 patients and malignant tumors in 85 (24 primary and 61 metastatic lesions). All but one patient were noncirrhotic. Seventeen patients were more than 70 years and 84 were less than 70 years of age. There were five postoperative deaths among these 101 patients: two intraoperative (coagulopathy after venovenous bypass in 1 and air embolus in 1), two from postoperative liver failure, and one resulting from a myocardial infarction. Three deaths were in patients older than 70 (18%), and two were in patients younger than 70 (2%) (P = 0.03). Complications developed in 20 of 96 survivors, three patients required reoperation for postoperative bleeding, and nine patients had some duration of bile leakage. In contrast, among those undergoing "minor" hepatectomies (n = 46), there were no deaths and six (13%) patients had complications. In patients undergoing major hepatectomies, estimated blood loss was 3836 +/- 3346 ml. Estimated blood loss was unaffected by experience (first 50 patients vs. second 51 patients) or use of the ultrasonic surgical aspirator, but has been reduced by the use of the Harmonic scalpel (2650 +/- 2706.1 ml vs. 3997 +/- 3405.8 ml, P = 0.026). The use of rapid-infusion systems aided in preventing intraoperative hypotension and hypothermia. Estimated blood loss was significantly greater than with minor anterior or lateral segmentectomies (n = 24) (3836 +/- 3346 ml vs. 975 +/- 518.8 ml, P < 0.0001). Hospital length of stay has been shortened, primarily by the use of closed suction drainage compared to open drainage (7.5 2 +/-.4 days vs. 18.8 +/- 8.4 days, P < 0.0001). Major hepatectomies continue to be formidable operations with the potential for copious blood loss and intraoperative instability. Proper patient selection, anesthesia support and availability of rapid-infusion technology, and familiarity with liver anatomy are important in keeping operative mortality and postoperative morbidity at an acceptable level.
Aged↗
Good trauma care is no accident.
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Humans↗
The challenges of trauma care in the rural setting.
Trauma occurring in the rural setting presents a unique set of challenges not found in more populated areas. Risk of death is distinctly increased, probably as a result of prehospital factors such as delayed recognition and inconsistency of EMS response and care. Lack of trauma trained physicians and hospital resources also contribute to a higher death rate. Development and designation of rural trauma centers can be instrumental in reversing this trend. The education in trauma care that goes hand-in-hand with designation is probably most responsible for better outcomes of trauma patients. The guiding philosophy in such a system should be one of 'minimal acceptable care' with early recognition of major trauma and expeditious transfer of these patients. This does not obviate the responsibility of rural trauma centers to deal quickly and effectively with patients in whom ongoing blood loss is an immediate threat to life and to exert a damage control approach as an initial phase of treatment.
Critical Care↗
Advances in liver surgery.
Techniques for liver surgery have evolved over the past few decades, which have, in turn, allowed for safer operations and have broadened indications for liver resection for benign and malignant liver tumors. Major advances have included appreciation of limiting liver resection to conserve functioning liver tissue and avoid extensive operations that carry a risk of postoperative liver failure, particularly in patients with cirrhosis--the so-called segment-oriented approach to liver resection; multidisciplinary management for patients with malignant liver disease to tailor treatment to each patient depending on tumor burden, condition of the liver, and associated co-morbidity; and development of laparoscopic liver resection to shorten postoperative recovery and reduce postoperative pain. Importantly, it is recommended that liver surgery, whether open or laparoscopic, be done by experienced liver surgeons in centers with the familiarity and resources to address the perioperative needs of these patients.
Endoscopy, Digestive System↗