I am a fellowship-trained minimally invasive and bariatric surgeon, who is involved in national surgical and specialty societies. My area of clinical and research interest is in outcomes of metabolic and bariatric surgery in special populations. As a surgeon at the Palo Alto Veterans Hospital, I am specifically interested in the outcomes of weight loss surgery in obese Veterans, who represent a population with a significant burden of co-morbidity, as well as challenging social, economic, and geographic circumstances. In addition, I am currently studying Veterans with spinal cord injury, with a goal to identify gaps in assessment and management of obesity in this special population.
Associate Professor - University Medical Line, Surgery - General Surgery
Director, Bariatric/Minimally Invasive Surgery, Palo Alto VA HSC (2007 - Present)
Director, Advanced GI/MIS Fellowship, Palo Alto VA HCS (2010 - Present)
Fellowship, Yale-New Haven Hospital, Minimally Invasive Surgery (2007)
Residency, Yale-New Haven Hospital, General Surgery (2006)
M.D., Washington University (1999)
B.S., M.S., Yale University, Biochemistry (1994)
Community and International Work
Sleeve gastrectomy versus medical management in the treatment of diabetes in the morbidly obese
diabetes in morbidly obese
Morbidly obese, diabetics
Opportunities for Student Involvement
Current Research and Scholarly Interests
Minimally Invasive Surgery
The impact of the COVID-19 pandemic on individuals living with spinal cord injury: A qualitative study.
PURPOSE/OBJECTIVE: To explore the impact of the COVID-19 pandemic as experienced and reported by individuals living with a spinal cord injury (SCI).RESEARCH METHOD/DESIGN: Descriptive qualitative design using in-depth semistructured interviews with individuals with SCI (n = 33) followed by thematic analysis.RESULTS: Three main themes described impacts of the COVID-19 pandemic. (a) Impact on health care use; subthemes elaborated that this was attributable to in-person health care facility restrictions or individual decisions to delay care. Individuals with SCI experienced lapses in primary and SCI-specialty care, rehabilitation/therapy services, and home care, but some made use of telehealth services. (b) Impact on weight and/or weight management lifestyle behaviors; subthemes discussed that engagement in physical activity declined because of fitness center closures, recreational activity cancellations, and safety precautions limiting community-based and outdoor activities. The pandemic disrupted participants' independence in purchasing and making preferred food selections which impacted healthy eating. Participants ate due to boredom, at nonmealtimes, and consumed unhealthy foods during the pandemic. (c) Impact on psychosocial factors; included subthemes noting reduced social interactions, social participation, and ability to pursue pastimes with family, friends, and groups they belonged to. The pandemic also triggered emotional reactions such as worry, fear, doubt, demotivation, and feelings of social isolation.CONCLUSIONS: Our findings highlight the magnitude of consequences faced by individuals with SCI when restrictions to health care, healthy lifestyle endeavors, and social participation occurred during the COVID-19 pandemic. Findings may inform SCI health care providers on what is needed in response to future public health or natural disaster crises. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
View details for DOI 10.1037/rep0000469
View details for PubMedID 36395055
2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery.
MAJOR UPDATES TO 1991 NATIONAL INSTITUTES OF HEALTH GUIDELINES FOR BARIATRIC SURGERY: Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) >35 kg/m2, regardless of presence, absence, or severity of co-morbidities.MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2.BMI thresholds should be adjusted in the Asian population such that a BMI >25 kg/m2 suggests clinical obesity, and individuals with BMI >27.5 kg/m2 should be offered MBS.Long-term results of MBS consistently demonstrate safety and efficacy.Appropriately selected children and adolescents should be considered for MBS.(Surg Obes Relat Dis 2022; https://doi.org/10.1016/j.soard.2022.08.013 ) © 2022 American Society for Metabolic and Bariatric Surgery. All rights reserved.
View details for DOI 10.1007/s11695-022-06332-1
View details for PubMedID 36336720
- Interaction between increasing body mass index and spinal cord injury to the probability of developing a diagnosis of nonalcoholic fatty liver disease OBESITY SCIENCE & PRACTICE 2022
- 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery 2022
Complete Telehealth for Multidisciplinary Preoperative Workup Does Not Delay Time to Metabolic and Bariatric Surgery: a Pilot Study.
PURPOSE: The COVID-19 pandemic accelerated implementation of telehealth throughout the US healthcare system. At our institution, we converted a fully integrated multidisciplinary bariatric clinic from face-to-face visits to entirely telehealth video/telephone visits. We hypothesized telehealth would increase the number of provider/patient encounters and therefore delay time to surgery.METHODS: This is a retrospective review of consecutive patients who underwent total telehealth preoperative workup. Demographics, comorbidities, and surgical characteristics were compared to the same number of consecutive patients who underwent a face-to-face approach 12months prior, using a Wilcoxon test for continuous variables and chi-square or Fisher's exact test for categorical variables. Differences between time and surgery were compared using inverse probability of treatment-weighted estimates and number of preoperative visits using Poisson regression with distance to hospital as a confounder. Noninferiority margin for time to surgery was set to 60days, and the number of visits was set to 2 visits.RESULTS: Between March of 2020 and December of 2021, 36 patients had total telehealth workup, and were compared to 36 patients in the traditional group. Age, sex, body mass index, and comorbidities did not differ between groups. The average number of days to surgery was 121.1days shorter in the telehealth group (90% bootstrap CI [-160.4,-81.8]). Estimated shift in the total number of visits was additional .76 visits in the traditional group (90% CI [.64, .91).CONCLUSIONS: The total telehealth approach to preoperative bariatric multidisciplinary workup did not delay surgery and decreased number of total outpatient visits and time to surgery.
View details for DOI 10.1007/s11695-022-06233-3
View details for PubMedID 36114438
Frequency and costs of low-value preoperative tests for patients undergoing low-risk procedures in the veterans health administration.
Perioperative medicine (London, England)
2022; 11 (1): 33
BACKGROUND: Clinical practice guidelines discourage routine preoperative screening tests for patients undergoing low-risk procedures. This study sought to determine the frequency and costs of potentially low-value preoperative screening tests in Veterans Health Administration (VA) patients undergoing low-risk procedures.METHODS: Using the VA Corporate Data Warehouse, we identified Operative Stress Score class 1 procedures ("very minor") performed without general anesthesia in VA during fiscal year 2019 and calculated the overall national and facility-level rates and costs of nine common tests received in the 30 preoperative days. Patient factors associated with receiving at least one screening test, and the number of tests received, were examined.RESULTS: Eighty-six thousand three hundred twenty-seven of 178,775 low-risk procedures (49.3%) were preceded by 321,917 potentially low-value screening tests representing $11,505,170 using Medicare average costs. Complete blood count was the most common (33.2% of procedures), followed by basic metabolic profile (32.0%), urinalysis (26.3%), electrocardiography (18.9%), and pulmonary function test (12.4%). Older age, female sex, Black race, and having more comorbidities were associated with higher odds of low-value testing. Transthoracic echocardiogram occurred prior to only 4.5% of the procedures but accounted for 47.8% of the total costs ($5,499,860). In 129 VA facilities, the facility-level proportion of procedures preceded by at least one test ranged from 0 to 81.2% and facility-level costs ranged from $0 to $388,476.CONCLUSIONS: Routine preoperative screening tests for very low-risk procedures are common and costly in some VA facilities. These results highlight a potential target to improve quality and value by reducing unnecessary care. Measures of low-value perioperative care could be integrated into VA's extensive quality monitoring and improvement infrastructure.
View details for DOI 10.1186/s13741-022-00265-0
View details for PubMedID 36096937
Preventive Health Screening in Veterans Undergoing Bariatric Surgery.
American journal of preventive medicine
INTRODUCTION: Individuals with obesity are vulnerable to low rates of preventive health screening. Veterans with obesity seeking bariatric surgery are also hypothesized to have gaps in preventive health screening. Evaluation in a multidisciplinary bariatric surgery clinic is a point of interaction with the healthcare system that could facilitate improvements in screening.METHODS: This is a retrospective cohort study of 381 consecutive patients undergoing bariatric surgery at a Veterans Affairs Hospital from January 2010 to October 2021. Age- and sex-appropriate health screening rates were determined at initial referral to a multidisciplinary bariatric surgery clinic and at the time of surgery. Rates of guideline concordance at both time points were compared using McNemar's test. Univariate and multivariate analyses were performed to identify the risk factors for nonconcordance.RESULTS: Concordance with all recommended screening was low at initial referral and significantly improved by time of surgery (39.1%‒63.8%; p<0.001). Screening rates significantly improved for HIV (p<0.001), cervical cancer (p=0.03), and colon cancer (p<0.001). Increases in BMI (p=0.005) and the number of indicated screening tests (p=0.029) were associated with reduced odds of concordance at initial referral. Smoking history (p=0.012) and increasing distance to the nearest Veterans Affairs Medical Center (p=0.039) were associated with reduced odds of change from nonconcordance at initial referral to concordance at the time of surgery.CONCLUSIONS: Rates of preventive health screening in Veterans with obesity are low. A multidisciplinary bariatric surgery clinic is an opportunity to improve preventive health screening in Veterans referred for bariatric surgery.
View details for DOI 10.1016/j.amepre.2022.06.014
View details for PubMedID 36100538
Rates, Variability, and Predictors of Screening for Obesity: Are Individuals with Spinal Cord Injury Being Overlooked?
2022; 15 (3): 451-457
INTRODUCTION: Individuals with spinal cord injury (SCI) are vulnerable to obesity. Annual obesity screening using body mass index (BMI) is the standard of care mandated by US Veterans Health Administration (VHA) guidelines. Our objective was to determine the rates, variability, and predictors of guideline-concordant annual screening for obesity, given potential challenges of height and weight measurements in individuals with SCI.METHODS: This is a cross-sectional retrospective study using US national VA databases. We identified all VHA patients with chronic SCI in the fiscal year (FY) 2019, their treating facility and frequency of recorded height and weight. We applied mixed-effects logistic regression models to assess associations between annual BMI screening and patient- and facility-level characteristics.RESULTS: Of 20,978 individuals with chronic SCI in VHA in FY19, guideline-concordant annual BMI screening was lacking in 37.9%. Accounting for facility-level factors (geographic region, SCI facility type, volume of patients with SCI treated at the facility), a mixed-effects logistic regression model demonstrated that lack of annual obesity screening was significantly associated with older patient age (p < 0.001) and fewer outpatient encounters (p < 0.001) but not other patient-level factors such as sex, race, level of injury, or rurality. The rate of obesity screening among different facilities within VHA varied widely from 11.1% to 75.7%.CONCLUSION: A large proportion of persons with SCI receiving care in VHA do not receive guideline-concordant annual obesity screening, an especially acute problem in some facilities. Older patients with fewer outpatient encounters are more likely to be missed. To inform the design of interventions to improve identification and documentation of obesity, further study is needed to assess potential barriers to obesity screening in the population with SCI.
View details for DOI 10.1159/000523917
View details for PubMedID 35263742
- ASMBS Position Statement on the Impact of Metabolic and Bariatric Surgery on Nonalcoholic Steatohepatitis. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery 1800
- Biliopancreatic access following anatomy-altering bariatric surgery: aliterature review. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery 2021
Assessment and management of gastroesophageal reflux disease following bariatric surgery.
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery
Gastroesophageal reflux disease (GERD) is a common disease in patients with obesity. The incidence of de novo GERD and the effect of bariatric surgery on patients with pre-existing GERD remain controversial. Management of GERD following bariatric surgery is complicated and can range from medical therapy to non-invasive endoscopic options to invasive surgical options. To address these issues, we performed a systematic review of the literature on the incidence of GERD and the various modalities of managing GERD in patients following bariatric surgery. Given the increased number of laparoscopic sleeve gastrectomy (LSG) procedures being performed and the high incidence of GERD following LSG, bariatric surgeons should be familiar with the options available to manage GERD following LSG as well as other bariatric procedures.
View details for DOI 10.1016/j.soard.2021.07.023
View details for PubMedID 34620566
Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration.
JAMA network open
2021; 4 (5): e217470
Importance: The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system.Objective: To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA.Design, Setting, and Participants: This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included.Exposures: A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation.Main Outcomes and Measures: Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram).Results: A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P<.001) at the facility level and 0.06 (P<.001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given.Conclusions and Relevance: Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.
View details for DOI 10.1001/jamanetworkopen.2021.7470
View details for PubMedID 33956131
Multidisciplinary Preoperative Management of Clinically Complex Patients Results in Delay to Bariatric Surgery
ELSEVIER SCIENCE INC. 2020: E2–E3
View details for Web of Science ID 000582798100006
Positive and Negative Independent Predictive Factors of Weight Loss After Bariatric Surgery in a Veteran Population.
INTRODUCTION: Factors predicting outcomes after bariatric surgery are yet to be elucidated. We aim to characterize patient-level factors that predict midterm weight loss.METHODS: A database of bariatric surgery at a Veterans Affairs (VA) hospital was retrospectively reviewed. Patient characteristics including age, race, sex, median zip code household income, and distance to the VA bariatric center were analyzed for relationships with percent excess body mass index loss (%EBMIL). Univariate and multivariate analyses were conducted to identify factors independently associated with weight loss after accounting for follow-up time, using stepwise variable selection. A multivariable mixed effects linear regression model was constructed with random intercepts for repeated measures by veteran and fixed effects for time, patient, and procedural characteristics, including comorbidities.RESULTS: A total of 1124 observations were analyzed for 340 bariatric patients. Most were male (77%), white (73%); mean age was 53.2years and mean preoperative BMI was 43.9kg/m2. Follow-up ranged from 99% at 1year, 54% at 5years, and 24% at 10years, with a mean of 6.9years for Roux-en-Y gastric bypass (RYGB) and 3.5years for laparoscopic sleeve gastrectomy (LSG). RYGB (p<0.001) and female (p=0.016) predicted greater %EBMIL up to 10years after surgery. African American race and higher comorbidity burden predicted poorer %EBMIL (p=0.008, p=0.012, respectively). Analysis of individual comorbidities demonstrated that type 2 diabetes was most strongly associated with poorer %EBMIL (p=0.048).CONCLUSION: RYGB and female sex are independent predictors of greater midterm weight loss after bariatric surgery. African American race and a high burden of comorbidity are predictive of poorer weight loss. Neither zip code median income nor distance from bariatric center was associated with weight loss.
View details for DOI 10.1007/s11695-020-04428-0
View details for PubMedID 32009214
Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery.
Anesthesia and analgesia
2019; 129 (3): 804-811
The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA).Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression.From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT.Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.
View details for DOI 10.1213/ANE.0000000000004291
View details for PubMedID 31425223
Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery.
Anesthesia and analgesia
BACKGROUND: The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA).METHODS: Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression.RESULTS: From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT.CONCLUSIONS: Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.
View details for DOI 10.1213/ANE.0000000000004291
View details for PubMedID 31206428
Variation in Surgeons' Requests for General Anesthesia When Scheduling Carpal Tunnel Release.
Hand (New York, N.Y.)
BACKGROUND: Carpal tunnel release (CTR) can be performed with a variety of anesthesia techniques. General anesthesia is associated with higher risk profile and increased resource utilization, suggesting it should not be routinely used for CTR. The purpose of this study was to examine the patient factors associated with surgeons' requests for general anesthesia for CTR and the frequency of routine use of general anesthesia by Veterans Health Administration (VHA) surgeons and facilities.METHODS: National VHA data for fiscal years 2015 and 2017 were used to identify patients receiving CTR. Mixed-effects logistic regression was used to evaluate patient, procedure, and surgeon factors associated with requests by the surgeon for general anesthesia versus other anesthesia techniques.RESULTS: In all, 18 145 patients underwent CTR performed by 780 surgeons in 113 VHA facilities. Overall, there were 2218 (12.2%) requests for general anesthesia. Although some patient (eg, older age, obesity), procedure (eg, open vs endoscopic), and surgeon (eg, higher volume) factors were associated with lower odds of requests for general anesthesia, there was substantial facility- and surgeon-level variability. The percentage of patients with general anesthesia requested ranged from 0% to 100% across surgeons. Three facilities and 28 surgeons who performed at least 5 CTRs requested general anesthesia for more than 75% of patients.CONCLUSIONS: Where CTR is performed and by whom appear to influence requests for general anesthesia more than patient factors in this study. Avoidance of routine use of general anesthesia for CTR should be considered in future clinical practice guidelines and quality measures.
View details for PubMedID 30789047
Development and validation of a predictive model for American Society of Anesthesiologists Physical Status.
BMC health services research
2019; 19 (1): 859
The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes.Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator.Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.
View details for DOI 10.1186/s12913-019-4640-x
View details for PubMedID 31752856
Preoperative Endoscopic Findings in Veterans Undergoing Bariatric Surgery: Prevalence and Predictors of Barrett's Esophagus.
There is no consensus regarding the need for routine esophagogastroduodenoscopy (EGD) in patients before bariatric surgery. The aim of our study is to determine the frequency and predictors of EGD findings in a Veteran population presenting for bariatric surgery.This is a single-center retrospective analysis of Veterans who underwent RYGB or LSG, at a Veterans Affairs hospital between January 2008 and December 2017. All patients received a preoperative EGD. Data abstracted included demographics, comorbidities, preoperative laboratory values, and EGD findings. Univariate and multivariate analyses were performed for common EGD pathologies.Of the 260 Veterans included in our cohort, majority were male (75.0%), Caucasian (73.5%), and aged 54.0 ± 9.0 years old with a BMI of 44.9 ± 7.0 kg/m2. Most had hypertension (78.9%), previously smoked (63.9%), and recently used a proton pump inhibitor (PPI) (53.1%). One third of Veterans had a completely normal preoperative EGD. Common preoperative EGD findings included gastritis (35.8%), hiatal hernia (25.8%), esophagitis (20.8%), duodenitis (10.4%), Barrett's esophagus (7.4%), and Helicobacter pylori infection (4.6%). Preoperative predictors for a normal EGD were female gender, absence of hypertension, and no recent PPI use. Preoperative predictors of Barrett's esophagus included older age, recent PPI use, and recent histamine H2 receptor blocker (H2B) use. Increased age, male gender, and PPI use were associated with a change in surgical and/or medical management.Preoperative factors can be used to identify patients at risk for gastroesophageal pathology. Our data support preoperative EGD especially in older males with a history of PPI or H2B use.
View details for DOI 10.1007/s11695-019-04234-3
View details for PubMedID 31713148
- ASMBS position statement on weight bias and stigma. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery 2019
- Low Value Preoperative Testing for Carpal Tunnel Release in the Veterans Health Administration ELSEVIER SCIENCE INC. 2018: E32
American Society for Metabolic and Bariatric Surgery review of the literature on one-anastomosis gastric bypass
SURGERY FOR OBESITY AND RELATED DISEASES
2018; 14 (8): 1088–92
The following review is being published by the American Society for Metabolic and Bariatric Surgery in response to numerous inquiries made to the Society by patients, physicians, society members, hospitals, and others regarding one-anastomosis gastric bypass as a primary treatment for obesity or metabolic disease. The review is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The review is not intended as, and should not be construed as, stating or establishing a local, regional, or national standard of care.
View details for DOI 10.1016/j.soard.2018.04.017
View details for Web of Science ID 000447482300002
View details for PubMedID 29907540
- Prevalence of Anemia 10 Years After Roux-en-Y Gastric Bypass in a Single Veterans Affairs Medical Center JAMA SURGERY 2018; 153 (1): 86–87
Low socioeconomic status is associated with lower weight-loss outcomes 10-years after Roux-en-Y gastric bypass.
Roux-en-Y gastric bypass (RYGB) is the criterion standard operation for weight loss. Low socioeconomic status (SES) is common in the Veteran population undergoing bariatric surgery, but the impact of SES on long-term weight-loss outcomes is not known. We hypothesize that low socioeconomic status is associated with less weight loss after gastric bypass in long-term follow-up.We performed a retrospective review of patients undergoing RYGB at a single Veterans Affairs (VA) hospital. Patients with at least 10 years of follow-up data in the electronic health record were included in the analysis. Weight loss was measured as percent excess body mass index loss (%EBMIL). The primary predictor variable, median household income, was determined using zip codes of patient residences matched to publicly available 2010 U.S. census data. Univariate relationships between income, weight loss, and other patient characteristics were evaluated. We calculated a multivariate generalized linear model of %EBMIL to estimate independent relationships with median household income quartile while controlling for patients' age, race, sex, and VA distance.Complete 10-year follow-up data were available for 83 of 92 patients (90.2%) who underwent RYGB between 2001 and 2007 and survived at least 10 years. The majority of patients were male (79.5%) and white (73.5%). The mean 10-year %EBMIL was 57.8% (SD: 29.5%, range - 36.0% - 132.8%). In univariate analysis, income was significantly associated with race (p < 0.001) and median distance to the VA bariatric center (p = 0.034), but income did not differ by gender (p = 0.73) or age (p = 0.45). Multivariate analysis revealed significantly lower 10-year %EBMIL for patients with the lowest income compared to patients with low-mid income (p = 0.03) and mid-high income (p = 0.01), after controlling for gender, race, age, and VA distance.Low socioeconomic status is associated with lower weight-loss outcomes, 10 years after RYGB. Durable weight loss is observed in all income groups.
View details for PubMedID 29987570
- An Integrated, Collaborative Multidisciplinary Clinic Improves 12-Month Follow-Up After Bariatric Surgery at a Single Veterans Affairs Medical Center BARIATRIC SURGICAL PRACTICE AND PATIENT CARE 2017; 12 (4): 170–72
A Health Services Research Agenda for Bariatric Surgery Within the Veterans Health Administration.
Journal of general internal medicine
In 2016, the Veterans Health Administration (VHA) held a Weight Management State of the Art conference to identify evidence gaps and develop a research agenda for population-based weight management for veterans. Included were behavioral, pharmacologic, and bariatric surgery workgroups. This article summarizes the bariatric surgery workgroup (BSWG) findings and recommendations for future research. The BSWG agreed that there is evidence from randomized trials and large observational studies suggesting that bariatric surgery is superior to medical therapy for short- and intermediate-term remission of type 2 diabetes, long-term weight loss, and long-term survival. Priority evidence gaps include long-term comorbidity remission, mental health, substance abuse, and health care costs. Evidence of the role of endoscopic weight loss options is also lacking. The BSWG also noted the limited evidence regarding optimal timing for bariatric surgery referral, barriers to bariatric surgery itself, and management of high-risk bariatric surgery patients. Clinical trials of pre- and post-surgery interventions may help to optimize patient outcomes. A registry of overweight and obese veterans and a workforce assessment to determine the VHA's capacity to increase bariatric surgery access were recommended. These will help inform policy modifications and focus the research agenda to improve the ability of the VHA to deliver population-based weight management.
View details for DOI 10.1007/s11606-016-3951-4
View details for PubMedID 28271434
View details for PubMedCentralID PMC5359154
- ASMBS Position Statement on Postprandial Hyperinsulinemic H ypoglycemia after Bariatric Surgery SURGERY FOR OBESITY AND RELATED DISEASES 2017; 13 (3): 371-378
Systems innovation model: an integrated interdisciplinary team approach pre- and post-bariatric surgery at a veterans affairs (VA) medical center.
Surgery for obesity and related diseases
Provision of bariatric surgery in the Veterans Health Administration must account for obese veterans' co-morbidity burden and the geographically dispersed location of patients relative to Veterans Affairs (VA) bariatric centers.To evaluate a collaborative, integrated, interdisciplinary bariatric team of surgeons, bariatricians, psychologists, dieticians, and physical therapists working in a hub-and-spokes care model, for pre- and post-bariatric surgery assessment and management.This is a description of an interdisciplinary clinic and bariatric program at a VA healthcare system and a report on program evaluation findings. Retrospective data of a prospective database was abstracted. For program evaluation, we abstracted charts to characterize patient data and conducted a patient survey.Since 2009, 181 veterans have undergone bariatric surgery. Referrals came from 7 western U.S. states. Mean preoperative body mass index was 46 kg/m(2) (maximum 71). Mean age was 53 years, with 33% aged>60 years; 79% were male. Medical co-morbidity included diabetes (70%), hypertension (85%), and lower back or extremity joint pain (84%). A psychiatric diagnosis was present in 58%. At 12 months, follow-up was 81% and percent excess body mass index loss was 50.5%. Among 54 sequential clinic patients completing anonymous surveys, overall satisfaction with the interdisciplinary team approach and improved quality of life were high (98% and 94%, respectively).The integrated, interdisciplinary team approach using a hub-and-spokes model is well suited to the VA bariatric surgery population, with its heavy burden of medical and mental health co-morbidity and its system of geographically dispersed patients receiving treatment at specialty centers. As the VA seeks to expand the use of bariatric surgery as an option for obese veterans, interdisciplinary models crafted to address case complexity, care coordination, and long-term outcomes should be part of policy planning efforts.
View details for DOI 10.1016/j.soard.2016.11.007
View details for PubMedID 28089437
Osteoarthritis in veterans undergoing bariatric surgery is associated with decreased excess weight loss: 5-year outcomes.
Surgery for obesity and related diseases
2016; 12 (7): 1426-1430
Obesity exacerbates pre-existing musculoskeletal disease and joint pain. This may limit physical activity in obese individuals.We sought to identify the disease burden and impact of osteoarthritis of the lumbar back, hip, knee, and ankle in veterans undergoing bariatric surgery.Veterans Affairs medical center.Retrospective review of a prospective bariatric database of operations performed at a single Veterans Affairs medical center. Patients with osteoarthritis of the lumbar spine, hip, knee, or ankle were identified and diagnosis confirmed by electronic health record review of prior radiographic reports. Analysis was performed using χ(2) test for continuous variables. Student's t test and one-way analysis of variance were used to compare qualitative variables.Of 254 bariatric surgical patients, 83.9% had preoperative musculoskeletal pain before bariatric surgery and 59.1% had a confirmed diagnosis of osteoarthritis of the lumbar spine, hips, knees, and/or ankles. Follow-up rate was 97.4%, 85.4%, and 82.6% at 1, 3, and 5 years respectively. Of patients with osteoarthritis, 58.6% had knee involvement and 46% had multiple sites involved. In the cohort without osteoarthritis, percent excess body mass index loss was 66.9% at 1 year versus 58.5% in the cohort with osteoarthritis (P = .009), 66.1% versus 51.9% (P = .001) at 3 years, and 64.3% versus 50.1% (P = .002) after 5 years. Percent total weight loss was 28.4% versus 25.2%, 28.0% versus 22.8%, and 27.1% versus 22.4%, respectively, at 1, 3, and 5 years.Osteoarthritis is common among veterans undergoing bariatric surgery. It is associated with significantly less weight loss compared to veterans who do not have osteoarthritis, up to 5 years after bariatric surgery.
View details for DOI 10.1016/j.soard.2016.02.012
View details for PubMedID 27260653
Chemerin Activation in Human Obesity
2016; 24 (7): 1522-1529
Chemerin is an inflammatory adipokine, whose activity is regulated by successive proteolytic cleavages at its C-terminus. It is secreted as an inactive precursor (chem163S); cleavage at Lys158 converts it to chem158K with modest activity. Chem157S is the most potent form and chem155A is inactive. The aim of this study was to determine if chemerin was activated in samples from patients with obesity.Using specific ELISAs for different chemerin forms and a pan-chemerin ELISA, chemerin forms in human obesity were characterized.Plasma chemerin from patients with obesity (BMI 44.3 ± 1.3 kg/m(2) , n = 29) was significantly higher than in lean controls (BMI 20.9 ± 0.7 kg/m(2) , n = 10) (160 ± 11 vs. 76.2 ± 5.5 ng/mL, respectively, P < 0.0001). This increase in chemerin was due to increased previously unattributed chemerin, with further C-terminal truncation demonstrated by mass spectrometry, accounting for ∼35% of total plasma chemerin. Chemerin forms in adipose tissue showed a different profile, with minimal chem163S and significant levels of chem157S. Chem155A was present in omental but not in subcutaneous adipose tissue. Unattributed chemerin forms were undetectable in adipose tissue.Chemerin is activated in adipose tissue of subjects with obesity, and further C-terminal processing occurs during the disposition of chemerin from adipose tissue, resulting in substantial levels of novel degraded forms in plasma that correlate with obesity.
View details for DOI 10.1002/oby.21534
View details for Web of Science ID 000379303200017
View details for PubMedID 27222113
- American Society for Metabolic and Bariatric Surgery position statement on accreditation of bariatric surgery centers endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons. Surgery for obesity and related diseases 2016; 12 (5): 946-954
Urgent and Elective Robotic Single-Site Cholecystectomy: Analysis and Learning Curve of 150 Consecutive Cases
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
2016; 26 (3): 185-191
The use of robotic single-site cholecystectomy has increased exponentially. There are few reports describing the safety, efficacy, and operative learning curve of robotic single-site cholecystectomy either in the community setting or with nonelective surgery.We performed a retrospective review of a prospective database of our initial experience with robotic single-site cholecystectomy. Demographics and perioperative outcomes were evaluated for both urgent and elective cholecystectomy. Cumulative sum analysis was performed to determine the surgeon's learning curve.One hundred fifty patients underwent robotic single-site cholecystectomy. Seventy-four (49.3%) patients underwent urgent robotic single-site cholecystectomy, and 76 (50.7%) underwent elective robotic single-site cholecystectomy. Mean total operative time for robotic single-site cholecystectomy was 83.3 ± 2.7 minutes. Mean operative time for the urgent cohort was significantly longer than for the elective cohort (95.0 ± 4.4 versus 71.9 ± 2.6 minutes; P < .001). There was one conversion in the urgent cohort and none in the elective cohort. There was one bile duct injury (0.7%) in the urgent cohort. Perioperative complications occurred in 8.7% of patients, and most consisted of superficial surgical-site infections. There were no incisional hernias detected. The surgeon's learning curve, inclusive of urgent and elective cases, was 48 operations.Robotic single-site cholecystectomy can be performed safely and effectively in both elective and urgent cholecystectomy with a reasonable learning curve and acceptable perioperative outcomes.
View details for DOI 10.1089/lap.2015.0528
View details for Web of Science ID 000372455000005
American Society for Metabolic and Bariatric Surgery position statement on long-term survival benefit after metabolic and bariatric surgery
SURGERY FOR OBESITY AND RELATED DISEASES
2016; 12 (3): 453-459
The following position statement has been issued by the American Society for Metabolic and Bariatric Surgery in response to numerous inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others regarding the benefit of metabolic and bariatric surgery on long-term survival. An overview of the current available published peer-reviewed scientific evidence is presented.
View details for DOI 10.1016/j.soard.2015.11.021
View details for Web of Science ID 000376223300001
View details for PubMedID 26944548
- ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management SURGERY FOR OBESITY AND RELATED DISEASES 2015; 11 (4): 739-748
- Standardized outcomes reporting in metabolic and bariatric surgery. Surgery for obesity and related diseases 2015; 11 (3): 489-506
- Standardized Outcomes Reporting in Metabolic and Bariatric Surgery OBESITY SURGERY 2015; 25 (4): 587-606
Telephone Follow-Up by a Midlevel Provider After Laparoscopic Inguinal Hernia Repair Instead of Face-to-Face Clinic Visit
JSLS-JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS
2015; 19 (1)
The need for more cost- and time-efficient provision of medical care has prompted an interest in remote or telehealth approaches to delivery of health care. We present a study examining the feasibility and outcomes of implementation of a telephone follow-up program for laparoscopic inguinal hernia repair.This is a retrospective review of consecutive patients who prospectively agreed to undergo telephone follow-up after laparoscopic inguinal hernia repair instead of standard face-to-face clinic visits. Patients received a telephone call from a dedicated physician assistant 2 to 3 weeks after surgery and answered a predetermined questionnaire. A face-to-face clinic visit was scheduled based on the results of the call or on patient request.Of 62 patients who underwent surgery, all agreed to telephone follow-up instead of face-to-face clinic visits. Their mean round-trip distance to the hospital was 122 miles. Fifty-five patients (88.7%) successfully completed planned telephone follow-up. Three patients (4.8%) were lost to follow-up, and 4 (6.5%) were erroneously scheduled for a clinic appointment. Of the 55 patients who were reached by telephone, 50 (90.9%) were satisfied and declined an in-person clinic visit. Five patients (9.1%) returned for a clinic appointment based on concerns raised during the telephone call. Of these, 1 was found to have an early hernia recurrence and 1 had a seroma.Telephone follow-up by a midlevel provider after laparoscopic inguinal hernia repair is feasible and effective and is well received by patients.
View details for DOI 10.4293/JSLS.2014.00205
View details for Web of Science ID 000368472200018
View details for PubMedCentralID PMC4370039
Preoperative Change in 6-Minute Walk Distance Correlates With Early Weight Loss After Sleeve Gastrectomy
JSLS-JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS
2014; 18 (3)
The 6-minute walk test (6MWT) is an objective preoperative measure of functional capacity and response to intervention in patients with heart or lung disease. In bariatric surgery, there has been no reliable preoperative measure predictive of postoperative success. Here we investigated the impact of bariatric surgery on changes in distance traveled in the 6MWT (the 6MWD) and whether preoperative changes in 6MWD correlated with weight change after surgery.This is a retrospective study of consecutive patients in which the 6MWT was performed before and after laparoscopic sleeve gastrectomy for weight loss. 6MWD and total weight were measured. Pearson correlation was used to determine association between variables.Of 100 patients who underwent laparoscopic sleeve gastrectomy, 31 patients had a preoperative 6MWT. Thirty patients (97%) were available for follow-up after surgery. Percentage of excess weight loss was 45.7% over an average of 7 months after surgery. There was a weak correlation between the postoperative weight loss and the change in preoperative and postoperative 6MWD (r = 0.28; P = .13). In a subset of patients who demonstrated a change in distance traveled in 2 separate preoperative 6MWD measurements (average 18.5% increase in distance), there was a strong correlation with postoperative weight loss (r = 0.82; P = .02).A demonstrated increase in 6MWD before surgery correlates strongly with early postoperative weight loss after laparoscopic sleeve gastrectomy. A multidisciplinary team that includes a physical therapist is useful in preparing bariatric patients for surgery.
View details for DOI 10.4293/JSLS.2014.00383
View details for Web of Science ID 000348437400070
View details for PubMedID 25392673
- Innovation in Safety, and Safety in Innovation JAMA SURGERY 2014; 149 (1): 7-9
Comparison of robotic and laparoendoscopic single-site surgery systems in a suturing and knot tying task
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2013; 27 (9): 3182-3186
BACKGROUND: Laparoendoscopic single-site (LESS) surgery has been established for various procedures. Shortcomings of LESS surgery include loss of triangulation, instrument collisions, and poor ergonomics, making advanced laparoscopic tasks especially challenging. We compared a LESS system with a robotic single-site surgery platform in performance of a suturing and knot-tying task under clinically simulated conditions. METHODS: Each of five volunteer minimally invasive surgeons was tasked with suturing a 5 cm longitudinal enterotomy in porcine small intestine with square knots at either end, using a laparoendoscopic or da Vinci robotic single-site surgery platform, within a 20 min time limit. A saline leak test was then performed. Each surgeon performed the task twice using each system. The time to completion of the task and presence of a leak were noted. Fisher's exact test was used to compare the overall completion rate within the defined time limit, and a Wilcoxon rank test was used to compare the specific times to complete the task. A p value of <0.05 was considered significant. RESULTS: All surgeons were able to complete the task on the first try within 20 min using the robot system; 60 % of surgeons were able to complete it after two attempts using the LESS surgery system. Time to completion using the robot system was significantly shorter than the time using the standard LESS system (p < 0.0001). There were no leaks after closure with the robot system; the leak rate following the standard LESS system was 90 %. CONCLUSIONS: Surgeons demonstrated significantly better suturing and knot-tying capabilities using the robot single-site system compared to a standard LESS system. The robotic system has the potential to expand single-site surgery to more complex tasks.
View details for DOI 10.1007/s00464-013-2874-y
View details for Web of Science ID 000323621500016
View details for PubMedID 23443484
- Biologic sealants: the next great thing in gastrointestinal surgery? journal of surgical research 2013; 182 (1): 30-31
Sleeve Gastrectomy as a Stand-alone Bariatric Operation for Severe, Morbid, and Super Obesity
JSLS-JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS
2013; 17 (1): 63-67
The laparoscopic sleeve gastrectomy (LSG) is emerging as an effective bariatric operation and is especially attractive in high-risk populations. In this study we examine the efficacy of LSG as a stand-alone operation in the veteran population.This is a retrospective review of consecutive patients who underwent LSG as a stand-alone procedure at the Palo Alto Veterans Affairs medical center with a minimum 12-month follow-up.Of 205 patients undergoing bariatric surgery, 71 patients had a sleeve gastrectomy, 40 of whom had the operation performed at least 12 months previously. Thirty-six (90%) were available for 1-year follow-up, with a mean follow-up duration of 22 months (range: 12-42), a mean body mass index of 48.3 kg/m(2), and an 83% male population. Mean percent excess weight loss was 61% at an average of 22 months, with no significant difference between severely obese, morbidly obese, and super obese cohorts. Diabetes remission was seen in 56% of patients, hypertension remission in 51.6%, and obstructive sleep apnea remission in 46.4%, and gastroesophageal reflux disease improved or did not change in 83%. Medication use significantly decreased after surgery.LSG is safe and effective as a stand-alone bariatric operation in the high-risk veteran population. It is effective in severely obese, morbidly obese, and super obese patients. LSG induces remission or improvement in comorbidities of nearly all patients, translating to a decrease in medication use.
View details for DOI 10.4293/108680812X13517013317077
View details for Web of Science ID 000323043700009
View details for PubMedID 23743373
A prior history of substance abuse in veterans undergoing bariatric surgery.
Journal of obesity
2013; 2013: 740312-?
The rates of obesity and substance abuse are high among US veterans.To examine weight loss and substance abuse rates following bariatric surgery in veterans with a history of substance abuse (SA).A prospective database of consecutive bariatric operations was reviewed. Data for SA patients were compared to patients without a substance abuse history (NA). Behavioral medicine staff followed patients throughout the pre- and postoperative courses.Of 205 bariatric surgery patients, there were 74 (36.1%) SA patients. The mean preoperative body mass index (BMI) was 46.2 ± 8.1 kg/m², and percent excess weight loss at 12 months was 71.8%, 58.0%, and 33.5% for Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic gastric banding, respectively, not significantly different than the NA group (P = 0.15, 0.75, 0.96). Postoperative substance abuse in SA and NA patients was 8.1% and 1.5%, respectively (P = 0.234).A prior history of substance abuse is common in veterans undergoing bariatric surgery; weight loss results are comparable to the general veteran bariatric cohort. Rates of substance abuse are low postoperatively, but higher in patients without a prior history of substance abuse. Close multidisciplinary followup throughout the postoperative course is likely to be integral to the patient's success.
View details for DOI 10.1155/2013/740312
View details for PubMedID 23840947
Concurrent Laparoscopic Morgagni Hernia Repair and Sleeve Gastrectomy
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
2012; 22 (10): 999-1002
The Morgagni-type anterior diaphragmatic hernia is a congenital defect that is a very uncommon hernia presenting in an adult. Surgical repair is usually recommended upon diagnosis and often requires synthetic mesh for a durable, tension-free repair. The use of synthetic mesh concurrently with several of bariatric operations is controversial owing to the potential for mesh infection. In this report we describe a laparoscopic repair of a symptomatic Morgagni hernia with synthetic mesh, concurrently with sleeve gastrectomy, in a morbidly obese man. The patient was a 58-year-old man with a body mass index of 48 kg/m(2) and associated co-morbid conditions that included obstructive sleep apnea, hypertension, hyperlipidemia, impaired fasting glucose, and osteoarthritis. He was diagnosed with Morgagni hernia with exertional dyspnia. He underwent concurrent laparoscopic Morgagni hernia repair with mesh and sleeve gastrectomy. At 2 months after surgery the patient was doing well and tolerating solid foods, and his percentage excess weight loss was 35%. He was exercising regularly and had no exertional dyspnea. Laparoscopy is an attractive approach to performing multiple intra-abdominal procedures concurrently. The Morgagni hernia repair with mesh can be performed safely and effectively using a laparoscopic approach. This can be performed concurrently with bariatric surgery in the morbidly obese.
View details for DOI 10.1089/lap.2012.0293
View details for Web of Science ID 000312379900012
View details for PubMedID 23067069
Portal Vein Thrombosis Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity
JSLS-JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS
2012; 16 (4): 639-643
Portal vein thrombosis has been documented after laparoscopic general surgery and has been uncommonly observed after laparoscopic bariatric surgery. Among bariatric operations, the sleeve gastrectomy is being performed with ever-increasing frequency. Here we report the case of a man who presented with portal vein thrombosis after laparoscopic sleeve gastrectomy.A 41-y-old man underwent an uneventful laparoscopic sleeve gastrectomy for the treatment of morbid obesity, and presented on postoperative day 10 with nonfocal abdominal pain, nausea, vomiting, and leukocytosis. Computed tomography revealed portal vein thrombosis, which was found in the setting of Clostridium difficile colitis.Portal vein thrombosis may be identified with increasing frequency as the number of laparoscopic bariatric operations continues to increase. A high index of suspicion is necessary to diagnose this rare, but potentially lethal, complication.
View details for DOI 10.4293/108680812X13517013316636
View details for Web of Science ID 000314201800023
View details for PubMedID 23484577
- Surgical Site Infections: Time to Modify the Wound Classification System? JOURNAL OF SURGICAL RESEARCH 2012; 175 (1): 54-55
Short-term medication cost savings for treating hypertension and diabetes after gastric bypass
SURGERY FOR OBESITY AND RELATED DISEASES
2012; 8 (3): 269-274
The cost of medication for the treatment of hypertension and diabetes in the morbidly obese is a significant economic healthcare burden. In the present study, we assessed the effect of gastric bypass surgery on the average annual costs for hypertension and diabetes medication.A prospective database of gastric bypass patients at the Palo Alto Veterans Affairs Health Care System was reviewed. The preoperative and postoperative medication requirements to treat hypertension and diabetes were identified before surgery and at 1 year postoperatively. Comparisons were made between the annual costs of the antihypertensive and diabetic medications before and after bariatric surgery using the Student paired t test.Of 106 patients who had undergone gastric bypass, 90 (85%) had either hypertension or diabetes. Of these 90 patients, 88 (98%) had hypertension and 60 (67%) had diabetes before surgery. Complete remission of hypertension occurred in 44% and remission of diabetes in 80% at 1 year after surgery. The annual cost of medications to treat hypertension was reduced by 65% at 1 year after surgery ($63.52 compared with $20.50, P < .0001). To treat diabetes, the annual medication cost was reduced by 88% at 1 year after gastric bypass surgery ($532.06 compared with $64.58, P < .0001). In the subset of patients with persistent hypertension or diabetes after surgery, the annual cost reduction for antihypertensive medications was 58% ($87.14 versus $36.82, P < .002). The annual cost reduction for diabetic medications was 69% ($1036.60 versus $322.90, P < .02).Gastric bypass surgery resulted in a significant reduction in the cost of medications to treat hypertension and diabetes in the morbidly obese at 1 year after surgery. These cost savings were also significant in the subset of patients who had persistent hypertension and diabetes after surgery.
View details for DOI 10.1016/j.soard.2011.05.009
View details for Web of Science ID 000304520900005
View details for PubMedID 21723203
- Preoperative finding of gastric neuroendocrine tumor (gastric carcinoid) in a patient evaluated for bariatric surgery. Surgery for obesity and related diseases 2011; 7 (5): e18-20
Early postoperative outcomes and medication cost savings after laparoscopic sleeve gastrectomy in morbidly obese patients with type 2 diabetes.
Journal of obesity
2011; 2011: 350523-?
Background. We investigated the effect of laparoscopic sleeve gastrectomy (LSG) on morbidly obese diabetics and examined the short-term impact of LSG on diabetic medication cost. Methods. A prospective database of consecutive bariatric patients was reviewed. Morbidly obese patients with type 2 diabetes who underwent LSG were included in the study. Age, gender, body mass index (BMI), diabetic medication use, glucose, insulin, and HbA1c levels were documented preoperatively, and at 2 weeks, 2 months, 6 months, and 12 months postoperatively. Insulin resistance was estimated using the homeostatic model assessment (HOMA). Use and cost of diabetic medications were followed. Results. Of 178 patients, 22 were diabetics who underwent LSG. Diabetes remission was observed in 62% of patients within 2 months and in 75% of patients within 12 months. HOMA-IR improved after only two weeks following surgery (16.5 versus 6.6, P < 0.001). Average number of diabetic medications decreased from 2.2 to <1, within 2 weeks after surgery; corresponding to a diabetes medication cost savings of 80%, 91%, 99%, and 99.7% after 2 weeks, 2 months, 6 months, and 12 months, respectively. Conclusion. Morbidly obese patients with diabetes who undergo LSG have high rates of diabetes remission early after surgery. This translates to a significant medication cost savings.
View details for DOI 10.1155/2011/350523
View details for PubMedID 22187636
View details for PubMedCentralID PMC3236514
Use of a flexible robotic transgastric natural orifice translumenal endoscopic surgery (NOTES) platform in a cadaver to test access, navigation, maneuverability, and stability
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2010; 24 (9): 2323-2323
The advancement of natural orifice translumenal endoscopic surgery (NOTES) depends on the availability of a suitable platform. A 2008 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) Working Group identified access, navigation, maneuverability, and stability to withstand instrument forces as the essential requirements for a successful NOTES platform . No single NOTES platform can adequately achieve all four of these key capabilities. In this study, the authors tested a novel flexible endoscopic robotic platform in a cadaver to determine how it performs with respect to these specific requirements.A highly maneuverable multichannel flexible robotic endoscopic platform developed for NOTES was used transgastrically in an adult cadaver to test the platform's ability to reach multiple intraabdominal targets. The device was under the control of the surgeon throughout the test. The surgeon was blinded to a control laparoscopic view. At each target organ, the platform was maneuvered via a joystick to provide different camera views and tool access orientation appropriate for the surgical tasks of each procedure. Standard endoscopic tools were used in the platform's two working channels to demonstrate the platform's ability to withstand the forces generated during tissue manipulation and clipping.The platform reached each target organ site without difficulty, relying on the endoscopic view only. The platform's unique ability to maintain stability in two- and three-dimensional space resisted forces exerted by tools in the tool channels used for tissue manipulation and clipping. Endoscopic visualization allowed the surgeon to reposition the platform easily to gain a different camera view or tool access orientation about an organ (see video in Supplementary material).The authors demonstrated that the four capabilities identified by NOSCAR can be provided by the flexible robotic endoscopic platform. These essential capabilities for the clinical implementation of NOTES were addressed specifically by this platform. The provision of these capabilities in a single device may further the advancement and adoption of NOTES.
View details for DOI 10.1007/s00464-010-0905-5
View details for Web of Science ID 000281776400043
View details for PubMedID 20174943
Post-traumatic stress disorder (PTSD) is not a contraindication to gastric bypass in veterans with morbid obesity
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2010; 24 (8): 1892-1897
The veteran population is routinely screened for post-traumatic stress disorder (PTSD). The prevalence of obesity in this population continues to increase. We examined whether weight loss outcomes in veterans with PTSD is comparable to results in veterans who do not suffer from PTSD, after gastric bypass. We also examined the effect of bariatric surgery on PTSD symptoms.This retrospective review of prospective data compares veterans with and without PTSD who underwent laparoscopic gastric bypass. Differences between the means of age, initial BMI, and percent excess weight loss were compared between the groups using a Student's t test. Pearson's chi(2) was used to evaluate the relationship between a diagnosis of PTSD, major depressive disorder (MDD), and other Axis I psychiatric disorders. A similar analysis was done to assess for a relationship between PTSD and obesity-related comorbidities, including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, and GERD.We identified 24 patients who had gastric bypass and a diagnosis of PTSD before surgery and compared them to those without PTSD. Both groups had a similar mean age and initial BMI. There was no significant difference between the percent excess weight lost after 1 year follow-up between the PTSD group (66%) and the non-PTSD group (72%) (p = 0.102). In assessing comorbid conditions, we found a significant association between the diagnosis of PTSD and MDD (p = 0.002), PTSD and other Axis I disorders (p = 0.004), and PTSD and GERD (p = 0.002). However, we saw no significant association between PTSD and DM (p = 0.977), HTN (p = 0.332), and obstructive sleep apnea (OSA) (p = 0.676). The severity of PTSD symptoms fluctuated in the postoperative period.Veterans with PTSD have comparable weight loss to those without PTSD after gastric bypass. In addition, surgery does not seem to have an adverse effect on PTSD symptoms, although PTSD symptomatology tends to fluctuate over time. Further study in this patient population is warranted.
View details for DOI 10.1007/s00464-009-0866-8
View details for Web of Science ID 000279488400015
View details for PubMedID 20063014
Does Preoperative Weight Change Predict Postoperative Weight Loss after Laparoscopic Roux-en-Y Gastric Bypass in the Short Term?
Journal of obesity
Background. Many institutions mandate preoperative weight loss prior to bariatric surgery. This study examines the correlation between preoperative weight change and postoperative success following laparoscopic Roux-en-Y gastric bypass. Methods. We retrospectively studied the correlation between change in BMI before surgery and change in BMI postoperatively, using linear regression analyses and one-way ANOVA, in 256 consecutive gastric bypass patients with 1-year followup. Results. Of 256 patients, 125 lost weight preoperatively (mean -1.7% BMI), while 131 maintained or gained weight (mean +1.2% BMI). Postoperatively, there was no significant difference in percent BMI loss between the two groups (34.6% and 34.5%). The percent change in BMI preoperatively did not predict postoperative BMI change after 1 year (P = n.s.). Conclusions. Our study did not show any correlation between preoperative weight change and postoperative weight loss after Roux-en-Y gastric bypass. Therefore, we do not believe that potential patients should be denied bariatric surgery on the basis of their inability to lose weight preoperatively.
View details for DOI 10.1155/2010/907097
View details for PubMedID 20798850
Video Self-Assessment Augments Development of Videoscopic Suturing Skill
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2009; 209 (5): 622-625
Development of surgical skills on inanimate models has been popularized by efforts to improve patient safety and efficiency of resident training. We evaluated whether surgical residents' acquisition of videoscopic suturing skill is accelerated by reviewing video of their own previous practice session.Fourteen residents from two general surgery training programs received didactic instruction on laparoscopy. Attempts at suturing and knotting were then timed and recorded for each subject, and half of them were provided a video of their attempts to review. After 7 to 10 days, repeat attempts were timed and recorded. Knots were mechanically tested, and videos were reviewed in blinded fashion.Baseline characteristics were similar between the two groups. Both groups demonstrated improvement of videoscopic suturing efficiency and quality. On a 27-point scale, suturing and knot quality scores improved by an average of 11.6 (SD 3.9) in the video review group and 2.3 (SD 6.0) in the control group (p = 0.007). Times to complete the tasks were reduced by 30.3% (SD 11%) in the video review group and 3.1% (SD 32%) in the control group (p = 0.075). Eighty-six percent of video review subjects found the videos useful, and 86% of control subjects believed that videos would have been useful.Development of videoscopic suturing skill is augmented by independent review of earlier attempts. Knot quality and technique are improved, with a trend toward increased speed. This minimal-cost method of enhancing skill training for junior residents parallels the effectiveness of video review in fields such as aviation and athletics.
View details for DOI 10.1016/j.jamcollsurg.2009.07.024
View details for Web of Science ID 000271876400011
View details for PubMedID 19854403
Management of Median Arcuate Ligament Syndrome: A New Paradigm
ANNALS OF VASCULAR SURGERY
2009; 23 (6): 778-784
Median arcuate ligament (MAL) syndrome is an anatomic and clinical entity characterized by extrinsic compression on the celiac axis, which leads to postprandial epigastric pain, vomiting, and weight loss. Although characterized a few decades ago, the existence of this syndrome is still challenged by several authors. We reviewed the management of MAL syndrome, with special emphasis on the minimally invasive approaches. We also report the first case of successful combination of minimally invasive surgery and endovascular therapy in the treatment of this syndrome. A PubMed search was carried out to identify articles in English from 1963 to 2008 using the keywords "median arcuate ligament syndrome" and "celiac artery compression syndrome." Additional articles were identified by a manual search of the references from the key articles. All clinical and experimental studies that contained material applicable to the topic were considered. Classic treatment of the condition is represented by open MAL release. However, permanent changes in the celiac artery wall lead to poor long-term outcomes, and associated complex vascular procedures have been employed. Laparoscopic treatment of MAL syndrome was reported in five cases. All patients had resolution of symptoms, but long-term follow-up is not available. Laparoscopic release of arcuate ligament syndrome with intraoperative duplex ultrasound may be used in patients with symptoms suggestive of the diagnosis. In patients with persistent celiac flow abnormalities noted on duplex ultrasound or postoperative imaging, celiac angioplasty and stenting are advocated. If this option is not available or does not relieve symptoms, vascular reconstruction should be employed.
View details for DOI 10.1016/j.avsg.2008.11.005
View details for Web of Science ID 000271259800011
View details for PubMedID 19128929
Intraoperative Endoscopy: A Requisite Tool for Laparoscopic Resection of Unusual Gastrointestinal Lesions-A Case Series
JOURNAL OF SURGICAL RESEARCH
2009; 155 (2): 318-320
Laparoscopy is increasingly becoming a preferred approach to surgery of the gastrointestinal tract. Proper localization of small benign tumors is essential for precise non-anatomical excisions and remains difficult with the laparoscopic approach due to the greatly diminished tactile feedback.Between July 2006 and June 2007, 4 patients underwent resection of benign small gastrointestinal lesions. All resections were performed laparoscopically, with intraoperative endoscopy, using picture-in-picture display of both views on a single monitor.All 4 cases were completed laparoscopically. Three involved gastric lesions and 1 involved a cecal lesion. Adequacy of resection was confirmed grossly by real-time intraoperative endoscopy and microscopically by histology. Gastric lesions included pancreatic heterotopia, a gastrointestinal stromal tumor, and a Dieulafoy's lesion. The cecal lesion was a granular cell tumor. Operative times ranged from 57 min to 110 min (mean 91 min), and the average postoperative length of hospital stay was 3.5 d.Real-time intraoperative endoscopy with picture-in-picture viewing is a powerful surgical tool allowing for simultaneous intra- and extra-luminal views. Thus, endoscopic guidance allows for even the most subtle lesions to be identified and precisely excised. In addition, the adequacy of the laparoscopic procedure can be evaluated in real time, allowing for immediate adjustments or revisions to be made when needed. The endoscopic view allows for hemostasis to be ensured, and for precise anatomical excisions to be performed, especially in cases requiring the preservation of the pylorus or ileocecal valve. Larger series are needed to further establish the efficacy of this surgical approach.
View details for DOI 10.1016/j.jss.2008.06.046
View details for Web of Science ID 000269332300021
View details for PubMedID 19482295
- Cholecystectomy in situs inversus totalis: laparoscopic approach. Case report and review of the literature International Medical Case Reports Journal 2009; 2: 27-29
- The growing problem of obesity in the older population: is surgery an option? Aging Health 2009; 5 (3): 291-300
- Does preoperative weight change predict postoperative weight loss after laparoscopic Roux-en-Y gastric bypass in the short term? Journal of Obesity 2009
Male Patients Above Age 60 have as Good Outcomes as Male Patients 50-59 Years Old at 1-Year Follow-up After Bariatric Surgery
2009; 19 (1): 18-21
It is estimated that 25% of Americans older than 60 years are obese. Male gender and advanced age are indicators of increased risk for bariatric surgery. Good results have been shown in patients older than 50, but nearly all published studies include a large majority of females, and few include patients >60 years old. In this study, we examined the results of males over 60 years old.We reviewed a prospective database of 107 consecutive patients who underwent bariatric surgery between April 2002 and June 2007 at the Palo Alto VA. Of these, 60 patients were males older than 50 and available for follow-up 12 months postoperatively. There were 47 males 50-59 years old (group I) and 13 males older than 60 years (group II). Data were analyzed using Student's t test.Mean preoperative body mass index was similar in both groups (49.4 vs. 47.5 kg/m(2); p = 0.468). Length of hospital stay was similar (3.2 vs. 3.5 days; p = 0.678), but early morbidity was higher in group II patients (30.8% vs. 8.5%; p = 0.037). Morbidity included urinary tract infection, cardiac arrhythmias, and early bowel obstruction. Excess weight loss after 1 year was not significantly different (63.6% vs. 60.6%; p = 0.565). Diabetes resolution or improvement was seen in 87% of group I patients and 90% of group II patients.Despite a higher early morbidity rate, obese males >/=60 years old perform as well as male patients 50-59 years old with respect to excess weight loss, mortality, length of stay, and improvement of diabetes, at 1 year postoperatively.
View details for DOI 10.1007/s11695-008-9734-1
View details for Web of Science ID 000262281700004
View details for PubMedID 18855082
Laparoscopic treatment of subxiphoid incisional hernias in cardiac transplant patients
JSLS-JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS
2008; 12 (3): 262-266
Symptomatic subxiphoid incisional hernias present difficult surgical problems, especially in immuno-suppressed cardiac transplant patients. Here, we describe the laparoscopic repair of subxiphoid incisional hernias in patients with a history of cardiac transplantation.Four patients with subxiphoid hernias who had previously undergone heart transplantation were identified from a prospective database. Each underwent a laparoscopic repair with mesh implantation.Three patients had a previous open repair. The mean age was 62.5 years, an average of 64.3 months after transplantation. At the time of surgery, all patients were immunosuppressed, and each had a subxiphoid, poststernotomy incisional hernia. Gore dual mesh was used in 2 patients, while Parietex mesh was used in 2. Mean operative time was 122 minutes, and all were completed laparoscopically. The mean length of stay was 6.5 days, and the mean defect size was 286.25 cm(2). There was a significant correlation between hernia size and length of stay (P=0.037). Postoperatively, one patient (25%) developed pulmonary edema, and 1 patient (25%) had a prolonged ileus.Symptomatic subxiphoid incisional hernias are a challenging surgical problem in patients with a history of sternotomy. Laparoscopic repair is safe and effective in immunosuppressed patients who have previously undergone cardiac transplantation.
View details for Web of Science ID 000258833000008
View details for PubMedID 18765049
- Design, Management, and Critical Evaluation of a Surgical Basic/Clinical Science Curriculum: The Role of an Educational Chief Resident J Surg Educ 2008; 65 (1): 36-42
- Virtual Three-Dimensional Computed Tomography Evaluation of the Gastric Pouch Following Laparoscopic Roux-Y Gastric Bypass Obes Surg 2008; 18 (4): 364-366
- A new modality to evaluate the gastric remnant after Roux-en-Y gastric bypass Surg Obes Relat Dis 2008; 4 (1): 46-49
- Update on obesity surgery World J Gastroenterol 2006; 12 (20): 3196-3203
- Metabolic consequences of bariatric surgery J Clin Gastroenterol 2006; 40 (8): 659-668
- Laparoscopic ventral hernia repair using a two 5-mm port technique J Soc Lap Surg 2005; 9 (1): 94-96
- A survivin gene signature predicts aggressive tumor behavior Cancer Research 2005; 65 (9): 3531-3534
- The impact of bariatric surgery on severely obese patients with diabetes Diabetes Spectrum 2003; 16 (4): 240-245
- Caenorhabditis elegans embryos contain only one major species of Ro RNP RNA 1995; 1 (3): 293-303