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Gastric bypass for morbid obesity in high-risk cardiac patients
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Abstracts: Plenary Session/Surgery for Obesity and Related Diseases / 1 (2005) 222–283
flated up to 30 mm Hg at a rate of 20 –30 mL/min.The left cervical vagus was exposed for recording. Cuff-type microelectrodes with Teflon-coated silver wires were implanted over the cut vagus. Mechanosensitive properties of gastric vagal afferent fibers were amplified, recorded, and analyzed. Ten rats (group 1) had the stomach divided horizontally to create a small (3– 4 mL) proximal pouch. In 10 rats (group 2), the stomach was divided vertically for a sleeve gastrectomy. Vagal nerve recording was done before and after gastrectomy with the balloon inflated and deflated. Results: Before gastrectomy, the resting vagal activity was 1.3 ⫾ 0.3 impulses/s. The increase of activity in response to gastric distension was 9.1 ⫾ 0.6 impulses/s. The threshold for response was 9 –17 mm Hg. After gastrectomy, the group 2 animals exhibited significantly greater increased of activity compared with group 1 (15.3 vs. 3.2 impulses/s), with lower threshold for response (4.1 vs. 5 mm Hg). The differences between the two mean thresholds for two durations of distension were similar to before gastrectomy. Conclusions: Sleeve gastrectomy leads to increased activity of tension-stimulated vagal afferent fibers. This may explain the early satiety and weight loss in patients treated for morbid obesity. PII: S1550-7289(05)00155-3 SESSION V (7:45 A.M.-9:15 A.M.) CONCURRENT WITH SESSION IV GASTRIC BYPASS TOPICS
26.
GASTRIC BYPASS REDUCES BIOCHEMICAL CARDIAC RISK FACTORS D. Brandon Williams, M.D., Ramzi S. Alami, M.D., Elise H. Lawson, B.S., Barry R. Sanchez, M.D., Bassem Safadi, M.D., Myriam J. Curet, M.D., John M. Morton, M.D., M.P.H., Stanford University Medical Center, Department of Surgery, Stanford, CA. Purpose: Coronary artery disease (CAD) is the leading cause of death in the United States, with obesity as a leading preventable risk factor for CAD. Certain biochemical markers have demonstrated a strong prediction for cardiovascular events. We hypothesized that in addition to the weight reduction benefit of gastric bypass, this procedure would also induce a salutary effect on biochemical markers for cardiac risk. Methods: At a single academic institution (2003–2004), we measured biochemical cardiovascular risk factor markers in 222 gastric bypass patients preoperatively and 3 and 6 months postoperatively. These markers included total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, lipoprotein A, high-sensitivity C-reactive protein, and homocystein. The data were analyzed by repeated measures regression analysis with autocorrelation. Results: For the 222 patients, the mean age was 43 years and 84% were women. The mean body mass index was 47 kg/m2 and 31% were diabetic, 50% were hypertensive, 18% were taking antilipid medications, and 1% had known CAD. All the measured biochemical markers of CAD risk showed significant improvement after gastric bypass.
Cardiac Risk Baseline Mean Factor (Range, % Abnormal) Lipids TC TG HDL LDL Lipo A CRP HC BMI
3 Months PostOp Mean (Range)
6 Months Post- P Value Op Mean (Range)
200.5 (126-334, 46.5) 168.4 (119-240) 169.3 (103-231) ⬍0.0001 187.5 (37-1422, 48.2) 129 (61-249) 119.1 (48-283) 0.0001 47.2 (22-106, 24.8) 41.7 (25-58) 48.8 (30-69) ⬍0.0001 128.1 (39-217, 42.7) 111.7 (64-179) 101.8 (50-148) 0.0005 35.7 (0.2-213, 33) 24.8 (1.2-122.7) 30.4 (1.4-177) 0.0015 10.7 (0.2-44.6, 85.8) 8.1 (0.2-24.7) 4.2 (0.2-15.9) 0.0013 10.8 (4.6-40.7, 9.4) 9.9 (5.6-15.9) 9.5 (4.3-18.1) 0.0192 47 39 35 .0001
Conclusions: In this study, gastric bypass significantly improved the biochemical risk factors for CAD. By modifying these cardiac risk factors and achieving weight loss, gastric bypass lowers cardiac risk. PII: S1550-7289(05)00156-5
27.
GASTRIC BYPASS FOR MORBID OBESITY IN HIGHRISK CARDIAC PATIENTS Grady D. Alsabrook, M.D., J. Wesley Alexander, M.D., Sc.D., Hope R. Goodman, M.P.T., UC Surgeons Center for Surgical Weight Loss and The Christ Hospital, Cincinnatti, OH. Purpose: Gastric bypass for patients with known cardiac disease has often been a relative contraindication owing to the inherent risks in this patient population. Methods: A total of 59 consecutive patients with a preoperative diagnosis of cardiac disease underwent open gastric bypass (mean age 51 years, mean body mass index 53 kg/m2). Of these patients, 44% had congestive heart failure, 19% had myocardial infarction, 17% had undergone angioplasty, and 20% had undergone coronary stent placement or coronary artery bypass graft. Comorbid conditions included diabetes mellitus (56%), hypertension (83%), hyperlipidemia (71%), thromboembolic disease (17%), and transplant immunosuppression (5%). Results: The median length of stay was 3 days (range 1–20). Thirty-one patients had 1 year of postoperative follow-up. The reduction in the excess body mass index at 1 year postoperatively was 62%. Complications up to 5 years postoperatively included incisional hernia in 5 (8.5%), biliary disease in 3 (5.1%), urinary tract infection in 3 (5.1%), deep venous thrombosis in 2 (3.4%), renal stones in 2 (3.4%), angina in 2 (3.4%), anastomotic ulcer in 2 (3.4%), dehydration in 2 (3.4%), gastrointestinal bleeding with obstruction in 2 (3.4%), splenic bleeding in 1 (1.7%), new atrial fibrillation in 1 (1.7%), coronary artery bypass grafting in 1 (1.7%), wound infection in 1 (1.7%), pneumonia in 1 (1.7%), and anastomotic leaks in 0 (0%). One death occurred in the series; the patient died of gastrointestinal bleeding associated with coumadin therapy. Change in Comorbid Conditions Of These 31 Patients
Diabetes
Hypertension
Hyperlipidemia
Pre-op condition Resolved Improved
16 9 (56%) 7 (44%)
24 10 (42%) 9 (37%)
19 14 (74%) 3 (16%)
Conclusions: Gastric bypass surgery in patients with cardiac disease is safe and effective in reducing the comorbid conditions of diabetes, hypertension, and hyperlipidemia. PII: S1550-7289(05)00157-7
Abstracts: Plenary Session/Surgery for Obesity and Related Diseases / 1 (2005) 222–283
flated up to 30 mm Hg at a rate of 20 –30 mL/min.The left cervical vagus was exposed for recording. Cuff-type microelectrodes with Teflon-coated silver wires were implanted over the cut vagus. Mechanosensitive properties of gastric vagal afferent fibers were amplified, recorded, and analyzed. Ten rats (group 1) had the stomach divided horizontally to create a small (3– 4 mL) proximal pouch. In 10 rats (group 2), the stomach was divided vertically for a sleeve gastrectomy. Vagal nerve recording was done before and after gastrectomy with the balloon inflated and deflated. Results: Before gastrectomy, the resting vagal activity was 1.3 ⫾ 0.3 impulses/s. The increase of activity in response to gastric distension was 9.1 ⫾ 0.6 impulses/s. The threshold for response was 9 –17 mm Hg. After gastrectomy, the group 2 animals exhibited significantly greater increased of activity compared with group 1 (15.3 vs. 3.2 impulses/s), with lower threshold for response (4.1 vs. 5 mm Hg). The differences between the two mean thresholds for two durations of distension were similar to before gastrectomy. Conclusions: Sleeve gastrectomy leads to increased activity of tension-stimulated vagal afferent fibers. This may explain the early satiety and weight loss in patients treated for morbid obesity. PII: S1550-7289(05)00155-3 SESSION V (7:45 A.M.-9:15 A.M.) CONCURRENT WITH SESSION IV GASTRIC BYPASS TOPICS
26.
GASTRIC BYPASS REDUCES BIOCHEMICAL CARDIAC RISK FACTORS D. Brandon Williams, M.D., Ramzi S. Alami, M.D., Elise H. Lawson, B.S., Barry R. Sanchez, M.D., Bassem Safadi, M.D., Myriam J. Curet, M.D., John M. Morton, M.D., M.P.H., Stanford University Medical Center, Department of Surgery, Stanford, CA. Purpose: Coronary artery disease (CAD) is the leading cause of death in the United States, with obesity as a leading preventable risk factor for CAD. Certain biochemical markers have demonstrated a strong prediction for cardiovascular events. We hypothesized that in addition to the weight reduction benefit of gastric bypass, this procedure would also induce a salutary effect on biochemical markers for cardiac risk. Methods: At a single academic institution (2003–2004), we measured biochemical cardiovascular risk factor markers in 222 gastric bypass patients preoperatively and 3 and 6 months postoperatively. These markers included total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, lipoprotein A, high-sensitivity C-reactive protein, and homocystein. The data were analyzed by repeated measures regression analysis with autocorrelation. Results: For the 222 patients, the mean age was 43 years and 84% were women. The mean body mass index was 47 kg/m2 and 31% were diabetic, 50% were hypertensive, 18% were taking antilipid medications, and 1% had known CAD. All the measured biochemical markers of CAD risk showed significant improvement after gastric bypass.
Cardiac Risk Baseline Mean Factor (Range, % Abnormal) Lipids TC TG HDL LDL Lipo A CRP HC BMI
3 Months PostOp Mean (Range)
6 Months Post- P Value Op Mean (Range)
200.5 (126-334, 46.5) 168.4 (119-240) 169.3 (103-231) ⬍0.0001 187.5 (37-1422, 48.2) 129 (61-249) 119.1 (48-283) 0.0001 47.2 (22-106, 24.8) 41.7 (25-58) 48.8 (30-69) ⬍0.0001 128.1 (39-217, 42.7) 111.7 (64-179) 101.8 (50-148) 0.0005 35.7 (0.2-213, 33) 24.8 (1.2-122.7) 30.4 (1.4-177) 0.0015 10.7 (0.2-44.6, 85.8) 8.1 (0.2-24.7) 4.2 (0.2-15.9) 0.0013 10.8 (4.6-40.7, 9.4) 9.9 (5.6-15.9) 9.5 (4.3-18.1) 0.0192 47 39 35 .0001
Conclusions: In this study, gastric bypass significantly improved the biochemical risk factors for CAD. By modifying these cardiac risk factors and achieving weight loss, gastric bypass lowers cardiac risk. PII: S1550-7289(05)00156-5
27.
GASTRIC BYPASS FOR MORBID OBESITY IN HIGHRISK CARDIAC PATIENTS Grady D. Alsabrook, M.D., J. Wesley Alexander, M.D., Sc.D., Hope R. Goodman, M.P.T., UC Surgeons Center for Surgical Weight Loss and The Christ Hospital, Cincinnatti, OH. Purpose: Gastric bypass for patients with known cardiac disease has often been a relative contraindication owing to the inherent risks in this patient population. Methods: A total of 59 consecutive patients with a preoperative diagnosis of cardiac disease underwent open gastric bypass (mean age 51 years, mean body mass index 53 kg/m2). Of these patients, 44% had congestive heart failure, 19% had myocardial infarction, 17% had undergone angioplasty, and 20% had undergone coronary stent placement or coronary artery bypass graft. Comorbid conditions included diabetes mellitus (56%), hypertension (83%), hyperlipidemia (71%), thromboembolic disease (17%), and transplant immunosuppression (5%). Results: The median length of stay was 3 days (range 1–20). Thirty-one patients had 1 year of postoperative follow-up. The reduction in the excess body mass index at 1 year postoperatively was 62%. Complications up to 5 years postoperatively included incisional hernia in 5 (8.5%), biliary disease in 3 (5.1%), urinary tract infection in 3 (5.1%), deep venous thrombosis in 2 (3.4%), renal stones in 2 (3.4%), angina in 2 (3.4%), anastomotic ulcer in 2 (3.4%), dehydration in 2 (3.4%), gastrointestinal bleeding with obstruction in 2 (3.4%), splenic bleeding in 1 (1.7%), new atrial fibrillation in 1 (1.7%), coronary artery bypass grafting in 1 (1.7%), wound infection in 1 (1.7%), pneumonia in 1 (1.7%), and anastomotic leaks in 0 (0%). One death occurred in the series; the patient died of gastrointestinal bleeding associated with coumadin therapy. Change in Comorbid Conditions Of These 31 Patients
Diabetes
Hypertension
Hyperlipidemia
Pre-op condition Resolved Improved
16 9 (56%) 7 (44%)
24 10 (42%) 9 (37%)
19 14 (74%) 3 (16%)
Conclusions: Gastric bypass surgery in patients with cardiac disease is safe and effective in reducing the comorbid conditions of diabetes, hypertension, and hyperlipidemia. PII: S1550-7289(05)00157-7