- Email: [email protected]
P40
322
Abstracts: Poster Session 2006 / 2 (2006) 310 –347
Background: Morbid obesity remains a significant health problem for many Americans. As the number of patients undergoing Rouxen-Y Gastric bypass grows, so does the potential for the development of complications in the bypassed stomach. One rare complication of the gastric remnant is perforation with or without bleeding. Methods: MacGregor et al reported perforation of the gastric remnant in only 11 of 4300 patients. Ulcer formation is most often complicated by the development of gastrointestinal bleeding. Upper and lower endoscopies are still the first diagnostic choice in the management of gastrointestinal bleeding, but neither allows access to the bypassed stomach. Angiography and nuclear-tagged scans can be helpful, but both require active bleeding, are often nondiagnostic, and can be difficult to obtain in critically ill patients. We report a series of seven patients who presented with complicated ulcer disease in the remnant stomach. Results: In our series five patients presented as new onset of right sided and/or epigastric pain, one presented in relation to another surgical problem and one presented in relation to the use of NSAID medication. There was one death; the other six underwent operative intervention. Conclusion: Perforation and bleeding from gastroduodenal ulcer formation are rare but serious complications in patients who have had Roux-en-Y gastric bypass. These patients most often present with pain followed by sepsis or SIRS, anemia of unknown etiology, or gastrointestinal bleeding without an identifiable source. Table 1
ASTⴱ Normal Elevated ALT Normal Elevated
Fatty liver N ⴝ 90
Portal fibrosis N ⴝ 84
NASH N ⴝ 98
Total n ⴝ 272
85 (94.4) 5 (5.6)
76 (90.5) 8 (9.5)
64 (65.3) 34 (34.7)
225 (82.7) 47 (17.3)
70 (77.8) 20 (22.2)
65 (77.4) 19 (22.6)
50 (51.0) 48 (49.0)
185(68.0) 87 (32.0)
ⴱAll data are no. (%).
PII: S1550-7289(06)00378-9
P38.
QUALITY OF LIFE 5-10 YEARS AFTER BARIATRIC SURGERY. Marlene M. Silva, Celina D.B. Sobreira, Alexandre Capeletto, Marta Magalinski, Cristiane E. Machado, Bruno Zilberstein, MD, PhD, Denis Pajecki, MD, PhD, Joel Faintuch, MD, PhD, Hospital das Clinicas, Sao Paulo, Brazil. Background: Roux-en-Y gastric bypass is an accepted anti-obesity procedure, but long-term results are not well established. In a prospective study, patients were investigated aiming to define long-term quality of life. Methods: Population (n⫽ 73) was 49.7 ⫺/⫹ 10.2 years old, 83.6% were females (66/73), and follow-up period was 88.6 ⫺/⫹ 12.8 months. Initial, minimum postoperative, and current BMI were respectively 56.6 ⫺/⫹ 10.9, 30.2 ⫺/⫹ 4.8 and 35.7 ⫺/⫹ 10.9 kg/m2. Both BAROS and SF-36 questionnaires were employed, along with clinical evaluation. Results: BAROS revealed an encouraging profile (1.5 ⫺/ 0.6 points) and several topics in SF-36 improved as well. However in 49.6% of those subjects with current BMI ⬎ 35 kg/m2 (total
group ⫽ 37/73, 50.7%) co-morbidities did not decrease, emotional, and pain domains of SF-36 remained stable, and mental health item diminished on late follow-up. Conclusion: 1) Quality of life was only partially improved after five years, with mixed results on SF-36 questionnaire; 2) Some degree of late weight gain and recurrence of co-morbidities may have played a role in such outcome. PII: S1550-7289(06)00379-0
P39.
NON-FOOD COMPULSIONS IN BARIATRIC CANDIDATES. M.A. Bicudo, Mara C.S. Lucia, Niraldo O. Santos, Marlene M. Silva, Denis Pajecki, MD, PhD, Joel Faintuch, MD, PhD, Bruno Zilberstein, MD, PhD, Joaquim J.G. Rodrigues, MD, PhD, Hospital das Clinicas, Sao Paulo, Brazil. Background: Aberrant alimentation patterns are well demonstrated in obese subjects, but other compulsions are controversial. In a prospective study, morbidly obese pre-operative patients were submitted to a detailed psychological and social questionnaire, aiming to identify abnormal behavior. Methods: Population (n⫽ 50, age 46 ⫺/⫹ 6 years (18- 60), 66% females, BMI 48.2 ⫺/⫹ 7.5 kg/m2) agreed to be interviewed at the Outpatient Service by experienced psychologists. Findings are shown as percentage of total group. Results: The following disturbances were reported: in 66% (33/ 50) excessive expenses with credit-card or other financial instruments, in 22% (11/50) difficulty in handling appointments and schedules, and in 8% (4/50) unbridled sexual drive. Most (60%, 30/50) considered themselves uncontrolled persons, and 10% (5/ 50) felt chronically nervous and anxious. Conclusion: 1) Emotional lability and compulsive behavior was not uncommon in the studied population; 2) Some of these derangements may be primary components of the obesity complex; 3) The possibility of an adverse surgical outcome in affected subjects cannot be ruled out. PII: S1550-7289(06)00380-7
P40.
AMELIORATION OF DIABETIC NEPHROPATHY AFTER GASTRIC BYPASS SURGERY. Christopher D. Still, DO, FACN, Christina Hartman, Peter Benotti, MD, FACS, Anthony Petrick, MD, FACS, William Strodel, MD, FACS, Stephanie Yeager, RD, Mary Jane Reed, MD, FACS, Geisinger Medical Center, Danville, PA. Background: Many studies have shown the dramatic, positive changes in macrovascular disease states such as diabetes mellitus and cardiovascular risk reduction after gastric bypass surgery (GBP). To date however, few studies have evaluated the effect of gastric bypass on microvascular changes such as diabetic nephropathy. A non-invasive urine marker to approximate the urinary excretion of protein is the micro-albumin creatinine ratio. The simultaneous urinary creatinine measurement allows for more accurate approximation of albumin excretion by adjusting for variations in
Abstracts: Poster Session 2006 / 2 (2006) 310 –347
patient’s hydration state. This is one of several validated screening tests for diabetic nephropathy. The purpose of this study was to determine the change, if any, in micro-albumin/creatinine ratio in diabetics after gastric bypass surgery. Methods: Baseline micro-albumin/creatinine ratios were obtained in 56 diabetic patients (male: 20; female 36) prior to undergoing GBP. Pre surgery results were compared to one-year post-surgical ratio. A two-sample t-test was used to determine significance. Less than 21 mg/gm was considered normal. Results: Mean pre-operative micro-albumin/creatinine ratio was 58.40 mg/gm. At one year follow up the average micro-albumin/ creatinine ratio decreased significantly to acceptable value of 18.26 mg/gm. Conclusion: Our preliminary results show significant improvements in micro-albumin/creatinine ratio and therefore amelioration of diabetic nephropathy after GBP. GBP results in not only significant macrovascular improvements but microvascular improvements as well. Our on going study will continue to look at these as well as other possible indicators of microvascular disease. PII: S1550-7289(06)00381-9
P41.
PATIENT SELECTION OF VITAMIN B12 (CYANOCOBALAMIN) ADMINISTRATION ROUTE AND HOW THIS EFFECTS OUTCOMES AND COMPLIANCE. Cathy Mozo, RD1, Leslie Berry, RD1, Steven Webb, MD, FAC2, John DePeri, MD FAC2, 1Laparoscopic Weight Loss Surgery Centers, Orange Park, FL, 2North Florida Surgeons, Jacksonville, FL. Background: Bariatric Patients undergoing gastric bypass surgery are routinely educated on the need to supplement Vitamin B12 after bypass due to lack of absorption. This lack of B12 absorption is related to the need for the cells lining the stomach to secrete a glycoprotein called intrinsic factor and to combine with B12 to form a B12-intrinsic factor complex for absorption in the ileum. Non-compliance with vitamin supplementation is an ongoing challenge with health care providers. Methods: The study population included 30 post gastric bypass patients who were given an option of B12 supplementation routes. Among these options were sublingual B12 1000 mcg every week, nasal gel administration 500 mcg 1 spray per week, or an injection of B12 monthly of 1000 mcg. Patients were routinely educated by the Registered Dietitian to let the sublingual tablet dissolve completely under the tongue and to not chew the tablet. In addition, instructions were provided on proper administration of the nasal B12. Results: When given a choice of Vitamin B12 administration routes, 25 out of 30 patients chose the sublingual B12 over all other options due to the ease of administration and convenience of obtaining. One patient chose nasally administered B12 and four patients chose injectable B12 due to primary care recommendation. All 30 patients had serum B12 levels within the normal value. Conclusion: When patients are given a choice of supplements and are able to chose the route that most meets their lifestyle needs, they are more compliant. There are several methods of B12 supplementation that can be utilized with equal outcomes. PII: S1550-7289(06)00382-0
323
P42.
GALLSTONE DISEASE AFTER LAPAROSCOPIC ROUXEN-Y GASTRIC BYPASS. Alex Escalona, MD, J. Francisco Guerra, MD, Nicolas Devaud, MD, Gustavo Perez, MD, Fernando Crovari, MD, Luis Ibez, MD, Pontificia Universidad Cato´lica de Chile, Santiago, Chile. Background: Morbid obesity is a well-known risk factor for gallstone disease. Laparoscopic Roux-en-Y Gastric Bypass (LRYGBP) is an effective bariatric surgical procedure for treating morbid obesity. The aim of this study is to evaluate the incidence of gallstone disease among patients who have undergone LRYGBP. Methods: 723 patients underwent LRYGBP between August 2001 and August 2005. All patients had a pre-surgery abdominal ultrasound (US). 565 patients had no evidence of gallstone disease prior LRYGBP and were prospectively followed during early and late post operative period. Clinical and demographic data together with surgical results were registered. Gallstone diagnoses was made through abdominal ultrasound performed in symptomatic patients and after 12 months follow-up in non-symptomatic patients. The median follow up was 15.9 months Results: Gallstone free rate was 96% after one year follow-up and 92% after 2 years. 32 patients (5.7%) developed gallstone disease after LRYGBP. 28 of them (86%) were female, with a mean age of 32 ⫾ 6 years. The mean time period for diagnosis was 13 ⫾ 3 months after LRYGBP.19 patients (59.3%) developed symptomatic cholelithiasis, including two cases with acute cholecystitis. 1 patient (3.1%) developed acute pancreatitis secondary to choledocholithiasis. Twelve patients (37.5%) showed no symptoms of gallstone disease being diagnosed with a follow-up abdominal US. 31 patients underwent laparoscopic cholecystectomy after diagnosis. There were no complications post surgery. Conclusion: Patients who undergo LRYGBP have a low incidence of gallstone disease after surgery. In those who develop the disease, laparoscopic cholecystectomy is a safe procedure after LRYGBP. PII: S1550-7289(06)00383-2 P43.
DESCRIPTION OF PSYCHOLOGICAL PROFILE IN THE MORBIDLY OBESE. ANALYSIS OF 644 MMPI-2 TESTS BEFORE BARIATRIC SURGERY. Sergio J. Bardaro, MD, Emma Patterson, MD, Jay Jan, MD, Laura July, MD, Luahna Ude, PhD, Robert Poole, PhD, Dennis Hong, MD, Legacy Health System, Portland, OR. Background: Bariatric surgery is the treatment of choice for morbid obesity, but it does not lead to equal results in every patient. Psychological factors may influence patients’ ability to adjust to the post-operative condition. We routinely administer the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) as a preoperative assessment to evaluate patients’ psychological characteristics. Methods: The preoperative MMPI-2 tests in 644 patients that underwent bariatric surgery were analyzed retrospectively. We focused on the validity and clinical scales to assess psychological profile of the morbidly obese. Normal range for both scales were between 45 -65.
Abstracts: Poster Session 2006 / 2 (2006) 310 –347
Background: Morbid obesity remains a significant health problem for many Americans. As the number of patients undergoing Rouxen-Y Gastric bypass grows, so does the potential for the development of complications in the bypassed stomach. One rare complication of the gastric remnant is perforation with or without bleeding. Methods: MacGregor et al reported perforation of the gastric remnant in only 11 of 4300 patients. Ulcer formation is most often complicated by the development of gastrointestinal bleeding. Upper and lower endoscopies are still the first diagnostic choice in the management of gastrointestinal bleeding, but neither allows access to the bypassed stomach. Angiography and nuclear-tagged scans can be helpful, but both require active bleeding, are often nondiagnostic, and can be difficult to obtain in critically ill patients. We report a series of seven patients who presented with complicated ulcer disease in the remnant stomach. Results: In our series five patients presented as new onset of right sided and/or epigastric pain, one presented in relation to another surgical problem and one presented in relation to the use of NSAID medication. There was one death; the other six underwent operative intervention. Conclusion: Perforation and bleeding from gastroduodenal ulcer formation are rare but serious complications in patients who have had Roux-en-Y gastric bypass. These patients most often present with pain followed by sepsis or SIRS, anemia of unknown etiology, or gastrointestinal bleeding without an identifiable source. Table 1
ASTⴱ Normal Elevated ALT Normal Elevated
Fatty liver N ⴝ 90
Portal fibrosis N ⴝ 84
NASH N ⴝ 98
Total n ⴝ 272
85 (94.4) 5 (5.6)
76 (90.5) 8 (9.5)
64 (65.3) 34 (34.7)
225 (82.7) 47 (17.3)
70 (77.8) 20 (22.2)
65 (77.4) 19 (22.6)
50 (51.0) 48 (49.0)
185(68.0) 87 (32.0)
ⴱAll data are no. (%).
PII: S1550-7289(06)00378-9
P38.
QUALITY OF LIFE 5-10 YEARS AFTER BARIATRIC SURGERY. Marlene M. Silva, Celina D.B. Sobreira, Alexandre Capeletto, Marta Magalinski, Cristiane E. Machado, Bruno Zilberstein, MD, PhD, Denis Pajecki, MD, PhD, Joel Faintuch, MD, PhD, Hospital das Clinicas, Sao Paulo, Brazil. Background: Roux-en-Y gastric bypass is an accepted anti-obesity procedure, but long-term results are not well established. In a prospective study, patients were investigated aiming to define long-term quality of life. Methods: Population (n⫽ 73) was 49.7 ⫺/⫹ 10.2 years old, 83.6% were females (66/73), and follow-up period was 88.6 ⫺/⫹ 12.8 months. Initial, minimum postoperative, and current BMI were respectively 56.6 ⫺/⫹ 10.9, 30.2 ⫺/⫹ 4.8 and 35.7 ⫺/⫹ 10.9 kg/m2. Both BAROS and SF-36 questionnaires were employed, along with clinical evaluation. Results: BAROS revealed an encouraging profile (1.5 ⫺/ 0.6 points) and several topics in SF-36 improved as well. However in 49.6% of those subjects with current BMI ⬎ 35 kg/m2 (total
group ⫽ 37/73, 50.7%) co-morbidities did not decrease, emotional, and pain domains of SF-36 remained stable, and mental health item diminished on late follow-up. Conclusion: 1) Quality of life was only partially improved after five years, with mixed results on SF-36 questionnaire; 2) Some degree of late weight gain and recurrence of co-morbidities may have played a role in such outcome. PII: S1550-7289(06)00379-0
P39.
NON-FOOD COMPULSIONS IN BARIATRIC CANDIDATES. M.A. Bicudo, Mara C.S. Lucia, Niraldo O. Santos, Marlene M. Silva, Denis Pajecki, MD, PhD, Joel Faintuch, MD, PhD, Bruno Zilberstein, MD, PhD, Joaquim J.G. Rodrigues, MD, PhD, Hospital das Clinicas, Sao Paulo, Brazil. Background: Aberrant alimentation patterns are well demonstrated in obese subjects, but other compulsions are controversial. In a prospective study, morbidly obese pre-operative patients were submitted to a detailed psychological and social questionnaire, aiming to identify abnormal behavior. Methods: Population (n⫽ 50, age 46 ⫺/⫹ 6 years (18- 60), 66% females, BMI 48.2 ⫺/⫹ 7.5 kg/m2) agreed to be interviewed at the Outpatient Service by experienced psychologists. Findings are shown as percentage of total group. Results: The following disturbances were reported: in 66% (33/ 50) excessive expenses with credit-card or other financial instruments, in 22% (11/50) difficulty in handling appointments and schedules, and in 8% (4/50) unbridled sexual drive. Most (60%, 30/50) considered themselves uncontrolled persons, and 10% (5/ 50) felt chronically nervous and anxious. Conclusion: 1) Emotional lability and compulsive behavior was not uncommon in the studied population; 2) Some of these derangements may be primary components of the obesity complex; 3) The possibility of an adverse surgical outcome in affected subjects cannot be ruled out. PII: S1550-7289(06)00380-7
P40.
AMELIORATION OF DIABETIC NEPHROPATHY AFTER GASTRIC BYPASS SURGERY. Christopher D. Still, DO, FACN, Christina Hartman, Peter Benotti, MD, FACS, Anthony Petrick, MD, FACS, William Strodel, MD, FACS, Stephanie Yeager, RD, Mary Jane Reed, MD, FACS, Geisinger Medical Center, Danville, PA. Background: Many studies have shown the dramatic, positive changes in macrovascular disease states such as diabetes mellitus and cardiovascular risk reduction after gastric bypass surgery (GBP). To date however, few studies have evaluated the effect of gastric bypass on microvascular changes such as diabetic nephropathy. A non-invasive urine marker to approximate the urinary excretion of protein is the micro-albumin creatinine ratio. The simultaneous urinary creatinine measurement allows for more accurate approximation of albumin excretion by adjusting for variations in
Abstracts: Poster Session 2006 / 2 (2006) 310 –347
patient’s hydration state. This is one of several validated screening tests for diabetic nephropathy. The purpose of this study was to determine the change, if any, in micro-albumin/creatinine ratio in diabetics after gastric bypass surgery. Methods: Baseline micro-albumin/creatinine ratios were obtained in 56 diabetic patients (male: 20; female 36) prior to undergoing GBP. Pre surgery results were compared to one-year post-surgical ratio. A two-sample t-test was used to determine significance. Less than 21 mg/gm was considered normal. Results: Mean pre-operative micro-albumin/creatinine ratio was 58.40 mg/gm. At one year follow up the average micro-albumin/ creatinine ratio decreased significantly to acceptable value of 18.26 mg/gm. Conclusion: Our preliminary results show significant improvements in micro-albumin/creatinine ratio and therefore amelioration of diabetic nephropathy after GBP. GBP results in not only significant macrovascular improvements but microvascular improvements as well. Our on going study will continue to look at these as well as other possible indicators of microvascular disease. PII: S1550-7289(06)00381-9
P41.
PATIENT SELECTION OF VITAMIN B12 (CYANOCOBALAMIN) ADMINISTRATION ROUTE AND HOW THIS EFFECTS OUTCOMES AND COMPLIANCE. Cathy Mozo, RD1, Leslie Berry, RD1, Steven Webb, MD, FAC2, John DePeri, MD FAC2, 1Laparoscopic Weight Loss Surgery Centers, Orange Park, FL, 2North Florida Surgeons, Jacksonville, FL. Background: Bariatric Patients undergoing gastric bypass surgery are routinely educated on the need to supplement Vitamin B12 after bypass due to lack of absorption. This lack of B12 absorption is related to the need for the cells lining the stomach to secrete a glycoprotein called intrinsic factor and to combine with B12 to form a B12-intrinsic factor complex for absorption in the ileum. Non-compliance with vitamin supplementation is an ongoing challenge with health care providers. Methods: The study population included 30 post gastric bypass patients who were given an option of B12 supplementation routes. Among these options were sublingual B12 1000 mcg every week, nasal gel administration 500 mcg 1 spray per week, or an injection of B12 monthly of 1000 mcg. Patients were routinely educated by the Registered Dietitian to let the sublingual tablet dissolve completely under the tongue and to not chew the tablet. In addition, instructions were provided on proper administration of the nasal B12. Results: When given a choice of Vitamin B12 administration routes, 25 out of 30 patients chose the sublingual B12 over all other options due to the ease of administration and convenience of obtaining. One patient chose nasally administered B12 and four patients chose injectable B12 due to primary care recommendation. All 30 patients had serum B12 levels within the normal value. Conclusion: When patients are given a choice of supplements and are able to chose the route that most meets their lifestyle needs, they are more compliant. There are several methods of B12 supplementation that can be utilized with equal outcomes. PII: S1550-7289(06)00382-0
323
P42.
GALLSTONE DISEASE AFTER LAPAROSCOPIC ROUXEN-Y GASTRIC BYPASS. Alex Escalona, MD, J. Francisco Guerra, MD, Nicolas Devaud, MD, Gustavo Perez, MD, Fernando Crovari, MD, Luis Ibez, MD, Pontificia Universidad Cato´lica de Chile, Santiago, Chile. Background: Morbid obesity is a well-known risk factor for gallstone disease. Laparoscopic Roux-en-Y Gastric Bypass (LRYGBP) is an effective bariatric surgical procedure for treating morbid obesity. The aim of this study is to evaluate the incidence of gallstone disease among patients who have undergone LRYGBP. Methods: 723 patients underwent LRYGBP between August 2001 and August 2005. All patients had a pre-surgery abdominal ultrasound (US). 565 patients had no evidence of gallstone disease prior LRYGBP and were prospectively followed during early and late post operative period. Clinical and demographic data together with surgical results were registered. Gallstone diagnoses was made through abdominal ultrasound performed in symptomatic patients and after 12 months follow-up in non-symptomatic patients. The median follow up was 15.9 months Results: Gallstone free rate was 96% after one year follow-up and 92% after 2 years. 32 patients (5.7%) developed gallstone disease after LRYGBP. 28 of them (86%) were female, with a mean age of 32 ⫾ 6 years. The mean time period for diagnosis was 13 ⫾ 3 months after LRYGBP.19 patients (59.3%) developed symptomatic cholelithiasis, including two cases with acute cholecystitis. 1 patient (3.1%) developed acute pancreatitis secondary to choledocholithiasis. Twelve patients (37.5%) showed no symptoms of gallstone disease being diagnosed with a follow-up abdominal US. 31 patients underwent laparoscopic cholecystectomy after diagnosis. There were no complications post surgery. Conclusion: Patients who undergo LRYGBP have a low incidence of gallstone disease after surgery. In those who develop the disease, laparoscopic cholecystectomy is a safe procedure after LRYGBP. PII: S1550-7289(06)00383-2 P43.
DESCRIPTION OF PSYCHOLOGICAL PROFILE IN THE MORBIDLY OBESE. ANALYSIS OF 644 MMPI-2 TESTS BEFORE BARIATRIC SURGERY. Sergio J. Bardaro, MD, Emma Patterson, MD, Jay Jan, MD, Laura July, MD, Luahna Ude, PhD, Robert Poole, PhD, Dennis Hong, MD, Legacy Health System, Portland, OR. Background: Bariatric surgery is the treatment of choice for morbid obesity, but it does not lead to equal results in every patient. Psychological factors may influence patients’ ability to adjust to the post-operative condition. We routinely administer the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) as a preoperative assessment to evaluate patients’ psychological characteristics. Methods: The preoperative MMPI-2 tests in 644 patients that underwent bariatric surgery were analyzed retrospectively. We focused on the validity and clinical scales to assess psychological profile of the morbidly obese. Normal range for both scales were between 45 -65.