Margaret Mary Showel, M.D.

• Assistant Professor of Oncology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0021061/margaret-showel

A more aggressive search for these occult hernias might reduce the complication rates of bands even further medicine vs medication order discount citalopram online. Similarly medicine reaction buy citalopram 20mg overnight delivery, the incidence of band erosions symptoms indigestion discount citalopram 20mg without prescription, originally in the 11 % range treatment quincke edema trusted citalopram 20 mg, has dropped to 0 symptoms food poisoning buy generic citalopram 40mg line. Suggestion of common pathophysiology between prolapse and erosion has been recently advocated symptoms 0f high blood pressure order citalopram 40mg with amex. Early erosions occur within the first 7 months and can be due to technical complications or infection. In fact, subcutaneous port infection can be one of the first signs of a missed esophageal or gastric injury. Other contributing factors to erosion are band overfilling or tight gastric placation and, possibly, maladaptive eating behaviors. Late erosions can result from tight adjustment sometimes in the setting of lack of restriction secondary to a misdiagnosed band prolapse. The decision of the optimal procedure to offer after a failed band should be largely related to the causes of failure. Such revisions should be considered only in patients with adequate primary weight loss, now experiencing a band complication [16]. In spite of the fact that these procedures are considered among the simplest reoperations after bariatric surgery, a high incidence of morbidity has been reported [7]. In fact, up to two-thirds of the patients will experience additional complications, including recurrent prolapse, erosion, and failure of weight loss, and eventually the majority of these patients will require conversion to an alternative procedure [7]. Some of these recurrences might be related to the failure of recognizing and correcting the underlying anatomic abnormality that led to the complication. Some authors speculate better weight loss and less trend toward future reoperations with band replacement, both because of the utilization of newer generation bands and technical factors (hiatal hernia repairs, utilization of new more proximal retrogastric tunnel) [20]. Port-related complications account for a significant number of revisions (12 %) [7]. The diagnosis of a port-tube complex complication is entertained when the port cannot be accessed any longer, the adjustments result in persistent lack of restriction, or abdominal pain of unclear origin is present. Of course, a more common band-related complication, such as intragastric migration or a prolapse, should be ruled out first by fluoroscopic contrast and endoscopic evaluations. Further fluoroscopic studies will identify the specific port-tube complex complication and guide the type of revision needed. This, of course, could contribute to added morbidity of general anesthesia, as well as of the procedure itself. An informed discussion with the patient has to be entertained, indicating the realistic results of this approach, and alternative options (conversions) should be presented. Due to these potentially disappointing results, several authors have advocated offering some of these patients a conversion to a different procedure. Conversion In the case of weight loss failure or weight regain, conversion to a different procedure is the strategy of choice. Conversions are also indicated in the setting of band complications, both first time and recurrent. As previously mentioned, no randomized trials are available to formulate a decision tree on the type of revision to perform. Consideration should be given to the comorbidities present at the time of reintervention. Occasionally, in the presence of significant inflammation of the peri-band tissues, a band removal only is performed at the first operation, followed by conversion at a later date (two-step approach). No clear data exist on the superiority of the two-step approach over the single step. It is obvious how complication rates are higher in the conversions than in the revisions (10. Although some of these findings can be explained by anatomical reasons (technical modifications and compromises due to the revisional nature of the second procedure, i. As expected, operating time and morbidity tend to be higher for the reoperative cases. After mobilizing the left lobe of the liver and entering the fibrotic sheath, full exposure of the locking mechanism allows for removal of the device. The fibrotic tract will aid in the identification of the gastro-gastric plication, which needs to be taken down. Awareness and avoidance of the fibrotic tissue, when possible, will allow for a safe preparation of the gastric pouch. As previously mentioned, upsizing the staple heights and oversewing of all the staple lines will minimize the risk of postoperative leak. Among its advantages are decreased chances of malnutrition, marginal ulcers, reactive hypoglycemia, and dumping syndrome. The mechanisms for postoperative leaks are again related to ischemia and fibrotic tissue, especially at the gastroesophageal junction. Also, inadvertent transection of a non-adequately unwrapped portion of the fundus can result in postoperative leaks. Because of the relatively inert material, once the buckle is opened or transected, the band will easily slide out. The presence of erosion might complicate this step, and based on the degree of intragastric migration and perigastric reaction, placement of intra-abdominal drains should be considered. In patients with preoperative dysphagia or gastric outlet obstruction, efforts should be made to restore the normal anatomy as much as possible, by taking down the gastric plication. According to a review of the academic centers in the United States, the increase between 2004 and 2007 was in the order of 125 % [25]. It is important to recognize how the approach to gastric bypass also changed over time. In fact, 85 % of gastric bypasses are now performed laparoscopically, according to the aforementioned study. The different procedures are divided, once again, into revisions, conversions, and reversals (Table 24. The expected complications and outcomes vary greatly based on the type of reoperation. Revisions Some clinical data exist on the potential anatomic abnormalities associated with weight regain. Revisions target these specific anatomic abnormalities without altering the anatomy and physiology of the primary procedure. Contradictory evidence exists on the role of restriction (pouch and anastomotic size) in weight regain. When all other potential contributors to weight regain are ruled out, in the presence of an isolated anatomic abnormality (large pouch, large anastomosis), revisional options can be discussed with the patient. Trimming of the pouch should always proceed with a calibration tube or endoscope in place in order to minimize narrowing of the gastroesophageal junction. Oversewing the staple line reduces the chance of bleeding and leak, and this should be evaluated intraoperatively (leak test and intraoperative endoscopy). Similarly, gastrojejunal anastomotic dilatation has been associated with loss or restriction and weight regain in some studies, but the contrary has also been demonstrated [28]. In general, modest weight loss improvements are obtained with these interventions and their durability remains largely unknown. Another potential benefit for the patient who regains weight is increasing the degree of malabsorption. Technically the lengthening of the Roux limb can be accomplished either by disconnecting the biliopancreatic limb flush to the roux limb or by resecting the entire jejunojejunostomy. The advantage of the first approach is the need for only one anastomosis to reconstruct the gastrointestinal tract (as opposed to two); the main disadvantage is the potential narrowing of the roux limb at the site of biliopancreatic transection. Whenever the indications for revision come from a chronic complication, such as gastro-gastric fistula or recurrent ulceration, the results seem to be more satisfactory. In the face of gastro-gastric fistulae, endoluminal procedures are rarely effective. Revisional options include resection of 24 Reoperative Bariatric Surgery 279 the fistulous tract, with or without remnant gastrectomy. The location of the fistula and the relation to the gastrojejunal anastomosis will dictate the need for resection and re-anastomosis. Special care should be taken not to leave vascularized gastric tissue without a drainage route. It is important to evaluate these patients for hypersecretory diseases, such as gastrinoma. Occasionally a 24-h pH study might be helpful to clarify the etiology, especially in refractory marginal ulcers. Typical approaches include resection of the gastrojejunostomy, pouch volume reduction, and reconstruction of the gastrojejunostomy. In fact, some of the early recurrent marginal ulcerations are determined by ischemia due to tension, more than acid hypersecretion. Full mobilization of a retrocolic retrogastric Roux limb might be challenging and result in injury to the mesentery. In these cases mobilization of the jejunal wall as it passes through the transverse mesocolon and then pivoting around its unmobilized mesentery will allow for additional length without risking injury to the mesentery itself. Finally, for marginal ulcers refractory to revisional procedures previously described, additional options include truncal vagotomy, near-total gastrectomy, or total gastrectomy. Advantages of resecting the roux limb include the avoidance of an additional anastomosis. If the roux limb is preserved, the biliopancreatic stump is anastomosed to the proximal roux limb, and the distal roux limb is anastomosed to the proximal common channel. Loop Gastric Bypass Some authors have advocated the use of a loop (or mini) gastric bypass as a primary bariatric procedure based on its easier technique and safer outcome. The presence of a long narrow gastric tube results in a tension-free gastrojejunostomy. Also the avoidance of a Roux reconstruction will decrease the chance of developing internal hernias and mesenteric hematomas. On the other hand, the presence of an afferent limb can predispose to the development of marginal ulcers, strictures, and bile gastritis. As for other bariatric procedures, the indications for reoperation include failure of weight loss, weight regain, and complications. The complications include bile reflux with recurrent marginal ulcer and, rarely, malabsorption/malnutrition. Whenever feasible, the simple resection of the afferent limb with creation of a jejunojejunostomy at least 100 cm for the gastrojejunostomy is all that is necessary. Alternatively, resection of the gastrojejunostomy with shortening of the pouch and recreation of both the gastrojejunostomy and jejunojejunostomy is necessary. Some authors have proposed this approach as an alternative to treat refractory reactive hypoglycemia as well [26]. It is then unclear if this is an artificially low number derived from the reluctance to revise this more complex procedure. Because it is less technically challenging, some authors advocate reduction of the sleeve volume as a first option. Most of the revisions, however, are necessary to reduce the degree of malabsorption by lengthening the common channel. The procedure can be accomplished laparoscopically even if the primary operation was done open. After taking down the gastrojejunostomy, the gastric reservoir is recreated by anastomosing the gastric pouch with the remnant. The deconstructed roux limb is then either resected or, if intestinal length is a concern, preserved by resecting only the jejunoje- 280 E. Another option is to resect the proximal alimentary side of the ileoileostomy and re-anastomose it with a more proximal portion of the biliopancreatic limb. Conversion the presence of a gastro-gastric fistula or the simple resolution of the gastric outlet obstruction will determine a certain weight regain. Although technically challenging, these conversions can be accomplished laparoscopically. After identification and removal of the gastric ring(s), the retrogastric and angle of His dissections are the most challenging steps. Parallel staple lines in close proximity to each other might create islands of poorly vascularized stomach, or gastric tissue without adequate outlet, and should be avoided. The intraoperative use of endoscopy or calibration tubes is invaluable for the identification and preservation of the gastroesophageal junction. The percentage of resolution of gastric outlet symptoms is very high (close to 100 %), and the weight loss is comparable with the primary operation [26]. The only potential treatment is reversal, in an effort to reduce the progression to liver failure. The reversal is fairly straightforward, entailing resection of the jejunoileostomy and creation of a jejunojejunostomy and an ileojejunostomy. Although weight regain is expected, this is, at least short term, a welcome side effect of the reversal. The basic concept of restriction is obtained by a lesser curvature-based gastric tube, with a restricted outlet supported by an extrinsic implant. Because of the nondivided nature of the gastric tube, the major reason for weight regain is the recanalization of the vertical staple line resulting in gastro-gastric fistula. The other indication for reoperation is related to the development of dysphagia and esophageal reflux symptoms secondary to gastric outlet obstruction. The obstruction is commonly caused by the different degree of erosion of the foreign body (silastic band or mesh) at the distal part of the gastric tube. Ideally, the foreign body (or bodies) should be completely removed to avoid recurrent erosions. The presence of a thick fibrotic gastric outlet could be obviated by the creation of a gastrogastrostomy. As in other procedures, the need for reoperation is dictated by either failure of weight loss or weight regain and by complications (such as worsening reflux symptoms, dysphagia, and gastric outlet obstruction).

Currently medicine ball exercises buy on line citalopram, there is no evidence-based consensus regarding optimal supplementation medications hair loss generic 40 mg citalopram overnight delivery. Patient selection for the procedure should consider the likelihood that the patient will comply with the more stringent supplementation strategy and follow-up required medications you cant crush citalopram 40mg low cost. A history of poor compliance and psychiatric conditions and a lack of resources or social support should serve as red flags symptoms kidney problems order discount citalopram line, cautioning against the procedure symptoms leukemia 40 mg citalopram with amex. It should be noted that the majority of patients in most series are without nutritional side effects medications prescribed for adhd purchase cheapest citalopram and citalopram. While this is likely a valid observation, caution should be used when interpreting this data, as subjects in large series or trials may have closer follow-up than in actual practice. This trend has been borne out on virtually all subsequent retrospective, prospective, and comparative series. There were no significant differences in perioperative morbidity or late complications. This effect seems to be as pronounced, if not more so in the super obese population. Curiously, there is not always a relationship between stool frequency and magnitude of weight loss, suggesting mechanisms other than fat malabsorption may play a role in the physiology of this procedure. Revisional Surgery Morbid obesity is a complex problem, and no single solution is likely to be a panacea. Even after surgical intervention, weight regain, or failure to achieve significant weight loss can be a problem. While gastric bypass and gastric banding are certainly effective and more commonly performed, longterm failure rates can be as high as 30 % of patients. For these reasons, the question as to how to manage these patients becomes pertinent [15, 16]. Revisional surgery, however, carries added surgical risks, and appropriate surgical technique and patient selection are important to this undertaking. Despite these successful and promising results, the complexity of this undertaking should not be underestimated, as the procedure requires 4 anastomoses, and long-term data is not yet available on patients undergoing such revisions. In addition, complications such as band intolerance, reflux, esophageal dilatation, erosion, and band slippage may require removal of the device. Patients with significant reflux or band intolerance may be better served with a gastric bypass. Conclusion Currently, bariatric surgery is the only effective means of sustained weight loss in the morbidly obese, which improves many obesity-related health problems and increases overall 220 V. Biliopancreatic diversion with duodenal switch is the most effective surgical option, in both magnitude of weight loss and higher rates of comorbidity resolution. Long-term data from multiple series are available that confirm the success and safety of this procedure. Patients and physicians should be aware of protein, iron, calcium, and vitamin D and A deficiencies. Aggressive supplementation strategies and lifelong follow-up are critical to the long-term success of this technique. Duodenal switch provides superior weight loss in the super-obese (bmi > 50 kg/m2) compared with gastric bypass. A comparison of a personal series of biliopancreatic diversion and literature data on gastric bypass help to explain the mechanisms of resolution of type 2 diabetes by the two operations. Early experience with two-stage laparoscopic roux-en-y gastric bypass as an alternative in the super-super obese patient. Concurrent prophylactic placement of inferior vena cava filter in gastric bypass and adjustable banding operations in the bariatric outcomes longitudinal database. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for super obesity. Duodenal switch provides superior resolution of metabolic comorbidities independent of weight loss in the super-obese (bmi > 50 kg/m2) compared with gastric bypass. Duodenal switch is a safe operation for patients who have failed other bariatric operations. Laparoscopic repeat sleeve gastrectomy versus duodenal switch after isolated sleeve gastrectomy for obesity. Understand the management of acute gastrointestinal leaks after bariatric surgery. Understand the management of chronic gastrointestinal fistula after bariatric surgery. Introduction Bariatric operations involving gastrointestinal resection and/ or reconstruction can be associated with gastrointestinal leaks and fistula. Common bariatric operations that can lead to development of gastrointestinal leaks include Roux-en-Y gastric bypass, sleeve gastrectomy, and the duodenal switch operation. The sleeve gastrectomy as a primary bariatric operation has recently been gaining popularity among surgeons and patients [1]. Gastrointestinal leak is one of the most dreaded complications following bariatric surgery as it can lead to significant morbidity and mortality. In a review of the published literature, the mean incidence of leaks after Roux-en-Y gastric bypass was reported to be 1. The incidence of leaks after sleeve gastrectomy is higher and has been reported at 2. Expeditious recognition and early institution of management for gastrointestinal leaks are keys to minimize the progression from systemic inflammatory response to eventual sepsis. Prompt management of gastrointestinal leak can also minimize the risk for development of a chronic fistula, which is often difficult to treat. This chapter reviews the etiologies of gastrointestinal leaks, common presenting signs and symptoms, diagnostic evaluation, and management of acute gastrointestinal leaks and chronic fistula. Technical factors that can lead to development of leaks include issues such as poor technique in construction of the anastomosis, the presence of excessive tension on the anastomosis, the presence of staple-line bleeding, and the presence of tissue ischemia. In most instances, all of the aforementioned factors may play a role in the development of leaks. Patientrelated factors contributing to the development of leaks include the presence of poor nutrition, current or recent smoking history, liver cirrhosis, and renal failure. In a study analyzing factors predictive of leaks after laparoscopic and open gastric bypass, Masoomi et al. Sites for leaks after gastric bypass include the gastrojejunostomy, the gastric remnant, and the jejunojejunostomy with the gastrojejunal anastomosis being the most common site for leaks. The primary reason for the higher leak rate observed at the gastrojejunal anastomosis is the presence of tension 221 N. Additionally, tissue ischemia plays a role due to the division of the jejunal mesentery, which can compromise tissue perfusion to the antimesenteric aspect of the jejunum. In contrast, the site of leak after sleeve gastrectomy can be anywhere along the long gastric staple line. The most common site of leak is within the upper aspect of the staple line near the gastric angle of His. The main reason for leaks in this region is the high intraluminal pressure associated with construction of the sleeve gastrectomy [5]. The increased intraluminal pressure can lead to increase in luminal radial force, which can potentially lead to disruption of the staple line. Additionally, the presence of a partial obstruction at the level of the incisura angularis can also lead to additional proximal pressure and can be a contributing factor in the development of leaks after sleeve gastrectomy. With regard to the vital signs, tachycardia is often the first vital sign to be abnormal [6]. Tachycardia in the early postoperative period should raise suspicion for possible gastrointestinal leaks. Laboratory examination suggestive of a leak includes leukocytosis and an elevated C-reactive protein level. In a study of 17 patients with leaks after gastric bypass, C-reactive protein level of greater than 229 mg/l was able to reliably indicate a leak [7]. Therefore, the position statement suggested that laparoscopic or open reexploration should be an appropriate diagnostic option when gastrointestinal leak is suspected, as reliance on false-negative imaging studies may delay operative intervention. The treatment options for postoperative leaks after bariatric surgery depend on the timing of leaks at presentation. Management of early and acute leaks includes conservative nonoperative management, reoperation with abdominal washout, closure of the defect or placement of a T-tube to intubate the defect, and wide peritoneal drainage. For late and chronic leaks, management may require performing a proximal gastrectomy with esophagojejunostomy [16]. Nonoperative Treatment Nonoperative treatment can be considered for small, contained leaks, particularly in hemodynamically stable patients. Acute presentations can often be managed successfully with (a) insertion of intraluminal stent to cover the staple-line defect or (b) drainage and T-tube insertion. Armstrong Resolution of leaks following stent insertion (%) Endoscopic stent with laparoscopic drainage 75 % Overall mortality 9. In a relatively large study of leaks after gastric bypass, Gonzalez and colleagues reported successful nonoperative treatment in 23 of 26 patients, with an overall morbidity of 62 % and no mortality [17]. Reoperation and Drainage the mainstay of surgical treatment includes drainage of all fluid collections and placement of abdominal drains. Additionally, some surgeons make an attempt at closure of the defect; however, these closures tend to break down due to poor tissue integrity at the leak site. Leaks at the jejunojejunostomy or the gastric remnant may be more amenable for primary closure, and revision of the anastomosis is rarely needed [2]. An alternative approach to control the leak site is placement of a T-tube directly into the defect [14]. This technique consists of obtaining a conventional T-tube drain and placing the T part of the drain directly into the defect. Oral contrast passed entirely through the stent without evidence of contrast extravasation the idea here is to create a track along the drain, hence creating a controlled fistula. Upon withdrawal of the tube, the well-formed fistulous track will collapse and eventually close. Endoscopic Stent Endoscopic stenting for management of bariatric leaks is a relatively new concept and was initiated from the experience of using endoscopic stenting in management of esophageal anastomotic leaks after esophagectomy [19]. Serra and colleagues reported on the use of coated selfexpanding stents for management of leaks after sleeve gastrectomy or duodenal switch in six patients with control of leaks in 83 % of cases [11]. Casella and colleagues reported the use of endoscopic stent for leak at the gastroesophageal junction after sleeve gastrectomy in three patients, with complete healing occurring in all patients [18]. Oshiro and colleagues reported successful management of proximal gastric leak using a covered endoscopic stent in two patients who underwent prior unsuccessful laparoscopic treatment for the leak [13]. In contrast, the largest series of eight cases of endoscopic stent for leak after sleeve gastrectomy was reported by Tan and colleagues [14]. They reported a 50 % success rate for closure of the leak, with four patients requiring premature removal of the stent due to either migration, hematemesis, or obstruction from kinking at the proximal aspect of the stent. One of the major difficulties with usage of stents for control of leaks is their ability to migrate. Eubanks and colleagues described the use of endoscopic stenting in 19 patients, although they described an overall healing rate of 84 %, stents had to be repositioned or replaced in 47 % of patients due to migration. In addition, endoscopic stenting was noted to be less effective for management of chronic fistula in this series. In another report, Fukumoto and colleagues reported a single case of endoscopic stent for leak after sleeve gastrectomy without success that required operative closure of the fistula [15]. Several principles should be followed when an esophageal stent is considered for management of a gastric leak after sleeve gastrectomy or gastric bypass. First, an endoscopy must be performed to evaluate the site of the leak, the size of the leak, and viability of the conduit. Gastric leaks at the proximal and mid-aspect of the gastric sleeve are the only leaks that are amenable to endoscopic treatment with stent. A leak at the distal staple line of the gastric sleeve, near the gastric antrum, will not be amenable to endoscopic stenting as the stent would be too small and would not provide appropriate sealing of the defect. Second, appropriate drainage of abdominal collection is of utmost importance using either laparoscopic or percutaneous technique in combination with nothing per oral and nutritional support using either total parenteral nutrition or jejunostomy feeding. Third, the size of the endoscopic stent should be selected erring on the larger size in an effort to prevent migration. Endoscopic Stent Technique With regard to technique for endoscopic stenting, the procedure starts with an endoscopy to determine the site and extent of the leak. Upon confirmation of the site of leak, it is important to make sure that there is an adequate landing zone above the leak site. Additionally, it is important to estimate the luminal diameter of the esophagus in selection of the size and length of the stent. It is also important to select only fully covered stent rather than partially covered stent, which can lead to tissue ingrowth and possibly compromise its removal at a later date. There are two techniques for deployment of the esophageal stent, fluoroscopic guidance versus endoscopic guidance. In the fluoroscopic guidance technique, the site of the leak is confirmed on fluoroscopy, and radiopaque markers (paper clips) are placed to outline the proximal and 226 N. An ultra-stiff guidewire is placed into the gastric antrum for sleeve gastrectomy patients or passed into the jejunal Roux limb for Roux-en-Y gastric bypass patients and its placement confirmed under fluoroscopy. The selected esophageal stent is inserted transorally over the guidewire down the esophagus and positioned between the two radiopaque markers.

Another way of looking at volume and mortality is demonstrated in a paper by Ghaferi treatment venous stasis citalopram 40 mg low price. The failure of the lower volume center to rescue the patient from the complication appears to account for the difference in mortality jnc 8 medications buy citalopram 40 mg online. Ninh Nguyen reported that looking at 35 medicine stick buy citalopram 20mg low price,000 bariatric operations performed between October 2007 and December 2009 the mortality at accredited centers was 0 symptoms 8dpo purchase citalopram 20mg amex. This represents a major opportunity that could be leveraged to improve mortality and major complications treatment quadricep strain order discount citalopram line. If education could be focused around this issue treatment 7th feb buy generic citalopram from india, and staff and surgeons can identify a patient with a major complication who needs advanced care early and arrange transfer, lives would be saved. This would also allow patients to be treated for their primary procedures within their local area and likely expand access. Setting up specific relationships between smaller community practice centers and tertiary care facilities would enable the early recognition and transfer of patients into a more coordinated opportunity for rescue. In addition overwhelming public comment was in favor of maintaining the requirement for accreditation. Part of the data that was presented in favor of abandoning accreditation did not separate out the issue of improvements from laparoscopy versus open cases or case mix (including lower-risk cases like adjustable gastric band) from accreditation [47]. The serious morbidity rate was similar in high-volume accredited and nonaccredited centers, suggesting that the difference may be a failure to rescue patients, which points directly to the structure and process implemented as part of accreditation [48]. A careful analysis by Flum showed an increase in numbers of procedures as well as a decrease in both reoperations and complications in the Medicare population [50]. By the time the cost in patient morbidity and mortality of this new decision can be demonstrated, many patients may have been harmed. It is the responsibility of each program to decide on the value of accreditation and to establish a program that reflects that value. The volume requirements in the first iteration of the quality program did not discriminate between procedure types and counted all procedures as equal. It became clear during the analysis of the volume data that device procedures have very low 30-day complication rates and mortality. In addition, the complications, although occasionally of a critical nature, usually are not. It became clear that it was the stapled procedures (making up the majority of the case volume around the country) that were important to analyze for safe practice. Programs/surgeons are encouraged to enter their data prospectively beginning with their first case as a data collection center. Now that Medicare has made a decision to allow surgeons to operate outside of accreditation, coupled with the lack of preauthorization required, Medicare patients will likely make up many of the early cases by a new center. Centers will be able to get onto the database very early, so that cases can be prospectively collected as they work to establish program structure. As the low-volume data accumulates further refinements in the volume requirement can be made. Putting off high-risk patients and starting with lower-risk patients and procedures with adequate oversight is crucial. The reputation of the surgeons will be a personal brand and since the patients are so socially connected in the digital world, problems with patients or with the program will be publically discussed on the Internet. The impact of this on the ability of a surgeon to grow a great practice depends on having a focus on patient safety and experience with very low complications, readmissions, and reoperations. Volume, in terms of a business model, is problematic and the structure of the program needs to plan for increasing volume increments. Volume, Reliability, and Composite Measures Statistical modeling predicts that outcomes reported by facilities may occur due to chance depending on the volume. For instance, a hospital with an annual volume of 1,000 cases reporting mortality of two in 1,000 patients is probably a better representation of the true risk of death than a small hospital reporting one death in 80 patients. To reduce this statistical "noise" in the data, a technique has been written about and utilized called "reliability adjustment. The overall observed effect is shrunk back toward the mean of the facilities with similar volume (not the overall mean) thereby correcting the observed riskadjusted rate by the volume of the facility. This allows for all hospital volumes within the sample to be assigned a reliability adjustment factor (from 0 to 1. This analytical tool allows different quality "signals" including reliability and risk-adjusted volume, risk-adjusted mortality, and risk-adjusted potentially life-threatening and life-threatening complications to be combined into a single composite measure of quality [52]. The composite measure is unique in that it can predict with reasonable accuracy how a center will perform in the future based on its past performance. Programs and surgeons can measure themselves against their peers around the nation and in their state. While the most important use of data is to provide regular feedback to programs/surgeons for process improvement, the composite measure gives the program a yardstick that allows them to compare their program to others. This can lead to efforts that will improve patient safety using evidence-based risk-adjusted results [13]. The composite measure explained the variability in comparing the rankings of hospitals to their subsequent performance. Patients and payers are looking for value, safety, and a great patient experience of care. Currently, there are some grading systems in use on the Internet that use administrative data. Programs can take a proactive approach by providing higher-quality data (clinical) and risk-adjusted outcomes to the public and payers. Composite measures are the best predictors of quality to use for accreditation Program Process and Structure Each program will need to develop protocols based on the procedures and groups of patients to whom they offer care. If possible, it is helpful to develop a process map so that you can outline each step of the program pathway for patient flow. As you build the program plan, specific protocols, personnel, equipment, and structural items will become apparent. Once the program is developed, you can match the cost of care to each activity allowing you to develop a cost structure based on the actual cost of care. The integrated health team should establish leadership and management of the process aspects of the program. A goal of every program is to demonstrate improved efficacy of longterm follow-up and programmatic structured care. Surgeons need to recognize the importance of this and ensure successful data capture. Although when the first quality program was put in place, the burden of data collection for the community surgeon came as an unwelcome and new burden. Collection of clinical data is required for ongoing maintenance of certification in surgery. The pressure on surgeons regarding collecting data and using it to improve their own outcomes will continue to increase. Data will be used to improve care through quality improvement, enhance or detract from reimbursement, and be increasingly transparent to patients. Surgeons and hospital administration want to ensure that they are investing in quality improvement projects that are based on high-quality data. An independent third-party clinical reviewer who has medical knowledge but no personal stake in the outcomes so that it is unbiased must collect it. In addition, the clinical reviewer must be trained and certified to determine when adverse events have taken place based on strict definitions for the data collection points. Blackstone Two types of data exist and are reported and used by a variety of outside stakeholders: administrative data and clinical data. Currently, administrative data is derived from hospital charts that are processed after discharge by coders. What the provider writes, or does not write in the chart, and all other information in the chart are examined by hospital coding teams that have a goal of maximizing the charges for the episode of care. Some examples are as follows: your patient continues to require oxygen on post-op day one after gastric bypass and you send her for a chest X-ray. This is not a fraudulent practice, but it is picked up by the state in their administrative data as a "900 code" complication. Vigilance in documentation is critical to ensure accurate reporting of administrative data. The surgeon and the program will need to invest significant resources to ensure that the data they are using and submitting for public consumption, whether by payers or the public, is of the highest quality. An early valuable project for the group is to analyze the difference between coding and the clinical record in a selected group of cases and work to coordinate the documentation in the medical record with the clinical course in order to ensure accurate public reporting through the coding by the hospital. Some hospitals have noted significant inaccurate coding because the medical record is not adequate for documentation. This is due to having standardized and strict definitions, impartial third-party bariatric surgery clinical reviewers, and ongoing training. This is a tremendous incentive for surgeons and hospitals to participate in a formal data collection system. The major cost of any collaborative network is the cost of collecting high-quality data. This cost for the most part will have to be paid by the hospital that is being accredited, but the hidden cost is the time for the surgeon to ensure that the data being collected is accurate. In 2013, with maintenance of certification now requiring reporting to a clinical registry, this has become a necessary cost of doing business for the surgeon. In order to get significant resources for the program, many hospital systems will require a business plan. In the contemporary era of surgery, surgeons are expected to work collaboratively with the hospital system to provide effective care to patients. Gaining a commitment from the system to collect high-quality data that allows the team to do continuous quality improvement, compare their results to others, and share best practice through collaboration at the local, state, regional, and national level will be a significant step. There were no characteristics of any patient in whom placement of a filter improved outcomes. Patient safety was shown to improve significantly and there was a cost savings of approximately $2. As a result, the cost savings of this single intervention paid for the administrative costs of the Michigan collaborative program [53]. The impact of process improvement is pivotal not only in terms of improving patient safety, but in decreasing cost of care and improving patient experience of care. It has an additional benefit: it builds the focus and collaboration of the team, even where surgeons are part of different private practices. While the primary goal of safety is paramount, 14 Quality in Bariatric Surgery 177 improving value (quality/cost) is impacted to a large extent by the cost of complications as the major driver of cost. In addition, improvement in patient experience has a direct effect on the bottom line of reimbursement. Increasingly providing value has become an important target for healthcare reform. The surgical treatment of obesity seminars and pathways should be updated as frequently as necessary to establish best practice in care. You may want to have a small subset of the committee meet to review surgeon data (surgeons, mid-levels, and quality team) and then have a more inclusive meeting where aggregate data is reviewed and opportunities for improvement as a group are identified and carried out. There are many avenues through which members of the local program (both surgeons and integrated health members) can seek to improve their knowledge base. It will be important, as surgery becomes part of the continuum of care for the patient with obesity and metabolic disease, that the understanding of the science of obesity and the modalities for management-including an understanding of the pathophysiology of obesity and other modalities of therapy (behavioral and medications)-become part of that knowledge base. In addition, staying current in a rapidly evolving field requires at least annual investment in ongoing medical education. In addition to this base of knowledge in the subject area, an investment in understanding quality itself and the process used to improve it will be key. The work was a sharing of best practice, based on a study done at Stanford Hospital where the adoption of a "readmission bundle" that leveraged "common sense care coordination" of patient education, discharge planning, and preoperative procedures. Fortunately, these investments will pay off for the team as they will improve the experience of care and improve outcomes, all of which will translate into improved value. This will be necessary, as all of the programs of the hospital will be judged in the future 178 R. Blackstone when a health plan, insurer, or employer is contracting and individual programs that bring value will have an influence over that contracting process. Improved quality may also result in higher reimbursement as compared to programs in lower quartiles of quality. Surgeon entering all the data themselves Conclusion Obesity is an epidemic of historic impact. The number of people who qualify for surgical management of obesity and related disease is growing and access to care is gradually improving. In this environment, many who are affected will seek the only durable solution: surgical therapy. Bariatric surgeons have established and embraced the new benchmark of a national culture of safety. Transparency of outcomes will be unavoidable in the future and surgeons/programs will be called upon to provide the data. The data registry is sufficiently mature for programs to begin this process immediately. It is critical that a framework of safety be established as a backdrop against which this growth may occur in a safe way. Metabolic and bariatric surgeons have been at the forefront of efforts to establish safe and effective care. Born of necessity and forged by visionary surgeons and integrated health leadership, they have joined and led the national imperative to reduce cost by reducing variation in surgical procedures and will have a major role to play in providing value as medicine moves on to its next frontier. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. Management and the worker; an account of a research program conducted by the Western Electric Company, Hawthorne Works, Chicago by F.

Before we go any further treatment 8th february generic 40 mg citalopram visa, we should address an important question that may be asked by dietitians not familiar with weight loss surgery medicine 44390 citalopram 40 mg amex. There is a huge (and growing) body of research on strategies for successful weight loss and weight maintenance: Does any of this apply to the weight loss surgery patient However treatment 7th feb bournemouth discount citalopram 20mg, because weight loss surgery patients have needs that set them off from the typical individual who is trying to lose weight symptoms nerve damage cheap 40 mg citalopram with visa, newcomers to the area of bariatric weight loss surgery dietetics should be aware of special considerations during the different phases of the weight loss process before and after surgery shakira medicine purchase citalopram 40mg. The question mark in the maintenance phase is meant to indicate that little research has been done on the nutritional considerations of patients several years out from weight loss surgery jnc 8 medications 40 mg citalopram fast delivery, as well as increasing differences among patients. For instance, we do not yet know whether (or to what degree) metabolic changes that occur immediately following surgery are maintained several years after surgery. To the extent that the physiological profile of bariatric surgery patients remains 129 C. Depends on many factors, such as insurance requirements, program characteristics, and patient readiness. Parrott How different are nutritional considerations from nonsurgical weight loss Some special considerations Unique to weight loss surgery Special considerations Some special considerations To the degree that, several years out, weight loss surgery patients are metabolically "the same" as patients who have not had weight loss surgery, then there is little rationale for treating them any different. What is clear, however, is that weight loss prior to surgery can improve surgical outcomes for many patients. However, this is not recommended for all patients, but rather for higher risk patients. Preparing the patient physiologically for surgery requires more than simply promoting weight loss. Improving specific comorbidities, such as elevated blood glucose, poor oxygen perfusion, and poor healing prior to weight loss surgery, may improve early postoperative recovery (less recovery time with better managed comorbidities. Nutrition Intervention Strategy In light of the above, we provide two different nutrition intervention strategies. The first provides general strategies for the patient to begin a pattern of healthy diet, exercise, and behaviors that will be continued following surgery. The second, which we call a "liver prep diet," provides modifications to the general pre-weight loss surgery diet for use when a shortterm intervention is needed to decrease liver fat and/or total 14 Nutrition Care Across the Weight Loss Surgery Process 131 weight prior to surgery. The diets are not mutually exclusive and may be used in tandem depending on the needs of the patient in preparing for both surgery and their life after surgery. Importance of Medical Nutrition Therapy Medical nutrition therapy-which includes a nutritional evaluation, labs, and education regarding lifestyle change- should be used to provide a patient with tools to appropriately control blood sugars and other targeted comorbidities as well as comply with program-specific weight loss. In some patients, preoperative weight loss may be an onerous task, due to mobility constraints, insulin resistance, and weightpromoting medications. Research indicates that preoperative weight loss with medical nutrition therapy can improve glycemic control and should therefore be utilized in obese patients with diabetes [10]. We should not assume that preoperative patients have good nutritional status or appropriate dietary intake. Additionally, the typical dietary intake of preoperative patients exceeds 50 % of energy intake from fat [12]. Nitrogen balance is severely compromised when dietary energy intake is less than 35 kcal/kg. Adding 100 g of carbohydrate per day decreases nitrogen loss by 40 % in modified protein fasts. All postoperative patients are at risk of developing proteinenergy malnutrition related to decreased oral intake, but presurgery patients on a liver prep diet may be susceptible as well. Prevention of protein malnutrition requires regular assessment of protein intake and counseling regarding ingestion of protein from protein-rich foods and protein supplements. In general, dietary protein should be established first in any diet in proportion to body weight, and then carbohydrates and fats should be added as determined by energy needs [11, 15]. However, even when a very-low-calorie diet is called for, it should not contain less than 45 g carbohydrates daily; otherwise adverse metabolic and emotional effects occur. Substituting one or more daily meals with meal replacements may be appropriate for patients needing to lose weight in preparation for surgery. Preparing the Patient for Lifestyle Changes Weight has been reported as an indicator of decreased liver mass, but may not be the best method (and is certainly not the only method) of evaluating how prepared for surgery or how successful a patient will be postoperatively with bariatric surgery. The main goal of the preoperative phase is to prepare the weight loss surgery patient for the lifestyle changes that are required after surgery. This will mean helping the patients to develop appropriate weight loss expectations, identifying areas in which additional support will be needed, and dispelling misconceptions (knowledge about nutritional lifestyle: what to eat In other words, what can patients reasonably expect within the first postoperative year in terms of weight loss, behaviors, and challenges Often, patients will come to the dietitian with questions that correspond to these key areas. A 10 % weight loss is associated with substantial improvement in risk profiles for diabetes and cardiovascular disease. However, weight loss surgery patients may expect to lose substantially more weight. How much weight the bariatric surgery patient can expect to lose depends on the type of surgical procedure. A slightly dated meta-analysis [20] estimates the following average percent excess weight loss within the first year by type of surgery (95 % confidence intervals are in parentheses): 132 Table 14. First, these are sample averages- individual patient results will almost certainly be different. Assuming a normal distribution for weight loss following surgery, approximately half of the patients can realistically expect to lose less weight-perhaps substantially less. If the numbers are correct, the unfortunate truth is that most patients will not reach their weight loss goal (assuming that is to lose all their excess weight). Notice that none of the averages (and, indeed, none of the 95 % confidence intervals) include 100 % of excess weight loss. So, a key (perhaps the most important) message regarding how much weight a patient can expect to lose is this: weight loss surgery, by itself, is no guarantee of losing all your excess weight. The patient should understand that weight loss surgery may help them reach their goals, but will not do it for them. But, whether they fall in the upper or lower ends of this distribution depends on the patient putting in place a range of lifestyle changes. In the section on the achieving phase, we will review some strategies that the dietitian can use to help the patient identify and make these changes. This highlights an important point for helping the patient to develop realistic and strategic expectations. If the patient understands that his or her body will always be "eager" to regain the lost weight, then they can grasp the fact that achieving and maintaining a healthy weight is something they must work at for the rest of their lives. We will review the healthy lifestyle skills that increase the likelihood of success in the section on achieving phase. The short answer, based on the research, is that you stand a good chance of regaining at least some weight [12, 21]. Whether and how much weight a patient may regain differs by surgical procedure as well as by a number of lifestyle factors. Recent research suggests that as obesity develops, a number of metabolic changes occur, which may not completely reverse when weight is lost. This means, in practical terms, that once a patient has gained a significant amount of weight, their body will always be primed to gain it back. Most, if not all, patients will have at least a vague awareness of why they should exercise. The hurdle is less likely to be their understanding than it is their ability, motivation, or opportunity. For many very heavy patients, it is not simply that they do not want to be physically active-they simply may not be physically able to participate in activities they think of as "exercise. The reality is that weight loss surgery will enable patients to participate in activities they may have found difficult or impossible previously. Patients may be aware that they need to make some kind of behavioral changes but have little understanding of what these changes are, why they need to make them, or strategies for making them. Research indicates that personality disorders [1], disinhibition [22], and a range of maladaptive behaviors [23] of which the patient may be 14 Nutrition Care Across the Weight Loss Surgery Process 135 vaguely aware (if at all) are all associated with lack of success with losing weight. While dietetics professionals can focus on behaviors associated with eating, addressing the deeper psychological and social motivations for eating may fall well outside their scope of knowledge and practice. Adequate hydration can also be assessed via fluid intake and output with patient observation of fluids consumed and urine concentration and frequency. Protein: Obtaining adequate protein is a major concern during the clear liquid phase and clinician should be alert to any protein intolerances or aversions are present before surgery or develop afterward. Patients will need to use supplements of high-quality powdered or liquid protein sipped slowly. Vitamins: Micronutrient supplements are needed to avoid micronutrient deficiencies. Typically, chewable or liquid micronutrient supplements are tolerated well in the first 4 weeks after surgery. Healing: Nutrition to Recover from Surgery Even before the patient has completely recovered from their surgery, dietitians can begin to work with the patient to begin to put into practice topics covered in nutrition counseling prior to surgery and strengthen those concepts and strategies through further education. Indeed, depending on program or insurance requirements, the period shortly after surgery may provide the dietitian with the most intensive patient contact. So, even though the nutritional focus may be somewhat different in this phase compared to the other phases, time spent in nutrition counseling sessions should also focus on strategies the patient will put into practice more intensively in the achieving phase (discussed later in this chapter). During the brief period shortly following surgery, dietary needs and limitations are unique for weight loss surgery patients. Resources for helping to design patient diet and diet progression during this period are available [25]. Additionally, this is the first phase in which the patient will begin to get used to their "new stomach"-discovering what they can and cannot comfortably tolerate. So, although food tolerance is an important issue the patient will face through the first year or so after surgery, we introduce the topic of food tolerance in this phase. The researchers also concluded that "a clear relationship exists between improved food tolerance and gastrointestinal quality of life" [26]. Physical Activity During this period of rapid weight loss, the general exercise goals are to avoid cardiopulmonary complications and preserve lean muscle mass. It may serve as a useful point of departure for developing individualized physical activity plans for weight loss surgery patients. This is a multi-organizational initiative resource that provides a guide for health 1 Available at. In order to prevent unwanted gastrointestinal symptoms (nausea, vomiting, and dumping) and subsequent complications (such as nutritional deficiencies and weight regain), patients who have undergone a bariatric procedure are required to make substantial changes to diet and eating behavior including consuming small portions, avoiding high-fat or sugar-full foods, eating slowly, and chewing food well. Parrott and fitness professionals (sponsored by the American College of Sports Medicine, the American Medical Association, and the American College of Sports Medicine). In one study, "lack of time" was the most commonly selected barrier to physical activity, followed by "too tired" and "pain and discomfort" [27]. So, when designing a physical activity plan for weight loss surgery patients, these common barriers need to be taken into account. Shifting the focus from "something you have to do" to "something your new body allows you to do" may be a key motivational strategy for dietetics professionals. Evaluate and Change Diet Composition to "More Healthy" Focus There are a number of existing resources that, with appropriate changes, can be applied to weight loss surgery patients. These general dietary targets should be modified based on special food source considerations for weight loss surgery patients. Achieving: Creating the New Normal After the patient has fully recovered from surgery, they now begin to put into practice the principles and behaviors to create their new lifestyle. Unfortunately, many weight loss surgery outcome studies do not report the inclusion of dietary interventions or other strategies used to help optimize weight loss outcomes. Yet, research outside of bariatric surgery makes clear that patients can affect these weight loss outcomes by devoting their time and energy toward making lifestyle changes in nutritional, physical, and behavioral health areas. Change should begin in the first year postoperatively with some "practice" lifestyle changes preoperatively in three key areas: nutrition and diet, behaviors, and physical activity. Rather, the goal is to develop healthy diet, exercise, and behavior patterns that will last them the rest of their lives. There are a few modifications to a healthy diet for the general population that can be made to adjust these diets to some special considerations for weight loss surgery patients. We will present some general resources for healthy eating patterns and then provide some guidance on how these healthy diets may be modified to maximize success in the bariatric patient. While research shows that both use of meal replacements and more frequent meals (approximately five times per day) may be associated with weight loss or maintenance of a healthy weight among individuals who have not had weight loss surgery [28], this has not been well researched among patients who struggle with obesity and/or candidates for weight loss surgery. Parrott While more frequent smaller meals and/or snacks may help some patients (by increasing satiety), this may not be appropriate for all patients. For patients who tend to be "grazers" or for whom certain foods may act as triggers and thus predispose the patient to binging episodes [29], the dietetic professional is cautioned to take a highly judicious and individualized approach.

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