Criteria for Patient Selection and Multidisciplinary Evaluation and Treatment of the Weight Loss Surgery Patient

Objective: To provide evidence‐based guidelines for patient selection and to recommend the medical and nutritional aspects of multidisciplinary care required to minimize perioperative and postoperative risks in patients with severe obesity who undergo weight loss surgery (WLS). Research Methods and Procedures: Members of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS in general and medical and nutritional care in particular. Pertinent abstracts and literature were reviewed for references. Multiple searches were carried out for various aspects of multidisciplinary care published between 1980 and 2004. A total of 3000 abstracts were identified; 242 were reviewed in detail. Results: We recommended multidisciplinary screening of WLS patients to ensure appropriate selection; preoperative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity‐related diseases associated with increased risk for complications or mortality; preoperative weight loss and cessation of smoking; perioperative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); preoperative and postoperative education and counseling by a registered dietitian; and a well‐defined postsurgical diet progression. Discussion: Obesity‐related diseases are often undiagnosed before WLS, putting patients at increased risk for complications and/or early mortality. Multidisciplinary assessment and care to minimize short‐ and long‐term risks include: comprehensive medical screening; appropriate pre‐, peri‐, and postoperative preparation; collaboration with multiple patient care disciplines (e.g., anesthesiology, pulmonary medicine, cardiology, and psychology); and long‐term nutrition education/counseling.     

The ethics of cesarean section on maternal request: a feminist critique of the American College of Obstetricians and Gynecologists' position on patient-choice surgery

In recent years, the medical establishment has been speaking in favor of women's autonomy in childbirth by advocating cesarean delivery on maternal request (CDMR). This paper offers to look at the ethical dimension of CDMR through a feminist critique of the medicalization of childbirth and its influence on present-day medical ethics. I claim that the medicalization of childbirth reflects a sexist bias with regard to conceptions of the body and needs to be used with caution when applied to women's reproductive health. I then use this perspective to critically analyze the position of the American College of Obstetricians and Gynecologists (ACOG) on the ethics of decision-making in patient-choice surgery. I claim that informed consent cannot be meaningfully exercised unless women are made aware of the sexist underpinnings of the medical model of childbirth and its influence on the ethical reasoning of the American College of Obstetricians and Gynecologists. I also express concern about the effects of normalizing patient-choice cesarean sections on the choices available to pregnant women using as examples the institutional rules on mandatory cesarean sections for women with a previous cesarean delivery or breech presentation. I conclude with a call for more research into the real cost of convenience in CDMR, particularly as our increasingly strained publicly funded healthcare system would greatly benefit from the de-medicalization of normal body functions rather than an increased dependence on costly surgical technology.     

Copper,selenium and zinc levels after bariatric surgery in patients recommended to take multivitamin-mineral supplementation

BackgroundBariatric surgery is widely performed to improve obesity-related disorders, but can lead to nutrient deficiencies. In this study we examined serum trace element concentrations before and after bariatric surgery.MethodsWe obtained serum trace element concentrations by inductively coupled plasma-mass spectrometry (ICP-MS) method in 437 patients (82% women, median preoperative body-mass index 46.7 kg/m² [interquartile range 42–51]) undergoing either gastric banding (22.7%), sleeve gastrectomy (20.1%), or gastric bypass (57.3%) procedures. Trace element data were available for patients preoperatively (n = 44); and 3 (n = 208), 6 (n = 174), 12 (n = 122), 18 (n = 39), 24 (n = 44) and 36 months (n = 14) post-operatively. All patients were recommended to take a multivitamin-mineral supplement after surgery.ResultsCopper deficiency was found in 2% of patients before surgery; and after surgery deficiency rates ranged from 0 to 5% with no significant change in median concentrations during follow-up (p = 0.68). Selenium deficiency was reported in 2% of patients before surgery; and after surgery deficiency rates ranged from 11 to 15% with a near-significant change in median concentrations (p = 0.056). Zinc deficiency was reported in 7% before surgery; and after surgery deficiency rates ranged from 7 to 15% with no significant change in median concentrations (p = 0.39).ConclusionsIn bariatric surgery patients recommended to take multivitamin-mineral supplements, serum copper, zinc and selenium concentrations were mostly stable during the first years after bariatric surgery. There was a possible tendency for selenium concentrations to decline during the early postoperative period.     

Cardiac surgery in 260 octogenarians: a case series

Background

The elderly undergo cardiac surgery more and more frequently, often present multiple comorbidities, assume chronic therapies, and present a unique physiology. Aim of our study was to analyze the experience of a referral cardiac surgery center with all types of cardiac surgery interventions performed in patients ≥80 years old over a six years’ period.

Methods

A retrospective observational study performed in a university hospital. 260 patients were included in the study (3.5% of the patients undergoing cardiac surgery in the study period).

Results

Mean age was 82 ± 1.8 years. Eighty-five percent of patients underwent elective surgery, 15% unplanned surgery and 4.2% redo surgery. Intervention for aortic valve pathology and coronary artery bypass grafting were performed in 51% and 46% of the patients, respectively. Interventions involving the mitral valve were the 26% of the total, those on the tricuspid valve were 13% and those on the ascending aortic arch the 9.6%. Postoperative low output syndrome was identified in 44 patients (17%). Mortality was 3.9% and most of the patients (91%) were discharged from hospital in good clinical conditions. Hospital mortality was lower in planned vs unplanned surgery: 3.8% vs 14% respectively. Chronic obstructive pulmonary disease (OR 9.106, CI 2.275 – 36.450) was the unique independent predictor of mortality.

Conclusions

Clinicians should be aware that cardiac surgery can be safely performed at all ages, that risk stratification is mandatory and that hemodynamic treatment to avoid complications is expected.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2253-15-15) contains supplementary material, which is available to authorized users.     

周六手术在医院运行管理中的价值和意义

目的 通过开展周六手术,缩短病人平均术前等待日及平均住院日。在保证医疗质量的前提下,达到提高效率,增加产能的目的。方法 在多部门协作的基础上,开展周六手术,改变原有人力配置方式和手术流程,以配合周六手术的进行。结果 手术流程再造后,与之前同期相比术前等待日缩短25.00%, 月平均手术台次增加12.35%, 病人平均住院日降低9.22%。结论 开展周六手术,能缩短患者平均住院日和术前等待日,为患者节约宝贵的时间和金钱,在一定程度上解决了患者看病难、看病贵的问题,提高了医院的工作效率。     

小型猪体外循环下心脏手术的麻醉

目的研究医学手术实验用小型猪体外循环下心脏手术的麻醉管理及麻醉效果。方法实验用小型猪34例,分为CPB下停跳组手术组（停跳组,18例）及CPB下并行手术组（并行组,16例）,行自体心包片三尖瓣置换术。记录实验中麻醉药物及血管活性药用量,基础麻醉、麻醉维持及麻醉苏醒时间,术后3天、一周存活状况等,并评价基础麻醉及全麻效果。结果 34例均在全麻下顺利完成手术,各期血流动力学平稳,仅停跳组一例术后3天内死亡,存活率97.1%,麻醉效果良好。结论合理的麻醉药物与血管活性药物的联合应用,仔细的临床观察与正确而迅速的处理是小型猪体外循环下心脏手术麻醉的关键。     

系列硬质胆囊镜的研发

中国医生提出的硬镜微创保胆取石（息肉）新概念,对于治疗胆囊结石和胆囊息肉取得较好的临床效果。目前国内外没有专门针对胆囊病手术所设计的内镜设备。专门为胆囊病手术的发展而研发的系列硬质胆囊镜及其配套附件,已经获得多项国家专利授权,并成功在国家认定的药物临床试验机构中应用手术120多例。     

糖原磷酸化酶BB在心脏直视手术后心肌损伤中的判定价值

目的:探讨糖原磷酸化酶BB对心脏直视手术后心肌损伤的判定价值.方法:108例行心脏瓣膜置换手术患者,分别于围术期多个时点取桡动脉血,测定血清糖原磷酸化酶BB、心肌肌钙蛋白I(cTnI)、肌酸磷酸激酶同工酶(CKMB)的水平,并检测心肌细胞凋亡程度.结果:血清糖原磷酸化酶BB于体外循环主动脉开放后最早达峰值,其峰值与cT...     

Statins Do Not Reduce Atrial Fibrillation After Cardiac Valvular Surgery: A Single Centre Observational Study

Introduction

Statins may theoretically reduce postoperative atrial fibrillation (AF) in patients after cardiac valvular surgery due to preservation of endothelial function and anti-ischaemic, anti-inflammatory and anti-remodelling effects.

Methods

Two hundred seventy-two patients who underwent cardiac workup and subsequently cardiac valvular surgery without AF and concomitant coronary artery bypass grafting (CABG) at our hospital were selected. Preoperative drug use and postoperative AF were recorded. AF was defined as any episode of AF longer than 10 s. In addition, results from echocardiography and blood samples were retrieved.

Results

Baseline characteristics were as follows: mean age was 65 ± 11 years, 142 (52%) patients were male, 189 (70%) had undergone aortic valve surgery and the mean left ventricular ejection fraction was 57 ± 12%. Statins were used by 79 patients (29%). Statin users, more often, had a prior percutaneous coronary intervention (25% vs 9%, p < 0.001) or CABG (24% vs 4%, p < 0.001), diabetes mellitus (22% vs 5%, p < 0.001) and more often used β-blockers (51% vs 24%, p < 0.001). Patients in the non-statin group more often had surgery on more than one valve (10% vs 3%, p = 0.043) and had a higher cholesterol level (222 ± 48 vs 190 ± 43 mg/dl, p < 0.001). Postoperative AF occurred in 54% (43/79) of the patients with and in 55% (106/193) of the patients without statins (p = 0.941). There was also no difference in the timing of onset of AF or duration of hospital stay.

Conclusion

In this observational study, statin use was not associated with a reduced incidence of AF in patients after cardiac valvular surgery.     

胃转流术后远端肠黏膜形态及生长因子表达的变化

目的：探讨胃转流术后远端肠管黏膜的适应性变化及生长因子的表达情况。方法：将8周龄的Wistar大鼠随机分为对照组、假手术组和胃转流术组,术后8周取吻合口远端肠管行常规病理切片检查,测量肠黏膜厚度和绒毛高度,采用免疫荧光法检测肠粘膜中表皮生长因子（EGF）和胰岛素样生长因子-1（IGF—1）的表达。结果：胃转流术组黏膜厚度（672±39与500±31um,P〈0．01）和绒毛高度（445±19与342±15um,P〈0．01）均显著高于假手术组（P〈0．01）,而对照组和假手术组间均无显著差异。与假手术组比较,胃转流术组肠粘膜中EGF和IGF-1的表达显著升高（P〈0．01）,而对照组和假手术组间无显著差异。结论：胃转流术后远端肠管粘膜发生适应性增生,同时伴随着EGF和IGF—1表达水平的升高。