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Query: UMLS:C0017168 (gastroesophageal reflux disease)
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Trochanteric bedsores are a serious condition because of the danger of osteoarthritis of the coxofemoral joint, which is a source of septicemia, and also because of the difficulty of covering them with skin owing to the mobility of the bone and the absence of skin laxity in the area. The authors suggest a new technique of closure after local preparation providing a clean "surgical" defect. They use a groin island flap raised in the Japanese "retrograde" manner (i.e. laterally to medially). This technique is of course the fruit of the authors' experience of the microsurgery. The distal portion of the flap is drawn, corresponding to the size of the defect (round shape). The proximal portion contains the vessels surrounded by subcutaneous and protected by a de-epithelialized triangle of skin with a distal base. The flap is passed through a subcutaneous tunnel between the femoral trigone and the trochanteric area to be covered. The donor site is closed by approximation of the edges after they have been undermined. The authors discuss the others possible surgical managements: 1) local flaps (transposition flap, Z plasties, are unsuitable; 2) the double S-rotation flap had the drawback of creating a large undermined area and leaving a scar on the trochanteric region; 3) simple GER-type muscle flaps are not advisable because the transposed muscle always indergoes a fibrous involution so that the graft provides insufficient protection; 4) myocutaneous flaps, and especially fascia lata myocutaneous flap, offer better indication, because of muscle only acts as a vascular pedicle for the skin flap. The only drawback is the relative defect resulting from raising the flap. The authors conclude that the groin island flap offers the following advantages; a skin material which is more than efficient; ideal vascularization; perfect corverage without undue tension of the trochanteric surface; an interesting training for the plastic surgeon performing microsurgical reconstruction.
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PMID:[Inguinal island flap for covering trochanteric bedsores]. 629 39

Severe obesity is associated with multiple comorbidities and is refractory to dietary management with or without behavioral or drug therapies. There are a number of surgical procedures for the treatment of morbid obesity, including purely gastric restrictive, a combination of malabsorption and gastric restriction or primary malabsorption. The purely gastric restrictive procedures, including vertical banded gastroplasty and laparoscopic adjustable silicone gastric banding, do not provide adequate weight loss. African-American patients do especially poorly after the banding procedure with the loss of only 11% of excess weight in one study. Gastric bypass (GBP) is associated with the loss of 66% of excess weight at 1 to 2 years after surgery, 60% at 5 years and 50% at 10 years. For unknown reasons, African-American patients lose significantly less weight than Caucasians after GBP. There is a risk of micronutrient deficiencies after GBP, including iron deficiency anemia in menstruating women, vitamin B12, and calcium deficiencies. Prophylactic supplementation of these nutrients is necessary. Recurrent vomiting after bariatric surgery may be associated with a severe polyneuropathy and must be aggressively treated with endoscopic dilatation before this complication is allowed to develop. The malabsorptive procedures include the partial biliopancreatic bypass (BPD) and BPD with duodenal switch (BPD/DS). The BPD appears to cause severe protein-calorie malnutrition in American patients; the BPD/DS may be associated with less malnutrition. Weight loss failure after GBP does not respond to tightening a dilated gastrojejunal stoma or reducing the size of the gastric pouch. These patients may require conversion to a malabsorptive distal GBP, similar to the BPD. However, because of the risk of severe protein-calorie malnutrition and calcium deficiency BPD should be reserved for patients with severe obesity comorbidity. The risk of death following bariatric surgery is between 1% and 2% in most series but is significantly higher in patients with respiratory insufficiency of obesity. In most patients, surgically induced weight loss will correct hypertension, type II diabetes mellitus, sleep apnea, obesity hypoventilation syndrome, gastroesophageal reflux, venous stasis disease, urinary incontinence, female sexual hormone dysfunction, pseudotumor cerebri, degenerative joint disease pains, as well as improved self-image and employability.
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PMID:Bariatric surgery for severe obesity. 1185 Dec 1

The prevalence of obesity is increasing worldwide. In the United States, in 1999, 27% of adults had a body mass index >30 kg/m(2), almost double the prevalence of 20 years earlier. The estimated mortality from obesity-related diseases in the United States is approximately 300,000 annually and growing. In the future, mortality related to obesity is expected to exceed that of smoking. Numerous diseases are caused or made worse by obesity. These include type 2 diabetes; hypertension; dyslipidemia; ischemic heart disease; stroke; obstructive sleep apnea; asthma; nonalcoholic steatohepatitis; gastroesophageal reflux disease; degenerative joint disease of the back, hips, knees, and feet; infertility and polycystic ovary syndrome; various malignancies; and depression. Type 2 diabetes is perhaps the most visible obesity-related problem. Present in at least 14 million Americans, it leads to serious complications and premature death. It is largely caused by obesity, and is generally cured by weight loss. The quality of life of the obese is markedly reduced, and the costs to health care systems are great. Preventive programs have yet to affect the rising prevalence. An effective solution is needed.
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PMID:The extent of the problem of obesity. 1252 43

A 1991 National Institutes of Health Consensus Conference concluded that severely obese adults could be eligible for bariatric surgery if they had a body mass index (BMI) > or =35 kg/m(2) with or > or =40 kg/m(2) without obesity comorbidity. It was thought at that time that there were inadequate data to support bariatric surgery in severely obese adolescents. An estimated 25% of children in the United States are obese, a number that has doubled over a 30-year period. Very little information has been published on the subject of obesity surgery in adolescents. Therefore we reviewed our 20-year database on bariatric surgery in adolescents. Severely obese adolescents, ranging from 12 to less than 18 years of age, were considered eligible for bariatric surgery according to the National Institutes of Health adult criteria. Gastroplasty was the procedure of choice in the initial 3 years of the study followed by gastric bypass, which was found to be significantly more effective for weight loss in adults. Distal gastric bypass (D-GBP) was used in extremely obese patients (BMI > or =60 kg/m(2)) before 1992 and long-limb gastric bypass (LL-GBP) was used for superobese patients (BMI > or =50 kg/m(2)) after 1992. Laparoscopic gastric bypass was used after 2000. Thirty-three adolescents (27 white, 6 black; 19 females, 14 males) underwent the following bariatric operations between 1981 and June 2001: horizontal gastroplasty in one, vertical banded gastroplasty in two, standard gastric bypass in 17 (2 laparoscopic), LL-GBP in 10, and D-GBP in three. Mean BMI was 52 +/- 11 kg/m(2) (range 38 to 91 kg/m(2)), and mean age was 16 +/- 1 years (range 12.4 to 17.9 years). Preoperative comorbid conditions included the following: type II diabetes mellitus in two patients, hypertension in 11, pseudotumor cerebri in three, gastroesophageal reflux in five, sleep apnea in six, urinary incontinence in two, polycystic ovary syndrome in one, asthma in one, and degenerative joint disease in 11. There were no operative deaths or anastomotic leaks. Early complications included pulmonary embolism in one patient, major wound infection in one, minor wound infections in four, stomal stenoses (endoscopically dilated) in three, and marginal ulcers (medically treated) in four. Late complications included small bowel obstruction in one and incisional hernias in six patients. There were two late sudden deaths (2 years and 6 years postoperatively), but these were unlikely to have been caused by the bariatric surgical procedure. Revision procedures included one D-GBP to gastric bypass for malnutrition and one gastric bypass to LL-GBP for inadequate weight loss. Regain of most or all of the lost weight was seen in five patients at 5 to 10 years after surgery; however, significant weight loss was maintained in the remaining patients for up to 14 years after surgery. Comorbid conditions resolved at 1 year with the exception of hypertension in two patients, gastroesophageal reflux in two, and degenerative joint disease in seven. Self-image was greatly enhanced; eight patients have married and have children, five patients have completed college, and one patient is currently in college. Severe obesity is increasing rapidly in adolescents and is associated with significant comorbidity and social stigmatization. Bariatric surgery in adolescents is safe and is associated with significant weight loss, correction of obesity comorbidity, and improved self-image and socialization. These data strongly support obesity surgery for those unfortunate individuals who may have difficulty obtaining insurance coverage based on the 1991 National Institutes of Health Consensus Conference statement.
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PMID:Bariatric surgery for severely obese adolescents. 1255 91

Some physicians have considered age > or = 50 years as a relative contraindication for bariatric surgery. Recent reports demonstrated the safety and efficacy of Roux-en-Y gastric bypass (RYGB) in this patient subgroup, but comparisons between laparoscopic technique (LT) and open technique (OT) have not been reported. A review of 52 patients > or = 50 years old who underwent RYGB between January 1999 and April 2002 was conducted. Demographics, operative data, and outcomes were assessed. Preoperative and postoperative renal and hepatic functions, electrolytes, anemia studies, and hematology results were compared. Patients were divided into LT and OT groups and operative outcomes were compared. The percentage of excess body weight loss was 66 +/- 4 per cent at mean follow-up of 12 months. Blood samples drawn after a mean of 8 +/- 2 months revealed no postoperative metabolic alterations. RYGB resulted in a reduction of the number of patients with hyperglycemia, hypertension, degenerative joint disease, gastroesophageal reflux disease, and continuous positive airway pressure-dependent sleep apnea (P < 0.05). The LT resulted in fewer intensive care unit admissions and shorter length of stay. RYGB is safe and well tolerated in patients > or = 50 years resulting in no renal, hepatic, or electrolytic alterations. Weight loss and control of obesity-related comorbidities are satisfactory. The LT results in fewer intensive care unit admissions and shorter length of stay than the OT.
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PMID:Gastric bypass for morbid obesity in patients 50 years or older: is laparoscopic technique safer? 1288 14

Obesity continues to plague our society in epidemic proportions. Surgery for morbid obesity is considered by many as the most effective therapy for this complex disorder. Today, multiple surgical procedures for the treatment of obesity are available. As with most procedures, there are benefits and risks associated with open and laparoscopic gastric bypass surgery, as well as with laparoscopic adjustable gastric banding and partial biliopancreatic bypass with a duodenal switch. The risks and complications associated with bariatric surgery may be serious and in some cases life threatening. However, surgery for obesity has shown remarkable results in helping patients to achieve significant long-term weight control. In addition, it is associated with improvement and often resolution of co-morbid conditions, including type 2 diabetes mellitus, systemic hypertension, obesity hypoventilation, sleep apnea, venous stasis disease, pseudotumor cerebri, polycystic ovary syndrome, complications of pregnancy and delivery, gastroesophageal reflux disease, stress urinary incontinence, degenerative joint disease, and non-alcoholic steatohepatitis.
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PMID:Surgical management of obesity: a review of the evidence relating to the health benefits and risks. 1564 1

The purpose of this cross-sectional study was to examine the number and type of active medical conditions among psychiatric patients treated by an assertive community treatment (ACT) team in an urban setting. Psychiatric hospitalization admission and discharge summaries of 70 patients were reviewed, and case managers on the treatment team were interviewed. Patients had a median of three active medical conditions. Osteoarthritis, hypertension, viral Hepatitis C infection, gastroesophageal reflux disease (GERD), and reactive airway disease were the most common active medical illnesses. The majority of patients were cigarette smokers and were diagnosed with alcohol or illicit substance use disorders, which were associated with viral hepatitis C infection and reactive airway disease in this patient population.
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PMID:Active medical conditions among patients on an assertive community treatment team. 1640 83

The purpose of this study was to examine the prevalence, risk factors, and consequences of obesity in borderline patients 6 years after an index admission for psychiatric reasons. Two hundred and sixty-four borderline patients who met Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncy, 1989) and Diagnostic and Statistical Manual of Mental Disorders (3rd ed. ref.) (DSM-III-R; APA, 1987) criteria for BPD were interviewed concerning their body mass index (BMI) and related medical problems. Seventy-four of the 264 borderline patients at 6-year follow up were obese, having a BMI > or = 30 kg/m2. They were significantly more likely than the nonobese patients to report suffering from diabetes, hypertension, osteoarthritis, chronic back pain, carpal tunnel syndrome, urinary incontinence, gastroesophageal reflux disorder, gallstones, and asthma. Four significant risk factors were found: chronic PTSD, lack of exercise, a family history of obesity, and a recent history of psychotropic polypharmacy. These results suggest that obesity is common among heavily treated borderline patients and is associated with a number of chronic medical disorders.
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PMID:Obesity and obesity-related illnesses in borderline patients. 1656 80

Obesity is epidemic in the modern world. It is becoming increasingly clear that obesity is a major cause of cardiovascular disease, diabetes, and renal disease, as well as a host of other comorbidities. There are at present no generally effective long-term medical therapies for obesity. Surgical therapy for morbid obesity is not only effective in producing long-term weight loss but is also effective in ameliorating or resolving several of the most significant complications of obesity, including diabetes, hypertension, dyslipidemia, sleep apnea, gastroesophageal reflux disease, degenerative joint disease, venous stasis, pseudotumor cerebri, nonalcoholic steatohepatitis, urinary incontinence, fertility problems, and others. The degree of benefit and the rates of morbidity and mortality of the various surgical procedures vary according to the procedure.
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PMID:The effect of obesity surgery on obesity comorbidity. 1661 33

More than half of the European population are overweight (body mass index (BMI) > 25 and < 30 kg/m2) and up to 30% are obese (BMI > or = 30 kg/m2). Being overweight and obesity are becoming endemic, particularly because of increasing nourishment and a decrease in physical exercise. Insulin resistance, type 2 diabetes, dyslipidemia, hypertension, cholelithiasis, certain forms of cancer, steatosis hepatis, gastroesophageal reflux, obstructive sleep apnea, degenerative joint disease, gout, lower back pain, and polycystic ovary syndrome are all associated with overweight and obesity. The endemic extent of overweight and obesity with its associated comorbidities has led to the development of therapies aimed at weight loss. The long-term effects of diet, exercise, and medical therapy on weight are relatively poor. With respect to durable weight reduction, bariatric surgery is the most effective long-term treatment for obesity with the greatest chances for amelioration and even resolution of obesity-associated complications. Recent evidence shows that bariatric surgery for severe obesity is associated with decreased overall mortality. However, serious complications can occur and therefore a careful selection of patients is of utmost importance. Bariatric surgery should at least be considered for all patients with a BMI of more than 40 kg/m2 and for those with a BMI of more than 35 kg/m2 with concomitant obesity-related conditions after failure of conventional treatment. The importance of weight loss and results of conventional treatment will be discussed first. Currently used operative treatments for obesity and their effectiveness and complications are described. Proposed criteria for bariatric surgery are given. Also, some attention is devoted to more basic insights that bariatric surgery has provided. Finally we deal with unsolved questions and future directions for research.
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PMID:Surgical treatment of obesity. 1823 Aug 19


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