Panniculectomy, documentation, reimbursement, and the WOC nurse.

Panniculectomy surgery is a reconstructive procedure performed to remove a panniculus, sometimes referred to as a pannus or abdominal apron. The pannus frequently contributes to a number of health concerns, including chronic wounds. Panniculectomy surgery becomes necessary for many patients who have had massive weight loss as a result of successful bariatric weight-loss surgery. Bariatric weight-loss surgery is one of the fastest growing specialties in America, and therefore, nurses can expect to care for increasing numbers of patients who require this reconstructive procedure. Despite the medical necessity of panniculectomy surgery, barriers to reimbursement exist. An update on the demographics of obesity, nationally and worldwide, are presented, especially as this information relates to the growing interest in panniculectomy surgery following massive weight loss. Bariatric weight-loss surgery and panniculectomy surgery are described and barriers to reimbursement are explained. The importance of wound care documentation in making the case for reimbursement is described, and a sample letter of appeal is provided.

Self-help and long-term behavior therapy for obesity.

The Trevose Behavior Modification Program, a self-help group offering continuing care for obesity, has recently been shown to produce large long-term weight losses. The present study aimed to replicate this finding across different settings and participants, assessing the weight losses and attrition rates of 128 participants in three Trevose program satellite groups that used the same treatment procedures and manual as the central Trevose group. The satellite groups' results closely paralleled those of the Central Group. Mean intent-to-treat weight loss, or final losses recorded for all participants regardless of their treatment termination date, was 13.7 +/- 0.7% of initial body weight (1.8 +/- 0.7 kg). At two years, 43.8% of participants remained in treatment, having lost a mean of 19.0 +/- 0.8% of their body weight (16.2 +/- 1.0 kg); at five years, 23.4% remained, having lost 18.4 +/- 1.1% of body weight (15.6 +/- 1.5 kg). These results demonstrate that the Trevose model of weight control, combining self-help and continuing care, can be extended and disseminated to other settings, with potentially significant public health consequences.

Outcome of biliopancreatic diversion in subjects with Prader-Willi Syndrome.

BACKGROUND: In Prader-Willi Syndrome (PWS), mental retardation and compulsive hyperphagia cause early obesity, the co-morbidities of which lead to short life-expectancy, with death usually occurring in their 20s. Long-term weight loss is mandatory to lengthen the survival; therefore, the lack of compliance in voluntary food restriction requires a surgical malabsorptive approach. METHODS: 15 PWS subjects were submitted to biliopancreatic diversion (BPD) and followed (100%) for a mean period of 8.5 (4-13) years. BPD consists of a distal gastrectomy with a long Roux-en-Y reconstruction which, by delaying the meeting between food and biliopancreatic juices, causes an intestinal malabsorption. Indication for BPD was BMI > 40 or > 35 with metabolic complications. Preoperative mean age was 21 +/- 5 years, mean weight 127 +/- 26 kg, and mean Body Mass Index (BMI, kg/m2) 53 +/- 10. According to Holm's criteria, all of the subjects had a total score > or = 8. IQ assessment was performed in each subject, with a mean score of 72 +/- 10. An arbitrary lifestyle score was given to each subject. RESULTS: No perioperative complications were observed. Percent excess weight loss (%EWL) was 59 +/- 15 at 2 years and 56 +/- 16 at 3 years, and then progressive regain occurred; at 5 years %EWL was 46 +/- 22 and at 10 years 40 +/- 27. Spearman rank test failed to demonstrate any correlation between weight loss at 5 years and patient data, except with lifestyle score (Spearman r = 0.8548, p < .0001). Current mean age is 31 +/- 7 years. CONCLUSION: BPD has to be considered for its value in prolonging and qualitatively improving the PWS patient's life.

Social rank, feeding and winter weight loss in red deer: any evidence of interference competition?

During winter at northern latitudes, large herbivores often exploit patches of concentrated, relatively high quality forage, which may lead to interference competition. The factors affecting success in contests and subsequent dominance rank, such as age and body weight, remain key issues in ungulate behavioural ecology. Maternal effects on offspring body weight are well known, but few studies have investigated if mother's social rank influence offspring rank. Moreover, no study has related dominance rank in ungulates to weight loss during winter. Outcomes of social interactions (n=7,609), feeding time and spatial position in red deer (Cervus elaphus) hinds and calves, and weight loss of calves, were registered from 1981 to 1996 at six winter-feeding sites within the county of Sor-Trondelag in Norway. The level of aggressiveness was higher among calves than among adult hinds, and the factors determining the outcome of contests also differed. The initiator won the majority of interactions (more than 90% in both hinds and calves). Social rank was related to both age and body weight in adult hinds, and related to body weight and mother rank in calves. The relationship between feeding time and rank was non-linear. Feeding time was correlated with rank only among high ranked hinds, while there was no such relationship among low ranked hinds or calves. There was no correlation between winter weight loss and social rank in calves. Our study therefore underlines that, although frequent aggression is observed at artificial feeding sites of northern herbivores, this is not necessarily sufficient to give rise to interference competition.

Determinants of long-term satisfaction after vertical banded gastroplasty.

BACKGROUND: The long-term usefulness of vertical banded gastroplasty (VBG) in achieving weight loss is controversial, and adverse effects related to the procedure may attenuate patient satisfaction. Our objective was to evaluate patient satisfaction, and to identify parameters that are related to such satisfaction, 3 to10 years after VBG. METHODS: All consecutive patients who underwent VBG in one surgical ward were invited for a follow-up study 3 to 10 years after surgery. Questions relating to symptoms and quality of life were evaluated in a personal interview using a structured questionnaire. RESULTS: Of the 122 patients who underwent VBG from 1986 to 1992, 75 patients were located and agreed to participate in the follow-up study. The average time since surgery was 5.4 +/- 1.8 years. The average weight loss was 24.9 +/- 12.4%, representing an excess body-weight loss of 58.6 +/- 30.4%. Overall, 65% of the patients were satisfied with the results of surgery while 19% expressed dissatisfaction. Significant improvement was seen in respiratory difficulties, ability to perform physical exercise, and mental status. Successful weight loss and the frequency of respiratory difficulties were the only independent parameters associated with patient satisfaction. Although vomiting, gastroesophageal reflux and difficulty in swallowing occurred in over two-thirds of the patients, their presence was not correlated with patient dissatisfaction. CONCLUSION: Despite the presence of a multitude of adverse effects, the majority of our patients were satisfied with the long-term results of VBG. Successful weight loss and improvement in respiratory difficulties were the major determinants of patient satisfaction.

Pancreatin enhanced erosion of and macromolecule release from 2,2-bis(2-oxazoline)-linked poly(epsilon-caprolactone).

The degradation and erosion of solvent cast films and injection molded bars prepared from poly(epsilon-caprolactone) (PCL) and 2,2'-bis(2-oxazoline) linked poly(epsilon-caprolactone) (PCL-O) were evaluated in simulated gastric fluid (SGF) (pH 1.2, pepsin present) and in simulated intestinal fluid (SIF) (pH 7.5, pancreatin present). After incubation of the polymer films (10 mg) and bars (70 mg) in the medium, the resulting decrease in molecular weight (degradation) was determined by size exclusion chromatography and the weight loss of the preparations was measured. In addition, the effect of pancreatin on FITC-dextran (MW 4400) release from PCL and PCL-O microparticles, prepared by w/o/w double emulsion technique, was studied. No degradation or weight loss was observed for either PCL or PCL-O films in SGF (12 h incubation, 37 degrees C). When compared to PBS pH 7.4, pancreatin hardly enhanced the weight loss of PCL films and bars. In contrast, pancreatin enhanced substantially erosion of PCL-O films and bars. Unlike PCL preparations, the PCL-O preparations showed surface erosion in SIF. Pancreatin increased considerably FITC-dextran release from both PCL and PCL-O microparticles. In conclusion, the present results demonstrate the enzyme sensitivity of the novel PCL-O polymer. In addition, the results show that pancreatin present in intestinal fluid may substantially affect drug release from PCL based preparations.

Obesity: surgical options.

Conservative treatment has been shown in long-term studies to be ineffective in morbid obesity. Surgical treatments break down into restrictive, malabsorptive, combined restrictive and malabsorptive or motility-reducing procedures. Laparascopic implantation of an adjustable gastric band is an efficient restrictive measure for treating the majority of patients with this condition. The adjustable gastric band enables weight loss and food intake to be adapted to the individual patient's need. Eighty percent to 90% of these patients can expect to lose 55-70% of their excess weight. Vertical banded gastroplasty is losing ground among the restrictive options. Preliminary experiences are encouraging but the long term results are disappointing when assessed by the standard criteria. Gastric bypass is gaining ground in Europe and a standard procedure in USA. This operation is estimated to give 70-80% excess weight loss and provide better quality of life than restrictive procedures. The biliopancreatic diversion with duodenal switch combines a sleeve gastrectomy with a duodenoileal switch to achieve maximum weight loss. Consistent excess weight loss between 70 and 80% is achieved with acceptable decreased long-term nutritional complications. The laparoscopic approach to this procedure has successfully created a surgical technique with optimum benefit and minimal morbidity, especially in the super obese patient. Intra-gastric stimulation is the least invasive surgical procedure at present. However, the excess weight loss is lowest with this method at only 32% in the first 2 years after the operation. Provided safety recommendations are observed, laparoscopic operations for obesity are fairly low-risk. The mortality rate in centres with experienced staff is less than 0.3%. Surgical treatment for obesity has proved that it is the best and most effective means of preventing the life-threatening complications and serious degenerative problems associated with morbid obesity. There is no one operation that is effective for all patients.

Human exposure to endocrine disrupters: consequences of gastroplasty on plasma concentration of toxic pollutants.

BACKGROUND: Body weight loss occurring after a hypoenergetic diet or a gastroplasty could be followed by an increase in blood concentration of potentially toxic pollutants that can interfere with the hormonal system (endocrine disrupters). DESIGN: Thirty obese individuals recruited for gastroplasty were compared before and after treatment with 45 normal-weight people. MEASUREMENTS: Blood samples were analyzed for DDT, DDE, HCB and PCBs no. 28, 52, 101, 118, 138, 153 and 180, by gas chromatography-mass spectrometry. RESULTS: The results indicate clearly that body weight loss occurring after gastroplasty increases plasma concentration of lipophilic pollutants. CONCLUSION: Gastroplasty increases plasma concentration of organochlorine pesticides and PCBs, which could be a risk factor of endocrine disruption. Future longitudinal research will have to determine if the advantages of body weight loss are reduced by this potentially harmful effect.