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H Spivak

Publications and source records attributed to H Spivak.

At least 19 recordsLinked to original sources
PubMed2003

The Lap-Band system in the United States: one surgeon's experience with 271 patients.

BACKGROUND: The LAP-BAND system is considered an important bariatric surgery procedure in many countries and is rapidly gaining acceptance in the United States. Outcomes data emerging in the United States parallel European and Australian experience. The purpose of this study was to examine our experience with this procedure in the United States. METHODS: Between November 2000 and September 2002, 271 patients (236 women) underwent LAP-BAND system placement. The mean age of patients was 40 years (18-63); preoperative mean body weight was 125 kg (93-192). Surgeries were performed using either the two-step (pars flaccida to perigastric) or the pars flaccida technique with three (1.1%) conversions to open procedures. Mean operative time was 42 min (23-86); average hospital stay was 1 day (4 h to 7 days). RESULTS: The mean body mass index (BMI) decreased from a baseline of 45.3 kg/m(2) (35-68) to 41.9 ( n = 178), 39.5 ( n = 101), 38.4 (n = 81), 36.5 (n = 72), 35.9 (n = 51), and 35.1 (n = 21) kg/m(2) at 3, 6, 9, 12, 18, and 24 months, respectively, after surgery. Mean excess weight loss was 40% at 12 months and 43% at 24 months. As patients lost weight, comorbid conditions improved. No deaths occurred, no bands had to be removed, and postoperative complications were minor: 20 (7.3%) access port problems, 18 (6.6%) gastric pouch dilatations, five (1.8%) gastric slippages, and five (1.8%) stoma obstructions. All were managed conservatively or repaired laparoscopically using the original bands. Additional complications included four cases of pneumonia and one case of pulmonary embolism. One patient required reoperation because of trocar site bleeding. CONCLUSIONS: The LAP-BAND system is a safe and effective bariatric procedure leading to considerable weight loss and reduction in comorbidity.

Adolescent↗
PubMed2003

Prospective study of 250 patients undergoing laparoscopic gastric banding using the two-step technique: a technique to prevent postoperative slippage.

BACKGROUND: The use of LAP-BAND adjustable gastric banding (LAGB) has gained tremendous popularity, but creation of the retrogastric tunnel is a considerable challenge, especially in the surgeon's early experience, and is associated with up to 10% band slippage and occasional gastric perforation. The two-step technique involves a crural dissection toward the angle of His through a pars flaccida approach. The technique facilitates passage of the band with no extensive posterior gastric wall dissection. METHODS: A prospective study investigated 250 patients (207 women and 43 men) who underwent LAGB from January 1999 to May 2002 using a two-step dissection technique. The mean age of these patients was 37 years (range, 18-58 years). Their mean preoperative weight was 120 kg (range, 90-169 kg), and their mean body mass index was 44 kg/m2 (range, 36-68 kg/m2). RESULTS: All the procedures except two were completed laparoscopically, and there were no deaths. The mean operative time was 61 min (range, 35-150 min), and the mean hospital stay was 1.2 days (range, 1-5 days). At 3 years, the mean body mass index had decreased from 44 kg/m2 to means of 39.9, 37.3, 34.4, 32.4, and 31.7 kg/m2 at 3, 6, 12, 24, and 36 months, respectively. The mean excess weight loss was 42.1% at 1 year, 51.4% at 2 years, and 55.5% at 3 years. There were four band slippages (1.6%), no band erosion, and no major morbidity. CONCLUSIONS: The use of LAGB with the two-step technique is technically simple, avoids intimate posterior gastric wall dissection, and facilitates tight posterior band support. It therefore is associated with only minimal perioperative complications and a low slippage rate.

Adolescent↗
PubMed2001

Laparoscopic gastric banding with Lap-Band for morbid obesity: two-step technique may improve outcome.

BACKGROUND: Laparoscopic placement of an adjustable gastric band is an attractive alternative for patients who can benefit from a restrictive bariatric procedure. Creation of the retrogastric tunnel (RGT) may, however, be a considerable challenge early in the surgeon's learning curve. Recent reports described up to 10% band slippage and occasional gastric perforation associated with RGT. The two-step (TS) technique involves a crural dissection towards the angle of His through a gastrohepatic ligament approach. It facilitates passage of the band's tubing posteriorly with no wide posterior gastric wall dissection. PATIENTS AND METHODS: Prospective data were registered for the 109 patients (92 females, 17 males) who underwent laparoscopic adjustable gastric banding from December 1998 to May 2000. In 11 patients the standard RGT approach was used, and in 98, the TS technique. The two groups were demographically similar. Mean age was 37 years (18-59); mean preoperative weight was 120 kg (90-165). RESULTS: All procedures were completed laparoscopically. The mean operative time was 59 minutes (31-150) and the mean hospital stay 1.2 days (1-5). Complications in the TS group were gastric wall hematoma in one patient, 3 days of intubation postoperatively in one patient, damage to a band demonstrated in a postoperative contrast study in one patient, and a port-site hernia in one patient. There was no band slippage in the TS group. Among the 11 patients undergoing RGT, there was band slippage in three (27%), immediately postoperatively in one and after 3 and 11 months in the other two. In a mean follow-up of 7 months (1-18), similar weight loss was found in both groups. The mean BMI decreased from 44 kg/m2 (36-61) preoperatively to 40, 38, 36, 34 kg/m2 at 1, 3, 6 and 9 months respectively. 52 patients required band adjustment; of these, 12 required two adjustments. CONCLUSION: Our experience with both the RGT and TS techniques indicates that the latter may offer better results, particularly in the early experience period. It is recommended that in their initial experience with the adjustable band, surgeons should become familiar with this approach.

Adolescent↗
PubMed2000

Laparoscopy: searching for the proper insufflation gas.

BACKGROUND: Although many aspects of laparoscopic surgery have been determined, the question of which insufflation gas is the best arises repeatedly. The aim of this study was to review the findings on the major gases used today in order to provide information and guidelines for the laparoscopic surgeon. METHODS: We reviewed the literature for clinical and laboratory studies on the currently used laparoscopic insufflation gases: carbon dioxide (CO(2)), nitrous oxide (N(2)O), helium (He), air, nitrogen (N(2)), and argon (Ar). The following parameters were evaluated: acid-base changes, hemodynamic and respiratory sequelae, hepatic and renal blood flow changes, increase in intracranial pressure, outcome of venous emboli, and port-site tumor growth. RESULTS: The major advantage of CO(2) is its rapid dissolution in the event of venous emboli. Hemodynamic and acid-base changes with CO(2) insufflation usually are mild and clinically negligible for most patients. Although N(2)O is advantageous for procedures requiring local/regional anesthesia, it does not suppress combustion. Findings show that Ar may have unwanted hemodynamic effects, especially on hepatic blood flow. There are almost no hemodynamic or acid-base sequelae with the use of He, air, and N(2), but they dissolve slowly and carry a potential risk of lethal venous emboli. CONCLUSIONS: Clearly, CO(2) maintains its role as the primary insufflation gas in laparoscopy, but N(2)O has a role in some cases of depressed pulmonary function or in local/regional anesthesia cases. Other gases have no significant advantage over CO(2) or N(2)O and should be used only in protocol studies. The relation of port-site metastasis to a specific type of gas requires further research.

Air↗
PubMed2000

Structured triacylglycerol emulsion, containing both medium- and long-chain fatty acids, in long-term home parenteral nutrition: a double-blind randomized cross-over study.

Structured lipid emulsion, an innovative approach in which both medium-chain and long-chain fatty acids are esterified to the same glycerol backbone, has been recently shown to be a safe and efficient way of providing energy to patients requiring parenteral nutrition. As yet, no assessment has been made of its safety and effect on liver functions during long-term treatment. Twenty-two home parenteral nutrition patients with Crohn's disease or short bowel syndrome were enrolled in a double-blind randomized, cross-over study. Twenty patients who completed the study were treated for 4 wk with a structured lipid emulsion and for 4 wk with long-chain triacylglycerol emulsion. Determined every 1 or 2 wk were blood pressure, body weight, respiratory rate, blood count, liver functions, albumin, transferrin, plasma lipids, free fatty acids (FFAs), and, at the end of each treatment period (weeks 4 and 8), plasma dicarboxylic acids and 3-OH-fatty acids. No differences were observed between the groups or within the groups between the two treatments with respect to either clinical safety and adverse event occurrence or laboratory assessments. Plasma dicarboxylic acids and 3-OH-fatty acids were similar and within normal range. No alteration of liver function occurred in any of the patients treated with the structured lipid emulsion, whereas two of the patients receiving long-chain triaclyglycerol emulsion developed abnormal liver function, which resolved after switching to the structured lipid emulsion. In conclusion, structured triacylyglycerols containing both medium- and long-chain fatty acids appear to be safe and well tolerated on a long-term basis in patients on home parenteral nutrition, and it may be associated with possible reduction in liver dysfunction.

Adolescent↗
PubMed2000

Pathogenesis and current management of gastrooesophageal-reflux-related asthma.

In the past decade the use of proton pump inhibitors on the one hand, and an aggressive surgical approach on the other hand have revolutionised the treatment of gastro-oesophageal reflux disease (GORD). Many studies have suggested that the successful management of GORD results in improvement of the symptoms of asthma which coexist in many of these patients. In this paper we review the pathogenesis and the medical and surgical treatment of GOR-related asthma. Both anti-reflux operations and anti-acid medications improve GORD and GOR-related asthma. Although anti-reflux surgery is superior to H2 blockers, there are not sufficient data to evaluate proton pump inhibitors compared with operation in controlling the symptoms of asthma.

Asthma↗
PubMed1999

Laparoscopic surgery of the gastroesophageal junction.

Incompetence of the lower esophageal sphincter mechanism leads to gastroesophageal reflux (GER), which is the most common indication for surgery of the gastroesophageal junction. Evaluation, diagnosis, and the modern surgical treatment of GER are discussed. Evaluation of patients with severe heartburn include upper endoscopy to evaluate the general condition of the esophagus, stomach, and duodenum; an upper gastrointestinal contrast study for a complete anatomic view of the esophagus and stomach; esophageal manometry to evaluate the function of the esophagus; 24-hour pH monitoring to determine esophageal acid exposure; and a gastric emptying study selectively to determine the presence of a motility disorder. These studies most often prove the diagnosis of gastroesophageal reflux, hiatal hernia, Barrett's esophagus, peptic esophageal stricture, paraesophageal hernia, or achalasia. The laparoscopic approach to treatments for these include Nissen fundoplication, Toupet fundoplication, Collis gastroplasty with fundoplication, modified Heller myotomy, esophageal diverticulectomy, and revisional operations. These procedures are described in detail. The results of these operations indicate that they are safe and effective and should be considered the new gold standard for correction of gastroesophageal pathology. Laparoscopic surgery has revolutionized many procedures traditionally performed through a laparotomy. Although they are technically more difficult and require a significant amount of time and practice for the surgeon to become proficient, it is becoming apparent that for functional surgery of the gastroesophageal junction laparoscopy is the access of choice.

Endoscopy, Digestive System↗
PubMed1999

Laparoscopic extraperitoneal inguinal hernia repair with spinal anesthesia and nitrous oxide insufflation.

BACKGROUND: Laparoscopic repair of inguinal hernia is traditionally performed under general anesthesia mainly because of the adverse effects that carbon dioxide pneumoperitoneum has on awake patients. Since a mandatory use of general anesthesia for all hernia repairs is questionable, the feasibility of laparoscopic extraperitoneal herniorraphy using spinal anesthesia combined with nitrous oxide insufflation was investigated. METHODS: Over a 4-month period, February to May 1998, we performed 35 consecutive total extraperitoneal inguinal hernia procedures (24 unilateral, 11 bilateral) using spinal anesthesia and nitrous oxide extraperitoneal gas. Data on operative findings, self-reported operative and postoperative pain and discomfort (visual analog pain scale), procedure-related hemodynamics, and complications were collected prospectively. RESULTS: All 35 procedures were completed laparoscopically without the need to convert to general anesthesia. Mean operative time was 39 +/- 7 min for unilateral hernia and 65 +/- 10 min for bilateral hernia. Incidental peritoneal tears occurred in 22 patients (63%) resulting in nitrous oxide pneumoperitoneum, which was well tolerated. The patients remained hemodynamically stable throughout the procedure, and operative conditions and visibility were excellent. Complications at a mean of 4 months after the procedure included seven uninfected seromas (20%), three patients with transient testicular pain, and one (3%) recurrence. CONCLUSIONS: Laparoscopic total extraperitoneal hernia repair can be safely and comfortably performed using spinal anesthesia with extraperitoneal nitrous oxide insufflation gas. This method provides a good alternative to general anesthesia.

Aged↗
PubMed1998

The use of bipolar cautery, laparosonic coagulating shears, and vascular clips for hemostasis of small and medium-sized vessels.

Advanced laparoscopic surgery requires a reliable method of hemostasis. In order to determine the efficacy of common hemostatic devices, we tested bipolar electrosurgery (BPES), laparosonic coagulating shears (LCS), and vascular clips (VC) on arteries of various sizes to compare the strength of hemostasis against elevated intraarterial pressure. The procedures were performed on a porcine model through a laparotomy. Segments of visceral arteries were isolated and cannulated with an angiocatheter that was linked to a pressure monitor. After hemostasis with the tested instrument and division of the vessel, the intraarterial pressure was elevated by infusion of saline solution through the angiocatheter. The pressure was recorded when bleeding occurred through the cut end of the vessel or when the pressure reached 300 mm Hg. All three devices were effective in maintaining hemostasis on small (diameter, 0.25-0.5 mm) and medium-sized arteries (diameter, 2-3.5 mm) with a success rate ranging between 75% and 100% (p = n.s.). Practice and technical finesse were required with the use of the LCS and BPES before excellent results could be obtained. The LCS has an advantage over BPES because it allows the surgeon to perform hemostasis and division simultaneously, thus keeping the operating field clean and avoiding instrument adhesion to the tissue.

Animals↗
PubMed1998

Performance of Massachusetts HMOs in providing Pap smear and sexually transmitted disease screening to adolescent females.

PURPOSE: To describe the extent to which health maintenance organizations (HMOs) provide preventive health services to female adolescent enrollees. METHODS: All Massachusetts HMOs were asked to provide 1992 Papanicolaou (Pap) smear, gonorrhea, chlamydia, syphilis, and human immunodeficiency virus test rates for adolescents from medical records and claims data. The rates were compared with criterion standards and national utilization data from the National Survey of Family Growth. Seven of 14 Massachusetts HMOs agreed to provide data for female members aged 15-21 years on the Pap smear rate (n = 34,415) and sexually transmitted disease (STD) test rate (n = 33,701). RESULTS: Papanicolaou smear rates for females in the HMOs ranged from 5% of 15-year-olds to 45% of 21-year-olds during 1992. Test rates for chlamydia and gonorrhea ranged from 2% and 3%, respectively, for 15-year-olds to 9% and 10% for 21-year-olds. Among 15-19-year-old females, only 18% received a Pap smear, and only 11% received an STD test through their HMO during 1992, despite professional guidelines recommending that all of the estimated 53% of sexually active females age 15-19 years should receive both Pap smears and STD tests. Among 18-21-year-old females, only 37% had had a Pap smear through their HMO during 1992, despite professional guidelines recommending Pap smears for all women age 18 years and over. CONCLUSIONS: Efforts are needed within HMOs to ensure that STD screening, Pap smears, and other health screening services are provided for sexually active adolescent enrollees.

Adolescent↗
PubMed1998

Management of pancreatic pseudocysts.

BACKGROUND: Operative internal drainage has been standard treatment for chronic unresolved pancreatic pseudocysts (PPs). Recently, percutaneous external drainage (PED) has become the primary mode of treatment at many medical centers. STUDY DESIGN: A retrospective chart review was performed of 96 patients with PPs who were managed between 1987 and 1996. Longterm followup information was obtained by telephone and mail questionnaire. RESULTS: Twenty-seven patients underwent computed tomographic (CT)-guided PED. PP resolution occurred in 17 patients. Clinical deterioration or secondary infection mandated urgent pancreatic debridement in 7 (26%) patients and cystgastrostomy in 2 (7%) patients. There was one hospital death in this group. Thirty-two patients underwent cystgastrostomy or cystjejunostomy (n = 21), distal pancreatectomy (n = 8), pancreatic debridement and external drainage (n = 2), or cystectomy (n = 1). Two (6%) patients required postoperative pancreatic debridement for failure of resolution and peritonitis and two patients underwent PED of abscess. There was one hospital death in the expectantly managed group of 37 patients. Median followup of 3 years (range, 0.5-9.3 years) in 66 patients revealed that 6, 3, and 4 patients of PED, surgery, and expectantly managed groups, respectively, had radiologic evidence of recurrent PPs. CONCLUSIONS: Operative management for PPs appears to be superior to CT-guided PED. Although the later was often successful, it required major salvage procedures in one third of the patients. An expectant management protocol may be suitable for selected patients.

Abscess↗
PubMed1997

Short-term effectiveness of anticipatory guidance to reduce early childhood risks for subsequent violence.

OBJECTIVE: To determine whether newly developed anticipatory guidance materials designed to teach the use of time-outs and the importance of reductions in childhood television viewing would be recalled by parents and if their use would result in changes in self-reported parental behavior. SUBJECTS AND SETTING: A total of 559 parents of children aged 14 months to 6 years recruited at the time of routine child health maintenance visits at 2 managed care pediatric departments in eastern Massachusetts. METHODS: In-person parent interviews were conducted in the waiting room prior to office visits, with follow-up telephone calls 2 to 3 weeks after the visit. Two groups of families were enrolled: a control group who received usual anticipatory guidance and an intervention group who received written materials. Intervention group providers were trained to include study topics during the office visit and to introduce the written materials. RESULTS: Provider training and the provision of written materials increased the parents' specific recall of anticipatory guidance of at least 2 to 3 weeks following the office visit. This effect was specific to the areas of intervention and did not carry over to other commonly used topics of anticipatory guidance. Among parents who had never used a time-out prior to the office visit, there was a significant increase in the use of time-outs. Parents who received anticipatory guidance regarding the link between exposure to television violence and subsequent violence in children were somewhat more likely to report reductions in weekend television viewing than were parents in the control group, although this change was not statistically significant. CONCLUSIONS: Certain parenting behaviors have been associated with subsequent violence. Brief, inexpensive anticipatory guidance in relevant areas, provided in the context of routine health supervision visits, appears to result in favorable short-term changes in parenting practices.

Child↗
PubMed1997

Acute colonic diverticulitis in the young.

BACKGROUND: Colonic diverticulitis in the young has been considered to have a virulent course, high morbidity, and high operative rate. As a result, elective resection of the involved colonic segment after the first clinical episode has been the usual practice. PURPOSE: This study presents our experience with acute diverticulitis in the young. METHODS: In the last nine years, 63 patients younger than 45 years were treated for acute diverticulitis at our institution. A retrospective review was performed to determine the clinical course and outcome of these patients. RESULTS: Clinical presentations, radiographic tests, operative findings, and pathology results revealed that 57 patients had a pericolonic contained disease (Hinchey State I). Two patients had a large pelvic abscess (Hinchey Stage II), and four patients had a diffuse peritonitis (Hinchey Stage III). Forty-one patients (65 percent) were successfully treated medically with antibiotics and bowel rest. Of 22 patients (35 percent) who underwent emergent operations, 12 patients' diseases had been erroneously diagnosed preoperatively (9 "appendicitis"). CONCLUSION: Diverticulitis at a young age does not have a specific aggressive nature. Although, it is associated with a high rate of emergency operations, many of these are performed for a mistaken diagnosis. The recommendation for routine elective resection following the first episode of diverticulitis should be reassessed.

Acute Disease↗