Manasi Kakade - Academia.edu (original) (raw)

Papers by Manasi Kakade

Journal of Gastrointestinal Surgery

The American surgeon, 2012

Marginal ulcer is a significant complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Mo... more Marginal ulcer is a significant complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Most marginal ulcers resolve with medical management, but nonhealing ulcers may require revision of the gastrojejunostomy, a procedure with significant morbidity and mortality. Traditionally, surgical therapy for refractory peptic ulcers includes a vagotomy. The current study evaluates the effectiveness of thoracoscopic truncal vagotomy (TTV) in the management of refractory marginal ulcers. All patients at two institutions with an intractable marginal ulcer after LRYGB treated with TTV between 2003 and 2010 were reviewed. Data were collected from chart review and telephone interview. Seventeen patients (mean age, 39 ± 13 years; 16 females) were diagnosed with marginal ulceration a median of 18 months after LRYGB and proceeded to TTV at a mean of 39 ± 43 weeks (range, 1 to 114 weeks) after the diagnosis. The median operative time was 89 ± 65 minutes (range, 45 to 318 minutes). Four patients...

Western Journal of Emergency Medicine, 2011

African-Americans are more likely than Caucasians to access healthcare through the emergency depa... more African-Americans are more likely than Caucasians to access healthcare through the emergency department (ED); however, the reasons behind this pattern are unclear. The objective is to investigate the effect of race, insurance, socioeconomic status, and perceived health on the preference for ED use. Methods: This is a prospective study at a tertiary care ED from June to July 2009. Patients were surveyed to capture demographics, healthcare utilization, and baseline health status. The primary outcome of interest was patient-reported routine place of healthcare. Other outcomes included frequency of ED visits in the previous 6 months, barriers to primary care and patient perception of health using select questions from the Medical Outcomes Study Short Form 36 (SF-36). Results: Two hundred and ninety-two patients completed the survey of whom 58% were African-American and 44% were uninsured. African-Americans were equally likely to report 3 or more visits to the ED, but more likely to state a preference for the ED for their usual place of care (24% vs. 13%, p < 0.01). No significant differences between groups were found for barriers to primary care, including insurance. African-Americans less often reported comorbidities or hospitalization within the previous 6 months (23% vs. 34%, p = 0.04). On logistic regression modeling, African-Americans were more than 2 times as likely to select the ED as their usual place of healthcare (OR 2.24, 95% CI 1.22-4.08). Conclusion: African-Americans, independent of health insurance, are more likely than Caucasians to designate the ED as their routine place of healthcare. [

Obesity surgery, Jan 11, 2014

Obesity poses serious health consequences, and bariatric surgery remains the most effective and d... more Obesity poses serious health consequences, and bariatric surgery remains the most effective and durable treatment. The goal of this study was to identify the association of race and socioeconomic characteristics with clinical outcomes following laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective review of all patients who underwent LRYGB between 2004 and 2010 was conducted. Outcomes analyzed included percent excess weight loss (%EWL), percent weight loss (%WL), change in body mass index (ΔBMI), and improvement or remission of obesity-associated medical conditions. In total, 663 patients met inclusion criteria with 170 (25.6 %) African Americans and 493 (74.4 %) European Americans. When compared to European Americans, the African American group included significantly more women and had a significantly higher preoperative BMI and lower socioeconomic status. In adjusted analyses, African Americans had significantly lower %EWL, %WL, and ΔBMI than the European Americans at 1-,...

Surgical Endoscopy, 2011

The aim of the present study was to investigate the influence of a supplement enriched in ω-3 fat... more The aim of the present study was to investigate the influence of a supplement enriched in ω-3 fatty acids on immune responses and plateletleukocyte complex formation in patients undergoing cardiac surgery. Patients in the supplement group (n = 7) took a supplement enriched in ω-3 fatty acids (Impact®) in addition to a hospital diet for five successive days before surgery; those in the control group (n = 7) took only hospital diet and did not take Impact®. Blood samples in both groups were collected at same time points. Before surgery, samples were collected five days before surgery, at the start of supplementation (baseline), and the end of supplementation (postoperative day (POD)-0). After surgery, samples were collected on POD-1 and POD-7. The expression of human leukocyte antigen (HLA)-DR, the ratio of CD4-/CD8-positive cells, the production of interferon (IFN)-γ by CD4-positive cells, plasma levels of cytokines, and leukocyte-platelet aggregates were measured. Before surgery (POD-0), the supplement caused significant increases in HLA-DR expression, CD4/CD8 ratio, and plasma levels of IFN-γ; these levels were significantly higher compared to those in the control group (P  0.05, respectively). After surgery (POD-1), all values dramatically decreased in comparison with those of POD-0; however, the values in the supplement group were significantly higher compared to their respective markers in the control group (P  0.05, respectively). Significant differences of HLA-DR expression and CD4/CD8 ratio persisted through POD-7. Before surgery (POD-0), plasma levels of interleukin (IL)-10 in the supplement group decreased significantly compared with those in the control group (P  0.05). After surgery (POD-1), plasma levels of IL-10 in both the control and supplement groups increased; these levels in the supplement group were significantly lower than those in the control group (P  0.05). Significant decreases in the percentage of leukocyte-platelet aggregates were found after supplementation; the difference between the supplement and the control groups was found on POD-0 and POD-1 (P  0.05, respectively). In conclusion, the dietary supplement increased HLA-DR expression, the CD4/CD8 ratio, and the production of IFN-γ by CD4-positive cells; conversely, the levels of IL-10 and the formation of leukocyte-platelet aggregates before and after surgery were suppressed. These beneficial effects may decrease the incidence of complications after surgery.

Surgical Endoscopy, 2012

Bariatric surgery remains the most effective treatment for morbid obesity, and laparoscopic Roux-... more Bariatric surgery remains the most effective treatment for morbid obesity, and laparoscopic Roux-en-Y gastric bypass (LRYGB) continues to be the preferred operation. However, data for long-term outcomes are lacking. Our goal was to determine the long-term clinical outcomes after LRYGB. Retrospective review of a prospectively maintained database was conducted on all patients who underwent LRYGB from 2001-2006. Only patients who had postoperative clinic visits both at ≤2 and ≥5 years were included. Data collected included patient demographics and postoperative clinical outcomes, including percent excess weight loss (%EWL), complications, and improvement or resolution of preoperative comorbidities (type 2 diabetes mellitus, hypertension, obstructive sleep apnea, and hyperlipidemia). Data were analyzed by using SAS (version 9.2) and SPSS (version 16) statistical software. There were 770 patients who underwent LRYGB at UAB from 2001-2006. Of these, 172 patients met inclusion criteria (148 women and 24 men) with a median age of 41 years and median body mass index of 46 kg/m(2). Median short- and long-term follow-up was 12 and 75 months, respectively. Mean %EWL was 69% for short-term and 65% for long-term follow-up (P = 0.0032). Of 172 patients, 66 experienced 81 complications at a median of 26 months after operation. The improvement or resolution of comorbidities was maintained in the long-term, and there was no statistically significant difference compared with improvement or resolution in the short-term. Although there was a statistically significant difference in %EWL between short- and long-term follow-up, both arms showed a clinically relevant %EWL (69 and 65%) and both were statistically significant compared with preoperative values. The improvement or resolution of comorbidities achieved with LRYGB was maintained in long-term follow-up. Thus, LRYGB resulted in significant improvement in clinical outcomes that were durable in the long term.

Surgery for Obesity and Related Diseases, 2011

1.2) and diarrhea (4.0 vs. 2.7). There is no different in the excess weight loss and mean BMI at ... more 1.2) and diarrhea (4.0 vs. 2.7). There is no different in the excess weight loss and mean BMI at 5 years between the two groups. Conclusion: Both LRYGB and LMGB are effective treatments for morbid obesity but may develop different gastrointestinal symptoms. This difference may be applied in the choice of gastric bypass procedures.

Journal of the American College of Surgeons, 2011

Protein supplements are routinely used after a laparoscopic gastric bypass (LGB). The aim of this... more Protein supplements are routinely used after a laparoscopic gastric bypass (LGB). The aim of this study was to evaluate the impact of an amino acid supplement on glucose homeostasis and hormonal and inflammatory markers after LGB. Thirty patients undergoing LGB were randomized to receive or not 24 g of an oral supplement containing a leucine metabolite, glutamine, and arginine twice daily. Changes in weight, glucose, insulin, C-peptide, insulin sensitivity, interleukin (IL) 6, C-reactive protein (CRP), leptin, insulin-like growth factor (IGF) 1, ghrelin, and incretins were assessed preoperatively and 2 weeks and 8 weeks postoperatively. Thirty patients (96.7% female, age 46.9 ± 8.4 years, body mass index 43.3 ± 4.1 kg/m(2)) were randomized. The experimental (n = 14) and control (n = 16) groups were not significantly different at baseline. Weight loss was similar for the 2 groups. Fasting glucose decreased significantly at 2 and 8 weeks compared with base line (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) with no difference between the experimental and control groups (p = 0.8), but insulin and calculated insulin sensitivity, which were similar at baseline, became significantly worse in the experimental group 8 weeks after surgery (p = 0.02 for insulin; p = 0.04 for the homeostasis model assessment of insulin resistance). CRP and IL-6, which were similar at baseline, were found to be significantly higher at 8 weeks in the experimental group (p = 0.018 and p = 0.05, respectively). Leptin and IGF-1 levels decreased significantly from baseline at 2 and 8 weeks (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), but there was no difference between the 2 groups. No significant changes in GLP-1, ghrelin, or gastric inhibitory polypeptide were noticed after 8 weeks. An amino acid supplement had no effect on the early postoperative incretins after LGB. It may have a negative influence on glucose kinetics and degree of inflammation. Future studies are needed to clarify these effects.

Journal of Gastrointestinal Surgery, 2010

Background Pancreatic necrosis is associated with high morbidity and mortality. The Atlanta Class... more Background Pancreatic necrosis is associated with high morbidity and mortality. The Atlanta Classification underwent proposed revisions in 2007 to better categorize acute pancreatitis. Methods From 1999 to 2008, patients with pancreatic necrosis treated with surgical debridement were analyzed. Computed tomography (CT) images were independently reviewed to classify of pancreatic collections according to the revised Atlanta classification. Results Seventy-three patients were categorized as infected extrapancreatic necrosis (40%), sterile extrapancreatic necrosis (29%), infected pancreatic necrosis (15%), sterile pancreatic necrosis (11%), or post-necrotic collection (5%). Mortality was 14%, and morbidity was 55%. Debridement with external drainage or open packing was associated with higher mortality than cystgastrostomy (p=0.03). Atlanta Classification was not associated with operative procedure or mortality. Degree of chronic disease, demonstrated by albumin level, and infection were associated with longer stay (p<0.05). Conclusion Type of necrosis by the revised Atlanta Classification was not associated with outcomes or type of operation. Debridement by cystgastrostomy was associated with lower mortality rates than external drainage or open packing. Length of stay was increased in patients with evidence of chronic disease, infection, and postoperative complications. Necrotizing pancreatitis continues to be associated with significant morbidity and mortality and should undergo aggressive treatment at tertiary care centers.

Gastroenterology, 2009

Background: Acute pancreatitis with necrosis associated with high rates of morbidity and mortalit... more Background: Acute pancreatitis with necrosis associated with high rates of morbidity and mortality, especially in those undergoing operative debridement. The Atlanta Classification developed in 1992, was recently revised in 2007, to better categorize acute pancreatitis improved imaging techniques. Aims: To utilize the 2007 revision of the Atlanta Classification to assess outcomes, morbidity and mortality in patients undergoing debridement of pancreatic necrosis. Methods: From 1999-2008, patients with pancreatic necrosis who were treated with surgical debridement were included in the analysis. Computed tomography (CT) images were independently reviewed to classify of pancreatic collections according to the revised Atlanta classification. Results: Seventy-three patients (54 males, 74%) with fluid collections were categorized as follows: infected walled off extrapancreatic necrosis (38%), sterile walled off extrapancreatic necrosis (26%), infected walled off pancreatic necrosis (16%), sterile walled off pancreatic necrosis (13%) and post-necrotic pancreatic collection (7%). Fortyone (56%) patients underwent endoscopic drainage prior to surgical consultation, 21 (52%) of which had infected necrosis at the time of operation (p = 0.012). In-hospital mortality was 14% (range 5-107 days). Those undergoing open debridement with external drainage (21, 24%) and open packing (5, 40%) had a significantly higher mortality than those undergoing cystgastrostomy with pancreatic debridement (46, 6.7%) (p = 0.03). Type of collection was not associated with operative procedure or mortality rate. Preoperative albumin levels < 1.5 mg/dl (p < 0.01), fungal (p < 0.05) and bacterial (p < 0.05) infections were associated with longer length of stay. Thirty-one (35%) patients experiencing post-operative complications had a significantly longer hospital stay (mean 36 days vs. 11 days, p < 0.01). Conclusion: With today's referral pattern at high volume centers, a high percentage of patients undergo endoscopic drainage prior to surgery. Cystgastrostomy and pancreatic debridement is associated with lower mortality rates than external drainage or open packing procedures. Collection type according to the revised Atlanta Classification was not associated with type of debridement morbidity rates. Length of stay was increased in patients with poor nutrition, infected necrosis and in those experiencing complications. Acute necrotizing pancreatitis continues to be associated with significant in-hospital morbidity and mortality rates, and should undergo aggressive treatment at tertiary care centers.

Journal of Gastrointestinal Surgery, 2009

Background The effect of preoperative pneumatic dilation or botulinum toxin injection on outcomes... more Background The effect of preoperative pneumatic dilation or botulinum toxin injection on outcomes after laparoscopic Heller myotomy (LHM) for achalasia is unclear. We compared outcomes in patients with and without multiple preoperative endoscopic interventions. Methods This cohort study categorized achalasia patients undergoing first-time LHM by the number of preoperative endoscopic interventions: zero or one intervention vs. two or more interventions. Outcomes of interest included surgical failure (defined as the need for re-intervention), gastrointestinal symptoms, and health-related quality of life. Logistic regression modeling was performed to determine the independent effect of multiple preoperative endoscopic interventions on the likelihood of surgical failure. Results One hundred thirty-four patients were included; 88 (66%) had zero to one preoperative intervention, and 46 (34%) had multiple (more than one) interventions. The incidence of surgical failure was 7% in the zero to one intervention group and 28% in the more than one intervention group (p<0.01). Greater improvements in gastrointestinal symptoms and healthrelated quality of life were seen in the zero to one intervention group. On logistic regression modeling, the likelihood of surgical failure was significantly higher in the more than one intervention group (odds ratio=5.1, 95% confidence interval 1.6-15.8, p=0.005). Conclusions Multiple endoscopic treatments are associated with poorer outcomes and should be limited to achalasia patients who fail surgical therapy.