Release in vitro of adipsin, vascular cell adhesion molecule 1, angiotensin 1-converting enzyme, and soluble tumor necrosis factor receptor 2 by human omental adipose tissue as well as by the nonfat cells and adipocytes

The relative release in vitro of adipsin, vascular cell adhesion molecule (VCAM) 1, angiotensin 1-converting enzyme (ACE), and soluble tumor necrosis factor alpha receptor 2 (sTNFR2) by explants of human omental and subcutaneous adipose tissue as well as the nonfat cell fractions and adipocytes from morbidly obese gastric bypass women was compared with that by tissue from obese abdominoplasty patients. Release of VCAM-1 and ACE by omental adipose tissue explants was 220% and 80% greater, respectively, over 48 hours of incubation than that by subcutaneous adipose tissue explants. However, this difference was not seen when release by adipocytes derived from omental fat was compared with that by adipocytes from subcutaneous fat. The release of adipsin and sTNFR2 by omental adipose tissue explants did not differ from that by subcutaneous tissue adipose tissue. The release of adipsin by tissue explants over 48 hours was 100-fold greater than that of VCAM-1, ACE, or sTNFR2. Most of the release of all 4 adipokines was due to the nonfat cells because adipsin release by adipocytes was only 13% of that by the nonfat cells derived from the same amount of adipose tissue, whereas ACE release by adipocytes was 7% and release of VCAM-1 as well as sTNFR2 by adipocytes was 4% or less of that by nonfat cells. The total release in vitro of ACE and sTNFR2, but not that of adipsin or VCAM-1, was enhanced in adipose tissue explants from morbidly obese women as compared with those by explants derived from obese women. We conclude that although human adipose tissue explants release appreciable amounts of adipsin and far smaller amounts of VCAM-1, ACE, and sTNFR2 in vitro, more than 87% of the release is due to the nonfat cells present in adipose tissue. Furthermore, the enhanced release of VCAM-1 and ACE seen in omental adipose tissue explants as compared with explants of subcutaneous adipose tissue is due to release by nonfat cells.

Unemployment rates and trauma admissions

In this article, we tested the hypothesis that the number and demographic characteristics of admissions to our trauma center were related to unemployment rates. The correlation study was conducted at The American College of Surgeons-verified level I trauma center in our area (New Orleans, Louisiana). It included all trauma admissions. Monthly unemployment rate data from our area were obtained from the Bureau of Labor Statistics. The hospital trauma registry supplied trauma emergency room admissions and demographic data. Mean daily trauma admissions were calculated for each month. Pearson correlations were used for statistical analysis. Over 24,000 trauma admissions occurred over a six-year period. Unemployment rates correlated with penetrating trauma admissions (r = 0.50; p < 0.001). Interestingly, unemployment rates inversely correlated with total trauma admissions (r = -0.73; p < 0.001), blunt trauma admissions (r = -0.81; p < 0.001), and ratio of blunt-to-penetrating trauma admissions (r = -0.82; p < 0.001). Higher percentage of male patients (r = 0.66; p < 0.001), percentage of African-American patients (r = 0.53; p < 0.001), and mortality (r = 0.56; p < 0.001) correlated positively with higher unemployment rates. We concluded that as unemployment rates decrease, emergency room penetrating trauma admissions decrease, while total and blunt trauma admissions increase. As the socioeconomic status (measured by unemployment rates) of the community changes, so do the demographic make-up and mortality of the trauma population. Our findings suggest that during times of economic hardships, certain population groups are at higher risk for trauma. Prevention should be aimed accordingly.

Regulation of adiponectin release and demonstration of adiponectin mRNA as well as release by the non-fat cells of human omental adipose tissue

OBJECTIVE

Adiponectin is an adipokine produced by adipose tissue. The present studies examined the in vitro release of adiponectin by human omental adipose tissue explants as well as the mRNA content of freshly isolated non-fat cells and adipocytes plus cultured preadipocytes and adipocytes derived from omental fat.

RESULTS

The release of adiponectin was reduced while that of interleukin-8 (IL-8) was enhanced in tissue explants from morbidly obese women. The release of adiponectin was also reduced by one-third in explants from morbidly obese diabetic women while that of IL-8 was unaffected by diabetes. The release of adiponectin was enhanced by insulin and by inhibition of endogenous tumor necrosis factor (TNFalpha) using etancercept. Adiponectin was released in appreciable amounts by the undigested matrix obtained by collagenase digestion of adipose tissue. The release of adiponectin by non-fat cells (matrix+SV cells) was comparable to that by the adipocytes derived from the same amount of tissue while the adiponectin mRNA content of the pooled matrix and SV cell fractions was 40% of that in intact tissue. The adiponectin mRNA content was 48-fold greater in isolated adipocytes than in non-fat cells derived from adipose tissue. In contrast, the amount of adiponectin mRNA in vitro differentiated omental adipocytes was 1 x l0(6)-fold greater than that in cultured preadipocytes while that of leptin was 3 x 10(4)-fold greater.

CONCLUSION

Adiponectin mRNA is present in the non-fat cells of freshly isolated adipose tissue and release by the non-fat cells derived from a gram of adipose tissue is comparable to that by adipocytes isolated from the same amount of tissue. While leptin is only released by mature adipocytes, adiponectin is released by both the non-fat cells and the fat cells derived from human omental adipose tissue.

Initial trocar placement and abdominal insufflation in laparoscopic bariatric surgery

INTRODUCTION

Initial trocar placement and abdominal insufflation in laparoscopic bariatric surgery can be challenging for the novice. One technique is the use of an optical viewing trocar without prior abdominal insufflation. This investigation tests the hypothesis that this technique can be taught to novice surgeons with good results.

METHODS

Patients undergoing laparoscopic bariatric surgery were included. Novice surgeons (residents/fellows) with 0-50 initial trocar placements placed the initial trocar and insufflated the abdomen in the presence of an expert surgeon (>300 initial trocar placements in morbidly obese patients). Trocar placement time was defined as the time to place the trocar into the peritoneal cavity (including infiltration of local anesthesia and incision). Insufflation time was defined as the time to insufflate the abdomen to a pressure of 10 to 15 mm Hg (including time to place tubing on trocar). Novice times were compared with expert times.

RESULTS

There were 81 patients (56 by expert and 25 by novice) in this study. No bowel or vessel injury during initial trocar placement was noted. No correlation was seen between times and BMI or waist/hip circumference (P = NS). Mean expert trocar placement time was shorter than the mean novice time (25 +/- 9 versus 54 +/- 27 s; P < 0.0001); although there was no difference in mean insufflation time (expert versus novice: 16 +/- 5 versus 19 +/- 10; P = NS). The mean total time to place the initial trocar and insufflate the abdomen for the novices was 72 +/- 26 s.

CONCLUSIONS

Initial trocar placement can be taught safely to novices. The technique using an optical viewing trocar without prior abdominal insufflation is effective and efficient in morbidly obese patients.

Are African-Americans as successful as Caucasians after laparoscopic gastric bypass?

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to provide weight loss comparable to open gastric bypass. It has been suggested that African-Americans (AA) are not as successful as Caucasians (CA) after bariatric surgery. Our hypothesis was that AAs are just as successful as CA after LRYGBP in terms of weight loss and comorbidity improvement.

METHODS

A retrospective chart review was performed on all AA and CA patients who underwent LRYGBP for a 6-month period. Success after LRYGBP [defined as (1) 25% loss of preoperative weight, (2) 50% excess weight loss (EWL), or (3) weight loss to within 50% ideal weight] was compared by ethnicity.

RESULTS

102 patients were included in this study. 97 patients (30 AA patients and 67 CA patients) had at least 1-year follow-up data available. Preoperative data did not differ between both groups. There was a statistically significant difference in %EWL between AA and CA (66% vs 74%; P<0.05). However, there was no ethnic difference in the percentage of patients with successful weight loss (as defined by any of the above 3 criteria). Furthermore, there was no statistical difference between the percentages of AA and CA patients who had improved or resolved diabetes and hypertension.

CONCLUSIONS

LRYGBP offers good weight loss in all patients. While there may be greater %EWL in CA patients, no ethnic difference in successful weight loss exists. More importantly, co-morbidities improve or resolve equally between AA and CA patients. LRYGBP should be considered successful in AA patients.

Adduction of amiloride hydrochloride in urea through a modified technique for the dissolution enhancement

Amiloride hydrochloride is a potassium-sparing diuretic since it favors sodium excretion and potassium reabsorption. In the present study, urea, a well-known adductor for linear compounds was successfully employed for inclusion of amiloride hydrochloride-a substituted cyclic organic compound through a modified technique. Formation of urea inclusion compounds was confirmed by FTIR, DSC and XRD. The minimum amount of rapidly adductible endocyte (RAE) required for adduction of amiloride hydrochloride in urea was estimated by a modified Zimmerschied calorimetric method. Urea-AH-RAE inclusion compounds containing varying proportions of guests were prepared and their thermal behavior studied by DSC. The inclusion compounds were also found to exhibit high content uniformity and markedly improved dissolution profile as demonstrated by increased dissolution efficiency. Studies reveal the possibility of exploiting co-inclusion of the drug in urea host lattice for the dissolution enhancement.

Results of Teenaged Bariatric Patients Performed in an Adult Program

BACKGROUND

Morbid obesity is a growing epidemic among adolescents. Bariatric surgery has proven to be the only long-term effective method in treating morbidly obese adults for over a decade. The laparoscopic approach has become a popular option. This study tested the hypothesis that laparoscopic Roux-en-Y gastric bypass is a feasible option in teenaged patients with good results through an adult bariatric program.

METHODS

All patients under the age of 20 at the time of surgery were included in this study. Each patient had undergone a laparoscopic Roux-en-Y gastric bypass. Charts were reviewed for preoperative evaluation, operative time, complications, and length of hospital stay. Percentage of excess body weight lost (%EBWL) was calculated at the follow-up.

RESULTS

Of the 202 patients who underwent a laparoscopic gastric bypass procedure at our institution, 5 (2%) were teenagers. The mean age was 18 years (range, 17-19). The mean height was 69 inches (range, 61-75). Average weight was 323 lbs (range, 227-394). The mean preoperative body mass index was 48 kg/m2 (range, 44-56). All patients had medical and psychological clearance prior to surgery. Mean operative time was 150 minutes (range, 130-172). There were no complications in this subset of patients. All 5 patients were discharged on postoperative day 2. Follow-up ranged from 17.8 to 44.8 months. The mean %EBWL was 77% (range, 58%-88%).

CONCLUSIONS

The laparoscopic gastric bypass procedure is technically feasible in teenaged patients, with excellent results even when performed in an adult bariatric program. Long-term data will be needed to determine its role in the treatment of morbidly obese adolescents.

Potential Financial Impact of First Assistant Billing by Surgical Residents

General surgery residency involves a mixture of 1) education of residents and 2) service by residents. The service that residents provide is not directly reimbursed in our current healthcare system by private healthcare insurance companies. This investigation characterizes the amount of reimbursement a typical resident would be able to collect if residents were allowed to collect for their services as a first assistant. The case logs of residents who graduated over 2 years from our general surgery residency program were reviewed. Data from each resident's last 2 years (postgraduate years 4 and 5) were included in this study. Relative value units (RVUs) for each Current Procedural Terminology code were reviewed. Collections were calculated by multiplying the Medicare conversion factor of $36.7856/RVU, the corresponding RVU, and a “standard” collection rate of 16 per cent for first assistants. There were 13 general surgery residents. These residents provided first assistant help with 91,473 RVUs over 2 years. A total amount of $535,380 could have been collected on first assistant fees for the last 2 years of their residency. Each resident would have been able to collect an average at least $41,414 just for first assistant operative fees. Resident assistance in the operating room provides significant savings for private healthcare insurance companies each year by reducing the need for first assistants. The data demonstrate that private insurance companies receive a considerable amount of pro bono service from residents. Changes in the financing of the current healthcare system in the United States will require educators to examine other sources ( i.e., private insurance companies) for support of graduate medication education.

Potential financial impact of first assistant billing by surgical residents

General surgery residency involves a mixture of 1) education of residents and 2) service by residents. The service that residents provide is not directly reimbursed in our current healthcare system by private healthcare insurance companies. This investigation characterizes the amount of reimbursement a typical resident would be able to collect if residents were allowed to collect for their services as a first assistant. The case logs of residents who graduated over 2 years from our general surgery residency program were reviewed. Data from each resident's last 2 years (post-graduate years 4 and 5) were included in this study. Relative value units (RVUs) for each Current Procedural Terminology code were reviewed. Collections were calculated by multiplying the Medicare conversion factor of $36.7856/RVU, the corresponding RVU, and a "standard" collection rate of 16 per cent for first assistants. There were 13 general surgery residents. These residents provided first assistant help with 91,473 RVUs over 2 years. A total amount of $535,380 could have been collected on first assistant fees for the last 2 years of their residency. Each resident would have been able to collect an average at least $41,414 just for first assistant operative fees. Resident assistance in the operating room provides significant savings for private healthcare insurance companies each year by reducing the need for first assistants. The data demonstrate that private insurance companies receive a considerable amount of pro bono service from residents. Changes in the financing of the current healthcare system in the United States will require educators to examine other sources (i.e., private insurance companies) for support of graduate medication education.

Non-closure of defects during laparoscopic Roux-en-Y gastric bypass

BACKGROUND

The concern about internal hernias has prompted recommendations for routine closure of defects during laparoscopic Roux-en-Y gastric bypass (LRYGBP). Our belief is that not all techniques require closure of defects. We hypothesize that non-closure of defects with our particular technique would not cause a significant clinically evident internal hernia rate.

METHODS

All patients who were operated on between December 2002 and June 2005 were included in this study. The technique that was utilized included an antecolic antegastric gastrojejunostomy (GJ), division of the greater omentum, a long jejunojejunostomy (JJ) performed with three staple-lines, a short (< 4 cm) division of the small bowel mesentery, and placement of the JJ above the colon in the left upper quadrant. Clinical records were reviewed for reoperations.

RESULTS

There was a total of 300 patients, and no incidence of internal hernia. In the first 100 patients, there was 97% follow-up for 1 year or more. Four patients underwent reoperations for unexplained abdominal pain. Intraoperative findings included an adhesive band from the JJ to the colon (1), an adhesive band from the JJ to the anterior abdominal wall (1), an adhesive band 3 cm from the GJ to the anterior abdominal wall (1), and adhesions of the jejunum to the anterior abdominal wall (1). No patient had an internal hernia.

CONCLUSIONS

Internal hernias are not common after this particular method of LRYGBP. Before adopting routine closure of potential spaces, surgeons should consider their technique, follow-up, and incidence of internal hernias. Routine closure of these defects is not always necessary.

Knowledge and opinions regarding Medicare reimbursement for laparoscopic cholecystectomy

BACKGROUND

Medicare, via its fee schedule, determines amount of payment to physicians for services for its beneficiaries. Because many private insurance companies base their payment schedule on Medicare rates, it is important for physicians to know the rates of commonly performed procedures. In addition, it seems that public perception is that physicians receive substantial payments for procedures. This investigation explores patient, student, resident, and surgeon knowledge and opinion of Medicare reimbursements for laparoscopic cholecystectomy.

METHODS

Patients, students, residents, and surgeons filled out an IRB-exempted survey. The survey included a written description of a laparoscopic cholecystectomy. All participants were asked to give their thoughts of what Medicare currently reimburses for a laparoscopic cholecystectomy ($622) and what they thought Medicare should reimburse for a laparoscopic cholecystectomy for our geographic area.

RESULTS

There were 105 participants (47 patients, 17 medical students, 33 surgical residents, and 8 attending surgeons) in the investigation. The reported mean reimbursements of what each group thought Medicare pays were patients, $9,396; students, $3,077; residents, $800; and surgeons, $711. The reported mean reimbursements of what each group thought Medicare should pay were patients, $8,067; students, $3,971; residents, $1,444; and surgeons, $1,600. The mean reimbursements were statistically different between all groups in both the amount Medicare currently pays and the amount Medicare should pay.

CONCLUSION

Most of our participants overestimated what Medicare currently pays for laparoscopic cholecystectomy. Even the mean amount reported in the attending surgeon group was greater than the actual payment. All groups felt Medicare should pay more than the current rate; however, only patients thought Medicare should pay less than they currently pay (probably because of the incorrect perception of the current fee schedule).

Band versus bypass: influence of an educational seminar and surgeon visit on patient preference

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are 2 common weight loss procedures. This investigation examined the effect of a preoperative educational seminar (ES) and surgeon visit (SV) on patients' choice of bariatric procedure.

METHODS

In our practice, patients choose their procedure. New patients receive an overview of both procedures in an ES, including the risks and benefits, and then meet individually with a surgeon (SV) to answer any additional questions. Three identical surveys (before the ES, after the ES, and after the SV) were given to new patients who voluntarily participated in this study. The survey queried procedure choice and influencing factors.

RESULTS

A total of 47 patients participated. Of these 47 patients, 31 had researched the procedures before the ES and 13 were unsure of the differences between laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding before the ES, 4 were after the ES, and 1 was after the SV. Also, 11% of patients changed their procedure choice as a result of attending the ES and SV; 15%, 13%, and 13% of patients were willing to be randomized to either procedure before the ES, after the ES, and after the SV, respectively.

CONCLUSIONS

Only 11% of patients changed their procedure choice as a result of attending the ES and SV. Thus, patient decisions are usually made before meeting the surgeon, and the information provided at the ES and SV simply reinforced those decisions. Only 13% of patients were willing (4% very willing and 9% somewhat willing) to be randomized to either procedure (laparoscopic Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding). It is likely that patients had confidence in, and were comfortable with, 1 procedure over the other, and therefore were unwilling to undergo the other procedure.

Does Pouch Size Matter?

BACKGROUND

Mechanical restriction, malabsorption, and hormonal changes appear to play a role in weight loss after Roux-en-Y gastric bypass (RYGBP). This investigation chose to investigate one aspect of the restrictive role of gastric bypass: the pouch size. Our hypothesis was that a small pouch size with no fundus after laparoscopic RYGBP (LRYGBP) would lead to greater loss of excess weight and weight loss success.

METHODS

Upper gastrointestinal radiological (UGI) studies were retrospectively reviewed by three blinded experts (2 bariatric surgeons and 1 expert radiologist), to determine pouch size and fundus size. The following grading system was utilized: Size I - smaller than average pouch, Size II - average pouch, Size III larger than average pouch, and Size IV - over 3 times the size of an average pouch. Fundus 0 - no fundus appreciated, Fundus I - slight amount of fundus barely noted, Fundus II - fundus noted, Fundus III - large amount of fundus noted, and Fundus IV - majority of the pouch was fundus. Percentage of excess weight loss (%EWL) and successful weight loss (A. >50% EWL, B. within 50% of ideal body weight, C. loss of >25% of preoperative weight) were calculated.

RESULTS

There were 59 patients in this study with 97% follow-up of >1 year. No Size IV or Fundus IV were noted. There were no statistically significant differences between in %EWL or success for either pouch size or fundus size.

CONCLUSIONS

While there may be a trend for the mean %EWL to be lower with larger pouches and larger amounts of fundus, no significant differences were found. Larger pouches and the presence of fundus (within reason) still result in a high rate of success after LRYGBP.

Laparoscopic repair of incarcerated diaphragmatic hernia with mesh

Diaphragmatic hernias are now being approached laparoscopically. Incarcerated diaphragmatic hernia poses a special problem due to concerns about contamination. We describe a laparoscopic repair of such a hernia with the use of prosthetic mesh.

Laparoscopic Re-operations for Band Removal after Open Banded Gastric Bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) has been demonstrated to be an effective treatment for weight loss in the morbidly obese. Numerous variations of the RYGBP have been performed, including placing a ring proximal to the gastric outlet. This ring in RYGBP is intended to decrease pouch dilation and limit weight regain. We reviewed our experience in laparoscopic re-operation after open banded RYGBP.

METHODS

All charts of patients who underwent laparoscopic revisional bariatric surgery were reviewed. Patients who had laparoscopic removal of the band following the open banded RYGBP were reviewed in this study.

RESULTS

There were 4 patients who had laparoscopic removal of the band. The indication in all patients was dysphagia and emesis. The ring removed was a silicone band (1) and a large braided non-absorbable suture (3). After the laparoscopic reoperation, there was immediate relief. There has been an average of 5.8 kg weight regain at average follow-up of 30 months.

CONCLUSIONS

This complication after open banded RYGBP may require operative intervention. Laparoscopic removal of a band is feasible and safe.

Solid dispersion adsorbates for enhancement of dissolution rates of drugs

Amalgamation of solid dispersion and melt adsorption technologies was utilized for enhancing the dissolution rate of poorly soluble drugs. Glibenclamide was employed as a model drug. PEG6000 and Gelucire44/14 were used as hydrophilic carriers for the preparation of solid dispersions, and lactose was utilized as an adsorbent for the preparation of solid dispersion adsorbates. A high dissolution rate of solid dispersion adsorbates was observed when compared to solid dispersions alone and one of the marketed products.

Laparoscopic bariatric patients’ will to help: the foundation of research

BACKGROUND

Bariatric surgery is a fast growing field. Clinical research is essential to its safe delivery. Bariatric patient enthusiasm for research participation has never been objectively measured. Our hypothesis was that most laparoscopic bariatric surgery patients would participate in clinical research.

METHODS

All postoperative patients were surveyed querying their willingness to participate in studies and quantifying the level of time, effort, and commitment they would comply with. Fisher's exact test, the Mann-Whitney U test, and the chi-square test were used to analyzed the responses. A total of 97 patients were the subject of this inquiry.

RESULTS

Of the 97 patients, 92% were willing to participate. Willingness was independent of race or diabetic status. Of those willing to participate, 93% agreed to additional blood tests done during routine blood draws and 75% agreed to additional blood draws. Although 98% agreed to donate fat samples during surgery, only 76% would donate at 1 month postoperatively. Also, 80% would spend 6 hours at 1 month postoperatively in the hospital for preoperative research. This decreased to 56% and 56% for 12 and 24 hours, respectively (P = .004). For postoperative research, 72% committed to 6 hours per month in the hospital. This decreased to 60% and 54% for 12 and 24 hours, respectively (P = .002). No statistical consensus was reached for the financial reimbursement patients desired for their time.

CONCLUSIONS

The results of our study have shown that almost all laparoscopic bariatric surgery patients are willing to participate in obesity-related research, including invasive procedures, when it coincides with their surgery. Enthusiasm decreased with the increasing time commitment in the pre- and postoperative period but remained for most patients.

Laparoscopic revision of the gastrojejunostomy for recurrent bleeding ulcers after past open revision gastric bypass

Late complications of open gastric bypass can include malnutrition, weight gain, stomal stenosis, and recurrent bleeding ulcers. Herein, we describe the case of a woman who had recurrent bleeding ulcers, after an open revision of a stenotic gastric bypass. She now underwent an uneventful laparoscopic revision of her gastrojejunostomy and was discharged within 72 hours. Laparoscopic revision of a gastrojejunostomy, even after an open revision following an open gastric bypass, can be done safely.

A research agenda for gastrointestinal and endoscopic surgery

BACKGROUND

Development of a research agenda may help to inform researchers and research-granting agencies about the key research gaps in an area of research and clinical care. The authors sought to develop a list of research questions for which further research was likely to have a major impact on clinical care in the area of gastrointestinal and endoscopic surgery.

METHODS

A formal group process was used to conduct an iterative, anonymous Web-based survey of an expert panel including the general membership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). In round 1, research questions were solicited, which were categorized, collapsed, and rewritten in a common format. In round 2, the expert panel rated all the questions using a priority scale ranging from 1 (lowest) to 5 (highest). In round 3, the panel re-rated the 40 questions with the highest mean priority score in round 2.

RESULTS

A total of 241 respondents to round 1 submitted 382 questions, which were reduced by a review panel to 106 unique questions encompassing 33 topics in gastrointestinal and endoscopic surgery. In the two successive rounds, respectively, 397 and 385 respondents ranked the questions by priority, then re-ranked the 40 questions with the highest mean priority score. High-priority questions related to antireflux surgery, the oncologic and immune effects of minimally invasive surgery, and morbid obesity. The question with the highest mean priority ranking was: "What is the best treatment (antireflux surgery, endoluminal therapy, or medication) for GERD?" The second highest-ranked question was: "Does minimally invasive surgery improve oncologic outcomes as compared with open surgery?" Other questions covered a broad range of research areas including clinical research, basic science research, education and evaluation, outcomes measurement, and health technology assessment.

CONCLUSIONS

An iterative, anonymous group survey process was used to develop a research agenda for gastrointestinal and endoscopic surgery consisting of the 40 most important research questions in the field. This research agenda can be used by researchers and research-granting agencies to focus research activity in the areas most likely to have an impact on clinical care, and to appraise the relevance of scientific contributions.

Nonalcoholic fatty liver disease of obesity

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are part of the same continuum. They are a major, under-recognized cause of chronic liver disease. Good medical treatment options do not exist to date. The mainstay of treatment is weight loss. Bariatric surgery offers weight loss and improvement of NAFLD and NASH.

What happens to patients who do not follow-up after bariatric surgery?

Loss of follow-up is a concern when tracking long-term clinical outcomes after bariatric surgery. The results of patients who are "lost to follow-up" are not known. After bariatric surgery, the lack of follow-up may result in less weight loss for patients. This study investigated the hypothesis that there are differences between patients who do not automatically return for their annual follow-up and those that do return. Patients who were greater than 14 months postoperative after laparoscopic gastric bypass were contacted if they had not returned for their annual appointment. They were seen in clinic and/or a phone interview was performed for follow-up. These patients (Group A) were compared with patients who returned to see us for their annual appointment (Group B) without us having to notify them. There were 105 consecutive patients, with 48 patients who did not automatically return for their annual appointment. Only six of these patients could not ultimately be contacted. There was no difference in preoperative body mass index between the two groups. Percentage excess body weight loss was greater in Group B (76 vs. 65%; P < 0.003). More patients had successful weight loss (defined as within 50% of ideal body weight) in Group B (50 [88%] vs. 28 [67%]; P < 0.02). We found that a significant number of patients will not comply with regular follow-up care after laparoscopic gastric bypass unless they are prompted to do so by their bariatric clinic. These patients have worse clinical outcome (i.e., less weight loss). Caution should be taken when examining the results of any bariatric study where there is a significant loss to follow-up.

Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass

BACKGROUND

The utility of routine upper gastrointestinal (UGI) studies after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a matter of great debate. Because the morbidity and mortality rates associated with an unrecognized postoperative leak are high after LRYGB, diagnosis of a postoperative leak earlier would be of benefit. Clinical signs, however, may predict the diagnosis of a postoperative leak more often. This study explored the hypothesis that UGI studies are more predictive than clinical signs for the early diagnosis of a postoperative leak after LRYGB.

METHODS

All patients who underwent LRYGB at the authors' institution were included in this study. Charts were reviewed to examine immediate clinical signs (heart rate, temperature, and white blood cell count within the first 24 h), UGI studies, and clinical course. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of clinical signs and UGI studies were calculated.

RESULTS

This study included 245 patients with a 3% rate of leak. The positive and negative predictive value of UGI studies were 67% and 99%, respectively. Only an elevated white blood count had a better predictive value (100% for negative predictive value). The efficiency of UGI studies (98%) was better than that of heart rate (83%), white blood count (8%), or temperature (95%).

CONCLUSIONS

According to our data, UGI studies are the most predictive of an early leak diagnosis. Clinical signs alone may not be as useful in predicting leaks early after laparoscopic gastric bypasses. Routine early postoperative UGI studies are a reasonable approach to predicting leaks after LRYGB.

What Happens to Patients who Do Not Follow-Up after Bariatric Surgery?

Loss of follow-up is a concern when tracking long-term clinical outcomes after bariatric surgery. The results of patients who are “lost to follow-up” are not known. After bariatric surgery, the lack of follow-up may result in less weight loss for patients. This study investigated the hypothesis that there are differences between patients who do not automatically return for their annual follow-up and those that do return. Patients who were greater than 14 months postoperative after laparoscopic gastric bypass were contacted if they had not returned for their annual appointment. They were seen in clinic and/or a phone interview was performed for follow-up. These patients (Group A) were compared with patients who returned to see us for their annual appointment (Group B) without us having to notify them. There were 105 consecutive patients, with 48 patients who did not automatically return for their annual appointment. Only six of these patients could not ultimately be contacted. There was no difference in preoperative body mass index between the two groups. Percentage excess body weight loss was greater in Group B (76 vs 65%; P < 0.003). More patients had successful weight loss (defined as within 50% of ideal body weight) in Group B (50 [88%] vs 28 [67%]; P < 0.02). We found that a significant number of patients will not comply with regular follow-up care after laparoscopic gastric bypass unless they are prompted to do so by their bariatric clinic. These patients have worse clinical outcome ( i.e., less weight loss). Caution should be taken when examining the results of any bariatric study where there is a significant loss to follow-up.

Substituting virtual reality trainers for inanimate box trainers does not decrease laparoscopic skills acquisition

OBJECTIVES

Inanimate and virtual reality box training help in developing basic laparoscopic skills. The lack of tactile feedback and lack of reality may be a detriment when training with virtual reality trainers. This study examined the hypothesis that there is no difference in laparoscopic skills acquisition when virtual reality trainers are partially substituted for inanimate box trainers.

METHODS

Medical students without laparoscopic experience were randomized into either Group A or Group B. Group A performed tasks on the LTS 2000 (an inanimate box trainer) alone for 10 sessions. Group B performed tasks on the box trainer as well as on the MIST-VR (a virtual reality trainer) for 10 sessions. Scores for 5 inanimate box trainer exercises (time and errors) for the first and tenth sessions were compared between both groups.

RESULTS

No statistical differences were seen in any exercises in the first session between Group A (n=14) and Group B (n=18) in either time or errors (P=NS for all comparisons). Mean times decreased in both groups from the first session to the last session. At the last session, again both groups demonstrated no differences in any of the exercises (P=NS for all comparisons).

CONCLUSIONS

No difference was found in laparoscopic skills acquisition when incorporating virtual reality trainers into a curriculum based on inanimate box trainers. Ideally, laparoscopic training laboratories should include both virtual reality and inanimate trainers.

Establishing a laparoscopic bariatric program in a safety net hospital

BACKGROUND

Most laparoscopic bariatric programs are situated in a community- or university-based hospital. The authors have recently initiated a program at a safety net hospital. This investigation hypothesizes that a laparoscopic bariatric program can be established at a safety net hospital with good clinical and financial results.

METHODS

A laparoscopic bariatric program was initiated December 2002 at a safety net hospital. The program included a dedicated operative suite, an operative team, a bariatric unit, and a clinical pathway. The data for all the patients who underwent laparoscopic gastric bypasses up to June 2003 were analyzed. The patients were analyzed by type of insurance: government-sponsored insurance (G) or commercial insurance (C).

RESULTS

There were 104 patients during this period. Their mean age was 40 years (range, 18-63 years), and their mean body mass index was 48 (range, 38-62). The median length of hospital stay was 2 days (mean, 3.9 days). Hypertension and diabetes were resolved for more than 80% of the patients. The average percentage of excess body weight loss was 73% after 1 year. There were no significant clinical differences between payor groups. The payor mix was 31% G and 69% C. The mean collection rates for hospital charges were 10% for G versus 53% for C (p < 0.0001).

CONCLUSIONS

A laparoscopic bariatric program can be established in a safety net hospital with good clinical results. Findings showed that 1-year weight loss and comorbidity improvement/resolution compares favorably with those of other programs. Despite the overall poor payor mix of many safety net hospitals, a bariatric program can be established and can attract a high rate of commercially insured patients.

Unexpected pathology during laparoscopic bariatric surgery

BACKGROUND

The popularity of bariatric surgery has increased in recent years with the escalating incidence of morbid obesity in our society. The improvement in minimally invasive technology and the increased number of laparoscopic bariatric procedures being performed have resulted in the discovery of unexpected pathology not suspected preoperatively. The authors hypothesized that the occurrence of unexpected pathology is not associated with immediate adverse outcomes during laparoscopic bariatric procedures.

METHODS

From December 2002 to June 2004, 398 patients underwent laparoscopic bariatric surgery for morbid obesity. A retrospective chart review was performed to determine the incidence of unexpected findings and their effect on patient results.

RESULTS

Nine unexpected pathologic lesions were found in eight patients (2%). The findings included lesions on the small bowel (n = 3), stomach (n = 4), and liver (n = 2). In all cases except one (for which a biopsy was performed), the abnormalities were found and removed laparoscopically. The final pathology showed gastric leiomyomas (n = 2), gastric gastrointestinal stromal cell tumors (n = 2), ectopic pancreatic tissue (n = 2), arteriovenous malformation (n = 1), biliary adenoma (n = 1), and fibrosed hemangioma (n = 1). The planned bariatric procedures were completed for all the patients without incident. No complications occurred postoperatively, and all were discharged in 1 to 3 days (mean, 2 days).

CONCLUSIONS

Unexpected findings occur with relative frequency during laparoscopic bariatric procedures. Biopsy or removal of these lesions usually does not increase complications nor preclude continuation of the planned bariatric procedure.

Prospective randomized controlled trial of laparoscopic trainers for basic laparoscopic skills acquisition

BACKGROUND

Laparoscopic surgery requires a different set of skills than traditional open surgery. The acquisition of basic laparoscopic skills may help novices when learning laparoscopic procedures. This study tested the hypothesis that the combination of virtual reality and box trainers leads to better basic laparoscopic skill acquisition than either method alone or no training.

METHODS

A randomized control trial involving preclinical medical students with no prior operative experience was performed. The students were grouped according to four training methods: virtual reality training, inanimate box training, a combination of both, and no training (control). The pre- and posttraining scores for four skills in the porcine laboratory were the metrics chosen for this study.

RESULTS

A total of 65 students participated in this study. There were no differences among any of the pretraining scores (p > 0.05). The posttraining times differed between the four groups. Post hoc analyses showed statistically significant differences (p < 0.05) between the participants trained with both trainers and the control subjects.

CONCLUSIONS

Our data demonstrate that the combination of virtual reality training and inanimate box training leads to better laparoscopic skill acquisition than either training method alone or no training at all. Optimal preclinical laparoscopic training should incorporate both virtual reality trainers and inanimate box trainers.

Vitamin and trace mineral levels after laparoscopic gastric bypass

BACKGROUND

Nutritional deficiencies are a concern after any bariatric surgery procedure. Restriction of oral intake and/or decreased absorption may cause vitamin abnormalities. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. An investigation was undertaken to examine preoperative and short-term (1-year) postoperative levels of vitamins/trace minerals in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP).

METHODS

Serum preoperative and postoperative vitamin/trace element levels of LRYGBP patients were recorded in a retrospective chart review (n = 100). Unavailable and undrawn levels were not included in the results.

RESULTS

Preoperative and 1-year postoperative percentage of abnormal levels were: vitamin A 11% and 17%, vitamin B(12) 13% and 3%, vitamin D-25 40% and 21%, zinc 30% and 36%, iron 16% and 6%, ferritin 9% and 3%, selenium 58% and 3%, and folate 6% and 11%.

CONCLUSIONS

Abnormal vitamin and trace mineral values are common both preoperatively and postoperatively in a bariatric surgery patient population. Routine evaluation of serum levels should be performed in this specific patient population.

Laparoscopic repair of congenital duodenal obstruction

CHARGE syndrome (or association) refers to a group of physical abnormalities occurring together: coloboma, heart defect, atresia choanae, retarded growth and development, genital hypoplasia, and ear anomalies/deafness. We report the successful use of laparoscopy in a patient with CHARGE syndrome and congenital duodenal obstruction.

Survey of minimally invasive surgery fellowship programs

INTRODUCTION

Since there was no accrediting body for minimally invasive surgery fellowships, this investigation was performed to characterize minimally invasive surgery fellowships.

MATERIALS AND METHODS

All minimally invasive surgery fellowships that were noted on the Society of American Gastrointestinal Endoscopic Surgeons website in July 2002 were sent a survey. Only those fellowships that had fellow(s) for the year 2001-2002 were included in the survey. All programs were contacted a second time if the survey was not returned. Incomplete responses were not included in the data.

RESULTS

There were 78 fellowships listed, of which 16 had no fellow in 2001-2002, one which was not a minimally invasive surgery fellowship, and one which was listed twice. Of the 19 (32%) programs that responded, there was an average of 1.3 clinical fellows per program (range, 1-3). All clinical fellowships were of one year duration. There was an average of 3.2 attendings for each program. Thirty-two percent of program directors had attended a laparoscopic fellowship. The average program received 50 applications and interviewed 12 applicants for the year 2001-2002. The average fellow had 14 (range, 0-42) manuscripts, abstracts, and/or presentations either completed or in progress. Average minimally invasive cases performed was bariatric 95, colon 33, solid organ (liver, spleen, kidney, adrenal) 32, antireflux 36, hernia 54, and endoscopy 48. However, the range of these cases varied and the lowest number of cases for each category was bariatric 5, colon 3, solid organ 8, antireflux 1, hernia 6, and endoscopy 0.

CONCLUSION

Minimally invasive surgery fellowships seem to be competitive for surgical residents. These fellowships vary in both research and clinical experience.

Topochemical models for the prediction of permeability through blood–brain barrier

Relationship between the topochemical indices and permeability of diverse series of compounds through blood-brain barrier has been investigated. Three-topochemical indices, Wiener's topochemical index--a distance-based topochemical descriptor, molecular connectivity topochemical index--an adjacency based topochemical descriptor and eccentric connectivity topochemical index--an adjacency-cum-distance based topochemical descriptor, were used for the present investigation. A data set comprising of 28 compounds with established CNS permeation tendency was selected for present study. The values of all the three-topochemical indices in the original as well as in the normalized form for each of the 28 compounds comprising the data set were computed using an in-house computer program. Resultant data was analyzed and suitable models were developed after identification of the permeable ranges. Subsequently, permeability characteristic was assigned to each compound involved in the data set using these models, which was then compared with the reported permeability through blood-brain barrier. Accuracy of prediction was found to vary from a minimum of 83% to a maximum of approximately 95% using these models.

Comparison of IL-8, IL-6 and PGE2 Formation by Visceral (Omental) Adipose Tissue of Obese Caucasian Compared to African-American Women

BACKGROUND

One of the key consequences of obesity is an enhanced release of cytokines such as IL-8 and IL-6 by adipose tissue. There may be differences in adiposity, inflammatory markers, and medical co-morbidity between morbidly obese African-American (AA) and Caucasian (CA) women. We hypothesized that there are ethnic differences in inflammatory markers and medical co-morbidities.

METHODS

We compared the mRNA content in omental fat and the release of IL-8, IL-6 and PGE(2) after a 4-hour incubation of explants of adipose tissue in women undergoing bariatric surgery. In addition, medical co-morbidities and fat measurements were examined and compared.

RESULTS

Medication usage differed, with CA women being three times more likely to report taking medication for depression compared to AA women (P< or =0.001). IL-8 and PGE(2) release over 4 hours by omental fat in vitro was the same in CA and AA women. Similar results were seen with respect to the COX-2 mRNA and IL-8 mRNA values at the start and at the end of the incubation. In CA and AA women, the IL-6 mRNA content in fat immediately after removal from the patients was the same.

CONCLUSIONS

In morbidly obese women seeking bariatric surgery, there are little ethnic differences between cytokine release by omental adipose tissue explants in vitro, or the mRNA content in omental adipose tissue of IL-6, IL-8 or COX-2. The only noted difference between AA and CA morbidly obese women was the greater use of antidepressants by CA women.

Outcome of a clinical pathway for discharge within 48 hours after laparoscopic gastric bypass

BACKGROUND

The benefits of laparoscopic gastric bypass (LGB) include decreased pain, quicker recovery, and shorter hospital stay. Our hypothesis was that a clinical pathway for 48-hour discharge after LGB can be implemented safely.

METHODS

Charts of patients undergoing LGB were retrospectively reviewed to assess our prospectively placed clinical pathway. Patients were discharged within 48 hours if they met the criteria of the pathway.

RESULTS

There were 104 patients who underwent LGB with no intraoperative conversions. Complications included 5 leaks, 5 reoperations, and no mortality. In our series, 76% (n=79) of patients were discharged within 48 hours. Gender and body mass index (BMI) did not differ between those who were discharged in 48 hours and those who were not (P=not significant). No patient who was discharged in 48 hours required return before their scheduled appointment.

CONCLUSIONS

A majority of patients after LGB can be discharged safely in 48 hours. A formal clinical pathway helps decrease hospital stay without adverse patient outcome.

Metabolic syndrome: yet another co-morbidity gastric bypass helps cure

BACKGROUND

The metabolic syndrome is a group of risk factors predictive of cardiovascular diseases. The rising number of obese Americans has increased the prevalence of metabolic syndrome. This study investigated the hypothesis that the incidence of metabolic syndrome is decreased after laparoscopic gastric bypass surgery.

METHODS

The charts of all patients who had undergone laparoscopic gastric bypass surgery during a 6-month period were reviewed for the presence of the diagnostic criteria for metabolic syndrome, both preoperatively and at least 1 year postoperatively. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATPIII) criteria were used to define the metabolic syndrome. These criteria included elevated blood pressure, fasting blood glucose, triglycerides, high-density lipoprotein cholesterol, and waist circumference.

RESULTS

Data were available for 53 patients. Before laparoscopic gastric bypass surgery, 32 (60%) of the 53 patients had metabolic syndrome, as defined by the NCEP ATPIII criteria. No difference was found in the preoperative body mass index between patients who had metabolic syndrome (47.4 kg/m(2)) and those who did not (49.8 kg/m(2); P = NS). The percentage of excess body weight lost after at least 1 year was 78% in patients with metabolic syndrome. After surgery, only 1 (2%) of the 53 patients had metabolic syndrome (P <.0001).

CONCLUSION

Metabolic syndrome is quite common in patients undergoing bariatric surgery. The results of our study have shown that laparoscopic gastric bypass surgery resolves metabolic syndrome in most patients. Metabolic syndrome should be considered another co-morbidity that improves and is cured after gastric bypass surgery.

Band versus bypass: randomization and patients' choices and perceptions

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are becoming increasingly popular; however, little is understood about patients' motivational factors and reasons for choosing a particular procedure. This investigation explored patient choices and perceptions concerning LRYGB and LAGB.

METHODS

A survey was given to 120 consecutive patients who had undergone LRYGB or LAGB 3-24 months earlier. The survey was designed to ascertain why patients chose banding or bypass, and how they rated their surgical outcome.

RESULTS

A total of 101 patients responded (84%): 22 had undergone LAGB, 79 LRYGB. The top reason for choosing LRYGB was greater expectation of weight loss, whereas LAGB was chosen for its lower risk. Overall, 21% (18/84) of the patients were willing to be involved in a prospective randomized study of bariatric procedure choice. Six of 19 (32%) patients who underwent LAGB, but only 12 of the 65 (18%) who underwent LRYGB stated that they would be willing to accept randomization between the operations.

CONCLUSIONS

Patients expressed varied reasons for choosing their procedure, most related to weight loss or safety profiles. Patients undergoing LAGB would have predicted similar results with either procedure, whereas those undergoing LRYGB showed a trend toward greater overall satisfaction with their operations (p = 0.06) and would have predicted an inferior outcome with the other procedure. Although the overall percentage of patients willing to be randomized is not high, a busy bariatric practice could recruit sufficient numbers of willing patients to undergo a prospective randomized trial of LRYGB and LAGB.

Taste change after laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding

BACKGROUND

Many patients have described changes in taste perception after weight loss surgery. Our hypothesis was that patients develop postoperative changes in taste that vary by bariatric procedure.

METHODS

Patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic adjustable gastric banding (LAGB) completed a 23-question institutional review board-approved survey postoperatively regarding their degree and type of taste changes and food aversion and how these influenced their eating habits.

RESULTS

A total of 127 patients participated. After removing the inadequately completed surveys, 82 LRYGB and 28 LAGB patients were included. Of these, 87% of LRYGB and 69% of LAGB patients believed taste is important to the enjoyment of food. More LRYGB patients (82%) than LAGB patients (46%) reported a change in the taste of food or beverages after surgery (P <.001). In addition, 92% of LAGB versus 59% of LRYGB patients characterized the change as a decrease in the intensity of taste (P <.05). Additionally, 68% of LRYGB and 67% of LAGB patients found certain foods repulsive and had developed aversions. Also, 66% of LRYGB and 70% of LAGB patients believed the taste changes were greater than expected preoperatively. Most patients (83% of LRYGB and 69% of LAGB patients) agreed that the loss of taste led to better weight loss.

CONCLUSION

Although most LRYGB and many LAGB patients experienced taste changes and food repulsion postoperatively, procedural differences were found in these taste changes. Taste changes need to be investigated further as a possible mechanism of weight loss after bariatric surgery.

Does laparoscopic gastric bypass result in a healthier body composition? An affirmative answer

BACKGROUND

Bariatric surgery results in sustained weight loss. While weight loss is the goal of bariatric surgery, fat loss and muscle conservation are germaine goals. This study investigated the hypothesis that body composition would significantly change after laparoscopic Roux-en-Y gastric bypass (LRYGBP).

METHODS

Patients undergoing LRYGBP were studied. Percent fat and percent water were calculated via bioelectrical impedance analysis (BIA). Waist and hip circumference were measured in all patients as well. Measurements were taken preoperatively, and at 1 month, 3 months, 6 months, and 1 year. Non-parametric ANOVA was utilized for statistical analysis.

RESULTS

There were 151 patients included in this study. Fat percentage (48.6 +/- 10.0 vs 34.6 +/- 10.8; P<0.001), total fat mass (141 +/- 37 vs 67 +/- 30; P<0.0001) and total water mass (108 +/- 27 vs 93 +/- 23; P<0.0001) decreased postoperatively at 1 year. Water percentage increased postoperatively at 1 year (37.0 +/- 6.6 vs 52.5 +/- 3.3; P<0.001). Waist:hip ratio improved from preoperatively to 1 year postoperatively (0.895 +/- 0.115 vs 0.811 +/- 0.076; P<0.001).

CONCLUSIONS

Bariatric surgery results not only in fat loss but also in a change in body composition. Improved waist:hip ratio, fat percentage decreases, and water percentage increases all indicate an overall healthy body composition. While weight loss is important, improvement in body composition should be another recognized benefit of bariatric surgery.

Most of the interleukin 1 receptor antagonist, cathepsin S, macrophage migration inhibitory factor, nerve growth factor, and interleukin 18 release by explants of human adipose tissue is by the non-fat cells, not by the adipocytes

The present studies were designed to compare the relative release of interleukin 1 receptor antagonist (IL-1Ra), cathepsin S, macrophage migration inhibitory factor (MIF), nerve growth factor (NGF), and interleukin 18 (IL-18) by adipocytes as compared with the non-fat cells present in subcutaneous and omental adipose tissue from morbidly obese gastric bypass patients as compared with obese abdominoplasty patients. The release of IL-1Ra, cathepsin S, and MIF by explants of human adipose tissue incubated for 48 hours averaged 6, 9, and 19 pmol/g, respectively, and was far greater than the release of NGF (0.05 pmol/g) or IL-18 (0.006 pmol/g). The release by human adipocytes of IL-1Ra, cathepsin S, and MIF was 0.13, 0.32, and 2.6 pmol/g, respectively, over 48 hours, whereas NGF release was 0.003 and IL-18 0.001 pmol/g. Only the total release of MIF by human adipose tissue explants was enhanced, whereas that of IL-18 was significantly reduced in explants from morbidly obese women. Most of (55%-73%) the release of IL-1Ra, cathepsin S, MIF, NGF, and IL-18 was by the adipose tissue matrix, whereas release by stromal-vascular (SV) cells was 3% to 28% of total release over 48 hours by the adipose tissue matrix, SV cells and adipocytes. The release of NGF by adipocytes was 42%, that of MIF was 27%, and for the other factors 15% or less of release over 48 hours by the adipose tissue matrix, SV cells, and adipocytes. Our results suggest that the non-fat cells in human adipose tissue contribute to most of the release of NGF, IL-18, IL-1Ra, cathepsin S, and MIF seen during primary culture of adipose tissue explants from obese women.

Emerging endoluminal therapies for gastroesophageal reflux disease: adverse events

BACKGROUND

Endoluminal therapies are emerging as a new therapeutic option for the treatment of gastroesophageal reflux disease (GERD). Many of these endoluminal therapies are touted as short outpatient procedures with minimal complications. It is thought that these complications are uncommon and minor. This investigation sought to summarize the adverse events of these endoluminal therapies for the treatment of GERD.

METHODS

The Manufacturer and User Facility Device Experience Database for the U.S. Food and Drug Administration's Center for Devices and Radiological Health Web site was searched to examine all voluntary adverse events reported on emerging endoluminal therapies. The adverse events can be divided into 3 categories: (1) radiofrequency ablation based, (2) injection based, and (3) suture based.

RESULTS

There were a total of 50 adverse events reported on 4 specific therapies. Half of the complications were found to result from injection-based therapy and 44% of the complications were found to result from radiofrequency ablation-based therapy. There were 8 deaths reported (5 in the injection-based group and 3 in the radiofrequency ablation-based group). Sixty-four percent of the adverse events resulted in hospitalizations and 10% of these patients required surgery.

CONCLUSIONS

Physicians must be aware that no endoluminal therapy is truly noninvasive. Complications and even deaths are associated with these treatments for GERD. Patients must be informed of all the potential risks and complications of these new technologies.

Laparoscopic repair of gastrointestinal leaks after laparoscopic gastric bypass

Gastrointestinal (GI) leak after gastric bypass is a cause of significant morbidity and a mortality that may exceed 50%. This study was performed to review our experience with laparoscopic repair of GI leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective chart review of all patients who underwent LRYGB over a 25-month period was performed. Patients who had any operation for a GI leak after LRYGB were included in this study. There were 300 patients who underwent LRYGB. No intraoperative conversions occurred. Eight (2.7%) patients underwent operative repair of a GI leak. Another patient had a gastrojejunostomy leak that was managed nonoperatively. The rate of GI leaks reduced from 5.3 per cent in the first 150 cases to 0.7 per cent in the last 150 cases (P < 0.05). One patient was converted to an open approach. Average operative time for the laparoscopic repairs was 133 minutes (range, 75-182 minutes). Sources of leak found at operation were gastrojejunostomy (3), enterotomy (3), jejunojejunostomy (2), gastric pouch (1), and cystic duct stump (1). Two patients had a GI leak from two sources. Average length of stay was 28 days (range, 4-78 days). Three patients whose stay was greater than a month were the result of sepsis and ventilator dependence. Further reoperations were required in two patients (laparoscopic) for abdominal washout and one patient (open) for enterotomy repair. One patient required computed tomography-guided drainage of an abscess. Mortality was 22 per cent (2) in patients who developed GI leaks. One patient died from sepsis-induced multiple organ failure and the other patient from a presumed pulmonary embolus. GI leaks cause significant morbidity and mortality. GI leak rates decrease with experience. Laparoscopic repair of GI leaks should be used judiciously. Conversions and further reoperations may be necessary.

Preoperative Carbohydrate "Addiction" Does Not Predict Weight Loss after Laparoscopic Gastric Bypass

BACKGROUND

Weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies. Dietary habits that exist preoperatively may continue after surgery and affect weight loss. This study investigated the hypothesis that preoperative carbohydrate addiction would predict weight loss after laparoscopic gastric bypass.

METHODS

104 consecutive patients in our LRYGBP program were included in the study. A preoperative survey was used to determine level of carbohydrate craving. This survey was scored from 0 to 60. A higher score indicated a higher level of carbohydrate addiction. Percentage of excess weight loss (%EWL) was determined after at least 1 year postoperatively in all patients.

RESULTS

Data were available in 95 (91%) of the patients. There was no correlation seen between level of carbohydrate addiction and %EWL at 1 year (r=0.02; P=NS). In addition, we looked at patients with successful weight loss (>50% %EWL; n=83) versus those patients who were considered unsuccessful (<50% EWL; n=12). There was no statistical difference in the level of preoperative carbohydrate craving between these 2 groups (36+/-13 vs 33+/-15; P=NS).

CONCLUSIONS

Consistently large carbohydrate intake preoperatively does not predict weight loss after LRYGBP. High level of carbohydrate addiction is not a contraindication to LRYGBP.

Ageism in breast cancer surgical options by medical students

INTRODUCTION

The similar long-term survival of breast conservation and modified radical mastectomy in treating early invasive breast cancer has been well established. Since doctors often find themselves in the position of making operative recommendations, characterization of factors that may influence their recommendations is important. Previous investigations have demonstrated the phenomenon of ageism (i.e., between patients aged 30 versus 60 years old) in doctors and doctors-in-training. Thus, this study was undertaken to investigate any possible economic bias of doctors-in-training in breast conserving procedures.

METHODS

Medical students were instructed on the efficacy of breast conservation in treating breast cancer. Then, their opinions were assessed using a questionnaire about recommendations for breast conservation as well as breast reconstruction after mastectomies in similar patients. All patients were between the ages of 41-54 years old but differed by occupation. Chi squared tests were used for statistical analysis.

RESULTS

Forty-eight students participated in the study. No differences were noted between "high income" occupations and "low income" occupations. However, subtle ageism was noted even in this similarly aged population. Modified radical mastectomy was recommended in 35 percent of the "older" age group (41-48 years old) versus 15 percent of "younger" patients (49-54 years old, p < 0.002). Further, breast reconstruction was recommended in 89 percent of younger patients versus only 72 percent of older patients (p < 0.004).

CONCLUSIONS

Medical students still demonstrate an age bias against older women in their recommendations of breast conservation and breast reconstruction. Educational efforts should be instituted during the medical school training to decrease this age bias in treatment of breast cancer.