Laparoscopic Roux-en-Y gastric bypass is safe and feasible after orthotopic liver transplantation

Liver transplantation has become a life-saving procedure for patients with end-stage liver disease. Since obesity is rampant in our society, it is not surprising that patients with a liver transplant suffer from obesity as well. In addition, Roux-en-Y gastric bypass (RYGBP) is a life-saving procedure for patients suffering from morbid obesity. However, a liver transplant is an extensive and invasive abdominal procedure. Further operations after orthotopic liver transplantation may be challenging. With increasing surgeon experience and technical advancements in laparoscopic equipment, previous abdominal surgery is no longer a contraindication to utilize the laparoscopic approach for RYGBP. In fact, herein, we describe the first laparoscopic RYGBP after orthotopic liver transplantation in the world literature.

Minimally invasive incisional herniorrhaphy: a review of 208 cases

BACKGROUND

Minimally invasive incisional herniorrhaphy has become an accepted approach for incisional hernia. However, the ideal technique for this procedure is not known. The authors present their technique and personal experience with minimally invasive incisional herniorrhaphy.

METHODS

A retrospective review investigated 208 consecutive patients who underwent minimally invasive incisional hernia repair under the supervision of a single surgeon between 1995 and 2002.

RESULTS

An intraperitoneal mesh repair was performed in all cases. There were no conversions. The mean operative time was 2.1 h (range, 0.8-4.5 h). The mean length of hospital stay was 2.5 days (range, 0-13 days). There were six complications, including two bowel perforations, and zero mortality. There were three recurrences during the follow-up period, which ranged from 6 to 72 months (median, 24 months).

CONCLUSIONS

Minimally invasive incisional herniorrhaphy yielded an acceptable morbidity and recurrence rate during the follow-up period. The outcome compares favorably with that for open incisional hernia repair. Although long-term follow-up evaluation is desirable, the data support the contention that the minimally invasive approach is an appropriate option for incisional hernia.

Laparoscopic lumbar hernia repair

Lumbar hernias are rare clinical entities that often pose a challenge for repair. Because of the surrounding anatomy, adequate surgical herniorraphy is often difficult. Minimally invasive surgery has become an option for these hernias. Herein, we describe two patients with lumbar hernias (one with a recurrent traumatic hernia and one with an incisional hernia). Both of these hernias were successfully repaired laparoscopically.

Laparoscopic Lumbar Hernia Repair

Lumbar hernias are rare clinical entities that often pose a challenge for repair. Because of the surrounding anatomy, adequate surgical herniorraphy is often difficult. Minimally invasive surgery has become an option for these hernias. Herein, we describe two patients with lumbar hernias (one with a recurrent traumatic hernia and one with an incisional hernia). Both of these hernias were successfully repaired laparoscopically.

Regulation of monocyte chemoattractant protein 1 (MCP-1) release by explants of human visceral adipose tissue

BACKGROUND

Monocyte chemoattractant protein-1 (MCP-1) is a chemokine involved in monocyte recruitment during inflammation whose plasma level is elevated in obesity.

OBJECTIVE

The present studies were designed to examine the release of MCP-1 in primary culture by explants of visceral adipose tissue from morbidly obese women.

RESULTS

Most of the MCP-1 released by adipose tissue explants was derived from the nonfat cells in adipose tissue. The release of MCP-1 by adipose tissue explants was upregulated almost five-fold between 3 and 48 h of incubation. Approximately half of this upregulation was due to the release of endogenous tumor necrosis factor alpha (TNFalpha) and IL-1beta based on the ability of a combination of a soluble TNFalpha receptor (etanercept) and a blocking antibody against IL-1beta to reduce MCP-1 release. The release of MCP-1 over 48 h was unaffected by insulin or dexamethasone but significantly reduced by the combination of both agents. MCP-1 release was reduced by 60% in the presence of an inhibitor of the nuclear factor kappaB (NF-kappaB) pathway. There were no significant effects of inhibitors of p44/42 mitogen-activated protein kinase (ERK), Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase (p38 MAPK) pathways on MCP-1 release. However, inhibition of MCP-1 release in the presence of inhibitors of both the p38 MAPK and NF-kappaB pathways was greater than that seen with only the NF-kappaB inhibitor.

DISCUSSION

The present data shows that MCP-1 formation is upregulated over a 48-h incubation of primary explants of visceral adipose tissue. Half of this upregulation is dependent upon endogenous TNFalpha and Il-1beta and involves the p38 MAPK and NF-kappaB pathways.

Safety and Efficacy of Initial Trocar Placement in Morbidly Obese Patients

HYPOTHESIS

The use of a nonbladed trocar with an optical view is a safe and effective method for initial trocar placement for laparoscopic bariatric surgery.

DESIGN

Retrospective review of consecutive patients.

SETTING

University-associated hospital.

PATIENTS

All patients who underwent laparoscopic bariatric surgery from December 2002 to November 2003.

INTERVENTION

Initial trocar placement.

MAIN OUTCOME MEASURES

Injury and bleeding during initial trocar placement, trocar placement time, and insufflation time. 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 time to insufflate the abdomen to a pressure of 10 to 15 mm Hg (including time to place tubing on trocar).

RESULTS

There were 228 patients who had no evidence of any bowel or vessel injury during initial trocar placement. In the last 50 patients, average body mass index (calculated as weight in kilograms divided by the square of height in meters) was 47 (range, 35-63). Average trocar placement time was 25 seconds (range, 10-60 seconds), and average insufflation time was 16 seconds (range, 5-25 seconds). In almost all cases, appropriate pneumoperitoneum was established in less than a minute. No correlation was seen between times and body mass index (trocar, P = .56; insufflation, P = .95) or waist-hip circumference (trocar, P = .74; insufflation, P=.48).

CONCLUSIONS

Initial trocar placement using a nonbladed trocar with an optical view without prior abdominal insufflation is safe and effective in morbidly obese patients. This method can be applied even in the super obese.

Why Would Laparoscopic Gastric Bypass Patients Choose Open Instead?

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to be comparable to open Roux-en-Y gastric bypass (ORYGBP) surgery in randomized studies. Although a steep learning curve exists, laparoscopic bariatric surgery offers advantages if performed by an experienced bariatric surgeon. Despite these facts, some patients still choose to undergo ORYGBP. This investigation explored the reasons why patients who have had LRYGBP would decide to undergo the laparoscopic operation.

METHODS

A survey was given to patients who had undergone LRYGBP. The survey was designed to ascertain what factors would influence them to have LRYGBP versus ORYGBP. Incomplete responses were not included in the data analysis.

RESULTS

There were 41 patients who filled out the survey. Over 90% of the patients felt LRYGBP is better than open gastric bypass. There were 4 patients who had seen another surgeon who recommended ORYGBP. Approximately 61% (23/38) of the patients would have stayed with their surgeon even if their surgeon did not offer LRYGBP. In addition, 79% of patients (31/39) would have ORYGBP if their insurance did not cover LRYGBP. Most patients (67%) would have ORYGBP if their surgeon thought LRYGBP was experimental. If they were told that LRYGBP was too risky for them, 77% of patients (30/39) would have undergone ORYGBP. Only 15% of patients (6/40) would not have had surgery if LRYGBP did not exist.

CONCLUSIONS

Patients are willing to undergo ORYGBP even if they believe that LRYGBP is better. Non-medical factors and/or surgeon recommendations instead of scientific data influence patient decision-making when choosing ORYGBP over LRYGBP.

One-stitch laparoscopic gastric bypass technique for adolescents

Morbid obesity is increasingly recognized in children and adolescents. The National Institute of Health Consensus Conference has concluded that bariatric surgery is the only consistent effective method for achieving long-term weight loss. Advantages of the laparoscopic approach, which include decreased hospital stay and morbidity, have been demonstrated in randomized controlled studies. Herein, we describe our technique of laparoscopic Roux-en-Y gastric bypass.

Laparoscopic Roux-en-Y gastric bypass with subtotal gastrectomy

Laparoscopic gastric bypass is a common procedure for morbid obesity. After gastric bypass, the distal stomach is unavailable for surveillance. When a suspicious distal gastric lesion is present preoperatively, a distal subtotal gastrectomy may be needed. Herein we describe such a case performed laparoscopically. Laparoscopic gastric bypass with subtotal gastrectomy for morbid obesity should be considered for patients with suspicious distal gastric lesions.

Postoperative gastrointestinal complaints after laparoscopic Nissen fundoplication

OBJECTIVES

Approximately 80% of patients complain of various symptoms immediately after laparoscopic Nissen fundoplication. These symptoms typically are treated medically without an extensive evaluation to identify the cause. We reviewed our experience of laparoscopic Nissen fundoplication to determine the course of postoperative symptomatology in our patient population, and present a rational approach to this problem.

METHODS

Over a 10-year period, 628 patients underwent primary laparoscopic Nissen fundoplication for gastroesophageal reflux disease; patients were evaluated with a standard set of questions for postoperative gastrointestinal complaints. Three- and 6-month follow-up data were compared by using the chi square test.

RESULTS

One-year follow-up data were available for 615 patients (98%). All of these patients had symptoms during the first 3 postoperative months. Early satiety (88%), bloating/flatulence (64%), and dysphagia (34%) were the most common; however, 94% of patients had resolution of their symptoms by the 1-year follow-up visit, and most had resolved after 3 months. Patients with persistent reflux or dysphagia after 3 months typically had an anatomic failure of the operation.

CONCLUSIONS

Most patients who have undergone laparoscopic Nissen fundoplication for gastroesophageal reflux disease will have gastrointestinal complaints during the initial 3 postoperative months. Nearly all of these patients will have resolved their symptomatology after 3 months. Those with persistent symptoms after 3 months warrant evaluation for operative failure.

Poor knowledge of basic cancer facts of physicians-in-training

PURPOSE

Since many physicians-in-training will play an important role in cancer screening, their understanding of cancer screening and basic cancer facts is paramount. This investigation was undertaken to determine their baseline knowledge in basic cancer facts.

METHOD

A questionnaire was used to assess the knowledge of basic cancer facts of medical students, medical residents and surgical residents. Participants were asked to rank five different malignancies in their correct order for both mortality and incidence. Physicians-in-training were given separate questions for male and female patients. The questions were considered correct if at least the first three malignancies were ranked in the appropriate order.

RESULTS

One-hundred-twelve second-year medical students and 78 residents were assessed. Few physicians-in-training ranked the malignancies in correct order for mortality (21% for female patients and 18% for male patients). Even fewer physicians-in-training ranked the malignancies in correct order for incidence (2% for female patients and 9% for male patients).

CONCLUSION

Most physicians-in-training lack an understanding of basic cancer facts. If this poor basic cancer fact knowledge represents an overall lack of cancer knowledge, educational efforts need to be focused on cancer care for all levels and specialties of physician training.

Laparoscopic Roux-en-Y Gastric bypass utilizing the triple stapling technique

OBJECTIVE

To evaluate the outcomes of a single surgeon's experience with laparoscopic Roux-en-Y gastric bypass (LRYGB) utilizing the triple stapling technique for creation of the jejunojejunostomy.

METHODS

A retrospective review of patients who underwent LRYGB utilizing the triple stapling technique for creation of the jejunojejunostomy (JJ) between 10/01 and 12/04 was performed.

RESULTS

LRYGB was performed in 435 consecutive patients. The mean age was 41 years (range, 14 to 68), and 82% were female. Mean initial body mass index was 50 (range, 35 to 91). One conversion to open (0.2%) was necessary. Mean operating time was 144+/-26 minutes. Mean length of stay was 2.3+/-1.5 days. There were 3 leaks at the gastrojejunostomy anastomosis (0.7%). No leaks occurred at the JJ anastomosis. One patient underwent revision of the JJ (0.2%) secondary to obstruction of the JJ on upper gastrointestinal study. Intraluminal bleeding occurred in 21 patients (4.8%). Patients required blood transfusion of 2.2+/-1.1 units (range, 0 to 5), but none required surgical or endoscopic intervention. Mortality occurred in 2 patients (0.5%). Mean excess body weight loss was 72% at 1 year.

CONCLUSION

Construction of the jejunojejunostomy utilizing the triple stapling technique is expeditious, safe, and associated with minimal complication.

Transforming growth factor beta1 release by human adipose tissue is enhanced in obesity

The present studies examined the effect of obesity in humans on the release of transforming growth factor beta1 (TGF-beta1) by human adipose tissue. The regulation of TGF-beta1 release by adipose tissue as well as the question of whether its release is due to the adipocytes or the nonfat cells in adipose tissue was also examined. There was a statistically significant (r=0.50) correlation between the body mass index of the fat donors and the subsequent release of TGF-beta1 release by subcutaneous adipose tissue. There was also a positive correlation between total TGF-beta1 release by adipose tissue explants and body fat content (r=0.69). The question of whether tumor necrosis factor alpha (TNF-alpha) and/or interleukin 1 beta (IL-1 beta) regulate the release of TGF-beta1 was investigated by incubation of adipose tissue explants with a soluble human TNF-alpha receptor (etanercept) and a neutralizing antihuman IL-1 beta antibody. The release of TGF-beta1 over 48 hours by adipose tissue explants was significantly enhanced in the presence of both the inhibitor of TNF-alpha and of IL-1 beta. It is of interest, in view of the elevated circulating insulin in blood of morbidly obese women, that the release of TGF-beta1 by adipose tissue was enhanced in the presence of insulin. The question of whether the release of TGF-beta1 by human adipose tissue explants was primarily due to adipocytes, as is the case for leptin, or the nonfat cells present in human adipose tissue, as is the case for IL-8 and prostaglandin E(2), was examined. The release of TGF-beta1 was primarily by the nonfat cells of human adipose tissue because release by adipocytes was less than 10% of that by the nonfat cells of adipose tissue.

Inpatient pain medication requirements after laparoscopic gastric bypass

INTRODUCTION

One of the benefits of laparoscopic Roux-en-Y gastric bypass (RYGBP) includes decreased pain, possibly resulting in decreased narcotic use, quicker recovery of bowel function, and shorter hospital stay. We utilize a pain management strategy for our patients undergoing laparoscopic RYGBP. We investigated this strategy as well as narcotic use and incidence of ileus.

METHODS

Inpatient data for patients who underwent laparoscopic RYGBP were collected. Our pain management strategy included a standing dose of ketorolac, morphine sulphate as needed, and propoxyphene hydrochloride/acetaminophen as needed after liquids were initiated. No PCAs were utilized.

RESULTS

There were 104 patients in this study. 12 patients did not undergo our pain management strategy due to reoperation (5), postoperative hemorrhage (2), and allergies (5). 2 patients required no pain medications other than ketorolac. Only 2 patients had a delay of discharge (postoperative day [POD] 3 and 5) due to lack of bowel function. An average of 11.2 mg of morphine and an average of 170 mg of propoxyphene (1.7 pills) were given by the end of POD 2. In addition, 74% of patients required no morphine on POD 2 and 48% of patients required no propoxyphene on POD 2. Bowel movements were reported in 65% patients on POD 1.

CONCLUSIONS

After laparoscopic RYGBP, only a minimal amount of narcotic use is necessary. Few patients have an ileus when utilizing this pain management strategy after laparoscopic RYGBP.

Internet Use in the Bariatric Surgery Patient Population

BACKGROUND

Many patients rely on the Internet for gathering medical information. Bariatric patients appear to explore the Internet for information regarding weight loss surgery. This investigation studied the hypothesis that Internet use is common among the bariatric population.

METHODS

From Oct 1 to Dec 31, 2003, every patient who visited our bariatric clinic was asked to fill out a questionnaire. This survey contained questions concerning use of the Internet and E-mail.

RESULTS

Of the 127 respondents, 89% owned a computer, had Internet access, and had an E-mail address. 85% of the patients had searched the Internet for bariatric information, and 98% of these patients (91/93) found the information useful. Of the patients who had access to the Internet, 36% searched for information about the hospital, 40% about the clinic, and 54% about the surgeon. Most of the patients believed that all doctors and all clinics should be available via E-mail (88% and 92% respectively).

CONCLUSIONS

Most patients who come to a bariatric clinic are Internet savvy. It is helpful for bariatric surgeons and clinics to post information about themselves on the Internet and to be available via E-mail.

Mallory-Weiss tear after laparoscopic Roux-en-Y gastric bypass

In the United States, the most common surgical procedure for morbid obesity is the Roux-en-Y gastric bypass. Pulmonary embolism, leak, bowel obstruction, and gastrointestinal bleeding are among the potential early fatal complications. Early postoperative bleeding after laparoscopic gastric bypass, although uncommon, presents a dilemma because of the danger of perforation from postoperative endoscopy and the inability to access the gastric remnant easily. We describe a case of a Mallory-Weiss tear causing massive upper gastrointestinal hemorrhage 1 week after laparoscopic Roux-en-Y gastric bypass. Bariatric surgeons should consider this diagnosis, especially when encountering a patient with a history of significant retching postoperatively.

Patients Postoperatively Forget Aspects of Preoperative Patient Education

BACKGROUND

Preoperative patient education is critically important to the success of any bariatric operation. In our clinic, we perform extensive preoperative education and informed consent. Part of the informed consent process includes a preoperative true/false quiz. This study tests the hypothesis that postoperative patients do not recall key components of their preoperative education.

METHODS

Preoperatively, all patients were required to take the true/false quiz and retake it, if necessary, until they received all the questions correct. All patients were given their preoperative informed consent quiz again at least 1 month after laparoscopic gastric bypass, during their postoperative clinic visit. Patients >1 year postoperatively from surgery were compared to patients <1 year postoperatively.

RESULTS

63 patients were included in this study. Originally, 46% of patients did not get all the questions correct the first time; mean score on the quiz preoperatively was 95%. Patients took the test an average of 8 months after surgery. Postoperatively, 46% of patients did not get all the questions correct; mean score on the quiz was 96%. The 2 most common incorrect answers were: "Obesity surgery is basically an aid to dieting: it does not mean that you will lose weight no matter what you eat or do (True)" and "Diabetes, high blood pressure, back pain and similar ailments always get better after obesity surgery (False)". Patients >1 year postoperative were more likely not to get all the questions correct (80% vs 36%; P<0.01; two-tailed Fisher's exact test).

CONCLUSIONS

Patients do not remember basic preoperative education facts after their bariatric surgery. Despite maximal efforts in verifying preoperative education, patients often forget this critical information after bariatric surgery. Patients 1 year after surgery forget more information.

Laparoscopic baseline ability assessment by virtual reality

BACKGROUND

Assessment of any surgical skill is time-consuming and difficult. Currently, there are no accepted metrics for most surgical skills, especially laparoscopic skills. Virtual reality has been utilized for laparoscopic training of surgical residents. Our hypothesis is that this technology can be utilized for laparoscopic ability metrics.

METHODS

This study involved medical students with no previous laparoscopic experience. All students were taken into a porcine laboratory in order to assess two operative tasks (measuring a piece of bowel and placing a piece of bowel into a laparoscopic bag). Then they were taken into an inanimate lab with a Minimally Invasive Surgery Trainer-Virtual Reality (MIST-VR). Each student repeatedly performed one task (placing a virtual reality ball into a receptacle). The students' scores and times from the animate lab were compared with average economy of movement and times from the MIST-VR. The MIST-VR scored both hands individually.

RESULTS

Thirty-two first- and second-year medical students were included in the study. There was statistically significant (P < 0.05) correlation between 11 of 16 possible relationships between the virtual reality trainer and operative tasks.

CONCLUSION

While not all of the possible relationships demonstrated statistically significant correlation, the majority of the possible relationships demonstrated statistically significant correlation. Virtual reality may be an avenue for measuring laparoscopic surgical ability.

Predicting dopamine receptors binding affinity of N-[4-(4-Arylpiperazin-1-yl) butyl]aryl carboxamides: computational approach using topological descriptors

Relationship between the topological indices and Dopamine D3 and D4 receptor binding affinities of N-[4-(4-Arylpiperazin-1-yl)butyl]aryl carboxamides has been investigated. Three topological indices, the Wiener's Index- a distance-based topological descriptor, molecular connectivity index- an adjacency based topological descriptor and eccentric connectivity index- an adjacency-cum-distance based topological descriptor were used for the present investigations. A data set comprising of 37 substituted N-[4-(4-Arylpiperazin-1-yl)butyl]aryl carboxamides was selected for the present studies. The values of the Wiener's index, eccentric connectivity index and molecular connectivity index for each of the 37 analogues comprising the data set were computed using in-house computer program. Resultant data was subsequently analyzed and suitable models were developed after identification of active ranges. Subsequently, a biological activity was assigned to each analogue using these models, which was then compared with the reported D3 and D4 receptor binding affinity. These models exhibited exceptionally high predictability.

Participants’ opinions of laparoscopic training devices after a basic laparoscopic training course

BACKGROUND

Basic laparoscopic skills are initially best taught and practiced in an inanimate setting. Various devices are used to aid in this education of laparoscopic skills. These devices range from simple box trainers to sophisticated virtual reality trainers. This investigation tested the hypothesis that participants would prefer one trainer to another trainer.

METHODS

Preclinical medical students volunteered for this study. All underwent a porcine laboratory. The students were then divided into 3 groups by method of training: group A--a virtual reality trainer (MIST-VR), group B--an inanimate box trainer (LTS 2000), and group C--both trainers. Each group participated in 10 laboratories with the assigned trainer(s). After completion of the laboratories, all students underwent a similar porcine laboratory. During this laboratory, opinions of each trainer and specific tasks were ascertained from each student.

RESULTS

No statistical difference was seen between groups A and B when asked if their specific trainer helped their skills, was realistic, helped in the animal laboratory, and was interesting. When group C was asked the same questions about each trainer, no statistical difference was seen except that 47% thought the MIST-VR was not realistic as opposed to 0% who thought the LTS 2000 was not realistic (P <.003). The level of difficulty of each task correlated with how much the specific task helped in development of skills for both trainers (P <.0001). In group C, 89% of the participants thought the LTS 2000 helped more that the MIST-VR and 56% thought the LTS 2000 was more interesting than the MIST-VR. In addition, 83% of students in group C chose LTS 2000 when asked to pick only one trainer.

CONCLUSIONS

While virtual reality trainers may have some advantages, most participants feel that inanimate box trainers help more, are more interesting, and should be chosen over virtual reality trainers if only one trainer is allowed. Further studies need to investigate if the opinions affect participants' utilization of these trainers.

Topological models for prediction of anti-HIV activity of acylthiocarbamates

Relationship of anti-HIV activity of acylthiocarbamates with distance based Wiener's index, adjacency based first-order molecular connectivity index and distance-cum-adjacency based augmented eccentric connectivity index was investigated. The values of all the three indices for each of the 61 compounds involved in the dataset were calculated using an in-house computer program. Resulting data was analyzed and suitable models were developed after identification of the active ranges. Subsequently, biological activity was assigned to each of the compounds involved in the dataset using these models which was then compared with the reported anti-HIV activity. Very high accuracy of prediction ranging from 95% to 98% was observed using these topological models.

Involvement of multiple signaling pathways in the post-bariatric induction of IL-6 and IL-8 mRNA and release in human visceral adipose tissue

The present studies were designed to determine the site of and the mechanism for the rapid increase in IL-6 and IL-8 mRNA observed in human visceral adipose tissue after removal during laparoscopic bariatric surgery. Upregulation of IL-6 and IL-8 mRNA as well as their release were seen within 3h whether one intact piece of tissue or minced pieces of adipose tissue were incubated in vitro. Most of the IL-6 and IL-8 mRNA content of visceral adipose tissue after 3h of incubation was in the non-fat cells. Actinomcyin D markedly reduced the upregulation of IL-6 and IL-8 mRNA. Incubation of adipose tissue explants with a soluble TNFalpha receptor (etanercept) plus a blocking antibody against IL-lbeta reduced by 55% the increase in IL-6 mRNA and by 42% that of IL-8 mRNA seen between 1 and 5h of incubation. The upregulation of IL-8 and IL-6 mRNA accumulation as well as their release over a 2 or 4h incubation was reduced by around 50% in the presence of an inhibitor of the p38 MAPK or an inhibitor of the NFkappaB pathway and by 85% in the presence of both inhibitors. The data suggest that the relative trauma and/or hypoxia that occurs when adipose tissue is removed results in the release of TNFalpha and IL-1beta. These cytokines, and probably other factors as well, enhance IL-6 and IL-8 mRNA accumulation in human adipose tissue explants through mechanisms involving the p38 MAPK and NFkappaB pathways.

Laparoscopic Removal of Gastric Band after Open Banded Gastric Bypass

Open banded gastric bypass has been the choice of some bariatric surgeons. This procedure includes a band (of various materials) around the gastric pouch. While there are advantages to this band, erosion and/or displacement of the band may occur. We describe a case of a symptomatic displaced band which was treated by laparoscopic removal. Laparoscopic removal of the band after open banded gastric bypass is feasible. Revision of previous bariatric surgery may be performed laparoscopically if the technical expertise is available.

Self-reported versus observed scores in laparoscopic skills training

BACKGROUND

Education in basic laparoscopic skills training is performed ideally in an inanimate laboratory. Monitoring of basic skills progression, which is essential during this tranining, often may be difficult because of the resources and manpower. This study investigated the differences between self-reported and observed scores during basic laparoscopic exercises.

METHODS

First-and second-year medical students involved in practice sessions using the LTS 2000 box trainer were included in the study. All the students were allowed to practice four tasks: placing pegs with their dominant and nondominant hands, transferring pegs from one hand to another starting with the dominant and nondominant hands, cannulating a pipe cleaner into a plastic tube, and progressing from one end of a rope to the other. Each student recorded his or her times and errors for each task. After these practice sessions, each student underwent an observed session (OS), performing all of the tasks, and was graded by a surgeon involved in laparoscopic education. All the students were asked to record another practice session. The self-reported performances from the session immediately before the OS (pre-OS) and the session immediately after the OS (post-OS) were compared with the performance in the OS.

RESULTS

A total of 36 students were included in this study. The mean time and mean error were similar between all the sessions. Although the scores in the OS did slightly differ from the scores in the pre-OS and post-OS, post hoc analysis showed that there was no statistically significant difference between the OS score and either the pre-OS or the post-OS score for any of the laparoscopic exercises.

CONCLUSIONS

No differences between observed scores and self-reported scores were noted. The use of self-reported scores may be a good method for monitoring performance during training in laparoscopic basic skills. The self-reporting of basic laparoscopic exercises may conserve resources.

Use of ciprofloxacin in the treatment of hospitalized patients with intra-abdominal infections

BACKGROUND

Numerous combination and single-agent antimicrobial regimens are available for the treatment of intra-abdominal infections. Selection of empiric agents must be directed at providing reliable activity against endotoxin-generating Escherichia coli, other gram-negative facultative bacteria, and anaerobes such as Bacteroides fragilis. Safety profiles, pharmacokinetic profiles, and cost-effectiveness must also be considered. Use of fluoroquinolones for the treatment of intra-abdominal infections has recently been advocated.

METHODS

We review 2 prospective, comparative clinical trials conducted between 1992 and 2002 that evaluated the efficacy and safety of IV ciprofloxacin in patients with intra-abdominal infections. Separate pharmacoeconomic analyses conducted for each study are also reviewed.

RESULTS

A total of 4 ciprofloxacin studies (2 clinical, 2 pharmacoeconomic) comprise the database. The combination of ciprofloxacin plus metronidazole was at least as effective as imipenem/cilastatin and clinically more effective than piperacillin/tazobactam therapy, based on clinical success end points. In 1 trial, treatment success for the clinically valid population was reported for 84% (93/111) of patients treated with IV ciprofloxacin/metronidazole, 86% (91/106) of those treated with IV/oral ciprofloxacin/metronidazole, and 81% of those treated with IV imipenem/cilastatin (91/113). The IV/oral ciprofloxacin/metronidazole regimen had a statistically significant lower mean infection-related cost than the IV only ciprofloxacin/metronidazole plus imipenem groups (difference of approximately 1100 US dollars; P = 0.029). In the second clinical trial, clinical resolution rates were statistically different for patients receiving IV/oral ciprofloxacin/metronidazole (74%) versus IV piperacillin/tazobactam therapy (63%; P = 0.047). Ciprofloxacin/metronidazole was more cost-effective compared with piperacillin/tazobactam (2200 US dollars-3600 US dollars lower cost-effective ratios per patient) regardless of whether the patient had a diagnosis of appendicitis or whether a switch to an oral drug was permissible.

CONCLUSIONS

In the studies reviewed herein, the combination of ciprofloxacin plus metronidazole was an effective and safe regimen for the treatment of intra-abdominal infections. This regimen has potential advantages over exclusively IV regimens, including the option of sequential IV/oral therapy, patient convenience, cost savings, and reduced hospital stay.

Topological models for the prediction of anti-HIV activity of dihydro (alkylthio) (naphthylmethyl) oxopyrimidines

Relationship between the topological indices and anti-HIV activity of Dihydro (alkylthio) (naphthylmethyl) oxopyrimidines has been investigated. Three topological indices--the Wiener's index--a distance-based topological index, molecular connectivity index--an adjacency based topological index and eccentric connectivity index--an adjacency-cum-distance based topological index were used for the present investigations. A data set comprising of 67 analogues of dihydro (alkylthio) (naphthylmethyl) oxopyrimidine (S-DABO) was selected for the present investigations. The values of the Wiener's index, molecular connectivity index and eccentric connectivity index for each of the 67 compounds comprising the data set were computed using an in house computer program. Resultant data were subsequently analyzed and suitable models were developed after identification of active ranges. Subsequently, a biological activity was assigned to each compound using these models, which was then compared with the reported anti-HIV activity. The use of models based upon these topological indices resulted in prediction of anti-HIV activity with an accuracy ranging from 86% to 89%.

Immunolocalization of fibroblast growth factor-2 (FGF-2) in the developing root and supporting structures of the murine tooth

Epithelio-mesenchymal interactions are active during the development of the root of the tooth and are regulated by a variety of growth factors, such as fibroblast growth factors. FGF-2, 3, 4, and 8 have all been shown to play a role in the development of the crown of the tooth, but less is known about the factors that govern root formation, particularly FGF-2. The aim of this study was thus to elucidate the spatial and temporal expression of FGF-2 in the root of the developing tooth, as this growth factor is believed to be a mediator of epithelio-mesenchymal interactions. Parasagittal sections of the maxillary and mandibular arches of post-natal mice were utilized and the roots of the molar teeth were studied. Immunocytochemistry utilizing an antibody to FGF-2 was performed on sections of teeth at various stages of development. Intense immunostaining for FGF-2 was observed in differentiating odontoblasts at the apical end of the tooth and in the furcation zone of the developing root at all the stages examined. FGF-2 localization was also observed in cementoblasts on post-natal days 16, 20 and 24. The pattern of localization of FGF-2 in the developing root suggests that this growth factor may participate in the signaling network associated with root development.

Multivariate analysis of factors associated with smoking cessation in women

BACKGROUND

Appropriate smoking cessation techniques, including counseling patients to stop smoking, could prevent multiple health-related problems. Identification of relevant factors in patients that smoke may be beneficial in targeting smoking cessation efforts. This investigation explores various factors associated with smoking cessation, specifically in women.

METHODS

All women (n = 675) presenting to a breast health center over a one year period were surveyed regarding their tobacco use. Any association between smoking cessation and various factors was determined by multivariate analysis.

RESULTS

Our population consisted of 47% African American women, 43% Caucasian women, and 10% women of other ethnicities. Sixty percent of all women never smoked. Of the women who had smoked, 57% quit. Except for alcohol use and exercise, no factor, including ethnicity, was associated with never smoking. Smoking cessation was associated with being married, being Caucasian, not using alcohol, and exercising. However, only Caucasian race and marriage were independently associated with smoking cessation.

DISCUSSION

In our population, African American women had a lower proportion of smoking cessation than Caucasian women. In patients with similar access to care, specifically preventive care, there are ethnic and social differences in smoking cessation.

Immunolocalization of fibroblast growth factor-2 (FGF-2) during embryonic development of the rat submandibular gland

Morphogenesis and cytodifferentiation of the salivary glands are dependent on epithelio-mesenchymal interactions, which are mediated either by direct intercellular contacts or by the expression of signaling molecules. One of these signaling molecules, fibroblast growth factor (FGF), is known to play a crucial role in embryonic cell proliferation, cell differentiation and cell migration. FGF-2 has been identified as a factor facilitating neoplastic progression in salivary glands in humans. The aim of this study was to elucidate the spatial and temporal expression of fibroblast growth factor-2 (FGF-2) in the developing rat submandibular gland. Submandibular glands were removed from foetal rats on days E14.5, 15.5, 16.5, 18.5 and 19.5. Immunolocalization utilizing an antibody to FGF-2 was performed on sections of the submandibular gland at all the derived stages. Diffuse and faint immunolocalization of FGF-2 was seen in the epithelium and mesenchyme of the submandibular gland on days E14.5, E15.5 and E16.5. Intense immunoreactivity for FGF-2 was observed in epithelial components of the gland i.e. in the differentiating acini and ducts, on day E18.5, while on day E19.5, the signal was again less intense. These observations suggest that FGF-2 may play a specific role in cytodifferentiation of the submandibular gland at a particular stage of development.

Weight Changes in Spouses of Gastric Bypass Patients

BACKGROUND

The effectiveness of gastric bypass for weight loss has been demonstrated. No study has documented the effect of this surgery on patient spouses' weight. Excess leftover food may be consumed by the spouses of gastric bypass patients, which may increase the total caloric intake compared to the preoperative intake. This investigation tested the hypothesis that there would be a significant change in patient spouse's weight.

METHODS

Patients who underwent Roux-en-Y gastric bypass (RYGBP) > or = 12 months before were included. Preoperative weights of their spouses were requested before RYGBP surgery. Current weights of spouses were collected > or = 12 months postoperatively. Chi-squared tests were used for statistical analysis.

RESULTS

63 patients were included in this study. 1 patient was divorced and current data was not available. 3 patients' spouses themselves had RYGBP during the study period, and their average weight loss was 49 kg. Of the spouses who had a significant change in weight (but did not have a RYGBP), 13 lost weight and 20 gained weight. In this subgroup of spouses, 75% (15/20) of obese spouses gained weight compared to only 38% (5/13) non-obese spouses (P <0.04).

CONCLUSIONS

Patients' spouses who are obese are more likely to have weight gain while the patients lose weight after RYGBP. Preoperative counseling should be offered to spouses of potential bariatric surgery patients, especially to spouses who are obese. This phenomenon suggests that obese spouses of bariatric patients should be counselled regarding weight gain or even be considered for candidates for bariatric surgery.

Application of graph theory: prediction of glycogen synthase kinase-3 β inhibitory activity of thiadiazolidinones as potential drugs for the treatment of Alzheimer's disease

The relationship of Wiener's index, a distance-based topological descriptor; Zagreb group parameter, M(1), an adjacency-based topological descriptor and eccentric connectivity index,an adjacency-cum-distance based topological descriptor with the glycogen synthase kinase-3 beta inhibitory activity of thiadiazolidinones has been investigated. A training set comprising 28 analogues of substituted thiadiazolidinones was selected for the present investigations. The values of the Wiener's index, Zagreb group parameter, and eccentric connectivity index for each of 28 analogues comprising the data set were computed. Resulting data was analyzed and suitable models developed after identification of active ranges. Subsequently, biological activity was predicted for each analogue involved in the data set using these models, which was then compared with the reported glycogen synthase kinase-3 beta inhibitory activities. Accuracy of prediction was found to vary from a minimum of approximately 83% for model based on Zagreb group parameter to a maximum of approximately 87% for model based on Wiener's index.

Insulin enhances vascular endothelial growth factor, interleukin-8, and plasminogen activator inhibitor 1 but not interleukin-6 release by human adipocytes

The present studies were designed to investigate the hormonal regulation of vascular endothelial growth factor (VEGF) release by human subcutaneous adipose tissue explants and adipocytes incubated in primary culture for 48 hours. Vascular endothelial growth factor and IL-8 release by adipocytes were less than 10% of that by tissue explants, whereas that of leptin in adipocytes was comparable to that by tissue. Dexamethasone inhibited VEGF formation by both adipose tissue explants and isolated adipocytes, whereas insulin stimulated VEGF release only in isolated adipocytes. Insulin also enhanced the formation of IL-8 and plasminogen activation inhibitor 1 (PAI-1), but not that of IL-6 by adipocytes although having little effect on that of IL-6 or PAI-1 by adipose tissue explants. Pertussis toxin stimulated lipolysis and inhibited leptin release by human adipose tissue or adipocytes but did not affect release of IL-8 or VEGF. Isoproterenol also stimulated lipolysis by human adipocytes, but this was not accompanied by any significant changes in VEGF, IL-8, IL-6, or PAI-1 release. In contrast, insulin stimulated VEGF release by human adipocytes, and this stimulation was enhanced in the presence of isoproterenol. Insulin stimulated VEGF formation as well as that of PAI-1 by human adipocytes, but not by explants under conditions where it had little effect on that of IL-6. The ability of insulin to stimulate VEGF formation by adipocytes suggests that the elevated circulating levels of insulin in obesity promote angiogenesis in adipose tissue as well as the enhanced accumulation of fat in human adipocytes.

Topological models for prediction of anti-inflammatory activity of N-arylanthranilic acids

Relationship of anti-inflammatory activity of N-arylanthranilic acids with distance based Wiener's index, adjacency based Zagreb indices M1 and M2, and distance-cum-adjacency based eccentric connectivity index (ECI) was investigated. A dataset comprising of 112 N-arylanthranilic acids was selected. The values of all the four indices for each of the 112 compounds were calculated using an in-house computer program. The dataset was divided randomly into training and test sets. The data was analyzed and suitable models were developed after identification the active ranges in the training set. Subsequently, a biological activity was assigned to each of the compound involved in the test set using these models, which was then compared with the reported anti-inflammatory activity. High accuracy of prediction ranging from 83% to 90% was observed using models based upon topological indices.

Topochemical Models for Prediction of Anti-HIV Activity of 4-Benzyl Pyridinone Derivatives

Relationship between topochemical indices and anti-HIV activity of 4-Benzyl pyridinone derivatives has been investigated. The values of molecular connectivity topochemical index (an adjacency based topochemical descriptor) Wiener's topochemical index (a distance based topochemical descriptor) and superadjacency topochemical index (an adjacency cum distance based topochemical descriptor) were calculated for each of the 32 compounds comprising the data set using an in-house computer program. The resultant data was analyzed and suitable models were developed after identification of the active ranges. Subsequently, a biological activity was assigned using these models to each of the compounds involved in the dataset which was then compared with the reported anti-HIV activity. Exceptionally high accuracy of prediction was observed using these models. These models offer vast potential for providing lead structures for the development of potent anti-HIV agents.

Topochemical model for prediction of anti-HIV activity of HEPT analogs

The relationship between the superadjacency topochemical index and the anti-HIV activity of HEPT analogs has been investigated in the present study. The values of superadjacency topochemical index of all the analogs involved in the data set were calculated using an in-house computer program. Resulting data were analyzed and a suitable model was developed after identification of the active range. Subsequently, a computed biological activity was assigned to each of the compounds involved in the dataset, which was then compared with the reported anti-HIV activity. Accuracy of prediction was found to be 88% using the said model. The predictive ability of the model indicates that this model can be used for predicting the anti-HIV activity of the compounds prior to synthesis and may prove to be highly beneficial for providing lead structures for development of potent anti-HIV agents.

Effects of a laparoscopic course on student interest in surgical residency

BACKGROUND

The number of surgical residency applicants has been declining. Early introduction of the discipline of surgery is thought to stimulate early interest in surgical residency. This study investigated the hypothesis that a laparoscopic skills course introduced in preclinical years would stimulate student interest in entering surgical residency.

METHODS

Preclinical medical students participated in a laparoscopic skills training course. All students underwent an animate laboratory at the beginning and at the end of the course. Students were divided into 4 separate groups: virtual reality, box trainer, both trainers, and control group. Before and after the course, students were asked their residency interest. First- and second-year medical students participated in the course.

RESULTS

Before the course, 56% of the students desired to go into general surgery or a surgical subspecialty. After the course, 49% of the students expressed interest in entering general surgery or a surgical subspecialty. A decrease occurred in students who desired to go into surgical subspecialty residency from 31% to 15% (P = NS), and an increase occurred in students who desired to go into general surgery residency from 25% to 34% (P = NS). No statistically significant difference was seen in the 4 individual training subgroup analyses.

CONCLUSIONS

Participation in a laparoscopic skills course does not affect medical student interest in entering surgical residency. A trend was noted in students choosing general surgery over surgical subspecialty training after this course. Surgical educators need to investigate methods to encourage preclinical medical student interest in surgical residencies.

Predicting baseline laparoscopic surgery skills

BACKGROUND

Laparoscopic surgery requires specialized dexterity even beyond that required for open surgery. Decreased tactile feedback, different eye-hand coordination, and translation of a two-dimensional video image into a three-dimensional working area are just some of the obstacles in the performance of laparoscopic surgery. Possession of certain nonsurgical skills may help in overcoming some of these obstacles. Prediction of baseline laparoscopic surgery skills may help further to refine the education of basic laparoscopic surgery skills. This investigation explores whether nonsurgical skills and demographic data can predict baseline laparoscopic surgery tasks.

METHODS

First- and second-year students were given a survey regarding nonsurgical dexterity skills. The survey inquired about typing skills, play with computer games, ability to sew, skill with music instruments, use of chopsticks, and experience operating tools. Demographic data were requested as well. All the students underwent four tasks: placing a piece of bowel in a retrieval bag, placing a stapler on the bowel, measuring a piece of bowel, and performing a liver biopsy in a porcine animal model. Both objective (time and error) and subjective evaluation were assessed for all the tasks. Statistical analysis using analysis of variances (ANOVA) Kruskal-Wallis test with post hoc tests, two-tailed unpaired t-tests/Mann-Whitney test, and Fischer's exact tests/chi-square tests was performed when appropriate.

RESULTS

There were 68 students in this investigation. Gender, medical student year, ethnicity, desire to enter a surgical field, and age were not associated with increased performance in any of the tasks. Chopstick use was associated with statistically significantly better mean time in placing a piece of bowel in a retrieval bag and measuring a piece of bowel (p < 0.04). The other nonsurgical dexterity skills did not statistically increase performance, as indicated by time, errors, or subjective scores, for the four tasks.

CONCLUSIONS

It is difficult to predict baseline laparoscopic surgery skills.

Effect of body mass index on nonalcoholic fatty liver disease in patients undergoing minimally invasive bariatric surgery

The risk factors for nonalcoholic fatty liver disease in patients undergoing bariatric surgery are under study. We wanted to determine the correlation between nonalcoholic fatty liver disease and patient factors such as obesity and liver function tests. A retrospective analysis was performed on 177 nonalcoholic morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass with liver biopsy, to identify risk factors for nonalcoholic fatty liver disease. The histologic grade of liver disease was compared with preoperative body mass index, age, and liver function tests. Simple steatosis and steatohepatitis were present in 90% and 42% of patients, respectively. Elevated transaminase levels were an independent risk for liver disease. Body mass index and liver disease were not correlated with univariate analysis. Regression analysis performed on age, body mass index, and liver disease demonstrated that the risk for liver disease increased with body mass index in the younger (<35 years old) age group and decreased with body mass index in the older (>45 years old) age group. There was a high incidence of steatosis and steatohepatitis in these nonalcoholic bariatric patients, and elevated transaminase level was indicative of disease. Body mass index was a positive risk factor for liver disease in younger patients but a negative risk factor in the older patients.

Laparoscopic Transgastric Esophageal Mucosal Resection for High-Grade Dysplasia

BACKGROUND

High-grade dysplasia of the esophageal mucosa has been shown to be a precursor to adenocarcinoma. In addition to esophagectomy, multiple ablative endoscopic techniques have evolved for the management of this condition. As a surgical alternative to esophagectomy, we describe for the first time a new option in the treatment of high-grade dysplasia.

MATERIALS AND METHODS

Two patients with a history of gastroesophageal reflux disease (GERD) underwent upper gastrointestinal endoscopy which demonstrated high-grade dysplasia of the distal esophagus. The first patient had a short segment (0.5-1.0 cm), and the second patient had a longer (2 cm) segment of dysplasia. The patient is placed in the modified lithotomy position. Five trocars are placed as if to perform a fundoplication. A complete circumferential mobilization of the esophagus is performed. The short gastric vessels are divided with the harmonic scalpel, to free up the fundus of the stomach. An anterior horizontal gastrotomy is performed three to four centimeters below the gastroesophageal junction. A solution of epinephrine and normal saline (1:100,000) is injected into the mucosa at the Z-line and, utilizing specially designed hook electrocautery, the mucosa is incised circumferentially around a lighted bougie. Using blunt dissection the mucosa is undermined, elevated, and excised in four quadrants. Three centimeters of the distal esophageal mucosa are resected. The gastrotomy is then closed using a linear stapler, and a 360 degrees fundoplication is performed around a 50 Fr bougie.

RESULTS

High-grade dysplasia was identified in the specimens from both patients; however, neither patient was found to have carcinoma in situ or invasive esophageal cancer. Our first patient has been followed for twenty months, the second for ten months. Both patients underwent routine upper gastrointestinal endoscopy for surveillance of the healing process. At eight months, the mucosa of the first patient showed complete regeneration of squamous epithelium. Our most recent patient appears to be progressing without complications and has also demonstrated normal squamous epithelium at ten months postoperatively, without changes of Barrett's epithelium.

CONCLUSION

The technique of laparoscopic transgastric esophageal mucosal resection is feasible and may be proven to be an alternative to esophagectomy for the management of high-grade dysplasia.

Routine preoperative upper endoscopy for laparoscopic gastric bypass: is it necessary?

Upper endoscopy is often performed in patients undergoing bariatric procedures. Various pathologies may be found during upper endoscopy that may change treatment plans for these patients. This study tested the hypothesis that routine use of upper endoscopy is necessary before laparoscopic gastric bypass. All patients in a 6-month period who underwent laparoscopic gastric bypass for the treatment of morbid obesity were reviewed. Demographic data, body mass index (BMI), operative reports, upper endoscopies, and Helicobacter pylori results were reviewed. Documentation of polyps, ulcerations, and hiatal hernias were noted. Hiatal hernias were further classified as small (3.5 to 4.0 cm), medium (4.0 to 4.5 cm), and large (>4.5 cm). All patients (N = 102) had preoperative upper endoscopy. There were 87 female and 15 male patients. BMI ranged from 38.2 to 63.2 (mean, 48.2) and weight ranged from 93 to 232 kg (mean, 133 kg). Hiatal hernia incidences were small, 36.3 per cent; medium, 27.5 per cent; and large, 26.5 per cent. All of these hernias were verified and repaired at time of surgery. Distal esophagitis was noted in 24 per cent of patients. Other pathology (gastric polyps, duodenitis, Schatzki ring) was observed in 5 per cent of patients. Overall, 91 per cent of patients had some type of pathology seen on upper endoscopy. Of the patients tested, 20 per cent were positive for H. pylori and were medically treated. Routine use of preoperative upper endoscopy revealed significant pathology in many patients before laparoscopic gastric bypass. The pathology found modified treatment in many cases. Bariatric surgeons should adopt the routine use of preoperative upper endoscopy during the workup for bariatric surgery.

TNFalpha release by the nonfat cells of human adipose tissue

OBJECTIVE

The primary aim was to investigate the relative importance of the adipocytes vs the nonfat cells present in human adipose tissue with respect to release of immunoreactive tumor necrosis factor-alpha (TNFalpha). The second aim was to examine the correlation between body mass index (BMI) and the subsequent release of adiponectin and TNFalpha by explants of human subcutaneous and visceral adipose tissue incubated in primary culture for 48 h.

RESULTS

We found that the maximal release of TNFalpha was seen during the first 4 h of a 48-h incubation by explants of human adipose tissue in primary culture. Over 95% of the TNFalpha released to the medium by human adipose tissue explants over a 4-h incubation came from the nonfat cells present in the adipose tissue. The release of TNFalpha by the nonfat cells released during collagenase digestion was slightly higher than that by the cells present in the adipose tissue matrix after collagenase digestion. TNFalpha release by the combined matrix and isolated nonfat cells was greater than that by explants of tissue indicating some upregulation induced by collagenase digestion. Immunoreactive TNFalpha disappeared from the medium with a half-time of approximately 10 h. There was a positive correlation coefficient of 0.79 between TNFalpha release by tissue explants and the BMI of the fat donors as well as a correlation of 0.52 between BMI and release by adipocytes. TNFalpha release negatively correlated [-0.60] with adiponectin release by adipose tissue. The release of TNFalpha was far less than that of adiponectin or IL-6, and less than that of plasminogen activator inhibitor-1, hepatocyte growth factor, or leptin over a 4-h incubation of human adipose tissue explants. TNFalpha release over 4 h was enhanced by lipopolysaccharide and inhibited by a cyclooxygenase-2 inhibitor.

CONCLUSION

The release of TNFalpha by adipose tissue of obese humans is primarily due to the nonfat cells present in adipose tissue. TNFalpha is a short-lived adipokine whose release by human adipose tissue in primary culture correlates with the BMI of the fat donors.

Comparison of the release of adipokines by adipose tissue, adipose tissue matrix, and adipocytes from visceral and subcutaneous abdominal adipose tissues of obese humans

The purpose of this study was to examine the source of adipokines released by the visceral and sc adipose tissues of obese humans. Human adipose tissue incubated in primary culture for 48 h released more prostaglandin E(2), IL-8, and IL-6 than adiponectin, whereas the release of plasminogen activator inhibitor 1 and hepatocyte growth factor was less than that of adiponectin but greater than that of leptin. IL-10 and TNFalpha were released in amounts less than those of leptin, whereas vascular endothelial growth factor and IL1-beta were released in much lower amounts. The accumulation of adipokines was also examined in the three fractions (adipose tissue matrix, isolated stromovascular cells, and adipocytes) obtained by collagenase digestion of adipose tissue. Over 90% of the adipokine release by adipose tissue, except for adiponectin and leptin, could be attributed to nonfat cells. Visceral adipose tissue released greater amounts of vascular endothelial growth factor, IL-6, and plasminogen activator inhibitor 1 compared with abdominal sc tissue. The greatly enhanced total release of TNFalpha, IL-8, and IL-10 by adipose tissue from individuals with a body mass index of 45 compared with 32 was due to nonfat cells. Furthermore, most of the adipokine release by the nonfat cells of adipose tissue was due to cells retained in the tissue matrix after collagenase digestion.

Haptoglobin release by human adipose tissue in primary culture

Haptoglobin is a putative adiposity marker because its concentration in blood is increased in obese humans. The present studies examined haptoglobin release by explants of adipose tissue in primary culture. Haptoglobin was released by explants of human visceral and subcutaneous adipose tissue at a nearly linear rate over 48 h. Explants of visceral adipose tissue released more haptoglobin than did explants of subcutaneous adipose tissue. The release of haptoglobin was quite variable, but there was a close correlation between haptoglobin release by visceral adipose tissue and that by explants of subcutaneous tissue from the same individual. Dexamethasone and niflumic acid, a cyclooxygenase-2 inhibitor, both inhibited haptoglobin release. There was release of haptoglobin by both isolated adipocytes and the adipose tissue matrix remaining after collagenase digestion of human adipose tissue. However, the amount of haptoglobin released by human adipose tissue explants in primary culture was quite low in relationship to the circulating level of haptoglobin.

Solid and papillary epithelial neoplasm of the pancreas

Solid and papillary epithelial (SPEN) is an uncommon pancreatic tumor often seen in young females. Although most of these neoplasms have a benign course, SPEN do have malignant potential. Treatment is surgical which is usually feasible either via enucleation or more radical procedures. Below we discuss diagnosis, treatment, and prognosis in detail.

The myth of the short esophagus

BACKGROUND

The advent of laparoscopic surgery has increased the number of fundoplications performed today. With the increase in laparoscopic fundoplications, the reports of short esophagus continue to increase. This investigation was undertaken to review our data regarding the entity described as "short esophagus."

METHOD

All charts of patients who had laparoscopic fundoplications performed from 1991 to 2000 were reviewed. Patients with laparoscopic fundoplications received esophagrams at 3 months postoperatively and then at 6 months.

RESULTS

A total of 628 fundoplications were performed, with 351 requiring hiatal hernia repair. After appropriate esophageal mobilization was performed, no further esophageal lengthening procedure was needed. There were 4 conversions, 16 recurrences, and 7 complications, and no deaths. Recurrences were due to "slipped fundoplications" ( n = 3), ineffective valves ( n = 5), and hiatal hernia disruptions ( n = 8).

CONCLUSIONS

In our series of fundoplications and hiatal hernia repairs, no short esophagus was noted. With proper esophageal mobilization, clinically the entity described as "short esophagus" may not exist.