Translation and Linguistic Validation of the Patient's Knee Implant Performance (PKIP) into Japanese.

Objective: The patient's knee implant performance (PKIP) is a patient-reported outcome measure, developed in the USA in English that evaluates knee functional performance before and after primary total knee arthroplasty (TKA). The PKIP assesses the level of satisfaction, confidence, and stability, while performing various activities, as well as the need for changing ways of doing activities. It comprises 24 items. The objective of this study was to present the methodology of the linguistic validation of the PKIP. Methods: The Japanese version of the PKIP was developed using a standard linguistic validation (LV) process. The LV involved the following steps: (1) conceptual analysis of the original version; (2) translation into Japanese using a dual forward/backward translation process; (3) review by an orthopaedics surgeon; (4) test on five respondents; and (5) proofreading. Results: The translation itself did not reveal major translatability issues, either cultural, semantic, or syntactic. Most of the activities listed (e.g., going up stairs, getting in/out of a car, and walking up a hill/ramp/incline) were easily translated. Only one activity was culturally sensitive and raised some discussion, i.e., "sitting down on a toilet," since the style of Japanese toilets is different from the western style. Overall, the respondents well understood the questionnaire. However, the expression "how your knee is working with your body" used in the opening sentence was an issue for both the clinician and the respondents. A compromise was found by using a Japanese equivalent of "how your knee functions with your legs." Conclusion: The rigorous translation process, which involved the collaboration of a minimum of thirteen people (sponsor, four translators, two coordinators (one in Japan and one in Europe), one clinician, and five respondents) enabled the production of a Japanese version of the PKIP conceptually equivalent to the USA English original.

Bariatric surgery versus medical treatment in mildly obese patients with type 2 diabetes mellitus in Japan: Propensity score-matched analysis on real-world data.

AIMS/INTRODUCTION: To compare glycemic control 1 year after treatment in patients with mildly obese (body mass index 27.5-34.9 kg/m2 ) type 2 diabetes mellitus who underwent bariatric surgery (BS) to those who received medical treatment (MT) in Japan. MATERIALS AND METHODS: A retrospective study using real-world data was carried out in electronic medical records from a tertiary care hospital and in the Japanese Medical Data Center Inc. claim database from 2008 to 2019. Each patient was propensity score-matched between the BS and the MT group by age, sex, body mass index, glycated hemoglobin and type 2 diabetes mellitus duration, and compared from the index date to the 1 year post-index. RESULTS: The study included 78 patients in the BS group and 238 patients in the MT group. The mean body mass index in the BS and the MT group was 32.1 and 32.0 kg/m2 , respectively. In the BS group, the patients underwent either laparoscopic sleeve gastrectomy with or without duodenojejunal bypass. The diabetes remission rate (glycated hemoglobin <6.5% without diabetes medication) at 1 year was 59.0% in the BS group and 0.4% in the MT group (P < 0.0001). Optimal glycemic control of glycated hemoglobin <7.0% was achieved in 75.6% in the BS group and in 29.0% in the MT group (P < 0.0001). The median monthly drug costs for metabolic syndrome decreased from $US126.5 (at baseline) to $US0.0 (at 1 year) in the BS group, whereas it increased from $US52.4 to $US58.3 in the MT group. CONCLUSIONS: BS for mildly obese patients with type 2 diabetes mellitus is more clinically- and cost-effective than MT in Japan.

Background characteristics and postoperative outcomes of insufficient weight loss after laparoscopic sleeve gastrectomy in Japanese patients.

AIM: Laparoscopic sleeve gastrectomy (LSG) is becoming popular in Japan, but insufficient weight loss is often observed in patients after LSG. We investigated the effect of LSG on obesity-related comorbidities and identified the background characteristics of Japanese patients with insufficient weight loss after LSG. METHODS: In this multi-institutional retrospective study at 10 certified bariatric institutions, 322 Japanese patients who underwent LSG with a follow-up period of more than 2 years were analyzed. Anthropometry, obesity-related comorbidities and psychosocial background data were collected. Weight loss was expressed as 2-year percent total weight loss (%TWL). RESULTS: Mean age, body weight, body mass index (BMI) and glycated hemoglobin were 46.9 years, 119.2 kg, 43.7 kg/m2 and 7.1%, respectively. Prevalence of mental disorders was 26.3%. Mean BMI declined to 30.3 kg/m2 at 2 years and %TWL was 29.9%. Improvements in the markers and prevalence of obesity-related comorbidities were observed. Remission rates of diabetes, dyslipidemia and hypertension were 75.6%, 59.7% and 41.8%, respectively. %TWL at the respective cut-off level of diabetes remission was 20.8%. Lower remission rates of diabetes in patients with %TWL <20%, and less calorie restriction and higher prevalence of mental disorders (46.9%) in patients with %TWL <15% were observed. Frequencies of %TWL <15% and <20% were 6.5% and 18.5%, respectively. CONCLUSION: %TWL 20% was a candidate cut-off point of insufficient weight loss for diabetes remission after LSG, and mental disorders might be relevant to intractable obesity in Japanese patients.

Effect of Roux-en-Y gastric bypass on liver mitochondrial dynamics in a rat model of obesity.

Bariatric surgery provides significant and durable improvements in glycemic control and hepatic steatosis, but the underlying mechanisms that drive improvements in these metabolic parameters remain to be fully elucidated. Recently, alterations in mitochondrial morphology have shown a direct link to nutrient adaptations in obesity. Here, we evaluate the effects of Roux-en-Y gastric bypass (RYGB) surgery on markers of liver mitochondrial dynamics in a diet-induced obesity Sprague-Dawley (SD) rat model. Livers were harvested from adult male SD rats 90-days after either Sham or RYGB surgery and continuous high-fat feeding. We assessed expression of mitochondrial proteins involved in fusion, fission, mitochondrial autophagy (mitophagy) and biogenesis, as well as differences in citrate synthase activity and markers of oxidative stress. Gene expression for mitochondrial fusion genes, mitofusin 1 (Mfn1; P < 0.05), mitofusin 2 (Mfn2; P < 0.01), and optic atrophy 1 (OPA1; P < 0.05) increased following RYGB surgery. Biogenesis regulators, peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α; P < 0.01) and nuclear respiratory factor 1 (Nrf1; P < 0.05), also increased in the RYGB group, as well as mitophagy marker, BCL-2 interacting protein 3 (Bnip3; P < 0.01). Protein expression for Mfn1 (P < 0.001), PGC1α (P < 0.05), BNIP3 (P < 0.0001), and mitochondrial complexes I-V (P < 0.01) was also increased by RYGB, and Mfn1 expression negatively correlated with body weight, insulin resistance, and fasting plasma insulin. In the RYGB group, citrate synthase activity was increased (P < 0.02) and reactive oxygen species (ROS) was decreased compared to the Sham control group (P < 0.05), although total antioxidant capacity was unchanged between groups. These data are the first to show an association between RYGB surgery and improved markers of liver mitochondrial dynamics. These observed improvements may be related to weight loss and reduced energetic demand on the liver, which could facilitate normalization of glucose homeostasis and protect against hepatic steatosis.

Feasibility of laparoscopic surgery after stent insertion for obstructive colorectal cancer.

INTRODUCTION: A growing number of patients with obstructive colorectal cancer are being treated with self-expanding metallic stents (SEMS) followed by laparoscopic resection. The aim of this study was to assess the feasibility of stent insertion and laparoscopic surgery for obstructive colorectal cancer and to compare these outcomes to regular laparoscopic surgery for non-obstructive colorectal cancer. METHODS: We retrospectively analyzed the outcomes of patients with a malignant colonic obstruction who underwent SEMS placement followed by elective laparoscopic resection. The comparison was made between stent-laparoscopy and laparoscopy alone for non-obstructive colorectal cancer. RESULTS: Colonic stenting as a bridge to surgery was successful in 97.1% of all cases. Fifteen patients underwent an elective laparoscopic surgery for left-sided colon and rectal cancer after SEMS. The mean interval from SEMS insertion to laparoscopic surgery was 21.5 days. There was no conversion to open surgery and no need for a diverting stoma. One patient (6.7%) experienced paralytic ileus. Our comparison of stent-laparoscopy to regular laparoscopy for non-obstructive colorectal cancer treatment showed comparable short-term postoperative outcomes with the exception of blood loss, which was greater in the stent-laparoscopy group. CONCLUSION: Elective laparoscopic surgery after colonic stenting is a safe and feasible strategy for the treatment of an acute malignant colonic obstruction.

Totally Laparoscopic Resection for Low Sigmoid and Rectal Cancer Using Natural Orifice Specimen Extraction Techniques.

BACKGROUND: A minilaparotomy for specimen extraction during laparoscopy occasionally results in postoperative wound complications. We have performed a totally laparoscopic resection for early colorectal cancer using the natural orifice specimen extraction technique. METHODS: From 2008 to 2013, we have performed a totally laparoscopic resection for clinical stage I and IIA low sigmoid colon and rectal cancers. A prospectively maintained database was reviewed to assess the outcomes after surgery. RESULTS: In total, 40 patients had high anterior resections using transanal specimen extraction, and 32 patients had low anterior resections with transanal pull-through. Eight patients (11%) reported conversion to conventional laparoscopic colorectal resections; anastomotic leakages occurred in 4 patients (5.6%). No mortality or cancer recurrence was observed during 42.5±16.2 months of follow-up. CONCLUSIONS: One natural orifice specimen extraction technique, known as transanal specimen extraction, has emerged as a promising form of totally laparoscopic surgical intervention for early-stage cancers of the low sigmoid colon and rectum.

Early Effects of Sleeve Gastrectomy on Obesity-Related Cytokines and Bile Acid Metabolism in Morbidly Obese Japanese Patients.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has wide-ranging positive effects on adipocytokine metabolism, bile acid profile, and chronic low-grade inflammation related to obesity. However, the early temporal changes in these markers following LSG have not been well investigated. This study aimed to evaluate the early effects of LSG on adipocytokines, bile acid profile, and inflammatory markers. METHODS: This was a nonrandomized prospective study examining morbidly obese Japanese patients undergoing LSG. Serial measurements of leptin, adiponectin, bile acids, fibroblast growth factor (FGF)-19, and inflammatory markers were performed preoperatively and 1 and 6 months after LSG. RESULTS: The study included ten patients (five females) with a mean age of 48.8 years and BMI 40.9 kg/m2. At baseline, 90% of the patients had T2DM, 70% had dyslipidemia, and 90% had hypertension. Patients lost 5.1 kg/m2 BMI at 1 month and 10.1 kg/m2 BMI at 6 months. The leptin levels sharply decreased, and FGF-19 increased significantly as early as 1 month postoperatively. Adiponectin levels showed an increasing trend at 1 month and a significant increase at 6 months. A significant decrease in high-sensitivity CRP and plasminogen activator inhibitor-1 was observed at 6 months. No significant changes were observed in interleukin (IL)-6, IL-8, tumor necrosis factor-α, serum amyloid A protein, or monocyte chemotactic protein-1 throughout the study. CONCLUSIONS: LSG improved the secretion of adipocytokines, increased FGF-19 secretion soon after surgery, and slowly ameliorated inflammation related to obesity through significant weight loss.

Outcomes of Bariatric Surgery in Morbidly Obese Patients with Multiple Sclerosis.

Obesity is common in patients with multiple sclerosis (MS); however, safety and efficacy of bariatric surgery in this population remain unclear. A database of 2,918 was retrospectively reviewed, yielding 22 (0.75%) severely obese patients with MS who underwent bariatric surgery. Sixteen surgical patients with complete follow-up data were matched to a nonsurgical control group of MS patients, based on age, BMI, MS subtype, and length of follow-up. MS relapse rates and trends in the timed twenty-five foot walk test (T25FW) were compared. In the surgical group (gastric bypass n = 19, sleeve gastrectomy n = 3), preoperative BMI was 46.5 ± 7.2 Kg/m2 and average excess weight was 60.4 kg. Follow-up data was collected at 59.0 ± 29.8 months. There were two major and four minor complications. Five patients required readmission and there were no mortalities. Percent excess weight loss was 75.5 ± 27.0%. In the 16 patients with follow-up data, patients who underwent bariatric surgery were significantly faster on the T25FW compared to the nonsurgical population. In conclusion, bariatric surgery is relatively safe and effective in achieving weight loss in patients with MS. In addition, surgery may help patients maintain ambulation. Findings support the need for further studies on bariatric surgery and disease-specific outcomes in this population.

Effect of Roux-en-Y Gastric Bypass on the NLRP3 Inflammasome in Adipose Tissue from Obese Rats.

OBJECTIVE: Obesity is associated with low-grade chronic inflammation. We hypothesized that Roux-en-Y gastric bypass (RYGB) surgery would reduce activation of the NLRP3 inflammasome in metabolically active adipose tissue (AT) of obese rats, and this change would be related to decreases in body weight and improved glycemic control. METHODS: Omental, mesenteric and subcutaneous fat depots were collected from Sprague-Dawley rats: Sham control and RYGB; 90-days after surgery. NLRP3, caspase-1, apoptosis-associated speck-like protein (ASC), IL-1ß, IL-18, IL-6 and MCP-1 gene and protein expression were quantified. Glucose metabolism was assessed by oral glucose tolerance test (OGTT). RESULTS: Compared to Sham surgery controls, RYGB surgery decreased IL-6, MCP-1, NLRP3, IL-18, caspase-1 and ASC in omental fat, and decreased IL-6, MCP1, IL-1ß, IL-18, caspase-1 and ASC gene expression in mesenteric fat. We observed differential gene expression between visceral and subcutaneous fat for IL-6 and IL-1ß, both being downregulated by RYGB in visceral, and upregulated in subcutaneous depots. These changes in gene expression were accompanied by a decrease in NLRP3, ASC, IL-18, caspase-1 and IL-1ß protein expression in omental tissue. We found a positive correlation between caspase-1, ASC, MCP-1, IL-18 and IL-6 gene expression following surgery and glucose AUC response in omental fat, while the change in glucose AUC response correlated with caspase-1 gene expression in subcutaneous fat. CONCLUSION: This study demonstrates that bariatric surgery reverses inflammation in visceral adipose tissue by suppressing NLRP3 inflammasome activation. These are the first data to implicate the NLRP3 inflammasome in diabetes remission after RYGB surgery.

Pre-operative opioid analgesia reduces clinical success of laparoscopic gastric electrical stimulation placement in patients with gastroparesis.

INTRODUCTION: Gastroparesis is a common chronic and costly disorder for which medical therapy is often unsuccessful. Gastric electrical stimulation (GES) has been used to treat refractory cases, however, response is variable and difficult to predict. This study aims to assess whether pre-operative opioid analgesics (OA) use affects clinical success of GES. METHODS: Records of 128 patients who underwent laparoscopic GES placement from March 2001 to September 2012 were analyzed retrospectively. Data collected included demographics, surgical outcomes, and clinical parameters. Pre- and post-operative opioid analgesic dosing (No = 0 morphine equivalents (ME)/day, Low = 0-40 ME/day, Mid = 41-80 ME/day, High >80 ME/day), as well as clinical symptom assessment was collected for up to 3 years post-operatively. Clinical success was defined as (1) OA reduction of >50 %, (2) maintenance of weight, or (3) symptom improvement. Descriptive statistics were computed for all factors. A p < 0.05 was considered statistically significant. RESULTS: Fifty-three patients were on OA pre-operatively compared to 69 patients who were not. Patients not on OA pre-operatively were less likely than those on OA pre-op group to be on OA post-operatively (p = 0.005); however, there were no differences in weight or symptom improvement. Sub-group analysis of the 53 patients on OA demonstrated significant improvement in clinical symptoms in the low-morphine cohort compared to the mid-morphine cohort (p = 0.02), and OA dosing post-operatively in the low-morphine cohort diminished significantly compared to mid- and high-morphine cohort (p = 0.032). There was no significant difference in weight. CONCLUSION: OA dosing pre-operatively significantly affects clinical success of GES placement. Criteria for offering GES implantation may need to take OA dosing into consideration.

Thromboembolic events in bariatric surgery: a large multi-institutional referral center experience.

INTRODUCTION: The risk of venous thromboembolic (VTE) events is increased in patients undergoing bariatric surgery. Population studies examining VTE rates after bariatric surgery often lack details and uniformity regarding the prophylactic regimens used. The aim of this study was to determine the incidence of VTE in patients undergoing laparoscopic bariatric surgery. METHODS: Database searches from Cleveland Clinic bariatric surgery programs in Cleveland, OH, and Weston, FL, were conducted from January 2005 to January 2013. Mechanical and chemical prophylaxes were provided for all patients as per protocol. Data on age, gender, body mass index (BMI), interval between procedure and VTE, inpatient versus outpatient status, anticoagulation prophylaxis, type of surgery and mortality were collected. RESULTS: A total of 4,293 patients underwent primary or revisional bariatric surgery during this 8-year time period. VTE events were identified in 57 patients (1.3 %). Pulmonary embolism (PE) was identified in 39 patients (0.9 %), and 15 of these patients had negative duplex studies of the lower extremities. Deep venous thrombosis only was identified in 18 patients (0.4 %). VTE rates for gastric bypass (n = 2,945), sleeve gastrectomy (n = 709), gastric banding (n = 467) and revisional procedures (n = 171) were 1.1, 2.9, 0.2 and 6.4 %, respectively. Eight patients had VTE diagnosed during their inpatient stay. The mean time to VTE diagnosis after surgery was 24 days. Seventeen patients who developed VTE had been prescribed extended prophylaxis for 2-4 weeks after discharge. There was only one VTE-related mortality from PE reported in this cohort (0.02 %). Univariate and multivariate analyses revealed age, BMI, open and revisional surgery as predictive of VTE (p < 0.05). CONCLUSION: The risk of VTE among morbidly obese patients undergoing bariatric surgery is persistent despite use of laparoscopy and aggressive prophylactic anticoagulation policy. Patients with advanced age, higher BMI and those undergoing open or revisional surgery are at higher risk of postoperative VTE.

Laparoscopic bariatric surgery can be performed through a single incision: a comparative study.

BACKGROUND: The application of single-incision laparoscopic surgery (SILS) in bariatric patients has been limited to less complex procedures. We evaluated the short-term outcomes of SILS sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), compared to a group of well-established minimally invasive techniques. METHODS: Twenty-eight morbidly obese patients who underwent SILS SG (n = 14) and RYGB (n = 14) were compared to a matched control group composed of 28 cases of conventional laparoscopic surgery (CLS). A single vertical 2.5-3-cm intra-umbilical incision, three-ports placed trans-fascially, and a liver suspension technique were used to perform SILS. RESULTS: Both groups were comparable in terms of age (p = 0.96), gender (p = 1.0), type of procedure (p = 1.0), and number of comorbidities (p = 0.63). Two (7%) SILS patients required placement of one additional port, and no conversions to CLS or open surgery were needed. The estimated blood loss (p = 0.48), operative time (p = 0.33), length of hospital stay (p = 0.79), overall 90-day perioperative complication rate (p = 1.0), and short-term weight loss (p = 0.53) were comparable between the two groups. In terms of pain control, the frequency of patient-controlled analgesia use in both groups was similar. However, the pain score (assessed by visual analog scale) was significantly less for SILS patients on postoperative days 1 (5.0 ± 2.1 vs. 6.5 ± 1.8; p = 0.007) and 2 (4.0 ± 2.0 vs. 5.1 ± 2.4; p = 0.49). Cosmetic satisfaction with the scar was high in the SILS group. No patients required reoperation or readmission during the 90 days after surgery. CONCLUSION: SILS is feasible in carefully selected bariatric patients and results in short-term outcomes comparable to those observed after CLS. Improved pain and cosmesis are potential benefits of SILS.

Clinical experience with a port-free internal liver retractor in laparoscopic bariatric surgery.

BACKGROUND: As laparoscopic techniques and instrumentation advance, bariatric surgery has begun to be performed through smaller incisions and fewer ports. Since the visualization of the dorso-lateral portion of the left liver lobe is critical for most bariatric procedures, surgeons have developed various techniques for providing adequate liver retraction without compromising patient safety. Herein, we present our experience with a port-free internal liver retractor used for bariatric cases. METHODS: Endolift™ does not require an additional port or anchoring to an external device. After insertion through an existing 5-mm port by means of the applier, one of the two attached clips (one on either end) was anchored to the left crus of the diaphragm while the other was fixed to the peritoneum above the right liver lobe through or beneath the falciform ligament. At the end of the surgery, the device was easily removed by using the applier. RESULTS: We used this technique for 31 Roux-en-Y gastric bypasses and 2 single-incision sleeve gastrectomies. There were 24 females and 9 males with a mean age of 46 and mean body mass index 45.0 kg/m(2). The mean operative time was 136.5 min. The time required for the placement of the device was 1-3 min. The approach to the upper part of the stomach was satisfactory in all patients. No device-related complications were observed. CONCLUSIONS: The internal liver retractor is easy to handle and provides adequate retraction and exposure for bariatric cases. It also has potential benefits for single-incision and reduced port laparoscopic procedures.

The effect of selective gut stimulation on glucose metabolism after gastric bypass in the Zucker diabetic fatty rat model.

BACKGROUND: Potential mechanisms underlying the antidiabetic effects of Roux-en-Y gastric bypass (RYGB) include altered nutrient exposure in the gut. The aim of this study was to evaluate the effects of selective gut stimulation on glucose metabolism in an obese diabetic rat model. METHODS: Sixteen male Zucker diabetic fatty rats were randomly assigned to 1 of 2 groups: RYGB with gastrostomy tube (GT) insertion into the excluded stomach or a control group with GT insertion into the stomach. An insulin tolerance test (ITT), oral glucose tolerance test (OGTT), and mixed meal tolerance test (MMTT) were performed before and 14-28 days after surgery. A glucose tolerance test via GT (GTT-GT) and MMTT via GT were performed postoperatively. RESULTS: Postoperatively, the RYGB group had significant decreases in weight and food intake. Both the ITT and OGTT tests revealed significantly improved glucose tolerance after RYGB. The GTT-GT showed a reversal of the improved glucose tolerance in the RYGB group. In response to meal stimulation, postoperatively, the RYGB group increased glucagon-like peptide 1 (GLP-1) secretion via the oral route and peptide YY secretion by both oral and GT routes. CONCLUSION: When foregut exposure to nutrients was reversed after RYGB, the improvement in glucose metabolism was abrogated. This model can be extended to identify the role of gut in glucose homeostasis in type 2 diabetes.

[A case of rapidly progressing treatment-resistant colorectal neuroendocrine carcinoma].

We performed primary lesion resection in a 48-year-old man diagnosed with sigmoid colon cancer showing multiple liver metastases and extensive lymph node metastases. Endocrine cell carcinoma was diagnosed from an excised specimen. In the early postoperative period, orbital metastases and thoracic spine metastasis were detected, while the multiple liver metastases and lymph node metastases worsened markedly. We administered radiotherapy for the orbital and thoracic spine metastases, but it was ineffective. Treatment with anticancer agents was also ineffective. The patient died 56 days after the operation.

Revisional bariatric surgery for unsuccessful weight loss and complications.

BACKGROUND: There are growing numbers of patients who require revisional bariatric surgery due to the undesirable results of their primary procedures. The aim of this study was to review our experience with bariatric patients undergoing revisional surgery. METHODS: We conducted a retrospective analysis to review the indications for revisional bariatric procedures and assess their postoperative outcomes. RESULTS: From 04/04 to 01/11, 2,918 patients underwent bariatric surgery at our institution. A total of 154 patients (5.3%) of these cases were coded as revisional procedures. The mean age at revision was 49.1 ± 11.3 and the mean BMI was 44.0 ± 13.7 kg/m2. Revisional surgery was performed laparoscopically in 121 patients (78.6%). Laparoscopic revisions had less blood loss, shorter length of hospital stay, and fewer complications compared to open revisions. Two groups (A and B) were defined by the indication for revision: patients with unsuccessful weight loss (group A, n = 106) and patients with complications of their primary procedures (group B, n = 48). In group A, 74.5% of the patients were revised to a bypass procedure and 25.5% to a restrictive procedure. Mean excess weight loss was 53.7 ± 29.3% after revision of primary restrictive procedures and 37.6 ± 35.1% after revision of bypass procedures at >1-year follow-up (p < 0.05). In group B, the complications prompting revision were effectively treated by revisional surgery. CONCLUSIONS: Revisional bariatric surgery effectively treated the undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed after both failed open and laparoscopic bariatric procedures without a prohibitive complication rate. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss.

Surgical management of early small bowel obstruction after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Limited data are available regarding early postoperative small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of the present study was to review our experience with early SBO after LRYGB. The setting was a tertiary referral bariatric center. METHODS: We reviewed a prospectively maintained database to assess the diagnosis, management, and outcomes of patients who underwent surgery for SBO within 30 days of LRYGB. RESULTS: From April 2004 to December 2011, 2126 patients underwent LRYGB. Of these patients, 11 (.5%) required surgical management for early SBO. Of the 11 patients, 9 were women and 2 were men. with a mean age of 53 years (range 35-70) and mean body mass index of 45 kg/m(2) (range 38-65). The average interval from LRYGB to the presentation of SBO was 5.0 days (range 2-15). All early SBOs were diagnosed by computed tomography with oral contrast. The causes of early SBO included kinking at the jejunojejunostomy in 4, an intraluminal blood clot near the jejunojejunostomy in 2, angulation of the Roux limb in 1, mesenteric hematoma in 1, intra-abdominal hematoma in 1, obstruction of common channel in 1, and pelvic adhesions from previous surgery in 1. Diagnostic laparoscopy was attempted in all patients. Four patients required conversion to open surgery. Postoperative complications developed in 5 patients; no patient died. Laparoscopic management of early SBO resulted in fewer complications than the open approach. CONCLUSION: Early SBO after LRYGB is uncommon; however, a prompt diagnosis and surgical intervention are important to prevent additional morbidity. The ability to complete the reoperation laparoscopically varies with the etiology and location of the obstruction.

Bariatric surgery in patients with liver cirrhosis.

BACKGROUND: Data regarding the management of bariatric patients with cirrhosis are scarce, and there is no strong evidence that supports a specific approach for this group of patients. The aim of this study was to review our experience with cirrhotic patients undergoing bariatric surgery. METHODS: A prospectively maintained database was reviewed to assess the outcomes of bariatric surgery for patients with known cirrhosis and for patients with cirrhosis discovered at surgery (unknown cirrhosis). RESULTS: From April 2004 to September 2011, 23 patients (12 with known cirrhosis and 11 with unknown cirrhosis) met inclusion criteria. There were 14 females and 9 males with a mean age of 51.5 ± 8.3 and a mean body mass index of 48.2 ± 8.6 kg/m2. Child-Pugh classes were A (n = 22) and B (n = 1). Patients had a high frequency of diabetes (83%), dyslipidemia (61%), and hypertension (83%). Procedures performed were laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 14), laparoscopic sleeve gastrectomy (LSG) (n = 8), and laparoscopic adjustable gastric banding (n = 1). Two patients underwent LSG successfully after transjugular intrahepatic portosystemic shunt. Mean length of hospital stay was 4.3 ± 2.7 days. Complications developed in 8 patients. One patient died of unknown cause 9 months after surgery. No patients had liver decompensation after surgery. The patients lost 67.4% ± 30.9% of their excess weight at 12 months follow-up and 67.7% ± 24.8% at 37 months follow-up. CONCLUSION: LRYGB and LSG can be performed without prohibitive complication rates in carefully selected patients with cirrhosis. In our experience, bariatric patients with cirrhosis achieved excellent weight loss and improvement in obesity-related co-morbidities.

Material design of plasma-enhanced chemical vapour deposition SiCH films for low-k cap layers in the further scaling of ultra-large-scale integrated devices-Cu interconnects.

Cap layers for Cu interconnects in ultra-large-scale integrated devices (ULSIs), with a low dielectric constant (k-value) and strong barrier properties against Cu and moisture diffusion, are required for the future further scaling of ULSIs. There is a trade-off, however, between reducing the k-value and maintaining strong barrier properties. Using quantum mechanical simulations and other theoretical computations, we have designed ideal dielectrics: SiCH films with Si-C2H4-Si networks. Such films were estimated to have low porosity and low k; thus they are the key to realizing a cap layer with a low k and strong barrier properties against diffusion. For fabricating these ideal SiCH films, we designed four novel precursors: isobutyl trimethylsilane, diisobutyl dimethylsilane, 1, 1-divinylsilacyclopentane and 5-silaspiro [4,4] noname, based on quantum chemical calculations, because such fabrication is difficult by controlling only the process conditions in plasma-enhanced chemical vapor deposition (PECVD) using conventional precursors. We demonstrated that SiCH films prepared using these newly designed precursors had large amounts of Si-C2H4-Si networks and strong barrier properties. The pore structure of these films was then analyzed by positron annihilation spectroscopy, revealing that these SiCH films actually had low porosity, as we designed. These results validate our material and precursor design concepts for developing a PECVD process capable of fabricating a low-k cap layer.