Bariatric surgery and bone disease: from clinical perspective to molecular insights.

The use of bariatric surgery for the treatment of morbid obesity has increased annually for the last decade. Although many studies have demonstrated the efficacy and durability of bariatric surgery for weight loss, there are limited data regarding long-term side effects of these procedures. Recently, there has been an increased focus on the impact of bariatric surgery on bone metabolism. Bariatric surgery utilizes one or more of three mechanisms of action resulting in sustained weight loss. These include restriction (gastric banding, vertical banded gastroplasty and sleeve gastrectomy), malabsorption surgery with or without associated restriction (Roux en Y gastric bypass, duodenal switch, biliopancreatic diversion and jejunoileal bypass) and changes in gut-derived hormones that control energy metabolism also referred to as neuro-hormonal control of energy metabolism (Roux en Y gastric bypass, duodenal switch, biliopancreatic diversion, jejunoileal bypass, surgical procedures as above and gastric sleeve). Weight reduction has been associated with increased bone resorption but the mechanisms behind this have not yet been fully elucidated. Each of the mechanisms of action of bariatric surgery (restriction, malabsorption, neuro-hormonal control of energy metabolism) may uniquely affect bone resorption. In this paper we will review the current state of knowledge regarding the relationship between bariatric surgery and bone metabolism with emphasis on possible mechanisms of action such as malnutrition, hormonal interactions and mechanical unloading of the skeleton. Further, we suggest a future research agenda.

Management of common bile duct stones in a rural area of the United States: results of a survey.

BACKGROUND: Laparoscopic common bile duct exploration has been reported to be highly successful and cost-effective. It remains unknown to what extent the procedure is used in routine surgical practice. METHODS: We conducted a survey of general surgeons practicing in a rural area of the United States. The type of practice, laparoscopic training, performance of cholangiography, and preferred approach to choledocholithiasis were elicited. RESULTS: Sixty-eight of 207 surveys (33%) were returned. Thirty respondents (45%) indicated that they perform laparoscopic common bile duct explorations. The likelihood of laparoscopic common bile duct exploration increased with a higher number of cholecystectomies per year (p < 0.05, chi-square) but was independent of training or routine cholangiography. The preferred approach to a patient with choledocholithiasis was endoscopic retrograde cholangiopancreatography (75%), followed by laparoscopic (21%) and open exploration (4%). Reasons for not performing laparoscopic exploration were time (58%), equipment (24%), good gastrointestinal backup (6%), reimbursement (3%), increased morbidity (1.5%), lack of skill (1.5%), and other/no reason (18%). CONCLUSION: Although 45% of practicing surgeons indicated that they perform laparoscopic common bile duct explorations, only 21% practiced it as their preferred approach. Time constraints and lack of equipment are the main factors preventing the application of the laparoscopic technique toward choledocholithiasis.

The current role of staging laparoscopy for adenocarcinoma of the pancreas: a review.

In the absence of metastatic disease patients with localized or locally advanced pancreatic cancer can benefit from surgical resection or chemoradiation. Despite the advances of imaging technology, however, noninvasive staging modalities are still inaccurate in identifying small volume metastatic disease leading potentially to inappropriate treatment and avoidable morbidity in a subgroup of patients. Staging laparoscopy may identify those patients with unsuspected metastatic disease on preoperative imaging and prevent unnecessary laparotomy or chemoradiation. A controversy exists, however, as to whether the procedure should be used routinely or selectively in pancreatic cancer patients with no evidence of metastasis on noninvasive staging. This review aims to assess the current role of staging laparoscopy by examining its diagnostic accuracy and ability to prevent unnecessary treatment as well as its morbidity, oncologic effect and cost-effectiveness. The available literature will be evaluated critically, its limitations identified and exisiting controversies addressed.

Early conversion for gangrenous cholecystitis: impact on outcome.

BACKGROUND: Early conversion from laparoscopic to open cholecystectomy for patients with gangrenous cholecystitis has been advocated. This study investigated the impact of early conversion on patient outcome. METHODS: Data from all patients with gangrenous cholecystitis undergoing laparoscopic cholecystectomy between 1992 and 2002 whose procedure had been converted to open surgery were prospectively collected and analyzed. Morbidity, length of stay, intensive care unit admission, and operative time served as outcome measures. RESULTS: Of the 97 patients in the study, 33 underwent conversion to open cholecystectomy. The conversion was early for 24% of the patients, after the initial dissection, for 33% and after an extended attempt at completion of the laparoscopic cholecystectomy for 37%. There was no difference in the overall morbidity among the groups, whereas the length of hospital stay appeared to be longer in the early conversion group. The operative time was significantly shorter after early conversion (p < 0.01, chi-square test). CONCLUSION: Laparoscopic cholecystectomy is not feasible for all patients with gangrenous cholecystitis. However, a concerted effort to perform the cholecystectomy with the minimally invasive approach does not have an adverse impact on patient outcome and is likely to benefit patients although it poses a moderate risk of conversion.

Open Rives-Stoppa ventral hernia repair made simple and successful but not for everyone.

BACKGROUND: The Rives-Stoppa (RS) repair of ventral incisional hernias (VIHR) is technically difficult. It involves the retromuscular placement of mesh anterior to the posterior fascia and the primary closure of the anterior fascia. Recurrence rates are 0-8%. We proposed that the operation could be done with equal success by placing the mesh in an intraperitoneal position and primarily closing the fascia anterior to the mesh. METHODS: 81 patients who had undergone an open RS-VIHR with intraperitoneal mesh were evaluated for hernia recurrence and factors associated with recurrence. RESULTS: 55 women and 26 men (mean BMI 38+/-9) underwent RS-VIHR (mean age 49+/-11 years). Of these patients, 44 (54%) had a prior VIHR, 30 (37%) had an incarcerated hernia and 34 (42%) had multiple fascial defects. PTFE was used in 83% and Prolene in 12%. Average LOS was 5.8+/-12 days. All received perioperative intravenous antibiotics and 28% were discharged on oral antibiotics. Follow-up averaged 30+/-24 months. Recurrent VIH developed in 12/81 (15%), with three occurring after removal of infected mesh and one after a laparotomy. Excluding these four, the recurrence rate was 10%. There was no correlation between hernia recurrence and age, BMI, hernia size, number of prior repairs, or LOS (t-test p>0.05). Hernia recurrence did not correlate with gender, prior peritoneal contamination, incarceration, multiple defects, adhesions, mesh type, oral antibiotics, cardiac disease, diabetes, tobacco use, or seroma (X(2) p>0.05). Those with a wound infection and/or abscess formation had a significantly higher recurrent hernia rate (60% vs. 8%, X(2) p<0.001). Patients with pulmonary disease had a significantly higher recurrence rate (50% vs. 12%, X(2) p=0.01). CONCLUSIONS: RS-VIHR with intraperitoneal mesh is a successful and less technically challenging method of repair than prior modifications. Aggressive efforts to identify infection and treat early may prevent abscess formation and subsequent recurrent hernia. Patients with chronic pulmonary disease have an unacceptably high recurrence rate and should not be considered as candidates for elective RS-VIHR.

Laparoscopic cholecystectomy for biliary dyskinesia: correlation of preoperative cholecystokinin cholescintigraphy results with postoperative outcome.

BACKGROUND: A gallbladder ejection fraction (EF) on cholescintigraphy of less than 35% after cholecystokinin (CCK) has been considered to be pathophysiologic and an indication for laparoscopic cholecystectomy (LC). METHODS: All patients undergoing LC for biliary dyskinesia between 1994 and 2001 were prospectively entered into a database. These patients were retrospectively evaluated with regard to demographics, the number of preoperative studies obtained, postoperative symptoms, and the number of postoperative studies obtained. RESULTS: Sixty patients underwent LC for biliary dyskinesia. The mean gallbladder EF was 14%, and 75% of patients were asymptomatic postoperatively. Persistent symptoms prompted further investigation in 6% of patients with a gallbladder EF <14% and in 35% of patients with an EF between 14 and 35% (p = 0.05). CONCLUSION: Laparoscopic cholecystectomy alleviated symptoms in 94% of patients with a gallbladder EF <14% after CCK injection. The diagnostic significance of a preoperative CCK cholescintigram (EF 14-35%) needs further investigation.

Biofilm formation and interaction with the surfaces of gallstones by Salmonella spp.

Salmonellae can exist in an asymptomatic carrier state in the human gallbladder. Individuals with gallstones are more likely to become typhoid carriers, and antibiotic treatments are often ineffectual against Salmonella enterica serovar Typhi in carriers with gallstones. Therefore, we hypothesized that Salmonella spp. form biofilms on the surfaces of gallstones, where the bacteria are protected from high concentrations of bile and antibiotics. A number of methods were utilized to examine biofilm formation on human gallstones and glass coverslips in vitro, including confocal, light, and scanning electron microscopy. In our assays, salmonellae formed full biofilms on the surfaces of gallstones within 14 days and appeared to excrete an exopolysaccharide layer that bound them to the surfaces and to other bacteria. Efficient biofilm formation on gallstones was dependent upon the presence of bile, as a biofilm did not form on gallstones within 14 days in Luria-Bertani broth alone. The biofilms formed by a Salmonella enterica serovar Typhi Vi antigen mutant, as well as strains with mutations in genes that eliminate production of four different fimbriae, were indistinguishable from the biofilms formed by the parents. Mutants with an incomplete O-antigen, mutants that were nonmotile, and mutants deficient in quorum sensing were unable to develop complete biofilms. In addition, there appeared to be selectivity in salmonella binding to the gallstone surface that did not depend on the topology or surface architecture. These studies should aid in the understanding of the Salmonella carrier state, an important but underresearched area of typhoid fever pathogenesis. If the basis of carrier development can be understood, it may be possible to identify effective strategies to prevent or treat this chronic infection.

Bidirectional endoscopy in patients with fecal occult blood.

BACKGROUND: Current screening protocols for colorectal cancer depend primarily on fecal occult blood testing (FOBT). However, positive test results do not always indicate the presence of a colonic neoplasm. METHODS: We reviewed the results of 100 consecutive bidirectional (upper and lower) endoscopic procedures performed to evaluate positive FOBT results. Patients were excluded if they presented with gross bleeding, a history of bowel lesions, or previous intestinal operations. There were 31 women and 69 men whose mean age was 51 years. RESULTS: Major abnormalities were found on esophagogastroduodenoscopy (n = 24), colonoscopy (n = 13), or both studies (n = 2). Active bleeding was manifested in two patients, (Barrett's ulcer, duodenal arteriovenous malformation). Two other patients had malignancy: One had a cecal adenocarcinoma and the other a gastric adenocarcinoma. Various benign lesions also were identified in the stomach including esophagitis (n = 8), ulcers/erosions (n = 8) varices (n = 5), and arteriovenous malformations (n = 2). Colonic pathology included polyps (n = 8), arteriovenous malformations (n = 3), and rectal varices (n = 1). Diverticulosis and hemorrhoidal disease were present in 29 and 16 patients, respectively, but were not considered to be likely sources of a positive FOBT. CONCLUSION: Positive FOBT results may indicate the presence of either upper or lower intestinal pathology, and bidirectional endoscopy is an efficient and accurate technique for the comprehensive evaluation of occult bleeding.

Holmium: YAG laser lithotripsy for gallstones. A preliminary report.

BACKGROUND: Most retained gallstones can be extracted at the time of operative exploration or endoscopic retrograde cholangiopancreatography (ERCP). Infrequently, impaction or associated anatomic abnormalities may prevent their clearance. We assessed the efficacy of the holmium:YAG laser in managing retained biliary calculi that had proven refractory to the usual methods of extraction. METHODS: Two patients with calculi impacted in the intrapancreatic common bile duct and one patient with residual stones in a nonfunctional gallbladder were treated with holmium:YAG laser lithotripsy. Two of these patients were treated under conscious sedation, and one received a general endotracheal anesthetic. Laser energy was delivered by a 272-mm optical fiber inserted through a 7-Fr fiberoptic endoscope. The ablative effects were monitored continuously via videoscopic. RESULTS: All of the stones were cleared successfully in a single therapeutic setting. In one patient, fragments of the impacted intraductal stone were extracted with an endoscopic wire basket. In the other two patients, stone debris was completely cleared with saline irrigation. No complications developed, and all patients remained free of recurrence during a 6-month follow-up period. CONCLUSIONS: The holmium:YAG laser is a multidisciplinary instrument that is safe and effective in the fragmentation of both urinary and biliary calculi. Because it can be delivered through a small-caliber fiberoptic endoscope, it should be particularly useful to laparoscopic surgeons who manage complicated biliary tract disease.

Jejunoileal causes of overt gastrointestinal bleeding: diagnosis, management, and outcome.

Major bleeding from the small intestine is uncommon and difficult to localize. We examined its etiologies and assessed available diagnostic and therapeutic approaches. The records of all adults undergoing operation for small intestinal hemorrhage over a 10-year period (1/89-12/98) were reviewed. There were eight men and four women with a mean age of 54 years. Six patients presented with arteriovenous malformations. Preoperative diagnosis was by endoscopy (three of six), scintigraphy (two of two), and/or angiography (two of six). Intraoperative panendoscopy was used for localization in 5 cases. Three other patients had tumors (leiomyoma, leiomyosarcoma, and adenocarcinoma) by CT scan (two) and/or scintigraphy (two). All were resected but one patient died of recurrence. Two patients underwent resection of a Meckel's diverticulum, one after angiographic diagnosis. Another patient with Crohn's disease had a positive angiogram and colonoscopy before resection. There were no operative deaths but major morbidity occurred in five patients (42%) and hospitalization averaged 17 days. We conclude that jejunoileal lesions are a rare cause of intestinal bleeding but can be associated with substantial morbidity. Arteriovenous malformations and tumors remain the most common causes. An accurate diagnosis and definitive management depend on selective preoperative imaging and judicious operative exploration.

Treatment of acute cholecystitis in non-critically ill patients at high surgical risk: comparison of clinical outcomes after gallbladder aspiration and after percutaneous cholecystostomy.

OBJECTIVE: This study was performed to compare the clinical outcome after gallbladder aspiration with that after percutaneous cholecystostomy in non-critically ill patients with acute cholecystitis who were at high risk from surgery. MATERIALS AND METHODS: Medical records of 53 consecutive non-critically ill, high-surgical-risk patients admitted with acute cholecystitis between July 1995 and July 1999 were reviewed. Thirty-one had gallbladder aspiration and 22 had percutaneous cholecystostomy. The primary outcome measure of clinical response within 72 hr and the secondary outcome measures of overall positive response rate, complication rate, time to resolution, and rate of recurrence of acute cholecystitis were compared between the two groups. RESULTS: Gallbladder aspiration and percutaneous cholecystostomy were technically successful in 30 (97%) and 21 (97%) patients, respectively; of these, 23 (77%) and 19 (90%) patients responded clinically within 72 hr (p > 0.2). Complications occurred in three patients (12%) after percutaneous cholecystostomy and in none after gallbladder aspiration (p < 0.05). No significant difference was noted in the other secondary outcome measures of the two groups. CONCLUSION: We found no significant difference in the clinical outcomes of gallbladder aspiration and percutaneous cholecystostomy in the treatment of acute cholecystitis in high-surgical-risk patients who are not critically ill. However, we found gallbladder aspiration to be significantly safer. Therefore, gallbladder aspiration should be the procedure of choice in high-risk patients with acute cholecystitis who are not critically ill, and percutaneous cholecystectomy should be reserved as a salvage procedure if gallbladder aspiration is technically or clinically unsuccessful.

Operations for peptic ulcer disease: paradigm lost.

Over the past several decades, the pharmacologic and endoscopic treatment of peptic ulcer disease (PUD) has dramatically improved. To determine the effects of these and other changes on the operative management of PUD, we reviewed our surgical experience with gastroduodenal ulcers over the past 20 years. A computerized surgical database was used to analyze the frequencies of all operations for PUD performed in two training hospitals during four consecutive 5-year intervals beginning in 1980. Operative rates for both intractable and complicated PUD were compared with those for other general surgical procedures and operations for gastric malignancy. In the first 5-year period (1980 to 1984), a yearly average of 70 upper gastrointestinal operations were performed. This experience included 36 operations for intractability, 15 for hemorrhage, 12 for perforation, and seven for obstruction. During the same time span, 13 resections were performed annually for gastric malignancy. By the most recent 5-year interval (1994 to 1999), the total number of upper gastrointestinal operations had declined by 80% (14 cases), although the number of operations for gastric cancer had changed only slightly. Operations decreased most markedly for patients with intractability, but the prevalence of operations for bleeding, obstruction, and perforation was also decreased. We conclude that improved pharmacologic and endoscopic approaches have progressively curtailed the use of operative therapy for PUD. Elective surgery is now rarely indicated, and emergency operations are much less common. This changed paradigm poses new challenges for training and suggests different approaches for practice.

Laparoscopic cholecystectomy and cirrhosis: a case-control study of outcomes.

The incidence of gallstone disease in patients with cirrhosis is greater than that in healthy patients. Previous surgical literature reported greater morbidity and mortality in patients with cirrhosis with both open and laparoscopic cholecystectomy (LC). We compared our recent experience with LC in patients with cirrhosis and controls. A retrospective review was performed using the search terms, "cirrhosis" and "laparoscopic cholecystectomy." Forty-eight patients with cirrhosis were identified and randomly matched with healthy controls by age and sex. Four controls were assigned per patient with cirrhosis. Outcomes assessed included mortality, duration of surgery, length of hospital stay, blood transfusion requirement, postoperative complications, and need for conversion to open cholecystectomy. Forty-eight patients with cirrhosis and 187 healthy controls underwent LC. Child-Pugh classification of severity of liver disease was as follows: Child's class A, 38 of 48 patients; Child's class B, 10 of 48 patients; and Child's class C, 0 of 48 patients. Patients with cirrhosis had statistically significantly lower albumin levels (P =.0001) and prolonged prothrombin times (P =. 05). Average duration of surgery for patients with cirrhosis was 1. 71 versus 1.57 hours (P =.57) for controls. Average length of hospital stay for patients with cirrhosis was 6.47 versus 4.77 days (P =.152) for controls. Average number of units of blood transfused in patients with cirrhosis was 0.156 versus 0.0 units (P =.025) in controls. Complications occurred in 6 of 48 patients with cirrhosis (12.5%) and 8 of 187 controls (4.2%; P <.05). No child's class C patient underwent LC. Four patients with cirrhosis (8.3%) and no controls were converted to open cholecystectomy. No postoperative infections were noted. There was no mortality in either group. LC in patients with Child's class A and B cirrhosis is reasonably safe and shows no increase in morbidity or mortality or worsening of outcome. Further studies are required to evaluate the management of acute gallbladder disease in Child's class C patients.

Operative management of diverticular emergencies: strategies and outcomes.

HYPOTHESIS: A selective surgical approach using either a 1- or a 2-stage resection is relatively safe and effective in the management of acute complicated colonic diverticulosis. DESIGN: A consecutive cohort study. SETTING: A university hospital. PATIENTS: Eighty-nine consecutive patients who underwent emergency operations for diverticular disease between July 1, 1984, and June 30, 1999. There were 53 male and 36 female patients (mean age, 47 years). The ethnic background was predominantly Mexican American (58 patients [65.2%]). INTERVENTIONS: Resections of the affected colon (n = 83) plus construction of a Hartmann pouch or mucous fistula (n = 72) or primary anastomosis (n = 11). MAIN OUTCOME MEASURES: Morbidity, mortality, and length of hospital stay. RESULTS: Sixty-eight operations were performed for perforation at an annual rate that has increased greater than 75% in the past 15 years. Another 14 patients underwent operations for obstruction, and 7 underwent operations to control unremitting hemorrhage. Surgical therapy included resection of the affected segment of the bowel in 83 (93%) of the 89 patients, and a Hartmann pouch or mucous fistula was added in 72 (81%). A primary anastomosis was performed in 4 (80%) of 5 right-sided lesions but in only 7 (8%) of 84 left-sided lesions. Morbidity occurred in 38 (43%) of the 89 patients, and the mortality was 4%, with 4 deaths occurring secondary to sepsis in high-risk patients with perforations (n = 3) or obstructions (n = 1). The average length of hospital stay was 19.7 days (range, 5-80 days). CONCLUSIONS: Emergency operations for diverticular disease are uncommon but may be associated with substantial morbidity and occasional mortality. Complicated diverticulosis may present at a relatively young age, and perforated forms appear to be increasing rapidly in prevalence. Most diverticular lesions can be satisfactorily managed using a selective approach based on resection with either a primary anastomosis or a temporary colostomy.