Fighting the obesity pandemic during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic created delays in surgical care. The population with obesity has a high risk of death from COVID-19. Prior literature shows the most effective way to combat obesity is by weight loss surgery. At different times throughout the COVID-19 pandemic, elective inpatient surgeries have been halted due to bed availability. Recognizing that major complications following bariatric surgery are extremely low (bleeding 0-4%, anastomotic leaks 0.8%), we felt outpatient bariatric surgery would be safe for low-risk patients. Complications such as DVT, PE, infection, and anastomotic leaks typically present after 7 days postoperatively, well outside the usual length of stay. Bleeding events, severe postoperative nausea, and dehydration typically occur in the first few days postoperatively. We designed a pathway focused on detecting and preventing these early post-op complications to allow safe outpatient bariatric surgery. METHODS: We used a preoperative evaluation tool to risk stratify bariatric patients. During a 16-month period, 89 patients were identified as low risk for outpatient surgery. We designed a postoperative protocol that included IV hydration and PO intake goals to meet a safe discharge. We sent patients home with a pulse oximeter and had them self-monitor their pulse and oxygen saturation. We called all patients at 10 pm for a postoperative assessment and report of their vitals. Patients returned to clinic the following day and were seen by a provider, received IV hydration, and labs were drawn. RESULTS: 80 of 89 patients (89.8%) were successfully discharged on POD 0. 3 patients were readmitted within 30 days. We had zero deaths in our study cohort and no morbidity that would have been prevented with postoperative admission. CONCLUSION: We demonstrate that by identifying low-risk patients for outpatient bariatric surgery and by implementing remote monitoring of vitals early outpatient follow-up, we were able to safely perform outpatient bariatric surgery.

Case Report: Metastatic renal cell carcinoma to the thyroid- A rare encounter.

Background: Renal cell carcinoma (RCC) accounts for approximately 4% of new adult cancers. By fine needle aspiration, identification of metastatic RCC to thyroid is challenging; therefore, surgical resection is indicated for definitive characterization. Our report surveys metastatic RCC to thyroid in our hospital. Methods: Twenty years retrospective review of electronic records in our institution identified five patients with metastatic renal cell carcinoma to the thyroid. We analyzed patient charts and pathology reports to evaluate clinical parameters and therapy. Results: In all cases, the original RCC was of clear cell type. Pathologic tumor stage ranged from pT1a to pT3a, Fuhrman nuclear grade varied from 2 to 4 and angiolymphatic invasion was noted in one case. In three patients, RCC in the thyroid occurred as an oligometastasis with no evidence of disease in the nephrectomy bed or other parts of the body. In two patients, concomitant recurrent RCC and metastases to liver, lung, brain and chest wall were documented. The thyroid metastases were found approximately 10 years after completion of nephrectomy with a range of 0-21 years. Three thyroid fine needle aspirations correctly identified the disease, one was negative, and one was classified as atypical cells present, suspicious for RCC. Conclusion: The thyroid gland is an uncommon location for RCC metastasis and can appear across a wide range of initial stages and grades of the disease. Thyroid metastases occurred as late as 21 years from the initial tumor resection. Increased awareness and a high index of suspicion are needed to detect metastasis, as they can be found in atypical locations and mimic primary disease.

Beyond the Average: Spatial and Temporal Fluctuations in Oxide Glass-Forming Systems.

Atomic structure dictates the performance of all materials systems; the characteristic of disordered materials is the significance of spatial and temporal fluctuations on composition-structure-property-performance relationships. Glass has a disordered atomic arrangement, which induces localized distributions in physical properties that are conventionally defined by average values. Quantifying these statistical distributions (including variances, fluctuations, and heterogeneities) is necessary to describe the complexity of glass-forming systems. Only recently have rigorous theories been developed to predict heterogeneities to manipulate and optimize glass properties. This article provides a comprehensive review of experimental, computational, and theoretical approaches to characterize and demonstrate the effects of short-, medium-, and long-range statistical fluctuations on physical properties (e.g., thermodynamic, kinetic, mechanical, and optical) and processes (e.g., relaxation, crystallization, and phase separation), focusing primarily on commercially relevant oxide glasses. Rigorous investigations of fluctuations enable researchers to improve the fundamental understanding of the chemistry and physics governing glass-forming systems and optimize structure-property-performance relationships for next-generation technological applications of glass, including damage-resistant electronic displays, safer pharmaceutical vials to store and transport vaccines, and lower-attenuation fiber optics. We invite the reader to join us in exploring what can be discovered by going beyond the average.

Thermal and spectroscopic characterization of copper and erbium containing aluminophosphate glass.

Thermal, Raman scattering, optical absorption, and photoluminescence characterizations were carried out on aluminophosphate glass containing Cu+/Cu2+ along with near-infrared (IR) emitting Er3+ ions of interest to photonic applications. Material synthesis was carried out by the melt-quench technique wherein Cu+ ions were incorporated at a high concentration by addition of 10 mol% of Cu2O together with SnO. The copper oxide doping was recognized to result in a decrease of the glass transition temperature of the matrix, however Er3+ doping displayed opposite propensity. Raman measurements under 785 nm excitation were consistent with calorimetry data indicating that copper ions modify glass structural features. The degree of copper oxidation during material preparation was assessed quantitatively through the Cu2+ absorption feature around 850 nm. The presence of substantial Cu+ concurred with the significant red shift in the near-ultraviolet glass absorption edge, and was analyzed in the context of optical band gap determinations. An evaluation of the luminescence decay kinetics of Cu+ ions in the presence of Er3+ agreed with a non-radiative energy transfer which appeared more effective for excitation of Cu+ near the glass absorption edge at 400 nm. Such excitation was confirmed to result in the sensitized near-IR emission from Er3+ ions around 1.53 µm of interest to lasers, the telecommunications, and spectral conversion in photovoltaic cells.

Roux-en-Y gastric bypass surgery alters serum metabolites and fatty acids in patients with morbid obesity.

AIM: Bariatric surgery induces significant weight loss, increases insulin sensitivity, and reduces mortality, but the underlying mechanisms are not clear. It was hypothesized that Roux-en-Y gastric bypass (RYGB) surgery improves metabolic profile along with weight loss. The objective of this pilot study was to evaluate changes in serum metabolites and fatty acids (FA) at 2 weeks and 6 months after RYGB. MATERIALS AND METHODS: Serum samples were collected pre-surgery, at 2 weeks and 6 months post-surgery from 20 patients undergoing RYGB surgery. Serum non-esterified free FA (NEFA) were measured. Serum metabolites and FA were measured using nuclear magnetic resonance spectroscopy and improved direct fatty acid methyl ester synthesis and the gas chromatography/mass spectrometry method, respectively, in subjects who completed follow-up at 6 months (n = 8). RESULTS: Mean (standard deviation) percent total weight loss was 6.70% (1.7) and 24.91% (6.63) at 2 weeks (n = 15) and 6 months (n = 8) post-surgery, respectively. NEFA were significantly reduced at 6 months post-surgery (P = 0.001, n = 8). Serum branched chain amino acids, 2-aminobutyrate, butyrate, 2-hydroxybutyrate, 3-hydroxybutyrate, acetone, 2-methylglutarate, and 2-oxoisocaproate were significantly reduced, while serum alanine, glycine, pyruvate, and taurine were significantly elevated at 6 months post-surgery compared with pre-surgery (n = 8, P < 0.05). Also, serum FA C10:0, C13:0, C14:0, C15:0, and C18:0 increased significantly (n = 8, P < 0.05) by 6 months post-surgery. CONCLUSIONS: Changes in serum metabolites and FA at 6 months post-RYGB surgery in this pilot study with limited number of participants are suggestive of metabolic improvement; larger studies are warranted for confirmation.

Laparoscopic approach for the treatment of chronic groin pain after inguinal hernia repair : Laparoscopic approach for inguinodynia.

BACKGROUND: Traditional methods of clinical research may not be adequate to improve the value of care for patients with complex medical problems such as chronic pain after inguinal hernia repair. This problem is very complex with many potential factors contributing to the development of this complication. METHODS: We have implemented a clinical quality improvement (CQI) effort in an attempt to better measure and improve outcomes for patients suffering with chronic groin pain (inguinodynia) after inguinal hernia repair. Between April 2011 and June 2016, there were 93 patients who underwent 94 operations in an attempt to relieve pain (1 patient had two separate unilateral procedures). Patients who had prior laparoscopic inguinal hernia repair (26) had their procedure completed laparoscopically. Patients who had open inguinal hernia repair (68) had a combination of a laparoscopic and open procedure in an attempt to relieve pain. Initiatives to attempt to improve measurement and outcomes during this period included the administration of pre-operative bilateral transversus abdominis plane and intra-operative inguinal nerve blocks using long-acting local anesthetic as a part of a multimodal regimen, the introduction of a low pressure pneumoperitoneum system, and the expansion of a pre-operative questionnaire to assess emotional health pre-operatively. RESULTS: The results included the assessment of how much improvement was achieved after recovery from the operation. Forty-five patients (48%) reported significant improvement, 39 patients (41%) reported moderate improvement, and 10 patients (11%) reported little or no improvement. There were 3 (3%) complications, 13 (11%) hernia recurrences, and 15 patients (13%) developed a new pain in the inguinal region after the initial pain had resolved. CONCLUSIONS: The principles of CQI can be applied to a group of patients suffering from chronic pain after inguinal hernia repair. Based on these results additional process improvement ideas will be implemented in an attempt to improve outcomes.

Effect of bariatric surgery on systemic and adipose tissue inflammation.

BACKGROUND: Obese patients are predisposed to developing insulin resistance and associated metabolic diseases such as diabetes and cardiovascular disease. The objective of this study was to determine the effect of bariatric surgery on adipose-derived inflammatory cytokines (adipokines), which play a key role in insulin resistance and obesity. We hypothesized that there is a significant increase in serum and tissue anti-inflammatory adiponectin with a decrease in circulating pro-inflammatory TNF-α and MCP-1, leading to reduced inflammation post-bariatric surgery. METHODS: In this study, we investigated the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic gastric band on serum and tissue levels of adiponectin and serum levels of MCP-1 and TNF-α. Samples of serum and adipose tissue were collected at the time of surgery, 2 weeks and 6 months postoperatively. Adipokine levels were assayed by ELISA kits. RESULTS: A significant increase in adiponectin levels 2 weeks after surgery was observed in the subcutaneous adipose tissue in both groups combined. Serum adiponectin in LRYGB patients showed an increasing trend, while MCP-1 showed a decreasing trend post-surgery. There was no difference in TNF-α among the groups. The number of patients enrolled did not allow for statistical power to be reached. CONCLUSION: Our results show significant and rapid increases in subcutaneous adipose adiponectin as early as 2 weeks post-bariatric surgery demonstrating reduced inflammation and possibly reduced insulin resistance. Future studies are warranted in larger cohorts with additional measurements of insulin sensitivity and inflammation.

Rural surgery rotation during surgical residency.

General surgery in the rural hospital is threatened by declining resident interest in pursuing a career in the rural setting. We found that by initiating a rural rotation of 3 months in the senior resident years, a case mix that more approximated that of the rural surgeons was experienced. Also, by experiencing a rural rotation, more residents chose to practice in a rural setting when compared with residents before the initiation of the rotation.

The role of laparoscopy in trauma: a ten-year review of diagnosis and therapeutics.

Minimally invasive surgery has found many applications in general surgery. The role of laparoscopy in trauma has been debated as a diagnostic, as well as therapeutic, tool in hemodynamically stable patients. This study evaluated laparoscopy in the trauma population. A retrospective review of all laparoscopies performed in hemodynamically stable trauma patients from 1996 until 2006 was conducted. Mechanisms of injury, perioperative data, and demographic variables were analyzed using descriptive statistics and Student's t test. Exploratory diagnostic laparoscopy was performed on 102 patients. Laparoscopy was negative for 65 per cent of patients; 12 per cent of these were converted to laparotomy due to adhesions, hemoperitoneum, or surgeon preference. None of the conversions revealed intra-abdominal injury at laparotomy. An injury was diagnosed at laparoscopy in the remaining 35 per cent, with 55 per cent conversion rate to repair the injury. Therapeutic laparoscopy included serosal repair, hemorrhage control, diaphragmatic repair, and other standard laparoscopic treatments. No patient required re-exploration, there were no missed injuries or other complications, and no patient died in this study. Laparoscopy has an important diagnostic and therapeutic role in selected hemodynamically stable trauma patients. Using a minimally invasive approach can reduce the potential morbidity of negative laparotomy.

Efficacy of laparoscopic appendectomy in appendicitis with peritonitis.

Laparoscopic appendectomy (LA) is safe and effective in cases of peritonitis, perforation, and abscess. We investigated our conversion rate and clinical outcomes in this patient population, as well as preoperative factors that predict operative conversion. A retrospective nonrandomized cohort of 92 patients underwent LA for acute appendicitis with peritonitis, perforation, or abscess at our institution between 1997 and 2002. Thirty-six of the 92 were converted to open appendectomy (OA), yielding a conversion rate of 39 per cent. The presence of phlegmon (42%), nonvisualized appendix (44%), technical failures (8%), and bleeding (6%) were reasons for conversion. Preoperative data had no predictive value for conversion. CT scan findings of free fluid, phlegmon, and abscess did not correlate with findings at the time of surgery. Total complication rates were 8.9 per cent in the LA group as compared to 50 per cent in the converted cohort. Postoperative data showed LA patients stayed 3.2 days versus 6.9 days for converted patients (P = 0.01). LA patients had less pneumonia (P = 0.02), intra-abdominal abscess (P = 0.01), ileus (P = 0.01), and readmissions (P = 0.01). LA is safe and effective in patients with appendicitis with peritonitis, perforation, and abscess, resulting in shorter hospital stays and less complication.

Minimally invasive parathyroidectomy: how effective is preoperative sestamibi scanning?

Minimally invasive parathyroidectomy (MIP) guided by preoperative sestamibi scanning has been shown to reduce operative time, hospital stay, and cost in treating primary hyperparathyroidism. However, controversy exists over routine preoperative sestamibi scanning. The purpose of this study was to determine the utility of sestamibi scanning at our institution as part of the MIP protocol and to analyze calcium and parathyroid hormone levels as possible predictors of successful sestamibi scanning. Charts of 37 consecutive patients undergoing MIP at our institution were reviewed, and age, sex, preoperative calcium, and parathyroid (PTH) levels, invasiveness of procedure, and pathologic diagnosis were recorded. Sestamibi scans were reviewed and scored by 4 nuclear medicine faculty based on the level of suspicion for parathyroid adenoma. Neither calcium nor PTH correlated significantly with sestamibi scan score (Spearman coefficient, r = 0.075, P = 0.67 and r = 0.277, P = 0.10, respectively). Receiver-operating-characteristic (ROC) analysis showed sestamibi scanning to have sensitivity and specificity in predicting MIP completion (87% and 68%). Logistic regression showed only sestamibi scan (P = 0.038), not calcium or PTH (P = 0.977 and P = 0.767) to be predictive of MIP completion. In conclusion, sestamibi scanning effectively predicted the ability to perform MIP. However, preoperative calcium and PTH predicted neither sestamibi scan results nor completion of MIP.

Hand-assisted laparoscopic radical nephrectomy: comparison with transabdominal radical nephrectomy.

The purpose of this study was to investigate whether hand-assisted laparoscopic radical nephrectomy (HALN) has benefits over the traditional transabdominal radical nephrectomy. More specifically we focused on the use of the hand-assisted technique as a definitive oncologic procedure for renal cancers. This study is a retrospective nonrandomized study comparing 12 hand-assisted laparoscopic radical nephrectomies with 12 transabdominal radical nephrectomies. All patients included in the study had the preoperative diagnosis of renal mass. HALN population averaged 1.83 +/- 1.64 (mean +/- standard deviation) major comorbidities versus 1.08 +/- 0.8 open (P = 0.032). The HALN OR time averaged 103 +/- 32.8 versus 57 +/- 18.3 minutes open (P = 0.001). The estimated blood loss mean for HALN was 83 versus 318 cm3 open (P = 0.001). Length of stay for HALN was 4.9 +/- 2.2 versus 5.9 +/- 2.9 days (P = 0.35). Days to regular diet was 2.9 +/- 2.3 in HALN versus 3.5 +/- 2.11 open (P = 0.52). Days of intravenous pain medications were 1.8 +/- 0.72 HALN versus 3.0 +/- 1.28 open (P = 0.016). Postoperative complication rates for the two groups were identical: two of 12 (ileus and post-operative bleeding). Tumor size mean was 6.8 +/- 2.99 cm for HALN versus 4.2 +/- 1.29 cm open (P = 0.012). Tumor margins were negative for 12 of 12 in HALN versus 11 of 12 open. Selection bias (selecting ailing patients to the HALN cohort) diminished the statistical significance of our postoperative recovery data. It is likely that a prospectively randomized study with a larger population may prove the hand-assisted approach equal if not superior to the open technique. The use of HALN in patients with renal tumors is an effective alternative to traditional transabdominal radical nephrectomy.