Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results.

BACKGROUND: The vertical gastrectomy (VG) is the restrictive part of the technically difficult biliopancreatic diversion with duodenal switch operation (DS). The VG was originally conceived of as an independent operation-the first stage of a two-stage DS that would reduce mortality and morbidity in the high-risk superobese because of a shorter operating time and no anastomoses. This article presents two-year data after VG. METHODS: Laparoscopic VG was performed in a nonrandomized fashion in obese patients that met the NIH criteria for bariatric surgery. By using 5-7 firings of 45-60-mm linear 3.5-mm GI staplers along a 32-Fr bougie, a greater-curvature gastrectomy is performed and a 60-80-ml gastric tube is created. VG was compared to adjustable Lap-Band placement, Roux-en-Y gastric bypass (RGB), and DS. RESULTS: Between November 2002 and August 2005, 216 patients underwent VG. The mean age was 44.7 years (range = 16-64) and 173 (80%) were female. The mean preoperative weight and body mass index (BMI) was 302 +/- 77 lbs and 49 +/- 11 kg/m2, respectively. Of the 216 patients, 5 (2.3%) had a BMI > 80 kg/m2, 6 (2.8%) had a BMI of 70-80 kg/m(2), and 25 (11.6%) had a BMI of 60-70 kg/m2. The mean operative time was 66 +/- 11 min (range = 45-180) and the mean length of hospital stay was 1.9 +/- 1.2 days. Complications occurred in 20 (6.3%) patients (vs. 7.1% after Lap-Band). Leaks occurred in 3 (1.4%) VG patients, reoperations were performed in 6 (2.8%), and no conversions to open or deaths occurred. Weight loss on par with the DS and RGB was achieved with just the VG alone. CONCLUSION: The VG operation is able to achieve significant weight loss comparable to the RGB and DS operations but with the low morbidity profile similar to that of Lap-Band placement.

Hand-assisted laparoscopic donor hepatectomy for living related transplantation in the porcine model.

Use of a minimally invasive approach for donor nephrectomy has proven to be safe and feasible and has increased the pool of donors for living related renal transplantation. A porcine study to assess the safety and feasibility of performing laparoscopic donor hepatectomy was performed, with potential application to human liver donors for living related liver transplantation. Of the 10 50-kg pigs used, 2 underwent an open left lateral segmentectomy to define the pig anatomy. Two subsequent pigs underwent a laparoscopic liver resection to refine the technique. Subsequently, under sterile conditions, six pigs underwent laparoscopic liver resection with use of a hand-assisted technique for long-term study. Diameters and lengths of hepatic vessels and ducts were measured. Operative blood loss, operative time, and warm ischemia duration were noted. Biopsies of the resected specimens were done to look for ischemia. There was one operative death in the group with chronic liver failure, due to stapler misfire and hemorrhage from the left hepatic vein. The only instance of morbidity was a wound infection. The resected liver had minimal warm ischemia time and microscopic changes, which led us to believe that the organ was suitable for transplantation. We believe that this long-term study establishes the feasibility of this procedure.

International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical approach, but 1 that has seen a surge in popularity because of its perceived technical simplicity, feasibility, and good outcomes. An international expert panel was convened in Coral Gables, Florida on March 25 and 26, 2011, with the purpose of providing best practice guidelines through consensus regarding the performance of LSG. The panel comprised 24 centers and represented 11 countries, spanning all major regions of the world and all 6 populated continents, with a collective experience of >12,000 cases. It was thought prudent to hold an expert consensus meeting of some of the surgeons across the globe who have performed the largest volume of cases to discuss and provide consensus on the indications, contraindications, and procedural aspects of LSG. The panel undertook this consensus effort to help the surgical community improve the efficacy, lower the complication rates, and move toward adoption of standardized techniques and measures. The meeting took place at on-site meeting facilities, Biltmore Hotel, Coral Gables, Florida. METHODS: Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed >500 cases. The topics for consensus encompassed patient selection, contraindications, surgical technique, and the prevention and management of complications. The responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement). RESULTS: Full consensus was obtained for the essential aspects of the indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 69 key questions. CONCLUSION: The present consensus report represents the best practice guidelines for the performance of LSG, with recommendations in the 3 aforementioned areas. This report and its findings support a first effort toward the standardization of techniques and adoption of working recommendations formulated according to expert experience.

Does surgically induced weight loss improve daytime sleepiness?

Morbid obesity is associated with excessive daytime sleepiness and reduced health-related quality of life. We prospectively evaluated the pre- and postoperative responses of bariatric surgery recipients with the Epworth Sleepiness Scale (ESS) and the Short Form-12. Participants (n = 223; 79% women) with a mean body mass index (BMI) and ESS of 44.8 ± 7.9 kg/m(2) and 7.9 ± 4.5, respectively, received a vertical gastrectomy (76%) or Roux-en-Y gastric bypass (12%). Preoperatively, 30% of patients complained of excessive daytime sleepiness (ESS > 10). Patients with preoperative excessive daytime sleepiness were more obese (p = 0.002), had higher fasting glucose levels (p = 0.02), more likely to have a diagnosis of sleep-disordered breathing (p < 0.001), report snoring (p < 0.001), and had lower health-related quality of life measures particularly physical function (p < 0.001), depression (p = 0.006), and sexual satisfaction (p = 0.04) than non-sleepy patients. At 12-months postoperatively, most patients experienced a significant reduction in BMI (28.6 ± 5.5 kg/m(2), p < 0.001) and excessive daytime sleepiness (mean ESS 5.3 ± 3.3, p < 0.001). Patients with a clinically relevant improvement in the ESS at 12-months post-operatively had greater improvements in physical function (p = 0.009) and snoring (p = 0.010) and were more likely still using positive airway pressure therapy (p = 0.032) than patients without a clinically relevant improvement. Statistically and clinically significant improvements in all health-related quality of life measures were noted at 24 months. Bariatric surgery is associated with dramatic weight loss and improvements in physical functioning and daytime sleepiness.

'Chromosomal Rainbows' Detect Oncogenic Rearrangements of Signaling Molecules in Thyroid Tumors.

Altered signal transduction can be considered a hallmark of many solid tumors. In thyroid cancers the receptor tyrosine kinase (rtk) genes NTRK1 (Online Mendelian Inheritance in Man = OMIM *191315, also known as 'TRKA'), RET ('Rearranged during Transfection protooncogene', OMIM *164761) and MET (OMIM *164860) have been reported as activated, rearranged or overexpressed. In many cases, a combination of cytogenetic and molecular techniques allows elucidation of cellular changes that initiate tumor development and progression. While the mechanisms leading to overexpression of the rtk MET gene remain largely unknown, a variety of chromosomal rearrangements of the RET or NTKR1 gene could be demonstrated in thyroid cancer. Abnormal expressions in these tumors seem to follow a similar pattern: the rearrangement translocates the 3'- end of the rtk gene including the entire catalytic domain to an expressed gene leading to a chimeric RNA and protein with kinase activity. Our research was prompted by an increasing number of reports describing translocations involving ret and previously unknown translocation partners.We developed a high resolution technique based on fluorescence in situ hybridization (FISH) to allow rapid screening for cytogenetic rearrangements which complements conventional chromosome banding analysis. Our technique applies simultaneous hybridization of numerous probes labeled with different reporter molecules which are distributed along the target chromosome allowing the detection of cytogenetic changes at near megabasepair (Mbp) resolution. Here, we report our results using a probe set specific for human chromosome 10, which is altered in a significant portion of human thyroid cancers (TC's). While rendering accurate information about the cytogenetic location of rearranged elements, our multi-locus, multi-color analysis was developed primarily to overcome limitations of whole chromosome painting (WCP) and chromosome banding techniques for fine mapping of breakpoints in papillary thyroid cancer (PTC).