Performance of Noninvasive Liver Fibrosis Tests in Morbidly Obese Patients with Nonalcoholic Fatty Liver Disease.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is highly prevalent in morbidly obese patients, and fibrosis is an independent predictor of mortality. Noninvasive tests (NITs) are being developed for the detection of advanced fibrosis (AF). PURPOSE: To assess the performance of three NITs (NAFLD fibrosis score, NFS, fibrosis-4 index, FIB-4, and aspartate aminotransferase-to-platelet ratio, APRI), in the identification of AF among morbidly obese patients. MATERIALS AND METHODS: Patients, who underwent bariatric surgery between 2004 and 2009 and had liver biopsy, were included. Fibrosis stages ≥ F2 and ≥ F3 were defined as significant and AF, respectively. Published and optimal thresholds (Youden index) for NFS, FIB-4 and APRI, sensitivity, specificity, positive and negative predictive values (PPV-NPV), and area under the receiver operator curves (AUROC) were evaluated. RESULTS: Among 584 patients (mean age 43.3 ± 11.3 years, 21.2% male, 75% white, mean BMI 45.5 ± 8.80), 31.7% had NASH. Stages distributions were F1 = 68.1%, F2 = 16.4%, F3 = 8%, and F4 = 3.2%. At published thresholds, all 3 NITs performed poorly for detection of AF, with AUROC < 0.62. Overall performance at optimal thresholds improved to 0.68, 0.72, and 0.74 for NFS, FIB-4, and APRI, respectively. At optimal thresholds, all tests had good NPV (94.4-95.9%) but low PPV (24.2-32.5%). Combinations of the tests did not improve their performance. CONCLUSIONS: NFS, FIB-4, and APRI fall short to detect advanced fibrosis but valuable for excluding advanced fibrosis. More research is needed to develop new NITs with high positive predictive value.

Preoperative prediction of stomach weight to be removed in laparoscopic sleeve gastrectomy procedure.

Sleeve gastrectomy (SG) is a surgical procedure that includes a longitudinal lateral gastrectomy to reduce food intake by reducing the capacity of the stomach. The technique of SG as a primary procedure has evolved since it was first introduced in 2001. Some perform the SG over smaller bougie sizes (30-40 Fr) or an NG tube. Some begin the SG near the pylorus (2 cm) while others avoid the antral/pyloric area. Establishing the mass or volume of stomach remaining is subject to limitations associated with the in vivo status. However, quantifying the amount (mass) of stomach removed is definitively an objective measure. The study was conducted to determine the relationship between the amount of stomach excised and the patient's gender and preoperative weight and height. Data was collected prospectively and was compiled in a review of 165 (136 Female and 29 Male) patients who underwent laparoscopic SG from December 7, 2001 to March 18, 2004 by a single surgeon at three institutions using the same technique for performance and measurement. The empty weight and capacity of resected stomach specimens were measured intra-operatively and subsequently correlated with the patient's gender, preoperative weight, and height. The mean height of male patients was 179.7+/-7.1 (CM) and the mean height of female patients was 165.1+/-7.1(CM). The mean weight of stomach tissue removed from male patients was 160.3±29.4 (G) and from female patients was 123.5±40.4 (G). The difference in height and weight between men and women was statistically significant (P-value<0.0001). The empty stomach weight and capacity both are linearly related to each other (R-square=0.9292, P-value<.0001). There is evidence showing the statistically significant correlation among preoperative height, gender, and preoperative weight and amount of stomach removed. For the average height patient, removal of gastric tissue weighing less than 160 grams in males and 120 grams in females may indicate an inadequate resection. This removes a stomach capacity of approximately 1600 cc's and 1200 cc's respectively.

Laparoscopic transduodenal sphincteroplasty.

BACKGROUND: Common bile duct stones are a difficult problem, often leading to conversion to an open operation or repeated endoscopic procedures. Both strategies are associated with added morbidity. MATERIALS AND METHODS: A new technique was developed to perform a traditional sphincteroplasty using minimally invasive methods. The procedure was performed on two patients with distal common bile duct stones; each patient had previously undergone at least two unsuccessful preoperative endoscopic retrograde cholangiopancreatography procedures by at least two different experienced endoscopists. RESULTS: In both patients, a laparoscopic transduodenal sphincteroplasty was successfully completed. A transduodenal common bile duct exploration was performed at the time of sphincterotomy, successfully clearing the common bile duct in both cases. There were no untoward postoperative sequelae. Follow-up at one year was satisfactory in both patients. CONCLUSION: Laparoscopic transduodenal sphincteroplasty can be safely performed in patients with common bile duct stones refractory to endoscopic retrograde cholangiopancreatography. This technique offers a new approach to the management of common bile duct stones, and can spare patients the need for an open operation or subsequent endoscopic procedures.