Panel report: best practices for the surgical treatment of obesity.

BACKGROUND: Bariatric surgery is a rapidly growing field. Advances in surgical technologies and techniques have raised concerns about patient safety. Bariatric surgeons and programs are under increased scrutiny from regulatory agencies, insurers, and public health officials to provide high quality and safe care for bariatric patients at all phases of care. METHODS: During the 2009 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on patient safety and best practices in bariatric surgery. The following article is a summary of this panel presentation. RESULTS AND CONCLUSIONS: Weight loss surgery is a field that is evolving and adapting to multiple external pressures. Safety concerns along with increasing public scrutiny have led to a systematic approach to defining best practices, creating standards of care, and identifying mechanisms to ensure that patients consistently receive the best and most effective care possible. In many ways, bariatric surgery and multidisciplinary bariatric surgery programs may serve as a model for other programs and surgical specialties in the near future.

Waste management health risk assessment: a case study of a solid waste landfill in South Italy.

An integrated risk assessment study has been performed in an area within 5 km from a landfill that accepts non hazardous waste. The risk assessment was based on measured emissions and maximum chronic population exposure, for both children and adults, to contaminated air, some foods and soil. The toxic effects assessed were limited to the main known carcinogenic compounds emitted from landfills coming both from landfill gas torch combustion (e.g., dioxins, furans and polycyclic aromatic hydrocarbons, PAHs) and from diffusive emissions (vinyl chloride monomer, VCM). Risk assessment has been performed both for carcinogenic and non-carcinogenic effects. Results indicate that cancer and non-cancer effects risk (hazard index, HI) are largely below the values accepted from the main international agencies (e.g., WHO, US EPA) and national legislation (D.Lgs. 152/2006 and D.Lgs. 4/2008).

The role of diagnostic laparoscopy for chronic abdominal conditions: an evidence-based review.

BACKGROUND: Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for chronic intraabdominal conditions. METHODS: A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. The search identified and reviewed six main categories that have received attention in the literature: pelvic pain and endometriosis, primary and secondary infertility, nonpalpable testis, and liver disease. RESULTS: The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. CONCLUSIONS: The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.

The role of staging laparoscopy for intraabdominal cancers: an evidence-based review.

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for the staging of intraabdominal cancers. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. The search identified and reviewed seven main categories that have received attention in the literature: esophageal cancer, gastric cancer, pancreatic cancer, hepatocellular carcinoma, biliary tract cancer, colorectal cancer, and lymphoma. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.

Laparoscopic resection of curable colon and rectal cancer: an evidence-based review.

The initial enthusiastic application of laparoscopic techniques to colorectal surgical procedures was tempered in the early 1990s by reports of tumor implants in the laparoscopic incisions. Substantial evidence has accumulated, including evidence from randomized controlled trials, to support that laparoscopic resection results in oncologic outcomes similar to open resection, when performed by well-trained, experienced surgeons. This review was developed in conjunction with guidelines published by the Society of American Gastrointestinal and Endoscopic Surgeons. Data from the surgical literature concerning laparoscopic resection of curable colorectal cancer was evaluated regarding diagnostic evaluation, preoperative preparation, operative techniques, prevention of tumor implants, and training and experience. Recommendations are accompanied by an assessment of the level of supporting evidence available at the time of the development of the guidelines.

Circumferential mucosectomy with stapled proctopexy is a safe, effective outpatient alternative for the treatment of symptomatic prolapsing hemorrhoids in the elderly.

BACKGROUND: Circumferential mucosectomy with stapled proctopexy (CMSP) was first introduced in 1993 as a less painful and highly effective alternative to traditional operative hemorrhoidectomy. Although CMSP has many advantages over traditional hemorrhoidectomy, some authorities and insurers continue to regard it as an inpatient procedure and others have been slow to adopt this progressive technique. This study documents the safe and effective outpatient nature of this procedure. METHODS: From December 2001 through August 2002, 33 patients with mucosal prolapse and prolapsing internal hemorrhoids were treated using circumferential mucosectomy with stapled proctopexy as outpatients at an ambulatory surgery center. Fourteen (42%) patients were treated using local anesthesia with intravenous sedation, 18 (55%) chose spinal anesthesia, and general anesthesia was used in one patient. Patients were evaluated postoperatively by telephone at 1 and 2 weeks, and seen in clinic at 4 weeks. RESULTS: One patient (3%) required an emergency department visit for minor postoperative bleeding. None of our elderly patients required emergency department evaluation and none reported significant complications. Four patients (13%) required urinary catheter placement prior to discharge from the surgery center due to urinary retention. One patient (3%) developed an uncomplicated urinary tract infection, which resolved with antibiotic treatment. Two patients were seen earlier than 4 weeks at the surgeon's request; one was immunocompromised from chemotherapy for metastatic carcinoid, and one reported persistent pain during initial telephone follow-up. No complications were identified in either patient, and no additional complications have been noted to date. CONCLUSIONS: CMSP is a safe, effective, time-efficient procedure for patients with mucosal prolapse and prolapsing hemorrhoids that can be performed safely in the ambulatory surgery center setting. Age is not a limiting factor in selecting patients for this safe outpatient procedure.

Colonoscopic retrieval of an appendiceal foreign body: prophylaxis for appendicitis?

Management of orally ingested foreign bodies usually consists of endoscopic retrieval while the objects reside within the esophagus or stomach. Although most foreign bodies that pass through the pylorus will be excreted without incident, some may become impacted distally, resulting in obstruction or perforation. Appendiceal foreign bodies have been reported rarely, yet have resulted in the development of acute appendicitis. We report the case of a young male who swallowed a nail that became impacted in the appendiceal lumen and was retrieved colonoscopically before the development of acute appendicitis.

Cryoanalgesic ablation for the treatment of chronic postherniorrhaphy neuropathic pain.

BACKGROUND: Chronic postoperative pain has been reported in as many as 62.9% of patients after inguinal herniorrhaphy. Moderate to severe neuropathic pain requiring intervention develops in 2.2% to 11.9% of patients as a result of ileoinguinal and genitofemoral nerve entrapment. Cryoanalgesic ablation has been successful in treating chronic pain from craniofacial neuralgia, facet joint syndrome, and malignant pain syndromes. We report our experience using cryoanalgesic ablation for chronic ileoinguinal and genitofemoral neuralgia after inguinal herniorrhaphy. METHODS: Ten patients with ileoinguinal, genitofemoral, or combined neuralgia underwent 12 cryoanalgesic ablations between April 1996 and June 2001. These patients were referred from a multidisciplinary pain clinic, and focused low-volume nerve blocks were used to map nerve involvement preoperatively. After surgical exposure, nerves and surrounding tissues were cooled to ?70 degrees C for 3 min using the Lloyd Neurostat. Patients were seen 2 weeks postoperatively and offered monthly follow-up assessments. RESULTS: Nine men and one woman, ages 20 to 54 (mean, 42.6 years) were treated during 58 months, with a mean follow-up period of 8.2 months, for ileoinguinal (n = 4), genitofemoral (n = 1), and combined (n = 5) neuralgia. Patients reported one to five prior herniorrhaphies (mean, 1.8), experienced neuropathic pain 0 to 14 years (mean, 6.3 years), and underwent up to 3 (mean, 1.3) ablative pain procedures before referral. After cryotherapy, patients reported overall pain reduction of 0% to 100% (mean, 77.5%; median, 100%); 80% reported decreased analgesic use, and 90% reported increased physical capacity. Two patients underwent additional cryotherapy, one for incomplete relief and one for recurrent pain, both with 100% efficacy. Wound infection (n = 1) was the only complication. CONCLUSIONS: Cryoanalgesic ablation successfully eliminates ileoinguinal and genitofemoral neuralgia in most patients, and should be considered early in the treatment of patients with postherniorrhaphy neuropathic pain.

Risks and benefits of PVC in medical applications.

The safety of using PVC in the medical field has been recently challenged due to the toxic activity it allegedly exerts on exposed patients. The environmental repercussions of disposing of PVC, once its use has terminated, represent an additional point of debate, used to sustain the advisability of abolishing PVC. The reasons that have led some to request the abolition of PVC involve valid questions of principle, perhaps, but they lack a technical evaluation of the benefit-risk ratio and the possible consequences this action would have on patients and on healthcare personnel. The purpose of this paper is therefore to help bring the terms of the question back into the realm of evidence and proof, attempting to formulate a brief picture of what is known, in terms of PVC uses in the clinical field, evaluating the benefits and risks to human health and to the environment, also in relation to possible alternatives, and discussing the margins of uncertainty that emerge. Evidence supports the conclusion that PVC is an important weapon in the complex arsenal medicine has at its disposal to care for patients and cure diseases. Though its use can be considered safe, recent surveys have identified in some patients possibility of risks associated with DEHP, the principal plasticizer of PVC for medical applications. Studies are in progress to eliminate these margins of risk and increase the safety for patients.

Persistent organic pollutants in food: public health implications.

Persistent organic pollutants are a heterogeneous group of chemicals sharing a number a common properties, including long term persistence and diffusion in the environment, and bioaccumulation through the food chain. Animal experiments and epidemiological studies suggest that the most sensitive adverse effects, such as disturbances on metabolism, development, and reproductive system, may occur in the range of current human exposure. Although the potential cancer risk of persistent organic pollutants remains undefined, the implementation of actions to reduce the exposure to these substances, which mainly occurs through the diet, is important.

Enteroscopic treatment of early postoperative small bowel obstruction.

BACKGROUND: Early postoperative small bowel obstruction (EPSBO) occurs in 1% of patients undergoing laparotomy and has a mortality rate exceeding 17%. Nasogastric (NG) decompression is successful in avoiding reoperation in 73% of patients. Repeat laparotomy has been recommended when obstruction does not resolve after 14 days of NG decompression. We report four patients with EPSBO treated successfully with push enteroscopy after failed NG decompression. METHODS: Four patients who failed NG decompression underwent push enteroscopy instead of repeat laparotomy. EPSBO was diagnosed if obstruction lasting more than 14 days developed after initial resolution of postoperative ileus, high NG output persisted postoperatively for 21 days in the absence of sepsis, or radiographic signs of obstruction persisted. Small bowel series or computed tomography were utilized when radiographic assessment was necessary. The Olympus SIF 100 push enteroscope was introduced with an overtube using topical anesthesia and intravenous sedation. After maximal insertion, the enteroscope was withdrawn without evacuation of insufflated air. NG tubes were placed after enteroscopy and patients were followed clinically. Flatus, defecation, and tolerance of a general diet defined resolution of EPSBO. RESULTS: EPSBO resolved 24 to 36 h following enteroscopy, and all patients were discharged on general diets 48 h after return of bowel function. Readmission has not been necessary during 18- to 30-month follow-up. CONCLUSIONS: Our experience suggests that push enteroscopy is successful in treating EPSBO and should be considered prior to reoperation. Push enteroscopy may eliminate the hazards of repeat laparotomy and reduce the morbidity, treatment cost, and lengthy hospital stays associated with this uncommon surgical complication.

Purification of the aldehyde oxidase homolog 1 (AOH1) protein and cloning of the AOH1 and aldehyde oxidase homolog 2 (AOH2) genes. Identification of a novel molybdo-flavoprotein gene cluster on mouse chromosome 1.

We report the cloning of the AOH1 and AOH2 genes, which encode two novel mammalian molybdo-flavoproteins. We have purified the AOH1 protein to homogeneity in its catalytically active form from mouse liver. Twenty tryptic peptides, identified or directly sequenced by mass spectrometry, confirm the primary structure of the polypeptide deduced from the AOH1 gene. The enzyme contains one molecule of FAD, one atom of molybdenum, and four atoms of iron per subunit and shows spectroscopic features similar to those of the prototypic molybdo-flavoprotein xanthine oxidoreductase. The AOH1 and AOH2 genes are 98 and 60 kilobases long, respectively, and consist of 35 coding exons. The AOH1 gene has the potential to transcribe an extra leader non-coding exon, which is located downstream of exon 26, and is transcribed in the opposite orientation relative to all the other exons. AOH1 and AOH2 map to chromosome 1 in close proximity to each other and to the aldehyde oxidase gene, forming a molybdo-flavoenzyme gene cluster. Conservation in the position of exon/intron junctions among the mouse AOH1, AOH2, aldehyde oxidase, and xanthine oxidoreductase loci indicates that these genes are derived from the duplication of an ancestral precursor.