Addressing morbid obesity as a barrier to renal transplantation with laparoscopic sleeve gastrectomy.

Morbid obesity is a barrier to renal transplantation and is inadequately addressed by medical therapy. We present results of a prospective evaluation of laparoscopic sleeve gastrectomy (LSG) for patients failing to achieve significant weight loss with medical therapy. Over a 25-month period, 52 obese renal transplant candidates meeting NIH guidelines for metabolic surgery underwent LSG. Mean age was 50.0 ± 10.0 years with an average preoperative BMI of 43.0 ± 5.4 kg/m(2) (range 35.8-67.7 kg/m(2)). Follow-up after LSG was 220 ± 152 days (range 26-733 days) with last BMI of 36.3 ± 5.3 kg/m(2) (range 29.2-49.8 kg/m(2)) with 29 (55.8%) patients achieving goal BMI of <35 kg/m(2) at 92 ± 92 days (range 13-420 days). The mean percentage of excess weight loss (%EWL) was 32.1 ± 17.6% (range 6.7-93.8%). A segmented regression model was used to compare medical therapy versus LSG. This revealed a statistically significant increase in the BMI reduction rate (0.3 kg/m(2)/month versus 1.1 kg/m(2)/month, p < 0.0001). Patients also experienced a 40.9% decrease in anti-hypertensive medications (p < 0.001) and a 49.7% decrease in total daily insulin dose (p < 0.001). LSG is a safe and effective means for addressing obesity in kidney transplant candidates in the context of a multidisciplinary approach.

Reliability of self-reporting of antibiotic consumption in the community - Index of Reliability.

WHAT IS KNOWN AND OBJECTIVE: To date, there is no evidence to indicate the reliability of how patients self-report their own antibiotic usage in the community. Such data are fundamental in supporting antimicrobial stewardship practices, and so there is a need to determine its accuracy and reliability. COMMENT: Patients in the community (n = 476) were required to recollect their antibiotic usage in the past three months. Simultaneously, similar information was obtained by careful extraction from their respective medical notes, which was qualitatively compared with the patient's recollection. Overall, concordance was high (88·1%), but age (<20 and >80 years) and sex (female) were significant factors of reliability. WHAT IS NEW AND CONCLUSION: This study suggests that basic self-reporting of antibiotic usage amongst patients is relatively reliable, with increasing accuracy with years until 80 years. Where such information is critical, the current study can help decide who to interview and whose notes to interrogate, in the quest to obtain reliable and accurate information.

Optimisation of storage conditions for maintaining culturability of penicillin-susceptible and penicillin-resistant isolates of Streptococcus pneumoniae in transport medium.

Methods employed by the World Health Organization (WHO) are used during this study to determine the optimum storage conditions for maintaining the culturability of Streptococcus pneumoniae in skimmed milk, tryptone, glucose and glycerin (STGG) transport medium. A comparison of S. pneumoniae strains sensitive and resistant to penicillin showed no significant difference in their survival ability in STGG medium. Furthermore, it is confirmed that storage at -70 degrees C remains most effective for maintaining viability by culture of S. pneumoniae. Storage at -20 degrees C would only be acceptable in the short-term, while storage at +4 degrees C is not recommended. Of note, this study has shown STGG medium at room temperature to be an efficient growth medium for pneumococci in the short-term. This work will help to establish robust sampling protocols when performing community studies to ensure culturability of comparison between community and laboratory pneumococci survival.

Elective cardiac operation in a patient with severe hemophilia and acquired factor VIII antibodies.

This paper describes a successful cardiac operation in a young boy with hemophilia, congenital heart disease, severe factor VIII deficiency, and an acquired high titer antibody to factor VIII. To our knowledge, there have been no published cases of elective cardiac operations in a person with severe hemophilia and an accompanying complex problem. Utilizing the team approach, we administered a megadose bolus of factor VIII concentrate preoperatively (eight times the calculated dose), followed by a continuous intravenous infusion at 500 units/hr throughout the procedure and at a reduced dose for the first 5 postoperative days. With the anamnestic rise in factor VIII antibody on day 5, activated prothrombin complex concentrates were substituted for factor VIII and provided continued adequate hemostasis during the remaining 9 postoperative days. The rapid infusion of large quantities of factor VIII was effective in neutralizing the low titer inhibitor and providing normal hemostasis during the procedure. In addition, activated prothrombin complex concentrates were substituted for factor VIII coagulant without recurrent bleeding or thromboembolic phenomena.

Use of endoscopic retrograde cholangiopancreatography to dislodge clip impingement on the common hepatic duct.

Despite advances in technical skill, bile duct injury during laparoscopic cholecystectomy is not an uncommon complication. We describe a technique of using ERCP, sphincterotomy, and balloon dilatation to dislodge clip impingement on the common hepatic duct after laparoscopic cholecystectomy.

Minimizing ports to improve laparoscopic cholecystectomy.

BACKGROUND: Minimizing the number and scope of ports used to perform laparoscopic cholecystectomy attempts to build on the improvements in postoperative pain control, rapid return to activity and work, patient satisfaction, and cosmetic result achieved by the laparoscopic method. METHODS: We studied 141 patients in two sequential studies: the first a prospective randomized trial with 41 patients, and the second an examination of the more minimal procedure in 100 patients. In the randomized trial, patients underwent laparoscopic cholecystectomy with three ports: three 5-mm ports or two 10-mm ports and one 5-mm port. The 100 patients underwent the three 5-mm port procedure. RESULTS: In the randomized trial, differences were not statistically significant. However, on the average, the group with three 5-mm ports required less medication over less time, had less postoperative pain, and took less time to return to activity than the second group with larger ports. A statistically significant difference was found in incisional pain between the smaller group (21 patients) with two 10-mm ports and one 5-mm port and the larger group (100 patients) with three 5-mm ports, whether the measure was overall incisional pain (p = 0.014) or a comparison based on specific ports (p = 0.001). The percentage of cases requiring port enlargement to remove the gallbladder was not significantly different between the groups. There were no conversions to an open procedure, no fourth trocars added, and no complications. No patient required overnight hospitalization. CONCLUSIONS: Reducing the number and size of ports in laparoscopic cholecystectomy sustains or enhances the improvements initiated by performing laparoscopic rather than open cholecystectomy. In a comparison of microlaparoscopic procedures, patients undergoing the procedure with the shorter incisions experienced significantly less pain.

Aortic injury during laparoscopic fundoplication: an underreported complication.

BACKGROUND: Advances in video equipment, instrumentation, and laparoscopic skills have enabled the performance of an increasing variety of procedures using minimally invasive techniques. Additionally, the public is more aware of the benefits of laparoscopic surgery, including decreased postoperative pain and shortened recovery period. Surgical treatment of gastroesophageal reflux disease (GERD) is blossoming as a result. As with all surgical procedures, complications can occur. This case report describes a complication of laparoscopic fundoplication not previously reported. Also summarized is a review of all complications associated with minimal access fundoplication reported in the literature. METHODS: After appropriate evaluation for surgical treatment of GERD that revealed a nonspecific esophageal motility disorder, a 52-year-old female underwent laparoscopic Toupet fundoplication. During the procedure, a needle injury occurred to the aorta at the level of the hiatus. Despite exploration during the original procedure, which had been converted to laparotomy, and at two subsequent operations, the intermittent bleeding source was not found. The patient eventually died secondary to blood loss. The aortic injury was discovered postmortem. CONCLUSION: A variety of intraoperative complications associated with laparoscopic fundoplication have been reported, including gastric, esophageal, and bowel perforations, cardiac tamponade, pneumothorax, celiac artery thrombosis, bleeding, and death. Although this is the first reported aortic injury during minimally invasive fundoplication not related to trocar placement, discussion with other surgeons indicates that this is not the only occurrence of this complication.

Cosmetic minilaparoscopic cholecystectomy.

BACKGROUND: Since its introduction in 1987, the technique of laparoscopic cholecystectomy has continued to undergo evolution. One area of refinement has been the optimization of cosmetic results. Surgeons have reduced port size and number or both in attempts to achieve this goal. In this report, we describe a method of adjusting port position to obtain more discreet scars. METHODS: Minilaparoscopic cholecystectomy is performed using three 5-mm ports. One port is placed in the umbilicus. Instead of placing the two additional ports in the right subcostal and subxiphoid positions, they are moved to either side of midline at the level of the pubic hairline. RESULTS: The result is one scar hidden in the umbilicus, with the two other scars located below the bikini line. These scars are nearly undetectable when the patient is wearing minimal clothing. CONCLUSION: We conclude that, in addition to minimizing port size and number, positioning of ports can be used to optimize cosmetic results.

Three-port microlaparoscopic cholecystectomy in 159 patients.

BACKGROUND: Laparoscopic cholecystectomy has undergone many refinements including reductions in port size and number. This study attempts to determine whether further reduction in port size from that previously reported by us can reduce postoperative pain without compromising the efficacy of the surgery. METHODS: In this study, 159 patients underwent laparoscopic cholecystectomy with three ports: one 5-mm umbilical port, one 3-mm subxiphoid port, and one 3-mm port in the right subcostal position. Data were collected prospectively for each patient on the duration of analgesic use, quantity of analgesic tablets consumed, postoperative pain, most painful incision, and days of recovery required before return to activity and work. These measures were compared with those collected from a group of 100 patients who had undergone laparoscopic cholecystectomy with three 5-mm ports in a previous study. RESULTS: Patients in the current study group required analgesics for a longer duration (4 vs 2.9 days; p = 0.001), used more analgesic tablets (10.7 vs 8.1; p = 0.007), and reported greater postoperative discomfort (5 vs 4.1; p = 0.016) as compared with all in the 5-mm port group. The 3-mm port group needed more days for recovery before leaving the house (2.9 vs 2.7; p = 0.504), but they returned to work earlier (5.1 vs 5.9; p = 0.065) than the group that had undergone cholecystectomy with three 5-mm ports, although there was not a significant difference between the groups. Operative time increased from 18.5 to 20.9 min (p = 0.054) in the group with two 3-mm ports. Five patients (3.1%) in the current group required enlargement of a port to complete the procedure, as compared with none in the comparison group. There was one complication (0.6%), as compared with two complications (2.0%) in the previous group. CONCLUSIONS: This study did not demonstrate a reduction in postoperative pain or a consistent improvement in recovery when the port size was reduced at the subcostal and subxiphoid positions. It did, however, show that ports could safely be reduced in size without a negative impact on the surgeon's ability to perform a cholecystectomy. Reducing port size can be a tool in the surgeon's armamentarium for use in the attempt to optimize cosmetic results.

Telerheumatology--diagnostic accuracy and acceptability to patient, specialist, and general practitioner.

This study examines the diagnostic accuracy and acceptability of telemedicine in the field of rheumatology. One hundred patients had a telephone and televisual consultation and the results were compared with a face-to-face consultation. While the telephone consultations were often unsatisfactory, the televisual consultations were highly accurate (97%) and acceptable to patients, general practitioners, and specialists.

Laparoscopic colposuspension using mesh reinforcement.

BACKGROUND: For patients with stress urinary incontinence, surgical reestablishment of the bladder neck has proved amenable to a laparoscopic approach, which shortens hospitalization and reduces tissue trauma. The use of mesh reinforcement to improve the durability of colposuspension can refine this proven procedure even further. METHODS: We performed laparoscopic Burch colposuspension on 54 patients with stress urinary incontinence and compared our results with those of other investigators. RESULTS: All patients reported resolution of incontinence postoperatively: 83.3% received no supplementary medication while 16.7% took antispasmodic-anticholinergic medications. Two cases required conversion to an open procedure. Hospital stay declined from 2.7 days (first quartile) to 1.9 days (last quartile) (average, 2.3 days). Complications were rare, and in a 28-month follow-up, no reoperations were required. CONCLUSION: Laparoscopic Burch colposuspension using mesh reinforcement provides durable resolution of stress incontinence with low risk of conversion, short hospitalization, and few complications.

Resolving gastroesophageal reflux with laparoscopic fundoplication. Findings in 138 cases.

BACKGROUND: The purpose of this study was to evaluate the results of 138 cases of gastroesophageal reflux disease resolved laparoscopically with the Rossetti modification of the Nissen fundoplication and to compare them with findings from other studies in an effort to evaluate the procedure's ability to transfer from an academic setting to a community hospital setting. METHODS: We performed laparoscopic Nissen fundoplication on 138 patients and followed them for up to 45 months. Measures included postoperative reflux persistence, complications, operating time, length of hospital stay, and others. These findings were compared, using the Fisher's exact test, chi-square test, and the two-sample t-test, with results from other studies using open and laparoscopic procedures. RESULTS: No patient undergoing laparoscopic fundoplication experienced gastroesophageal reflux after surgery. Complications, not statistically significantly different from those in other studies, occurred in 15 (10.9%), and conversion to an open procedure was required in two (1.5%). The most common postoperative complaint has been dysphagia (21.7%). Operative time averaged 70.6 min, decreasing from an average of 236 min for the first 10 cases to 40.8 min for the last 10. This measure was statistically significantly lower than all other operative times to which it was compared, except one to which it was almost identical (69.9 min). Length of stay (LOS) averaged 2.3 days, ranging from a low of 7 h to a high of 9 days, which made it fall well within limits set by other studies. Overall, LOS fell from a 3.0-day average for the first 20 cases to a 1.9-day average for the last 20 cases. CONCLUSIONS: Laparoscopic Nissen fundoplication resolved gastroesophageal reflux in all 138 patients, and measures for complications, operating time, and LOS were well within values reported by other studies, indicating the ability of this procedure to be successfully transferred from academic medical centers to the community hospital setting.

Familial polyposis in children: early detection and preferred treatment.

Familial polyposis is a disease with high malignant potential. When the diagnosis is established, surgical removal of the premalignant tissue should be complete. Reports of early malignant expression of the disease have led us to recommend early surveillance and treatment of children from affected families. We describe four children who had total colectomy, rectal mucosectomy, and ileoanal anastomosis, and relate our reasons for preferring this modality of therapy for familial polyposis in young patients.

A comparison of laparoscopic Nissen fundoplication and Rossetti's modification in 239 patients.

BACKGROUND: Laparoscopic Nissen fundoplication and the Rossetti modification represent two different surgical approaches to resolving gastroesophageal reflux disease (GERD). Concerns have arisen that the Rossetti modification results in increased postoperative dysphagia. In this study, we compared a group of patients who underwent a laparoscopic Nissen fundoplication with a group who had undergone the Rossetti modification to determine if there was a significant difference in postoperative dysphagia. Additionally, we wanted to confirm that the Nissen procedure performed laparoscopically could resolve GERD as successfully as the Rossetti modification, with no difference in operative complications. METHODS: We prospectively collected data on 101 patients who underwent laparoscopic Nissen fundoplication and compared outcomes with those of 138 patients who had undergone the laparoscopic Rossetti modification in a previous series. RESULTS: All patients experienced resolution of reflux symptoms. No statistically significant differences were found between the groups in terms of intraoperative or postoperative complications, conversions to open procedure, or length of hospitalization. Paradoxically, there was a significant difference in operating time between the Rossetti and the Nissen groups (70.6 min vs 45.6 min, p = 0.006). Postoperative dysphagia requiring dilation was significantly higher in the Rossetti group (21.7% vs 8.9%, p = 0.008). However, there was a significantly higher percentage of patients in the Rossetti group who had had esophagitis preoperatively (95.7% vs 86.1%, p = 0.009), although the proportion of patients having Barrett's esophagus was higher in the Nissen group (9.4% vs 24.8%, p = 0.001). CONCLUSIONS: Both approaches resolved reflux symptoms without significant differences in complications, conversions, or length of stay. Preoperative differences between groups, as well as the method of sequentially comparing the two different procedures, prevent us from attributing greater postoperative dysphagia in the Rossetti group solely to the choice of surgical approach. Prospective randomized studies are needed to control for variables, such as surgical team experience and patient differences.

A comparison of three standard methods of identifying mast cells in endobronchial biopsies in normal and asthmatic subjects.

Reported mast-cell counts in endobronchial biopsies from asthmatic subjects are conflicting, with different methodologies often being used. This study compared three standard methods of counting mast cells in endobronchial biopsies from asthmatic and normal subjects. Endobronchial biopsies were obtained from atopic asthmatic subjects (n = 17), atopic nonasthmatic subjects (n = 6), and nonatopic nonasthmatic control subjects (n = 5). After overnight fixation in Carnoy's fixative, mast cells were stained by the short and long toluidine blue methods and antitryptase immunohistochemistry and were counted by light microscopy. Method comparison was made according to Bland & Altman. The limits of agreement were unacceptable for each of the comparisons, suggesting that the methods are not interchangeable. Coefficients of repeatability were excellent, and not different for the individual techniques. These results suggest that some of the reported differences in mast-cell numbers in endobronchial biopsies in asthma may be due to the staining method used, making direct comparisons between studies invalid. Agreement on a standard method is required for counting mast cells in bronchial biopsies, and we recommend the immunohistochemical method, since fixation is less critical and the resultant tissue sections facilitate clear, accurate, and rapid counts.

A randomized controlled trial using instant photography to diagnose and manage dermatology referrals.

BACKGROUND: Fifteen percent of GP consultations are for dermatological conditions; 4% of these are referred to a dermatologist. There are long waiting lists for dermatology appointments. This study examines the value of instant photography in managing dermatology referrals. OBJECTIVE: The purpose of our study was to compare outcomes of referral for dermatology appointments between patients whose referral letters do or do not include instant photograph(s). METHODS: Patients (136), referred to a dermatologist by GPs in two urban health centres, were randomly allocated to study and control groups. Instant photographs, taken by the GP, were included in the referral letters. Control group patients were given out-patient appointments in the usual way. The numbers of study group patients needing an appointment for diagnosis or management and with a changed diagnosis after face-to-face consultation were recorded. Waiting time from referral to appointment or management plan was recorded for both groups. RESULTS: For 63% of the study group (45/71), a diagnosis and a management plan were made without the patient requiring an appointment. This included 38% (27/71) who, after diagnosis and initial management, needed an appointment and 25% (18/71) who did not. The remainder of the study group (37%; 26/71) required a face-to-face consultation. The mean time for formulation of a management plan for patients without an appointment was 17 days (SD = 11); waiting times for appointments in study and control groups were similar (mean 55 days; SD = 40). CONCLUSIONS: Instant photography is helpful in managing dermatology referrals and offers the potential to reduce numbers requiring an out-patient appointment by 25%.

Lower limb ischaemia-reperfusion injury alters gastrointestinal structure and function.

BACKGROUND: It has been suggested that bowel permeability is altered following abdominal aortic aneurysm surgery. The effect of ischaemia-reperfusion injury to the lower limb on the morphological structure, neutrophil infiltration and permeability of the bowel was investigated. METHODS: Histological assessment of the bowel was undertaken in five groups of Wistar rats: control, 3 h of bilateral hind limb ischaemia and 3 h of bilateral hind limb ischaemia followed by 1, 2 or 3 h of reperfusion. Using an everted gut sac model and 14C-labelled polyethylene glycol, the effect of ischaemia-reperfusion on small bowel permeability was studied. RESULTS: The small bowel showed a significant decrease in mucosal thickness, villus height and crypt depth in animals subjected to ischaemia followed by 2-hr reperfusion (mean(s.e.m.) 420(15), 217(9) and 163(6) microns respectively) compared with controls (481(11), 245(6) and 195(6) microns) (P < 0.05). Neutrophil count within the lamina propria was similar in the different groups. A significant increase in mean(s.e.m.) 14C-labelled polyethylene glycol translocation was detected in animals subjected to ischaemia-reperfusion compared with controls (760(40) versus 560(27) c.p.m. per ml per h) (P < 0.05). CONCLUSION: These data suggest that reperfusion of acutely ischaemic extremities produces structural and functional changes in the small intestine, although these changes are not associated with increased neutrophil infiltration within the bowel wall.