Economic Evaluation of Weight Loss and Transplantation Strategies for Kidney Transplant Candidates with Obesity.

Novel anti-obesity medications, particularly glucagon-like peptide-1 receptor agonists (GLP-1RAs), have expanded weight loss (WL) options for kidney transplant (KT) candidates with obesity beyond lifestyle modifications and bariatric surgery. However, varying effectiveness, risk profiles, and costs make strategy choice challenging. To aid decision-making, we used a Markov model to examine the cost-effectiveness of different WL strategies over a 10-year horizon. A target WL of 15% of total body weight was used for the base-case scenario, and we compared these strategies to a 'liberal' KT strategy of transplanting candidates with obesity. Outcomes included costs (2023 US dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. In analysis, a liberal KT strategy was favored over lifestyle modifications and GLP-1RAs. Among WL strategies, bariatric surgery was most effective and cost the least, while lifestyle modification had the highest cumulative costs and was least effective. Compared to liberal KT, bariatric surgery cost $45,859 per QALY gained. GLP-1RAs were favored over bariatric surgery only when drug costs were below $5,000 per year (base cost $12,077). In conclusion, for KT candidates with obesity, a liberal KT strategy and bariatric surgery are preferred over lifestyle modifications alone and GLP-1RAs based on outcomes and cost-effectiveness.

Changes in Smoking Behavior Before and After Gastric Bypass: A 7-year Study.

OBJECTIVE: To evaluate smoking history and change in smoking behavior, from 1 year before through 7 years after Roux-en-Y gastric bypass (RYGB) surgery, and to identify risk factors for post-surgery smoking. BACKGROUND: Smoking behavior in the context of bariatric surgery is poorly described. METHODS: Adults undergoing RYGB surgery entered a prospective cohort study between 2006 and 2009 and were followed up to 7 years until ≤2015. Participants (N = 1770; 80% female, median age 45 years, median body mass index 47 kg/m2) self-reported smoking history pre-surgery, and current smoking behavior annually. RESULTS: Almost half of participants (45.2%) reported a pre-surgery history of smoking. Modeled prevalence of current smoking decreased in the year before surgery from 13.7% [95% confidence interval (CI) = 12.1-15.4] to 2.2% (95% CI = 1.5-2.9) at surgery, then increased to 9.6% (95% CI = 8.1-11.2) 1-year post-surgery and continued to increase to 14.0% (95% CI = 11.8-16.0) 7-years post-surgery. Among smokers, mean packs/day was 0.60 (95% CI = 0.44-0.77) at surgery, 0.70 (95% CI = 0.62-0.78) 1-year post-surgery and 0.77 (95% CI = 0.68-0.88) 7-years post-surgery. At 7-years, smoking was reported by 61.7% (95% CI = 51.9-70.8) of participants who smoked 1-year pre-surgery (n = 221), 12.3% (95% CI = 8.5-15.7) of participants who formerly smoked but quit >1 year pre-surgery (n = 507), and 3.8% (95% CI = 2.1-4.9) of participants who reported no smoking history (n = 887). Along with smoking history (ie, less time since smoked), younger age, household income <$25,000, being married or living as married, and illicit drug use were independently associated with increased risk of post-surgery smoking. CONCLUSION: Although most adults who smoked 1-year before RYGB quit pre-surgery, smoking prevalence rebounded across 7-years, primarily due to relapse.

Minimally Invasive Ivor-Lewis Esophagectomy for Esophageal Cancer After Gastric Bypass.

The increasing prevalence of morbid obesity in the United States has been accompanied by a concomitant rise in bariatric surgery to help combat the epidemic. The relationship between obesity and certain cancers, such as esophageal adenocarcinoma, is well established. The need for minimally invasive techniques to treat esophageal cancer in patients with previous bariatric surgery is growing and can present a unique surgical challenge. This report presents the case of a 55-year-old woman with a previous Roux-en-Y gastric bypass who was shown by endoscopy to have an invasive adenocarcinoma located in the distal thoracic esophagus. This necessitated an excision of the thoracic esophagus and the gastric pouch. A laparoscopic and thoracoscopic Ivor-Lewis esophagogastrectomy was performed for this complex patient with esophageal adenocarcinoma. The remnant stomach was fashioned into a gastric conduit using a 60-mm linear stapler with a staple height of 4.1 mm (Echelon, Ethicon Endosurgery, Blue Ash, OH). The reconstruction was performed using a 25-mm Orvil (Covidien, Minneapolis, MN, USA) and EEA 25-mm DST XL (Covidien) to create a circular stapled thoracic esophagogastric anastomosis. A feeding jejunostomy was placed in the residual 130-cm Roux limb. The study demonstrated that minimally invasive esophagectomy is safe and technically feasible with appropriate oncologic outcomes for patients with previous gastric bypass. This cohort of patients will undoubtedly continue to grow in the coming years.

Laparoscopic resection of choledochal cyst with Roux-en-Y hepaticojejunostomy: a case report and review of the literature.

BACKGROUND: Choledochal cysts are associated with ductal strictures, stone formation, cholangitis, rupture, secondary biliary cirrhosis and increased incidence of cholangiocarcinoma. The surgical approach to choledochal cysts has evolved from the cyst-enterostomy to a complete excision with more recent use of minimally invasive approaches. We report a complete minimally invasive approach to a Type 1 choledochal cyst and summarize the literature containing large case series of similar approaches. METHODS AND OPERATIVE TECHNIQUE: A 38-year-old female with a history of vague epigastric pain for multiple years was diagnosed with a Type 1 choledochal cyst on MRCP. The operative approach was an elective laparoscopic resection of choledochal cyst and Roux-en-Y hepaticojejunostomy. There were no intraoperative complications and discharge occurred on postoperative day three. Approximately 1 month after resection, she was diagnosed with a small retrohepatic fluid collection which was treated percutaneously and was diagnosed as a hematoma. A PubMed literature review focusing on surgical approaches to Type 1 choledochal cysts methods of repair and postoperative complications was performed and summarized. RESULTS AND DISCUSSION: The literature search performed on the subject of choledochal cyst management in adults and laparoscopic approaches resulted in a review of twenty-one articles. Ten of the articles were review articles regarding surgical approach and management of the disease. An additional two were case reviews, and eight reported on laparoscopic approaches to management of choledochal cysts. In this paper, we summarize the eight articles that provide information on the laparoscopic management and outcomes for choledochal cysts. While operative times were longer on the laparoscopic procedures, hospital stay was shorter and there was no increase in complication rates. The most common complications reported were postoperative bile leak followed by anastomotic stricture. CONCLUSION: This case highlights the management of laparoscopic resection of choledochal cyst as a viable, safe and feasible approach based on this case and a literature review.

Thoracoscopic management of volvulus of the gastric conduit following minimally invasive Ivor-Lewis esophagectomy.

BACKGROUND: We present a case of emergent thoracoscopic management of volvulus of the gastric conduit following minimally invasive Ivor-Lewis esophagectomy. The patient is a 69-year-old Caucasian male with a history of adenocarcinoma of the lower third of the esophagus. Initial presentation was dysphagia with solid foods, which progressed in severity until he was unable to swallow anything. EUS demonstrated a partially obstructing mass at 33 cm; biopsy revealed poorly differentiated adenocarcinoma, stage T3N2Mx. PET scan did not reveal any metastatic disease. Preoperative management included neo-adjuvant chemoradiation therapy (5-FU and cisplatin) and early placement of a jejunal feeding tube. Intra-operative leak test was performed as a matter of routine following completion of the esophagogastric anastomosis. A nasogastric tube was placed intra-operatively and removed on POD2 according to our standard pathway. Postoperatively, the patient progressed without difficulty to POD4, when we routinely obtain an upper GI swallow study. This demonstrated a lack of transit of contrast through the distal neo-esophagus. Follow-up endoscopy revealed volvulus of the gastric conduit with obliteration of the lumen. METHOD: We immediately took the patient to the OR for thoracoscopic detorsion, which we accomplished successfully by entering the existing trochar sites and using blunt dissection.␣Upon entering the thoracic cavity, the staple line that had been oriented anteriorly was now posterior. Attachments were gently teased away from the chest wall and the conduit was detorsed and anchored to the chest wall in the correct orientation with silk suture. Intra-operative endoscopy demonstrated a patent conduit. RESULTS: Postoperative upper GI fluoroscopy now showed good transit of contrast. The patient continued to improve and was eventually advanced to mechanical soft diet and discharged on postoperative day 9. CONCLUSIONS: Early intervention is indicated in cases of volvulus of the gastric conduit following Ivor-Lewis esophagectomy.

Perioperative truncal peripheral nerve blocks for bariatric surgery: an opioid reduction strategy.

BACKGROUND: Bariatric surgical patients are vulnerable to cardiopulmonary depressant effects of opioids. The enhanced recovery after surgery (ERAS) protocol to improve postoperative morbidity recommends regional anesthesia for postoperative pain management. However, there is limited evidence that peripheral nerve blocks (PNB) have added benefit. OBJECTIVE: Study the effect of PNB on postoperative pain and opioid use following bariatric surgery. SETTING: Academic medical center, United States. METHODS: We conducted a cohort study of patients who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) surgery. A total of 44 patients received the control ERAS protocol with preoperative oral extended-release morphine sulfate (MS), while 45 patients underwent a PNB with either intrathecal morphine (IM) or oral MS per local ERAS protocol. The PNB group either underwent preoperative bilateral T7 paravertebral (PVT) PNBs (27 patients) with IM or postoperative transversus abdominis plane (TAP) PNBs (18 patients) with oral MS. The primary outcome compared total opioid consumption between the ERAS control group and the PNB group up to 48 hours postoperatively. Secondary outcomes included comparison by block type and postoperative pain scores. RESULTS: PVT or TAP PNB patients had a reduction in mean postoperative oral morphine equivalent (OME) requirements compared with the ERAS protocol cohort at 24 hours (93.9 versus 42.8 mg), P < .0001; at 48 hours (72.6 versus 40.5 mg); and in pain scores at 24 hours (5.64/10 versus 4.46/10), P = .02. OME and pain scores were higher in the SG cohort. CONCLUSION: Addition of truncal PNB to standard ERAS protocol for bariatric surgical patients reduces postoperative total opioid consumption.

Clinical Outcomes and Hospital Utilization Among Patients Undergoing Bariatric Surgery With Telemedicine Preoperative Care.

Importance: Bariatric surgery is the mainstay of treatment for medically refractory obesity; however, it is underutilized. Telemedicine affords patient cost and time savings and may increase availability and accessibility of bariatric surgery. Objective: To determine clinical outcomes and postoperative hospital utilization for patients undergoing bariatric surgery who receive fully remote vs in-person preoperative care. Design, Setting, and Participants: This cohort study comparing postoperative clinical outcomes and hospital utilization after telemedicine or in-person preoperative surgical evaluation included patients treated at a US academic hospital. Participants underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy after telemedicine or in-person preoperative surgical evaluation between July 1, 2020, to December 22, 2021, or January 1, 2018, to December 31, 2019, respectively. Follow-up was 60 days from date of surgery. Exposures: Telemedicine-based preoperative care. Main Outcomes and Measures: Clinical outcomes, including operating room delay, procedure duration, length of hospital stay (LOS), and major adverse events (MAE), and postoperative hospital resource utilization, including emergency department (ED) visit or hospital readmission within 30 days of the surgical procedure. Results: A total of 1182 patients were included; patients in the telemedicine group were younger (mean [SD] age, 40.8 [12.5] years vs 43.0 [12.2] years; P = .01) and more likely to be female (230 of 257 [89.5%] vs 766 of 925 [82.8%]; P = .01) compared with the control group. The control group had a higher frequency of comorbidity (887 of 925 [95.9%] vs 208 of 257 [80.9%]; P < .001). The telemedicine group was found to be noninferior to the control group with respect to operating room delay (mean [SD] minutes, 7.8 [25.1]; 95% CI, 5.1-10.5 vs 4.2 [11.1]; 95% CI, 1.0-7.4; P = .002), procedure duration (mean [SD] minutes, 134.4 [52.8]; 95% CI, 130.9-137.8 vs 105.3 [41.5]; 95% CI, 100.2-110.4; P < .001), LOS (mean [SD] days, 1.9 [1.1]; 95% CI, 1.8-1.9 vs 2.1 [1.0]; 95% CI, 1.9-2.2; P < .001), MAE within 30 days (3.8%; 95% CI, 3.0%-5.7% vs 1.6%; 95% CI, 0.4%-3.9%; P = .001), MAE between 31 and 60 days (2.2%; 95% CI, 1.3%-3.3% vs 1.6%; 95% CI, 0.4%-3.9%; P < .001), frequency of ER visits (18.8%; 95% CI, 16.3%-21.4% vs 17.9%; 95% CI, 13.2%-22.6%; P = .03), and hospital readmission (10.1%; 95% CI, 8.1%-12.0% vs 6.6%; 95% CI, 3.9%-10.4%; P = .02). Conclusions and Relevance: In this cohort study, clinical outcomes in the telemedicine group were not inferior to the control group. This observation suggests that telemedicine can be used safely and effectively for bariatric surgical preoperative care.

Barriers to Bariatric Surgery: a Mixed Methods Study Investigating Obstacles Between Clinic Contact and Surgery.

PURPOSE: Populations most affected by obesity are not reflected in the patients who undergo bariatric surgery. Gaps in the referral system have been studied, but there is a lack of literature investigating obstacles patients encounter after first contact with bariatric surgery clinics. We aim to identify patient populations at risk for attrition during bariatric surgery evaluation and determine patient reported barriers to bariatric surgical care. MATERIALS AND METHODS: This study was a single institution, retrospective, mixed methods study from 2012 to 2021 comparing patients who underwent bariatric surgery to those that withdrew. Surveys were performed of patients who withdrew, collecting information on patient knowledge, expectations, and barriers. RESULTS: This study included 5982 patients evaluated in bariatric surgery clinic. Those who attained bariatric surgery (38.8%) were more likely to be White (81.2 vs. 75.6%, p<0.001), married (48.5 vs. 44.1%, p=0.004), and employed full time (48.2 vs. 43.8%, p=0.01). They were less likely to live in an area with low income (37.1 vs. 40.7%, p=0.01) or poverty (poverty rate 15.8 vs. 17.4, p<0.001). Of the 280 survey respondents, fear of complications, length of insurance approval process, and wait time between evaluation and surgery were the most reported barriers. CONCLUSION: Patients who undergo bariatric surgery were more likely to be White, married, employed full time, and reside in more resourced environments which is not reflective of communities most affected by obesity. The complexity of insurance coverage requirements was a major barrier to bariatric surgery and should be a focus of future healthcare reform.

Identifying barriers to shared decision-making about bariatric surgery in two large health systems.

OBJECTIVE: Prior research suggests shared decision-making (SDM) could improve patient and health care provider communication about bariatric surgery. The aim of this work was to identify and prioritize barriers to SDM around bariatric surgery to help guide implementation of SDM. METHODS: Two large US health care systems formed multidisciplinary teams to facilitate the implementation of SDM around bariatric surgery. The teams used a nominal group process approach involving (1) generation of multilevel barriers, (2) round-robin recording of barriers, (3) facilitated discussion, and (4) selection and ranking of barriers according to importance and feasibility to address. RESULTS: One health system identified 13 barriers and prioritized 5 as the most important and feasible to address. The second health system identified 14 barriers and prioritized 6. Both health systems commonly prioritized six barriers: lack of insurance coverage; lack of understanding of insurance coverage; lack of organizational prioritization of SDM; lack of knowledge about bariatric surgery; lack of interdepartmental clarity between primary and specialty care; and limited training on SDM conversations and tools. CONCLUSIONS: Health systems face numerous barriers to SDM around bariatric surgery, and these can be easily identified and prioritized by multistakeholder teams. Future research should seek to identify effective strategies to address these common barriers.

MRI as First Line Imaging for Suspected Acute Appendicitis during Pregnancy: Diagnostic Accuracy and level of Inter-Radiologist Agreement.

OBJECTIVE: Evaluation of acute appendicitis (AA) in pregnancy is supported with diagnostic imaging. Typically, ultrasound (US) is performed first, and then often followed by magnetic resonance imaging (MRI) due to continued diagnostic uncertainty. The purpose of our study was to evaluate the sensitivity, specificity, and accuracy of US as compared to MRI and to evaluate the inter-radiologist agreement amongst body Radiologists with varying levels of expertise. MATERIALS AND METHODS: We performed a retrospective study of 364 consecutive pregnant patients with clinical suspicion of AA at a single center over a 6-year period. Sensitivity, Specificity, accuracy, positive and negative predictive values were calculated for US and MRI. Inter Radiologist agreement was determined using Cohen's Kappa analysis between original interpreting Radiologist and retrospective review by expert Radiologist. RESULTS: Thirty-one of 364 patients (8.5%) underwent appendectomy based on preoperative diagnosis, with confirmation of acute appendicitis (AA) by pathology in 19. US was able to visualize the appendix in only 6 (1.65%), 5 of whom had appendicitis. 141 patients underwent MRI, and correctly diagnosed appendicitis in 9. No patient with a negative MRI diagnosis had AA. The sensitivity, and negative predictive value for diagnosing AA with MRI was 100%. The MRI inter-reader agreement for appendix visualization and overall accuracy were 87.9 and 98% with Cohen Kappa of 0.7 and 0.56 respectively. CONCLUSIONS: Our data suggests that MRI should be considered the first line imaging modality in pregnant patients suspected of having AA. Body Radiologists with varied levels of experience in MRI readouts had substantial agreement.

Auricular nerve stimulation using the NSS-2 BRIDGE device to reduce opioid requirement following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Evidence supports the use of complementary techniques to reduce pain and opioid use after surgery. The NSS-2 BRIDGE device (NBD; Innovative Health Solutions, Inc., Versailles, Indiana) modulates pain via stimulation of the nucleus of the auricular branch of the cranial nerves at the level of the brainstem and the limbic system. OBJECTIVE: To investigate the role of auricular nerve field stimulation for pain control following gastric bypass surgery. SETTINGS: U.S. academic medical center. METHODS: A total of 18 subjects were included. Subjects were divided in 2 groups: NBD group (n = 8) and a control group (n = 10). The NBD was placed following laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery in the recovery room. The effectiveness of NBD was assessed comparing the relative use of opioid consumption (oral morphine equivalents) and pain (0 = no pain to 10= worst possible pain) at 24 and 48 hours after surgery. In addition, the device tolerability (1-10) was assessed, with 8-10 considered excellent. Data were analyzed using unpaired t tests and presented as mean ± standard deviation. Alpha was set up at .1. RESULTS: Compared with the control group, the use of NBD was associated with a 60.2% reduction in oral morphine equivalents (38.15 vs 15.2 mg; P < .1) and a 28% reduction in pain (5.0 vs 3.6; P = .1) at 24 hours after surgery. The tolerability of NBD was reported to be excellent. CONCLUSIONS: This report suggests that NBD may represent an interesting alternative to control perioperative pain and limit opioid use following bariatric surgery. This needs to be confirmed by a placebo-controlled, randomized study.

Surgical placement of customized abdominal vagus nerve stimulating and gastrointestinal serosal surface recording electrodes.

Bioelectronic medical approaches to control vagus nerve-to-organ signaling have the potential to treat cardiac, respiratory, gastrointestinal (GI) and metabolic diseases, such as obesity. Unlike cervical vagus nerve stimulation (VNS), abdominal VNS could provide specific therapeutic control of the GI tract without off-target effects on thoracic organs; however, surgical approaches for abdominal VNS electrode placement are not well established. Moreover, optimal device configurations and additional placement of GI recording electrodes for closed-loop control are largely unknown. We designed VNS cuff and GI planar serosal electrodes and tested placement of these devices in laparoscopic surgery in two cadavers. We determined that electrode positioning on the ventral abdominal vagus nerve and gastric antrum was feasible but other sites, such as the duodenum and proximal stomach, were more difficult. The current investigation can guide potential placement and design of VNS cuff and GI electrodes for development of closed-loop GI therapeutic devices.

Laparoscopic management of sigmoidorectal intussusception.

Adult intussusception is an uncommon entity. Surgical resection is required because of the high incidence of pathological lead point. We report a case of sigmoidorectal intussusception caused by a large tubulovillous adenoma. The patient underwent laparoscopic sigmoidectomy.

An Old Idea is a Novel Concept for Supplemental Funding of Surgical Residency Programs.

Background In July 2014, the Institute of Medicine released a review of the governance of Graduate Medical Education (GME), concluding that changes to GME financing were needed to reward desired performance and to reshape the workforce to meet the nation's needs. In light of the rapid emergence of alternative payment systems, we evaluated the financial value of resident participation in operative surgical care.  Methods The Department of Surgery provided Current Procedural Terminology (CPT) codes for procedures performed by the general surgical service at our institution for the 2011 academic year. For each code, the charge and total instances were provided. CPTs allowing an assistant fee were identified using the Searchable Medicare Physician Fee Schedule. This approach enabled calculation of the potential resident contribution to GME funding. Results A total of 515 unique CPTs were potentially billable for a total of 6,578 procedures, of which 2,552 (39%) were reimbursable. These CPTs would have generated $1,882,854 in assistant charges. The top 50 most frequent CPTs resulted in 4,247 procedures. Within the top 50, 1362 procedures (32% of the top 50, 21% of the total) were reimbursable. Of the total assistant charges, $963,227 (51%) occurred in the top 50 most frequent CPTs. Conclusions Credit for resident participation in operative care as co-surgeon would average $67,244 per resident, compared to our current funding of $142,635 per resident. This type of alternative funding could provide 47% of current educational support. The skew in distribution of procedures also suggests that such a system could provide guidance to a more balanced operative experience. Such performance-based credentialing could be used to ensure appropriate housestaff for a given case; these reimbursements could also be adjusted based on quality metrics to provide for transformational change in patient outcomes.

Genetic and molecular abnormalities in cholangiocarcinogenesis.

Cholangiocarcinomas are biliary tree neoplasms of cholangiocyte origin. Several clinical risk factors are associated with cholangiocarcinogenesis. During the last decade, there has been an increasing interest in the causative molecular mechanisms of cholangiocarcinoma because of its poor prognosis and the lack of effective therapies. A better understanding of cholangiocarcinoma tumor initiation, promotion, and progression, as well as neurotransmitter, neuroendocrine, and endocrine growth effects, may elucidate molecular targets for diagnostic and therapeutic purposes.

Proximal Roux-en-Y gastric bypass: Addressing the myth of limb length.

BACKGROUND: Some studies suggest that changes in weight or metabolic outcomes are affected by the lengths of the gastrointestinal limbs in the Roux-en-Y gastric bypass. METHODS: Participants (N = 1,770) underwent primary Roux-en-Y gastric bypass and were followed ≤7 years in the Longitudinal Assessment of Bariatric Surgery-2, a multicenter US cohort study. Alimentary limb and biliopancreatic limb lengths were measured according to research protocol; common channel was measured in a subsample (N = 547). Aimentary limb, biliopancreatic limb, and common channel ratio to total small bowel length were calculated. RESULTS: Median presurgery body mass index was 46 (25th-75th percentile: 43-51) kg/m2. Medians (25th-75th percentiles) for alimentary limb length were 125 cm (100-150), for biliopancreatic limb length were 50 cm (50-60), and common channel length were 410 cm (322-520). Statistics for ratios to the small bowel length were 0.23 (0.18-0.27) for alimentary limb, 0.09 (0.07-0.10) for biliopancreatic limb, and 0.69 (0.63-0.73) for common length. There were no significant associations between alimentary limb, biliopancreatic limb, common channel, alimentary limb ratio, biliopancreatic limb ratio or common channel ratio, and either weight loss or improvement in cardiometabolic outcomes. CONCLUSION: The common channel length in Roux-en-Y gastric bypass is highly variable between individuals. None of the limb lengths in this study, nor alimentary limb, biliopancreatic limb, or common channel ratios, seem to be related to weight loss or metabolic improvements >7 years.

Bariatric Surgery Among Medicare Subgroups: Short- and Long-Term Outcomes.

OBJECTIVE: This study sought to examine weight change, postoperative adverse events, and related outcomes of interest among age-qualified (AQ) and disability-qualified (DQ) Medicare recipients compared with non-Medicare (NM) patients undergoing an initial bariatric procedure. METHODS: The Longitudinal Assessment of Bariatric Surgery (LABS-2) is an observational cohort study of 2,458 adults who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) bariatric surgery. Weight, percentage body fat, functional status, and comorbidities, as well as postoperative adverse events, were assessed at baseline and annually for 5 years. The 1,943 participants who reported insurance type were categorized into the following groups: AQ, DQ, or NM. RESULTS: The median preoperative BMI ranged from 45 to 48 kg/m2 across groups. For RYGB, 5-year BMI loss was approximately 30% for all groups, and for LAGB, BMI loss was 12% to 15%. Diabetes remission after 5 years was also similar across groups within procedure types (RYGB: 33%-40%; LAGB: 13%-19%). The frequency of adverse events after RYGB ranged from 4.1% for NM participants to 6.7% for DQ participants. After LAGB, there were no adverse events for the AQ group, whereas 3% of DQ participants and 1.8% of NM participants had at least one adverse event. CONCLUSIONS: Medicare participants experienced substantial BMI loss and diabetes remission, with a frequency of adverse events similar to that of NM participants.

Aberrant crypt foci as precursors in colorectal cancer progression.

Colorectal cancer progression originates when accumulated genetic and epigenetic alterations cause genomic instability and a malignant phenotype. Subsequent molecular pathway deregulation leads to histopathologic changes that are clinically evident as aberrant crypt foci (ACF) and visualized by high-magnification chromoscopic colonoscopy. ACF are biomarkers of increased colorectal cancer risk, particularly those with dysplastic features. Genetic profiling using genomic instability, loss of heterozygosity, and methylation analysis has revealed a minority population of ACF genotypically analogous to cancer.

Post-laparoscopic cholecystectomy pain: effects of intraperitoneal local anesthetics on pain control--a randomized prospective double-blinded placebo-controlled trial.

Postoperative pain after laparoscopic cholecystectomy (LC) is generally less than open cholecystectomy; however, the postoperative shoulder and abdominal pain experienced by patients still causes preventable distress. Intraperitoneal irrigation of the diaphragmatic surface and gallbladder fossa using normal saline, bupivacaine, or lignocaine may effectively control visceral abdominal pain after an LC. Two hundred patients with similar demographics undergoing elective LC were randomized to one of four groups of 50 patients each, including Group A placebo control, Group B with isotonic saline irrigation, Group C with bupivacaine irrigation, and Group D with lignocaine irrigation. All patients received preperitoneal abdominal wall infiltration with 0.25 per cent bupivacaine to control parietal (somatic) abdominal pain. The visual analogue and verbal rating pain scores at 0, 4, 8, 12 and 24 hours for both shoulder and abdominal pain were recorded in a prospective double-blind fashion at four points during the first 24 postoperative hours. Analgesia requirements, vital signs, blood glucose, and incidence of nausea and vomiting were also recorded. Patients in each group demonstrated a significant difference in visual analogue and verbal rating pain scores and analgesic consumption when compared with controls. Lignocaine controlled pain significantly better than saline or bupivacaine. Bowel function recovery was similar in all patients, and there were no significant complications. We conclude that intraperitoneal irrigation with either saline, bupivacaine, or lignocaine can significantly reduce visceral abdominal pain after LC. Lignocaine was the most efficacious local anesthetic in this trial and has a high safety profile when used at recommended doses.