Correction to: Prior bariatric surgery lowers complication rates following spine surgery in obese patients.

The AHRQ (Agency for Healthcare Research and Quality) has requested the correction of the result Tables 1-3 of this study: All stated numbers below 10 shall be modified to read "<10" instead.

Prior bariatric surgery lowers complication rates following spine surgery in obese patients.

BACKGROUND: Bariatric surgery (BS) is an increasingly common treatment for morbid obesity that has the potential to effect bone and mineral metabolism. The effect of prior BS on spine surgery outcomes has not been well established. The aim of this study was to assess differences in complication rates following spinal surgery for patients with and without a history of BS. METHODS: Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years 2004-2013. BS patients and morbidly obese patients (non-BS) were divided into cervical and thoracolumbar surgical groups and propensity score matched for age, gender, and invasiveness and complications compared. RESULTS: One thousand nine hundred thirty-nine spine surgery patients with a history of BS were compared to 1625 non-BS spine surgery patients. The average time from bariatric surgery to spine surgery is 2.95 years. After propensity score matching, 740 BS patients were compared to 740 non-BS patients undergoing thoracolumbar surgery, with similar comorbidity rates. The overall complication rate for BS thoracolumbar patients was lower than non-BS (45.8% vs 58.1%, P < 0.001), with lower rates of device-related (6.1% vs 23.2%, P < 0.001), DVT (1.2% vs 2.7%, P = 0.039), and hematomas (1.5% vs 4.5%, P < 0.001). Neurologic complications were similar between BS patients and non-BS patients (2.3% vs 2.7%, P = 0.62). For patients undergoing cervical spine surgery, BS patients experienced lower rates of bowel issues, device-related, and overall complication than non-BS patients (P < 0.05). CONCLUSIONS: Bariatric surgery patients undergoing spine surgery experience lower overall complication rates than morbidly obese patients. This study warrants further investigation into these populations to mitigate risks associated with spine surgery for bariatric patients.

Perioperative risk factors for 30-day mortality after bariatric surgery: is functional status important?

BACKGROUND: Although the mortality from bariatric surgery is low, perioperative determinants of morbidity and mortality in the bariatric surgery population to date have not been fully defined. This study aimed to evaluate the factors capable of predicting perioperative mortality based on preoperative characteristics with a national patient sample. METHODS: From the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, all the primary bariatric procedures performed between 2007 and 2009 were identified. Using univariate analysis, factors associated with increased perioperative (30-day) mortality were identified. Logistic regression was used to select correlates of 30-day mortality, which were subsequently integrated into a simplified clinical scoring system based on the number of comorbid risk factors. RESULTS: The study identified 44,408 patients (79 % women, 21 % men) with a mean age of 45 ± 11 years. The cumulative 30-day perioperative mortality rate was 0.14 %. The majority of the procedures performed included laparoscopic gastric bypass (54 %) followed by laparoscopic gastric banding (33 %) and open gastric bypass (7 %). Independent predictors associated with significantly increased mortality included age >45 years [adjusted odds ratio (AOR), 2.45], male gender (AOR = 1.77), a body mass index (BMI) of 50 kg/m(2) or higher (AOR, 2.48), open bariatric procedures (AOR, 2.34), diabetes (AOR, 2.88), functional status of total dependency before surgery (AOR, 27.6), prior coronary intervention (AOR, 2.66), dyspnea at preoperative evaluation (AOR, 4.64), more than 10 % unintentional weight loss in 6 months (AOR, 13.5), and bleeding disorder (AOR, 2.63). Ethnicity, hypertension, alcohol abuse, liver disease, and smoking had no significant association with mortality in this study. Risk stratification based on the number of preoperative comorbid factors showed an exponential increase in mortality as follows: 0-1 comorbidities (0.03 %), 2-3 comorbidities (0.16 %), and 4 comorbidities or more (7.4 %). CONCLUSION: This model provides a straightforward, precise, and easily applicable tool for identifying bariatric patients at low, intermediate, and high risk for in-hospital mortality. Notably, baseline functional status before surgery is the single most powerful predictor of perioperative survival and should be incorporated into risk stratification models.

Bariatric Surgery Lowers Rates of Spinal Symptoms and Spinal Surgery in a Morbidly Obese Population.

STUDY DESIGN: Retrospective analysis of New York State Inpatient Database years 2004-2013. OBJECTIVE: Assess rates of spinal diagnoses and procedures before and after bariatric surgery (BS). SUMMARY OF BACKGROUND DATA: BS for morbid obesity helps address common comorbidity burdens and improves quality of life for patients. The effects of BS on spinal disorders and surgical intervention have yet to be investigated. MATERIALS AND METHODS: Patients included in analysis if they underwent BS and were seen at the hospital before and after this intervention. Spinal conditions and rates of surgery assessed before and after BS using χ 2 tests for categorical variables. Multivariable logistic regression analysis used to compare rates in BS patients to control group of nonoperative morbidly obese patients. Logistic testing controlled for comorbidities, age, biological sex. RESULTS: A total of 73,046 BS patients included (age 67.88±17.66 y, 56.1% female). For regression analysis, 299,504 nonbariatric, morbidly obese patients included (age 53.45±16.52 y, 65.6% female). Overall, rates of spinal symptoms decreased following BS (7.40%-5.14%, P <0.001). Cervical, thoracic, lumbar spine diagnoses rates dropped from 3.28% to 2.99%, 2.91% to 2.57%, and 5.39% to 3.92% (all P <0.001), respectively. Most marked reductions seen in cervical spontaneous compression fractures, cervical disc herniation, thoracic radicular pain, spontaneous lumbar compression fractures, lumbar spinal stenosis, lumbar spondylosis. Controlling for comorbidities, age and sex, obese nonbariatric patients more likely to have encounters associated with several cervical, thoracic or lumbar spinal diagnoses and procedures, especially for cervical spontaneous compression fracture, radicular pain, lumbar spondylosis, lumbar spinal stenosis, posterior procedures. BS significantly lowered comorbidity burden for many specific factors. CONCLUSIONS: BS lowered rates of documented spinal disorders and procedures in a morbidly obese population. These findings provide evidence of additional health benefits following BS, including reduction in health care encounters for spinal disorders and rates of surgical intervention.

Dietary flaxseed protects against lung ischemia reperfusion injury via inhibition of apoptosis and inflammation in a murine model.

BACKGROUND: The hallmark of lung ischemia-reperfusion injury (IRI) is the production of reactive oxygen species (ROS), and the resultant oxidant stress has been implicated in apoptotic cell death as well as subsequent development of inflammation. Dietary flaxseed (FS) is a rich source of naturally occurring antioxidants and has been shown to reduce lung IRI in mice. However, the mechanisms underlying the protective effects of FS in IRI remain to be determined. METHODS: We used a mouse model of IRI with 60 min of ischemia followed by 180 min of reperfusion and evaluated the anti-apoptotic and anti-inflammatory effects of 10% FS dietary supplementation. RESULTS: Mice fed 10% FS undergoing lung IRI had significantly lower levels of caspases and decreased apoptotic activity compared with mice fed 0% FS. Lung homogenates and bronchoalveolar lavage fluid analysis demonstrated significantly reduced inflammatory infiltrate in mice fed with 10% FS diet. Additionally, 10% FS treated mice showed significantly increased expression of antioxidant enzymes and decreased markers of lung injury. CONCLUSIONS: We conclude that dietary FS is protective against lung IRI in a clinically relevant murine model, and this protective effect may in part be mediated by the inhibition of apoptosis and inflammation.

Mixed adenoneuroendocrine carcinoma (MANEC) of the gallbladder: a possible stem cell tumor?

A 48 year-old African American woman presented to her physician complaining of a rapidly evolving epigastric and right upper quadrant abdominal pain. A PET-CT of the abdomen and pelvis demonstrated hypermetabolic, polypoid masses within the gallbladder and several tumors in the left lobe of the liver for which she underwent diagnostic laparoscopy. The gallbladder revealed a 3.5 × 3.3 × 2.4 tan-brown exophytic mass located at the fundus and growing into the lumen with multiple contiguous papillary projections arising from the mucosal surface. A concurrent large cell neuroendocrine carcinoma and papillary adenocarcinoma of the gallbladder was revealed histologically. There was shared reactivity to antibodies directed against the distinct antigens for each morphological component with transitional tumor cells (of both histological components) located at the areas where the two tumor types merged, revealing common immunoreactivity for carcinoembryonic antigen, cancer antigen 19-9, keratin 19, c-kit (cluster of differentiation protein 117 (CD117)) and epithelial cell adhesion molecule. Ultrastructurally, individual cells were demonstrated to have overlapping features of neuroendocrine and glandular differentiation. The aforementioned histological, ultrastructural and immunohistochemical profile is strongly suggestive of a biphenotypic stem/progenitor cell tumor of the gallbladder.

Bacterial burden and wound outcomes as influenced by negative pressure wound therapy .

UNLABELLED:  Abstract: Negative pressure wound therapy (NPWT) has consistently shown significant clinical benefits in wound healing, but the mechanisms are not fully elucidated. While a reduction in bacterial burden is one possible contributor, studies have shown mixed results in this regard. The present study used a porcine infected wound model to test the effect of NPWT on bacterial burden. METHODS: Infected wounds (Pseudomonas aeruginosa, coagulase negative Staphylococcus, and Bacteroides fragilis) in a porcine model were treated with V.A.C.® therapy with the standard GranuFoam™ dressing, V.A.C. therapy with the GranuFoam Silver® dressing, or moist gauze for a period of 7 days with three dressing changes. Quantitative and semiquantitative bacterial cultures, histological samples, and digital photographs were taken at dressing changes. RESULTS: The wounds continued to show gross and microscopic improvement when treated with standard NPWT and NPWT with silver compared to moist wound care controls. However, the bacterial burden in all wounds continued to increase and broadened to include local skin flora, which had been absent immediately after wounding. These increases in bacteria were not affected by the use of silver dressings. CONCLUSION: Negative pressure wound therapy with either standard NPWT foam or silver NPWT foam produced significant improvements in local wound appearance. This occurred despite a persistently high level of bacterial infection; thus, the improvement in healing of these infected wounds cannot be explained by a change in the bacterial burden. .

Single-incision laparoscopic cholecystectomy using flexible endoscopy: saline infiltration gallbladder fossa dissection technique.

BACKGROUND: The introduction of natural orifice translumenal endoscopic surgery has led to the development of new techniques to accomplish minimally invasive procedures using flexible endoscopic instruments. This study evaluated a technique used in endoscopic mucosal resection and applied it to dissection of the gallbladder from the liver bed. METHODS: Eight patients underwent an elective transumbilical single-incision cholecystectomy using a flexible endoscope at the authors' institution from August 2007 to February 2008. An endoscopic injection needle was used to inject 20 ml of saline strategically into the gallbladder fossa. After infiltration, dissection of the gallbladder and hilum was performed with endoscopic instruments, whereas the cystic duct and artery were clipped using laparoscopic instruments. RESULTS: None of the eight patients had inadvertent perforation of the gallbladder during dissection. The technique of infiltrating the potential space between the gallbladder and the liver bed leads to a significantly improved visualization of the plane between them. CONCLUSION: The injection of saline to develop surgical planes is an effective tool in performing a cholecystectomy using flexible endoscopic instrumentation. The enhancement of this potential space improved visualization in all patients. This technique has great potential value for dissections and requires further evaluation of its effectiveness in other applications.

Bouveret Syndrome: When a Stone Cannot Pass the Pylorus.

Bouveret syndrome, a rare cause of intestinal obstruction, occurs by passage of a gallstone through a cholecystoduodenal fistula into the intestinal lumen. Presenting symptoms are nausea, vomiting, and abdominal pain. In some cases, chronic symptoms result in weight loss. Typically, the syndrome is diagnosed via x-ray, ultrasound, or computed tomography. Treatment options are endoscopic or surgical. Endoscopic approaches include mechanical lithotripsy, electrohydraulic lithotripsy, stone extraction, laser lithotripsy, extracorporeal shockwave lithotripsy, and/or duodenal stenting. When stone fragments migrate distally, surgical removal becomes necessary. We describe a distinct endoscopic treatment via stone breakage, followed by pushing the fragments of the stone into the jejunum, resolving the intestinal obstruction.

Trends in splenectomy: where does laparoscopy stand?

BACKGROUND AND OBJECTIVES: Laparoscopic splenectomy (LS) has been shown to offer superior outcomes when compared to open splenectomy (OS). Despite the potential advantages associated with the minimally invasive technique, laparoscopy appears to be underused. We sought to evaluate the nationwide trends in LS. METHODS: The Nationwide Inpatient Sample (NIS) database was queried for both OS and LS procedures performed from 2005 through 2010. Partial splenectomies and those performed for traumatic injury, vascular anomaly, or as part of a pancreatectomy were excluded. The included cases were examined for age of the patient and comorbid conditions. We then evaluated the postoperative complications, overall morbidity, mortality, and length of hospital stay. RESULTS: A total of 37,006 splenectomies were identified. Of those, OS accounted for 30,108 (81.4%) cases, LS for 4,938 (13.3%), and conversion to open surgery (CS) for 1,960 (5.3%). The overall rate of morbidity was significantly less in the LS group than in the OS group (7.4% vs 10.4%; P < .0001). The LS group had less mortality (1.3% vs 2.5%, P < .05) and a shorter length of stay (5.6 ± 8 days vs 7.5 ± 9 days). CONCLUSIONS: Despite the benefits conferred by LS, it appears to be underused in the United States. There has been an improvement in the rate of splenectomies completed laparoscopically when compared to NIS data from the past (8.8% vs 13%; P < .05). The conversion rate is appreciably higher for LS than for other laparoscopic procedures, suggesting that splenectomies require advanced laparoscopic skills and that consideration should be given to referring patients in need of the procedure to appropriately experienced surgeons.

Laparoendoscopic single-site surgery for the placement of an adjustable gastric band: a large cohort comparison.

BACKGROUND: Laparoendoscopic single-site (LESS) surgery has been shown to be a well-tolerated alternative for the placement of an adjustable gastric band. To date, only small series have suggested that this approach may provide potential clinical benefits over standard multiport laparoscopy. The objective of this study was to compare the outcomes of patients undergoing LESS adjustable gastric banding (LESS-AGB) and a cohort of patients undergoing standard multiport laparoscopic adjustable gastric banding (LAGB). METHODS: A total of 206 patients underwent placement of an adjustable gastric band. Of these, 106 patients underwent LESS-AGB and were compared with a demographically similar cohort of 100 patients who underwent standard LAGB. Data collected included operative time, parenteral and oral narcotic consumption, duration of patient controlled analgesia (PCA) device, subjective pain scores using the 0-10 numeric pain intensity scale, and length of stay. Unpaired t test was used for analysis. RESULTS: Compared with multiport LAGB patients, LESS-AGB patients reported significantly less pain at the first postoperative hour (P = .012), twelfth postoperative hour (P = .017), and twenty-fourth postoperative hour (P = .012), and consumed fewer oral analgesic tablets (P = .012). Operative times were significantly longer in the LESS-AGB group (P = .029). No significant differences were seen in duration of PCA, parenteral narcotic consumption, or length of stay. One LESS-AGB case required conversion to multiport laparoscopy. Complication rates were similar between the 2 groups. CONCLUSION: LESS-AGB is associated with less pain and less oral analgesic consumption than multiport LAGB. Given these clinical advantages and superior cosmetic results, laparoendoscopic single-site surgery may be an attractive alternative approach for patients considering LAGB.

Single port sleeve gastrectomy: strategic use of technology to re-establish fundamental tenets of multiport laparoscopy.

BACKGROUND: Laparoscopic sleeve gastrectomy is commonly performed using multiple ports. The quest to minimize surgical trauma has led to the development of single port laparoscopy, which has been shown to be a safe, less-invasive method of performing a variety of abdominal surgeries. We describe the feasibility and safety of single port sleeve gastrectomy (SPSG) for morbid obesity at an academic affiliate of a university hospital. METHODS: A total of 25 patients undergoing elective SPSG were compared with a demographically similar contemporaneous cohort of 9 patients who underwent standard multiple port laparoscopic sleeve gastrectomy. The data collected included the operative time, narcotic consumption, duration of patient controlled analgesia use, subjective pain scores, and length of stay. RESULTS: The patients undergoing SPSG experienced significantly less pain at 1 hour postoperatively (P = .039). No statistically significant difference was found in pain between the 2 groups at 12 and 24 hours (P = .519 and P = .403, respectively). The quantity of narcotic use (P = .538), duration of patient controlled analgesia use (P = .820), and length of stay (P = .571) were not significantly different between the 2 groups. The operative time for SPSG was 118 minutes versus 101 minutes for multiple port surgery (P = .160). CONCLUSIONS: SPSG is safe and feasible for selected patients. The patients undergoing SPSG reported significantly less pain at the first postoperative hour. No significant differences between the 2 groups were seen in any of the other postoperative parameters.

Single-incision laparoscopic cholecystectomy using a flexible endoscope.

OBJECTIVE: To describe our experience with a single-incision laparoscopic cholecystectomy (SILC) performed using a flexible endoscope as the means of visualization and surgical dissection. The use of flexible endoscopy in intra-abdominal surgery has never been described. DESIGN: Prospective observational case series. PATIENTS: Eleven patients with symptomatic cholelithiasis were selected based on age, clinical presentation, body habitus, and history of previous abdominal surgery. Patients with acute or chronic cholecystitis were excluded. RESULTS: All procedures were completed laparoscopically via the single umbilical incision without the need to convert to an open operation and without introduction of any additional laparoscopic instruments or trocars. The mean operative time was 149.5 minutes (range, 99-240 minutes). The mean length of hospital stay was 0.36 days. There were no associated intraoperative or postoperative complications. CONCLUSIONS: In our experience, SILC performed with a flexible endoscope is feasible and safe. Further studies are needed to determine its advantages in reference to postoperative pain and complication rate in juxtaposition with the current standard laparoscopic cholecystectomy.

Resection-plication-release for hypertrophic cardiomyopathy: clinical and echocardiographic follow-up.

BACKGROUND: Abnormal positioning and size of the mitral valve contribute to the systolic anterior motion and mitral-septal contact that are important components of obstructive hypertrophic cardiomyopathy (HCM). The RPR repair (resection of the septum, plication of the anterior leaflet, and release of papillary muscle attachments) addresses all aspects of this complex pathology. This study reports outcomes regarding effectiveness of the RPR repair. METHODS: Fifty consecutive unselected patients (average age, 55.8 years) undergoing RPR repair for obstructive HCM from 1997 to 2007 were studied. Each patient underwent preoperative and postoperative transthoracic echocardiograms to document gradient, ejection fraction, degree of mitral regurgitation, and systolic anterior motion. Intraoperative transesophageal echocardiogram was used to guide all surgical repairs. Clinical follow-up included patient interviews to determine New York Heart Association (NYHA) status. RESULTS: Concomitant operations were performed in 25 patients (50%). Postoperative mortality was 0%. Average mean left ventricular outflow tract gradients decreased from 134 +/- 40 to 2.8 +/- 8.0. Mitral regurgitation improved from a mean of 2.5 to 0.1 (p < 0.001). Average length of stay was 6.9 +/- 2.7 days. NYHA class improved from 3.0 +/- 0.6 to 1.2 +/- 0.5. Follow-up was 100%, with a mean of 2.5 +/- 1.8 years. Average mitral regurgitation at follow-up was 0.9, with no residual systolic anterior motion. CONCLUSIONS: The RPR repair is safe and effective for symptomatic obstructive HCM. Our data support repair of the mitral valve that results in good intermediate outcomes with respect to gradient, mitral regurgitation, and clinical status.