Comparison of Stromal/Stem Cells Isolated from Human Omental and Subcutaneous Adipose Depots: Differentiation and Immunophenotypic Characterization.

The emerging field of regenerative medicine has identified adipose tissue as an abundant source of stromal/stem cells for tissue engineering applications. Therefore, we have compared the differentiation and immunophenotypic features of adipose-derived stromal/stem cells (ASC) isolated from either omental or subcutaneous adipose depots. Human tissue samples were obtained from bariatric and plastic surgical practices at a university-affiliated teaching hospital and a private practice, respectively, with informed patient consent. Primary cultures of human ASC were isolated from adipose specimens within 24 h of surgery and culture expanded in vitro. The passaged ASC were induced to undergo adipogenic or osteogenic differentiation as assessed by histochemical methods or evaluated for surface antigen expression profiles by flow cytometry. ASC yields per unit weight of tissue were comparable between omental and subcutaneous depots. At passage 0, the immunophenotype of omental and subcutaneous ASC were not significantly different with the exception of CD105 and endoglin, a component of the transforming growth factor ß receptor. The adipogenic differentiation of omental ASC was less robust than that of subcutaneous ASC based on in vitro histochemical and PCR assays. Although the yield and immunophenotype of ASC from omental adipose depots resembled that of subcutaneous ASC, omental ASC displayed significantly reduced adipogenic differentiation capacity following chemical induction. Further studies are necessary to evaluate and optimize the differentiation function of omental ASC in vitro and in vivo. Pending such analyses, omental ASC should not be used interchangeably with subcutaneous ASC for regenerative medical applications.

Univariate and multivariate analyses of preoperative factors influencing symptomatic outcomes of transoral fundoplication.

BACKGROUND: Preoperative factors predicting symptomatic improvement after transoral fundoplication (TF) in chronic gastroesophageal reflux disease (GERD) patients with persistent symptoms on proton-pump inhibitors (PPIs) therapy have not been elucidated fully. METHODS: Univariate and multivariate logistic regression analyses were performed on data from 158 consecutive patients who underwent TF with the EsophyX device between January 2010 and June 2012 in 14 community centers. Variables included age, gender, body mass index, GERD duration, PPIs therapy duration, presence of hiatal hernia, esophagitis, Hill grade, quality of life scores (QOL) on PPIs, % total time pH < 4, and DeMeester score on reflux testing off PPIs. RESULTS: All patients suffered from typical GERD symptoms. Additionally, 78% (124/158) of patients suffered from atypical symptoms. Six percent (10/158) with recurrent GERD symptoms refractory to PPI therapy underwent revisional procedure (9 laparoscopic Nissen, 1 TF). Median follow-up was 22 (range 10-43) months. For patients with typical symptoms, univariate analyses revealed 4 preoperative factors predictive of successful outcomes: age ≥ 50 [odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.2-4.8, p = 0.014], GERD Health-related Quality of Life score (GERD-HRQL) ≥ 15 on PPIs (OR = 6.0, CI = 1.2-29.4, p = 0.026, Reflux Symptom Index score > 13 on PPIs (OR = 2.4, CI = 1.1-5.2, p = 0.027), and Gastroesophageal Reflux Symptom Score ≥ 18 on PPIs (OR = 2.6, CI = 1.2-5.8, p = 0.018). Age and GERD-HRQL score remained significant predictors by multivariate analysis. For patients with atypical symptoms, only GERD-HRQL score ≥ 15 on PPIs (OR = 9.9, CI = 0.9-4.6, p = 0.036) was associated with successful outcomes. CONCLUSIONS: Elevated preoperative QOL scores on PPIs and age ≥ 50 were most closely associated with successful outcome of TF in patients with persistent symptoms despite medical therapy.

Laparoscopic sleeve gastrectomy: our first 100 patients.

BACKGROUND: Laparoscopic sleeve gastrectomy is becoming a popular procedure for the morbidly obese patient. Its utilization as a standalone procedure has good results with weight loss in short- and midterm reports. The aim of this study was to assess our technique and whether it warranted any modifications in the early postoperative period. METHODS: Our first 100 consecutive patients undergoing laparoscopic sleeve gastrectomy were retrospectively reviewed. Data analysis was conducted at 3 and 6 months to assess the percentage of excess body weight loss and comorbidity status change. RESULTS: The percentage of excess body weight loss at the 3- and 6-month marks was 34.2% and 49.1%, respectively. Comorbidities were also improved at the 3- and 6-month marks. Hypertension resolved in 38%, hyperlipidemia resolved in 19%, and diabetes in 46%. Complication rate during the first 6 months was 10%. Major complications included 2 patients with postoperative bleeding, 2 patients with acute renal failure from dehydration, and 1 postoperative bleeding patient who developed a gastric fistula. No surgical reintervention was required for any complication. CONCLUSION: Our technique is a safe method that is easily reproducible and does not require any modification. Laparoscopic sleeve gastrectomy is an excellent surgical option with a low complication rate.

Hemoperitoneum secondary to avulsed short gastric arteries after vomiting: the first documented case in North America.

This is the first documented case in North America wherein a 26-year-old man presented to the emergency room with hemoperitoneum secondary to avulsed short gastric arteries after violent emesis.

Transoral incisionless fundoplication: 2-year results from the prospective multicenter U.S. study.

The aim of this study was to assess prospectively 2-year outcomes of transoral incisionless fundoplication (TIF) in a multicenter setting. A 14-center U.S. registry was designed to evaluate the effects of the TIF 2.0 procedure on chronic gastroesophageal reflux disease (GERD) in over 100 patients. Primary outcome was symptom assessment. Secondary outcomes were proton pump inhibitor (PPI) use, degree of esophagitis, safety, and changes in esophageal acid exposure. One hundred twenty-seven patients underwent TIF between January 2010 and April 2011, 19 (15%) of whom were lost to follow-up. Eight patients undergoing revisional surgery were included, as failures, in the 108 remaining patients. No serious adverse events were reported. GERD Health-related Quality of Life and regurgitation scores improved by 50 per cent or greater in 63 of 96 (66%) and 62 of 88 (70%) patients who had elevated preoperative scores. The Reflux Symptom Index score normalized in 53 of 82 (65%) patients. Daily PPI use decreased from 91 to 29 per cent. In patients amenable to postoperative testing, esophagitis healed in 12 of 16 (75%) and esophageal acid exposure normalized in eight of 14 (57%). TIF safely achieved sustained symptomatic control over a 2-year period in two-thirds of patients with a virtual absence of de novo side effects.

The effects of transoral incisionless fundoplication on chronic GERD patients: 12-month prospective multicenter experience.

PURPOSE: This study aimed to assess the impact of transoral incisionless fundoplication (TIF) on patients with chronic gastroesophageal reflux disease (GERD) at 12-month follow-up. METHODS: Clinical outcomes of 100 consecutive patients with chronic GERD who underwent TIF between January 2010 and February 2011 were analyzed. RESULTS: There were no major complications reported. Esophageal acid exposure was normalized in 14/27 (52%) of patients who underwent 12-month pH testing. Seventy-four percent of all patients were off proton pump inhibitors versus 92% on daily proton pump inhibitors before TIF, P<0.001. Daily bothersome heartburn and regurgitation symptoms were eliminated in 66/85 (78%) and 48/58 (83%) of patients. Median reflux symptom index score was reduced from 20 (0 to 41) to 5 (0 to 44), P<0.001. Two patients reported de novo dysphagia and 1 patient reported bloating (scores 0 to 3). Six patients underwent revision; 5 laparoscopic Nissen fundoplication and 1 TIF. CONCLUSIONS: TIF provided a safe and effective therapeutic option for carefully selected patients with chronic GERD.

Association between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common co-morbidity identified in obese patients. It is well established that patients with GERD and morbid obesity experience a marked improvement in their GERD symptoms after Roux-en-Y gastric bypass. Conflicting data exist for adjustable laparoscopic gastric banding and GERD. Laparoscopic sleeve gastrectomy (LSG) has become a popular adjunct to bariatric surgery in recent years. However, very little data exist concerning LSG and its effect on GERD. METHODS: A retrospective chart review was performed of 176 LSG patients from January 2006 to August of 2009. The preoperative and postoperative GERD symptoms were evaluated using follow-up surveys and chart review. RESULTS: Of the 176 patients, 85.7% of patients were women, with an average age of 45 years (range 22-65). The average preoperative body mass index was 46.6 kg/m(2) (range 33.2-79.6). The average excess body weight lost at approximately 6, 12, 24 months was calculated as 54.2%, 60.7%, and 60.3%, respectively. Of the LSG patients, 34.6% had preoperative GERD complaints. Postoperatively, 49% complained of immediate (within 30 d) GERD symptoms, 47.2% had persistent GERD symptoms that lasted >1 month after LSG, and 33.8% of patients were taking medication specifically for GERD after LSG. The most common symptoms were heartburn (46%), followed by heartburn associated with regurgitation (29.2%). CONCLUSION: In the present study, LSG correlated with the persistence of GERD symptoms in patients with GERD preoperatively. Also, patients who did not have GERD preoperatively had an increased risk of postoperative GERD symptoms.