The effect of a low-carbohydrate diet on the nonalcoholic fatty liver in morbidly obese patients before bariatric surgery.

BACKGROUND: Bariatric surgery may be complicated by enlargement of the liver, especially of the left lobe, caused by nonalcoholic fatty liver disease often present with morbid obesity. METHODS: The effect of a very low carbohydrate diet for 4 weeks before surgery on liver density and volume was assessed in 14 candidates for bariatric surgery. Computed tomography (CT) scans were performed before and at termination of the diet period. RESULTS: The CT scans clearly showed a significant increase in mean liver density (p = 0.06) and a decrease in mean liver volume (p = 0.01). The increased mean density of the left lobe was markedly greater than that of the right lobe. CONCLUSIONS: The findings show that 4 weeks of a very low carbohydrate diet reduces liver fat content and liver size, particularly of the left lobe. This approach may render bariatric surgery or any foregut operations less difficult in morbidly obese patients and may be a useful treatment for nonalcoholic fatty liver disease.

The Lap-Band system in the United States: one surgeon's experience with 271 patients.

BACKGROUND: The LAP-BAND system is considered an important bariatric surgery procedure in many countries and is rapidly gaining acceptance in the United States. Outcomes data emerging in the United States parallel European and Australian experience. The purpose of this study was to examine our experience with this procedure in the United States. METHODS: Between November 2000 and September 2002, 271 patients (236 women) underwent LAP-BAND system placement. The mean age of patients was 40 years (18-63); preoperative mean body weight was 125 kg (93-192). Surgeries were performed using either the two-step (pars flaccida to perigastric) or the pars flaccida technique with three (1.1%) conversions to open procedures. Mean operative time was 42 min (23-86); average hospital stay was 1 day (4 h to 7 days). RESULTS: The mean body mass index (BMI) decreased from a baseline of 45.3 kg/m(2) (35-68) to 41.9 ( n = 178), 39.5 ( n = 101), 38.4 (n = 81), 36.5 (n = 72), 35.9 (n = 51), and 35.1 (n = 21) kg/m(2) at 3, 6, 9, 12, 18, and 24 months, respectively, after surgery. Mean excess weight loss was 40% at 12 months and 43% at 24 months. As patients lost weight, comorbid conditions improved. No deaths occurred, no bands had to be removed, and postoperative complications were minor: 20 (7.3%) access port problems, 18 (6.6%) gastric pouch dilatations, five (1.8%) gastric slippages, and five (1.8%) stoma obstructions. All were managed conservatively or repaired laparoscopically using the original bands. Additional complications included four cases of pneumonia and one case of pulmonary embolism. One patient required reoperation because of trocar site bleeding. CONCLUSIONS: The LAP-BAND system is a safe and effective bariatric procedure leading to considerable weight loss and reduction in comorbidity.

Prospective study of 250 patients undergoing laparoscopic gastric banding using the two-step technique: a technique to prevent postoperative slippage.

BACKGROUND: The use of LAP-BAND adjustable gastric banding (LAGB) has gained tremendous popularity, but creation of the retrogastric tunnel is a considerable challenge, especially in the surgeon's early experience, and is associated with up to 10% band slippage and occasional gastric perforation. The two-step technique involves a crural dissection toward the angle of His through a pars flaccida approach. The technique facilitates passage of the band with no extensive posterior gastric wall dissection. METHODS: A prospective study investigated 250 patients (207 women and 43 men) who underwent LAGB from January 1999 to May 2002 using a two-step dissection technique. The mean age of these patients was 37 years (range, 18-58 years). Their mean preoperative weight was 120 kg (range, 90-169 kg), and their mean body mass index was 44 kg/m2 (range, 36-68 kg/m2). RESULTS: All the procedures except two were completed laparoscopically, and there were no deaths. The mean operative time was 61 min (range, 35-150 min), and the mean hospital stay was 1.2 days (range, 1-5 days). At 3 years, the mean body mass index had decreased from 44 kg/m2 to means of 39.9, 37.3, 34.4, 32.4, and 31.7 kg/m2 at 3, 6, 12, 24, and 36 months, respectively. The mean excess weight loss was 42.1% at 1 year, 51.4% at 2 years, and 55.5% at 3 years. There were four band slippages (1.6%), no band erosion, and no major morbidity. CONCLUSIONS: The use of LAGB with the two-step technique is technically simple, avoids intimate posterior gastric wall dissection, and facilitates tight posterior band support. It therefore is associated with only minimal perioperative complications and a low slippage rate.

Laparoscopic gastric banding with Lap-Band for morbid obesity: two-step technique may improve outcome.

BACKGROUND: Laparoscopic placement of an adjustable gastric band is an attractive alternative for patients who can benefit from a restrictive bariatric procedure. Creation of the retrogastric tunnel (RGT) may, however, be a considerable challenge early in the surgeon's learning curve. Recent reports described up to 10% band slippage and occasional gastric perforation associated with RGT. The two-step (TS) technique involves a crural dissection towards the angle of His through a gastrohepatic ligament approach. It facilitates passage of the band's tubing posteriorly with no wide posterior gastric wall dissection. PATIENTS AND METHODS: Prospective data were registered for the 109 patients (92 females, 17 males) who underwent laparoscopic adjustable gastric banding from December 1998 to May 2000. In 11 patients the standard RGT approach was used, and in 98, the TS technique. The two groups were demographically similar. Mean age was 37 years (18-59); mean preoperative weight was 120 kg (90-165). RESULTS: All procedures were completed laparoscopically. The mean operative time was 59 minutes (31-150) and the mean hospital stay 1.2 days (1-5). Complications in the TS group were gastric wall hematoma in one patient, 3 days of intubation postoperatively in one patient, damage to a band demonstrated in a postoperative contrast study in one patient, and a port-site hernia in one patient. There was no band slippage in the TS group. Among the 11 patients undergoing RGT, there was band slippage in three (27%), immediately postoperatively in one and after 3 and 11 months in the other two. In a mean follow-up of 7 months (1-18), similar weight loss was found in both groups. The mean BMI decreased from 44 kg/m2 (36-61) preoperatively to 40, 38, 36, 34 kg/m2 at 1, 3, 6 and 9 months respectively. 52 patients required band adjustment; of these, 12 required two adjustments. CONCLUSION: Our experience with both the RGT and TS techniques indicates that the latter may offer better results, particularly in the early experience period. It is recommended that in their initial experience with the adjustable band, surgeons should become familiar with this approach.

Lawn mower-related injuries to children.

Lawn mower-related injuries to children are relatively common and can result in severe injury or death. Many amputations during childhood are caused by power mowers. Pediatricians have an important role as advocates and educators to promote the prevention of these injuries.

Teflon buttress inhibits recanalization of uncut stapled bowel.

The uncut Roux limb operation is designed to have the benefits of a Roux limb but still have electrical continuity from proximal to distal bowel, thus eliminating the risk of Roux stasis syndrome. The main complication has been recanalization of the uncut staple line leading to bile reflux. This study aims to employ a new technique, which will not allow recanalization of an uncut staple line but will not interfere with normal bowel myoelectric activity. Fourteen mongrel dogs, 25 to 35 kg, underwent a midline laparotomy under general anesthesia. An uncut staple line was placed 25 cm from the ligament of Treitz. In seven animals an uncut staple line alone was placed, and in the other seven animals the bowel was stapled between a sandwich of Teflon reinforcing strips such that the staples were held on both sides of the bowel by the Teflon. A jejunojejunostomy was placed 6 cm proximal to the staple line. Insulated bipolar electrical leads were placed around the staple line. After the electrical leads were monitored 2 days to 3 months postoperatively for bowel myoelectric activity, The animals were killed and the operative sites inspected. No animal suffered morbidity or mortality from the procedure. All seven unreinforced staple lines recanalized and all seven reinforced staple lines remained competent. The duodenal pacemaker potentials were transmitted through the staple line in five animals (3 controls and 2 with Teflon reinforcement) with in 1 week postoperatively. The uncut staple line does not reliably transmit the duodenal pacemaker potentials. The staple line does not recanalize when it is reinforced with a permanent material, increasing the utility of the "uncut" Roux limb operation.

Pathogenesis and current management of gastrooesophageal-reflux-related asthma.

In the past decade the use of proton pump inhibitors on the one hand, and an aggressive surgical approach on the other hand have revolutionised the treatment of gastro-oesophageal reflux disease (GORD). Many studies have suggested that the successful management of GORD results in improvement of the symptoms of asthma which coexist in many of these patients. In this paper we review the pathogenesis and the medical and surgical treatment of GOR-related asthma. Both anti-reflux operations and anti-acid medications improve GORD and GOR-related asthma. Although anti-reflux surgery is superior to H2 blockers, there are not sufficient data to evaluate proton pump inhibitors compared with operation in controlling the symptoms of asthma.

Structured triacylglycerol emulsion, containing both medium- and long-chain fatty acids, in long-term home parenteral nutrition: a double-blind randomized cross-over study.

Structured lipid emulsion, an innovative approach in which both medium-chain and long-chain fatty acids are esterified to the same glycerol backbone, has been recently shown to be a safe and efficient way of providing energy to patients requiring parenteral nutrition. As yet, no assessment has been made of its safety and effect on liver functions during long-term treatment. Twenty-two home parenteral nutrition patients with Crohn's disease or short bowel syndrome were enrolled in a double-blind randomized, cross-over study. Twenty patients who completed the study were treated for 4 wk with a structured lipid emulsion and for 4 wk with long-chain triacylglycerol emulsion. Determined every 1 or 2 wk were blood pressure, body weight, respiratory rate, blood count, liver functions, albumin, transferrin, plasma lipids, free fatty acids (FFAs), and, at the end of each treatment period (weeks 4 and 8), plasma dicarboxylic acids and 3-OH-fatty acids. No differences were observed between the groups or within the groups between the two treatments with respect to either clinical safety and adverse event occurrence or laboratory assessments. Plasma dicarboxylic acids and 3-OH-fatty acids were similar and within normal range. No alteration of liver function occurred in any of the patients treated with the structured lipid emulsion, whereas two of the patients receiving long-chain triaclyglycerol emulsion developed abnormal liver function, which resolved after switching to the structured lipid emulsion. In conclusion, structured triacylyglycerols containing both medium- and long-chain fatty acids appear to be safe and well tolerated on a long-term basis in patients on home parenteral nutrition, and it may be associated with possible reduction in liver dysfunction.

Laparoscopy: searching for the proper insufflation gas.

BACKGROUND: Although many aspects of laparoscopic surgery have been determined, the question of which insufflation gas is the best arises repeatedly. The aim of this study was to review the findings on the major gases used today in order to provide information and guidelines for the laparoscopic surgeon. METHODS: We reviewed the literature for clinical and laboratory studies on the currently used laparoscopic insufflation gases: carbon dioxide (CO(2)), nitrous oxide (N(2)O), helium (He), air, nitrogen (N(2)), and argon (Ar). The following parameters were evaluated: acid-base changes, hemodynamic and respiratory sequelae, hepatic and renal blood flow changes, increase in intracranial pressure, outcome of venous emboli, and port-site tumor growth. RESULTS: The major advantage of CO(2) is its rapid dissolution in the event of venous emboli. Hemodynamic and acid-base changes with CO(2) insufflation usually are mild and clinically negligible for most patients. Although N(2)O is advantageous for procedures requiring local/regional anesthesia, it does not suppress combustion. Findings show that Ar may have unwanted hemodynamic effects, especially on hepatic blood flow. There are almost no hemodynamic or acid-base sequelae with the use of He, air, and N(2), but they dissolve slowly and carry a potential risk of lethal venous emboli. CONCLUSIONS: Clearly, CO(2) maintains its role as the primary insufflation gas in laparoscopy, but N(2)O has a role in some cases of depressed pulmonary function or in local/regional anesthesia cases. Other gases have no significant advantage over CO(2) or N(2)O and should be used only in protocol studies. The relation of port-site metastasis to a specific type of gas requires further research.

Laparoscopic extraperitoneal inguinal hernia repair with spinal anesthesia and nitrous oxide insufflation.

BACKGROUND: Laparoscopic repair of inguinal hernia is traditionally performed under general anesthesia mainly because of the adverse effects that carbon dioxide pneumoperitoneum has on awake patients. Since a mandatory use of general anesthesia for all hernia repairs is questionable, the feasibility of laparoscopic extraperitoneal herniorraphy using spinal anesthesia combined with nitrous oxide insufflation was investigated. METHODS: Over a 4-month period, February to May 1998, we performed 35 consecutive total extraperitoneal inguinal hernia procedures (24 unilateral, 11 bilateral) using spinal anesthesia and nitrous oxide extraperitoneal gas. Data on operative findings, self-reported operative and postoperative pain and discomfort (visual analog pain scale), procedure-related hemodynamics, and complications were collected prospectively. RESULTS: All 35 procedures were completed laparoscopically without the need to convert to general anesthesia. Mean operative time was 39 +/- 7 min for unilateral hernia and 65 +/- 10 min for bilateral hernia. Incidental peritoneal tears occurred in 22 patients (63%) resulting in nitrous oxide pneumoperitoneum, which was well tolerated. The patients remained hemodynamically stable throughout the procedure, and operative conditions and visibility were excellent. Complications at a mean of 4 months after the procedure included seven uninfected seromas (20%), three patients with transient testicular pain, and one (3%) recurrence. CONCLUSIONS: Laparoscopic total extraperitoneal hernia repair can be safely and comfortably performed using spinal anesthesia with extraperitoneal nitrous oxide insufflation gas. This method provides a good alternative to general anesthesia.

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Safe transportation of newborns at hospital discharge.

All hospitals should set policies that require the discharge of every newborn in a car safety seat that is appropriate for the infant's maturity and medical condition. Discharge policies for newborns should include a parent education component, regular review of educational materials, and periodic in-service education for responsible staff. Appropriate child restraint systems should become a benefit of coverage by Medicaid, managed care organizations, and other third-party insurers.

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Transporting children with special health care needs.

Children with special health care needs should have access to proper resources for safe transportation. This statement reviews important considerations for transporting children with special health care needs and provides current guidelines for the protection of children with specific health care needs, including those with a tracheostomy, a spica cast, challenging behaviors, or muscle tone abnormalities as well as those transported in wheelchairs.

Asthma and gastroesophageal reflux: fundoplication decreases need for systemic corticosteroids.

An association between gastroesophageal reflux (GER) and asthma has been suggested for many decades. Although antireflux therapy (medical and surgical) has been shown to be beneficial in patients with asthma, response to therapy has not been well quantified. The aim of this study was to evaluate long-term outcome in patients with asthma and associated GER undergoing fundoplication. From a database of more than 600 patients with GER treated surgically between 1991 and 1996, 39 patients with asthma as their primary indication for surgery were identified. Asthma symptom scores were determined using the National Asthma Education Program classification, and medication frequency scores were determined preoperatively and at latest follow-up (median follow-up 2.7 years). Comparisons were made using the Wilcoxon rank-sum test. Asthma symptom scores decreased significantly after antireflux surgery. More important, the medication scores for use of systemic corticosteroids decreased significantly postoperatively (2.2 preoperatively vs. 0.7 postoperatively; P = 0.0001). Of the nine patients who required daily oral corticosteroids, seven have discontinued treatment entirely (78%). In patients with asthma associated with GER, symptoms of asthma are improved following fundoplication. Especially important has been the ability to wean patients from systemic corticosteroids postoperatively. Fundoplication should be offered to those patients with GER-associated asthma, especially those who are steroid dependent.

The hospital record of the injured child and the need for external cause-of-injury codes. American Academy of Pediatrics. Committee on Injury and Poison Prevention, 1998-1999.

Proper record-keeping of emergency department visits and hospitalizations of injured children is vital for appropriate patient management. Determination and documentation of the circumstances surrounding the injury event are essential. This information not only is the basis for preventive counseling, but also provides clues about how similar injuries in other youth can be avoided. The hospital records have an important secondary purpose; namely, if sufficient information about the cause and mechanism of injury is documented, it can be subsequently coded, electronically compiled, and retrieved later to provide an epidemiologic profile of the injury, the first step in prevention at the population level. To be of greatest use, hospital records should indicate the "who, what, when, where, why, and how" of the injury occurrence and whether protective equipment (eg, a seat belt) was used. The pediatrician has two important roles in this area: to document fully the injury event and to advocate the use of standardized external cause-of-injury codes, which allow such data to be compiled and analyzed.

Laparoscopic surgery of the gastroesophageal junction.

Incompetence of the lower esophageal sphincter mechanism leads to gastroesophageal reflux (GER), which is the most common indication for surgery of the gastroesophageal junction. Evaluation, diagnosis, and the modern surgical treatment of GER are discussed. Evaluation of patients with severe heartburn include upper endoscopy to evaluate the general condition of the esophagus, stomach, and duodenum; an upper gastrointestinal contrast study for a complete anatomic view of the esophagus and stomach; esophageal manometry to evaluate the function of the esophagus; 24-hour pH monitoring to determine esophageal acid exposure; and a gastric emptying study selectively to determine the presence of a motility disorder. These studies most often prove the diagnosis of gastroesophageal reflux, hiatal hernia, Barrett's esophagus, peptic esophageal stricture, paraesophageal hernia, or achalasia. The laparoscopic approach to treatments for these include Nissen fundoplication, Toupet fundoplication, Collis gastroplasty with fundoplication, modified Heller myotomy, esophageal diverticulectomy, and revisional operations. These procedures are described in detail. The results of these operations indicate that they are safe and effective and should be considered the new gold standard for correction of gastroesophageal pathology. Laparoscopic surgery has revolutionized many procedures traditionally performed through a laparotomy. Although they are technically more difficult and require a significant amount of time and practice for the surgeon to become proficient, it is becoming apparent that for functional surgery of the gastroesophageal junction laparoscopy is the access of choice.