A Review of Meta-Analyses in Plastic Surgery: Need for Adequate Assessment of Publication Bias.

INTRODUCTION: Publication bias describes a phenomenon in which significant positive results have a higher likelihood of being published compared to negative or nonsignificant results. Publication bias can confound the estimated therapeutic effect in meta-analyses and needs to be adequately assessed in the surgical literature. METHODS: A review of meta-analyses published in five plastic surgery journals from 2002 to 2022 was conducted. The inclusion criteria for meta-analyses were factors that demonstrated an obligation to assess publication bias, such as interventions with comparable treatment groups and enough power for statistical analysis. Acknowledgment of publication bias risk, quality of bias assessment, methods used in assessment, and individual article factors were analyzed. RESULTS: 318 unique meta-analyses were identified in literature search, and after full-text reviews, 143 met the inclusion criteria for obligation to assess publication bias. 64% of eligible meta-analyses acknowledged the confounding potential of publication bias, and only 46% conducted a formal assessment. Of those who conducted an assessment, 49% used subjective inspection of funnel plots alone, while 47% used any statistical testing in analysis. Overall, only 9/143 (6.3%) assessed publication bias and attempted to correct for its effect. Journals with a higher average impact factor were associated with mention and assessment of publication bias, but more recent publication year and higher number of primary articles analyzed were not. CONCLUSIONS: This review identified low rates of proper publication bias assessment in meta-analyses published in five major plastic surgery journals. Assessment of publication bias using objective statistical testing is necessary to ensure quality literature within surgical disciplines.

Discrepancies in Gender Representation Between Integrated and Independent Plastic Surgery Programs.

PURPOSE: Despite increasing female representation in integrated plastic surgery training programs, independent programs have lower representation and slow improvement in female enrollment. Self-reported resident data were used to investigate trends of female representation in integrated and independent programs. METHODS: Data were collected from Accreditation Council of Graduate Medical Education resources of active residents' characteristics. Self-reported gender data were collected for integrated, independent, and general surgery programs from annual reports since 2009. χ2 analysis was conducted to compare female enrollment of integrated programs, independent programs, general surgery programs, and general surgery programs with matriculation-year adjustment. RESULTS: In 2008, 89 independent programs had nearly identical percentage of female enrollment with 30 integrated programs at 23.8% and 23.1%, respectively. Differences in representation between independent and integrated programs became significant in 2012, with independent programs demonstrating 25.1% female enrollment compared with 30.5% in integrated programs. This trend of higher female representation in integrated programs has persisted since 2012. To correct for preexisting disparity in general surgery programs, we compared female enrollment of independent programs with female enrollment of that class' general surgery matriculation-year 5 years earlier. In all examined years, general surgery still had proportionally higher female enrollment compared with independent programs, even with conservative 5-year matriculation adjustment. CONCLUSIONS: Dramatic differences in female enrollment were found between integrated and independent programs, with representation in integrated programs rising more quickly. Adjustments for previous rates of female enrollment in general surgery did not yield explanation for low independent program enrollment. Increasing female representation in independent training models will continue to create a more diverse workforce.

Surgical Fellowships Demonstrate Variable Improvement in Gender Representation Despite Greater Female Enrollment in General Surgery Residencies.

OBJECTIVE: Despite increasing female representation in General Surgery (GS) residency training programs, proportional improvement of female enrollment in surgical fellowships has yet to be quantified. We aimed to assess if female enrollment in surgical fellowships has improved at an equivalent rate in 7 different surgical fellowship options after GS. DESIGN AND SETTING: Data were collected from Accreditation Council for Graduate Medical Education (ACGME) resources which disclosed active resident and fellow characteristics. Gender identification was self-reported by residents to ACGME. Gender data collected for GS programs and surgical fellowships including Surgical Critical Care, Colon, and Rectal Surgery, Pediatric Surgery, Plastic Surgery, Surgical Oncology, Thoracic Surgery, and Vascular Surgery from annual reports. Pearson Chi-squared analysis was conducted between GS residencies and fellowship programs in their corresponding years using Stata15 software. RESULTS: In all years examined, fellowships in Vascular, Thoracic, and Plastic Surgery had significantly lower female enrollment in proportion to the number of female GS residents (p = <0.02). In all years examined, Surgical Oncology, Pediatric, Colon and Rectal, and Surgical Critical Care had female enrollment that was, at minimum, proportional to female enrollment in GS residency, indicating equitable gender representation. Surgical Oncology (2016), Pediatric (2020) and Surgical Critical Care (2016) fellowships each had 1 year where female enrollment was significantly higher than General Surgery. CONCLUSIONS: The enrollment of female surgeons in Plastic, Vascular, and Thoracic Surgery fellowships has not improved proportionally despite an increase in female GS residents. These results suggest the possibility of persistent factors that deter female enrollment in Vascular, Thoracic and Plastic Surgery fellowships that are not present to the same degree in fields with equitable fellowship female enrollment. Female representation in surgical fellowships is vital to improving gender diversity in all disciplines of surgery, particularly academic surgery.

Industry Payments to Plastic Surgeons, 2013 to 2018: Who's Getting Paid?

BACKGROUND: The Physician Payments Sunshine Act of 2010 mandated that all industry payments to physicians be publicly disclosed. To date, industry support of plastic surgeons has not been longitudinally characterized. The authors seek to evaluate payment trends from 2013 to 2018 and characteristics across plastic surgeon recipients of industry payments. METHODS: The authors cross-referenced those in the 2019 American Society of Plastic Surgeons member database with Centers for Medicare & Medicaid Services Open Payments database physician profile identification number indicating industry funds received within the study period. We categorized surgeons by years since American Board of Plastic Surgery certification, practice region, and academic affiliation. RESULTS: A sum of $89,436,100 (247,614 payments) was received by 3855 plastic surgeons. The top 1 percent of earners (n = 39) by dollar amount received 52 percent of industry dollars to plastic surgeons; of these, nine (23 percent) were academic. Overall, 428 surgeons (11 percent) were academic and received comparable dollar amounts from industry as their nonacademic counterparts. Neither geographic location nor years of experience were independent predictors of payments received. The majority of individual transactions were for food and beverage, whereas the majority of industry dollars were typically for royalties or license. CONCLUSIONS: Over half of all industry dollars transferred went to just 1 percent of American Society of Plastic Surgeons members receiving payments between 2013 and 2018. Considerable heterogeneity exists when accounting for payment subcategories.

Gender Disparity in 2013-2018 Industry Payments to Plastic Surgeons.

BACKGROUND: The gender pay gap in medicine has been under intense scrutiny in recent years; female plastic surgeons reportedly earn 11% less than their male peers. "Hidden" pay in the form of industry-based transfers exposes compensation disparity not captured by traditional wage-gap estimations. OBJECTIVES: The aim of this study was to reveal the sex distribution of industry payments to board-certified plastic surgeons across all years covered by the Center for Medicare and Medicaid Services Open Payment Database (CMS OPD). METHODS: We obtained the National Provider Identifier (NPI) for each surgeon in the American Society of Plastic Surgeons (ASPS) member directory to record gender. Next, "General Payments" data points from annual files for all years present in the CMS OPD, 2013 to 2018, were aggregated and joined to provider details by Physician Profile ID before quantitative analysis was performed. RESULTS: Of 4840 ASPS surgeons, 3864 (79.8%) reporting ≥1 industry payment were included with 3220 male (83.3%) and 644 female (16.7%). Over 2013 to 2018, females received mean [standard deviation] 56.01 [2.51] payments totaling $11,530.67 [$1461.45] each vs 65.70 [1.80] payments totaling $25,469.05 [$5412.60] for males. The yearly ratio of male-to-female payments in dollars was 2.36 in 2013, 2.69 in 2014, 2.53 in 2015, 2.31 in 2016, 1.72 in 2017, and most recently 1.96 in 2018. CONCLUSIONS: Individual male plastic surgeons received over twice the payment dollars given to their female counterparts, accepting both more frequent and higher-value transfers from industry partners. Payment inequity slightly declined in recent years, which may indicate shifting industry engagement gender preferences.

Doxycycline-Coated Silicone Breast Implants Reduce Acute Surgical-Site Infection and Inflammation.

BACKGROUND: Surgical-site infection after implant-based breast reconstruction remains a leading cause of morbidity. Doxycycline is an antibiotic used to treat soft-tissue infections. The authors hypothesize that doxycycline-coated breast implants will significantly reduce biofilm formation, surgical-site infection, and inflammation after bacterial infection. METHODS: Pieces of silicone breast implants were coated in doxycycline. In vitro studies to characterize the coating include Fourier transmission infrared spectroscopy, elution data, and toxicity assays (n = 4). To evaluate antimicrobial properties, coated implants were studied after methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa inoculation in vitro and in a mouse model at 3 and 7 days (n = 8). Studies included bacterial quantification, cytokine profiles, and histology. RESULTS: Coated silicone breast implants demonstrated a color change, increased mass, and Fourier transmission infrared spectroscopy consistent with a doxycycline coating. Coated implants were nontoxic to fibroblasts and inhibited biofilm formation and bacterial adherence after MRSA and P. aeruginosa incubation in vitro, and measurable doxycycline concentrations at 24 hours were seen. In a mouse model, a significant reduction of MRSA and P. aeruginosa bacterial colonization after 3 and 7 days in the doxycycline-coated implant mice was demonstrated when compared to the control mice, control mice treated with intraperitoneal doxycycline, and control mice treated with a gentamicin/cefazolin/bacitracin wash. Decreased inflammatory cytokines and inflammatory cell infiltration were demonstrated in the doxycycline-coated mice. CONCLUSIONS: A method to coat silicone implants with doxycycline was developed. The authors' doxycycline-coated silicone implants significantly reduced biofilm formation, surgical-site infections, and inflammation. Further studies are needed to evaluate the long-term implications.

Sphingosine-coating of plastic surfaces prevents ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is a major cause of morbidity and mortality in critically ill patients. Here, we employed the broad antibacterial effects of sphingosine to prevent VAP by developing a novel method of coating surfaces of endotracheal tubes with sphingosine and sphingosine analogs. Sphingosine and phytosphingosine coatings of endotracheal tubes prevent adherence and mediate killing of Pseudomonas aeruginosa, Acinetobacter baumannii, and Staphylococcus aureus, even in biofilms. Most importantly, sphingosine-coating of endotracheal tubes also prevented P. aeruginosa and S. aureus pneumonia in vivo. Coating of the tubes with sphingosine was stable, without obvious side effects on tracheal epithelial cells and did not induce inflammation. In summary, we describe a novel method to coat plastic surfaces and provide evidence for the application of sphingosine and phytosphingosine as novel antimicrobial coatings to prevent bacterial adherence and induce killing of pathogens on the surface of endotracheal tubes with potential to prevent biofilm formation and VAP. KEY MESSAGES: Novel dip-coating method to coat plastic surfaces with lipids. Sphingosine and phytosphingosine as novel antimicrobial coatings on plastic surface. Sphingosine coatings of endotracheal tubes prevent bacterial adherence and biofilms. Sphingosine coatings of endotracheal tubes induce killing of pathogens. Sphingosine coatings of endotracheal tubes ventilator-associated pneumonia.

Publishing Conversion Rates and Trends in Abstracts Presented at the American Association for Hand Surgery Annual Meeting: A Five-Year Review.

Background: Abstract presentation at scientific meetings grants attendees early access to innovation within the field, and ultimate journal publication serves as marker of research quality. This study aims to assess the publication conversion rate of abstracts presented at the American Association for Hand Surgery (AAHS) annual conference over 5 years and examine variables related to publication. Methods: Abstract information for oral and poster presentations from the 2012 to 2016 AAHS annual meetings was obtained through the AAHS website. A comprehensive literature search was conducted for journal publications correlating with abstracts based on titles, authors, and key words. Variables analyzed included study type, time to publication, and journal of publication. Results: In all, 1135 abstracts were reviewed from the 5-year period, consisting of 535 oral presentations and 600 posters. Overall, 532 articles (47%) were published. The publication conversion rate was 49% for oral presentations and 45% for posters. Mean time to publication was 11 months, with most publications occurring within 2 years (87%). The most common journals for publication were Journal of Hand Surgery (30%), HAND (21%), and Plastic and Reconstructive Surgery (7%). Conclusions: About half of the studies presented at the annual AAHS meeting become published, with similar rates between oral and poster formats. Most of the successful abstracts achieved publication within 2 years from presentation, demonstrating the need for timely completion of manuscripts. The publication conversion rate increased in recent years, emphasizing the continued improvement of the scientific quality of presentations at the AAHS meeting.

Global Contributions to Aesthetic Surgery Journal Over the Past Decade.

BACKGROUND: The Aesthetic Surgery Journal (ASJ) is a world-renowned publication with valuable contributions from around the globe. OBJECTIVES: To better characterize the journal's evolving representation of global contributions to aesthetic surgery, the authors examined the author affiliations of all articles published in ASJ over the last decade. METHODS: A PubMed search was performed for all journal articles published in ASJ from January 2008 to August 2018. For each article, the first author's primary affiliation as indexed in MEDLINE was recorded as the source country. Data were tabulated by source country and year. The authorless errata, corrigenda, and Cosmetic Surgery National Data Bank Statistics were excluded from analysis. RESULTS: A total of 1746 articles were published during this period, contributed from 49 distinct countries. All continents other than Antarctica were represented. Higher income countries where aesthetic surgery is more prevalent produced 87% of published articles. The total number of published articles in ASJ has climbed from 77 annually in 2008 to 318 in 2018 as of August. In 2008, 27.3% of articles were from non-US countries, whereas in 2018 this increased to 43.7%. In particular, Turkey, the United Kingdom, Australia, Brazil, and Italy demonstrate steady increases in contributions over the 10-year period. CONCLUSIONS: Publications in ASJ have increased in number over the past decade, and the journal has become increasingly global in its network of contributing authors. The increased global contribution to the ASJ may enhance readers' experience both in the United States and in the world beyond.

A Case Report of a Breast Implant-Associated Plasmacytoma and Literature Review of Non-ALCL Breast Implant-Associated Neoplasms.

Lymphomas associated with breast implants are rare, with the most common being anaplastic large cell lymphoma (ALCL). Non-ALCL breast implant-associated lymphomas are even more rare, with only a small handful of such neoplasms reported to date. Given the need to better understand these pathologies as well as the increasing clinical and media attention being paid to these diseases, we review the available literature of hematolymphoid neoplasms other than ALCL associated with breast implants and describe the first case of a patient diagnosed with a primary breast implant-associated plasmacytoma.

Ketorolac does not increase perioperative bleeding: a meta-analysis of randomized controlled trials.

BACKGROUND: Postoperative pain control is essential for optimal patient outcomes. Ketorolac is an attractive alternative for achieving pain control postoperatively, but concerns over postoperative bleeding have limited its use. METHODS: Computer searches of the MEDLINE, EMBASE, and Cochrane Library databases were performed. Twenty-seven double-blind, randomized, controlled studies were reviewed by two independent investigators for the incidence of adverse events, including postoperative bleeding. Comprehensive meta-analysis software was used to evaluate the differences between ketorolac and control groups. RESULTS: Twenty-seven studies with 2314 patients were analyzed. Postoperative bleeding occurred in 33 of 1304 patients (2.5 percent) in the ketorolac group compared with 21 of 1010 (2.1 percent) in the control group (OR, 1.1; 95 percent CI, 0.61 to 2.06; p = 0.72). Adverse events were similar in the groups, 31.7 percent in the control group and 27.9 percent in the ketorolac group (OR, 0.64; 95 percent CI, 0.41 to 1.01; p = 0.06). There was a lower incidence of adverse effects with low-dose ketorolac (OR, 0.49; 95 percent CI, 0.27 to 0.91; p = 0.02). Pain control with ketorolac was superior to controls and equivalent to opioids. CONCLUSIONS: This is the first meta-analysis of randomized controlled trials examining whether there is increased postoperative bleeding with ketorolac. Postoperative bleeding was not significantly increased with ketorolac compared with controls, and adverse effects were not statistically different between the groups. Pain control was found to be superior with ketorolac compared with controls. Ketorolac should be considered for postoperative pain control, especially to limit the use of opioid pain medications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Facial and hand allotransplantation.

Vascularized composite allotransplantation (VCA) is a novel therapeutic option for treatment of patients suffering from limb loss or severe facial disfigurement. To date, 72 hand and 19 facial transplantations have been performed worldwide. VCA in hand and facial transplantation is a complex procedure requiring a multidisciplinary team approach and extensive surgical planning. Despite good functional outcome, courses after hand and facial transplantation have been complicated by skin rejection. Long-term immunosuppression remains a necessity in VCA for allograft survival. To widen the scope of these quality-of-life-improving procedures, minimization of immunosuppression to limit risks and side effects is needed.

Extracranial-intracranial bypass: resurrection of a nearly extinct operation.

BACKGROUND: Giant intracranial artery aneurysms (GIAAs) are often not amenable to neurosurgical clipping or endovascular coiling. Extracranial-intracranial (EC-IC) bypass, a procedure that has been essentially abandoned for the treatment of intracranial ischemic disease, followed by parent vessel occlusion, is often successful in treating these aneurysms. Vascular surgeons should be familiar with this operation, especially in centers with neurosurgical capability. METHODS: A retrospective review of patients treated from 1990 to 2010 at New York University Medical Center was performed. Office and hospital records of all patients identified were reviewed with attention to the age and sex of the patient, presenting symptoms, preoperative testing, procedure performed, type of bypass conduit, graft patency, intraoperative and postoperative complications, length of follow-up, and overall outcome. EC-IC bypass was performed using a graft of great saphenous vein (GSV) or radial artery (RA). The vascular surgeon harvested the vascular conduit, tunneled the graft, and performed the extracranial anastomosis, and the intracranial anastomosis was performed by the neurosurgeon. RESULTS: A total of 36 patients (14 men, 22 women) underwent 37 EC-IC bypasses with 34 GSV and three RA grafts. The median age was 57 years (interquartile range, 49-66 years), and the median follow-up was 53 months (interquartile range, 29-77 months). Aneurysm location was the internal carotid artery in 30 patients, the basilar artery in three, and the middle cerebral artery in four. All 37 aneurysms were excluded from the cerebral circulation, with 33 grafts remaining patent at follow-up, as determined by serial cerebral or magnetic resonance angiogram. At follow-up, 33 of 34 of the GSV grafts (88%) and three of three (100%) of the RA grafts were patent. There were two deaths (5.6%), despite patent grafts. Postoperative graft occlusion led to homonymous hemianopsia in one patient and temporary hemiparesis in another (5.6%). Graft occlusions were asymptomatic in two patients. CONCLUSIONS: EC-IC bypass is a safe and effective treatment for GIAAs, with acceptable rates of morbidity (5.6%), mortality (5.6%), and graft patency (89.2%). We suggest that the technique described in this report should be routinely used for treatment of GIAAs in centers where neurosurgery and vascular surgery services are available and should be considered a standard procedure in the armamentarium of the vascular surgeon.

Expression profiling of liposarcoma yields a multigene predictor of patient outcome and identifies genes that contribute to liposarcomagenesis.

Liposarcomas are the most common type of soft tissue sarcoma but their genetics are poorly defined. To identify genes that contribute to liposarcomagenesis and serve as prognostic candidates, we undertook expression profiling of 140 primary liposarcoma samples, which were randomly split into training set (n = 95) and test set (n = 45). A multigene predictor for distant recurrence-free survival (DRFS) was developed by the supervised principal component method. Expression levels of the 588 genes in the predictor were used to calculate a risk score for each patient. In validation of the predictor in the test set, patients with low risk score had a 3-year DRFS of 83% versus 45% for high risk score patients (P = 0.001). The HR for high versus low score, adjusted for histologic subtype, was 4.42 (95% CI, 1.26-15.55; P = 0.021). The concordance probability for risk score was 0.732. In contrast, the concordance probability for histologic subtype, which had been considered the best predictor of outcome in liposarcoma, was 0.669. Genes related to adipogenesis, DNA replication, mitosis, and spindle assembly checkpoint control were all highly represented in the multigene predictor. Three genes from the predictor, TOP2A, PTK7, and CHEK1, were found to be overexpressed in liposarcoma samples of all five subtypes and in liposarcoma cell lines. RNAi-mediated knockdown of these genes in liposarcoma cell lines reduced proliferation and invasiveness and increased apoptosis. Taken together, our findings identify genes that seem to be involved in liposarcomagenesis and have promise as therapeutic targets, and support the use of this multigene predictor to improve risk stratification for individual patients with liposarcoma.

More consistent postoperative care and monitoring can reduce costs following microvascular free flap reconstruction.

Great variability exists in microsurgical postoperative care in the United States. Lack of standardized postoperative monitoring protocols and appropriate training of monitoring personnel leads to inefficiency and increased cost of providing microsurgical postoperative care. A 45-question survey was sent to all plastic surgery and plastic surgery-based microsurgery program directors in the United States. Questions focused on the number and type of flaps performed, length of stay, complications, postoperative monitoring setting, training provided to monitoring personnel, and limitations in flap monitoring. The response rate was 31% with 3407 microvascular free flaps performed annually at 26 centers. A total of 1533 flaps were monitored in the intensive care unit (ICU) for an average of 3.1 days. In 45% of responding centers patients were cared for in an ICU secondary to a lack of adequately trained nurses at alternative sites. Printed postoperative protocols were provided to nurses in 39% of centers. With a comparative increase cost of $2878 to $3345 per day for ICU care, this translates into an annual increased cost of $13.7 to $15.9 million to the responding centers. Improved nursing training and the use of standardized postoperative protocols may allow patients to be monitored in non-ICU settings postoperatively, thereby reducing the costs associated with providing postoperative microsurgical care.

Endovascular treatment of spontaneous dissections of the superior mesenteric artery.

BACKGROUND: Spontaneous dissection of the superior mesenteric artery (SMA) is exceedingly rare. Treatment options range from observation to anticoagulation to open surgery or endovascular repair. We present our experience to date in the management of isolated SMA dissections. METHODS: A retrospective review of the vascular surgery and radiology databases from 1998 to 2008 was performed. In general, incidental radiologic findings of a dissection were managed expectantly. The decision to intervene was based on anatomic suitability, patient comorbidities and symptoms, and physician preference. Endovascular stents were placed using a brachial approach, with the choice of stent determined by physician preference. Patients who underwent endovascular stent placement (ESP) were maintained on antiplatelet therapy for 6 months postoperatively. Follow-up consisted of yearly office visits and adjunctive computerized tomography (CT) or magnetic resonance imaging (MRI) when clinically indicated. RESULTS: CT or MRI imaging identified nine patients (7 men, 2 women) with an isolated SMA dissection. One patient also had a concomitant celiac artery dissection. Median age was 70 years (range, 46-73 years). Median follow-up time was 32 months (range, 13.8-62.5 months). Presentations included an incidental radiologic finding in three patients and acute onset abdominal pain in six. Treatment included expectant management in four patients, anticoagulation in two, and ESP in three. ESP was performed primarily in two patients and in a third patient after initial management with anticoagulation failed. The reduction in the diameter of the true lumen was significantly greater in patients treated with ESP vs patients who were successfully managed expectantly or with anticoagulation (F = 15.59, P < .005). No procedural complications were associated with ESP. CONCLUSIONS: An isolated SMA dissection is a rare entity that may be managed successfully in a variety of ways based on clinical presentation. Endovascular stenting can be performed with good results and may be the preferred treatment in patients with symptomatic isolated SMA dissections.

Gastric banding as a salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass.

BACKGROUND: This study reviews outcomes after laparoscopic adjustable gastric band (LAGB) placement in patients with weight loss failure after Roux-en-Y gastric bypass (RYGBP). METHODS: All data was prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included pre-operative age and body mass index (BMI), gender, conversion rate, operative (OR) time, length of stay (LOS), percentage excess weight loss (EWL), and postoperative complications. RESULTS: 11 patients (seven females, four males) were referred to our program for weight loss failure after RYGBP (six open, five laparoscopic). Mean age and BMI pre-RYGBP were 39.5 years (24-58 years) and 53.2 kg/m(2) (41.2-71 kg/m(2)), respectively. Mean EWL after RYGBP was 38% (19-49%). All patients were referred to us for persistent morbid obesity due to weight loss failure or weight regain. The average time between RYGBP and LAGB was 5.5 years (1.8-20 years). Mean age and BMI pre-LAGB were 46.1 years (29-61 years) and 43.4 kg/m(2) (36-57 kg/m(2)), respectively. Vanguard (VG) bands were placed laparoscopically in most patients. There was one conversion to open. Mean OR time and LOS were 76 minutes and 29 hours, respectively. The 30-day complication rate was 0% and mortality was 0%. There were no band slips or erosions; however, one patient required reoperation for a flipped port. The average follow-up after LAGB was 13 months (2-32 months) with a mean BMI of 37.1 kg/m(2 )(22.7-54.5 kg/m(2)) and an overall mean EWL of 59% (7-96%). Patients undergoing LAGB after failed RYGBP lost an additional 20.8% EWL (6-58%). CONCLUSION: Our experience shows that LAGB is a safe and effective solution to failed RYGBP.

Glial cell missing 1 regulates placental growth factor (PGF) gene transcription in human trophoblast.

Placental growth factor (PGF, previously known as PlGF) is prominently expressed by trophoblasts in human placenta, whereas most nontrophoblast cells express low levels of PGF mRNA under normal physiological conditions. We have shown that hypoxia decreases PGF expression in the trophoblast, but little is known about transcriptional regulation of PGF gene expression. We sought to determine promoter regions of the human PGF gene that contribute to its restricted high constitutive expression in the trophoblast. Overlapping putative promoter regions of human PGF gene encompassing 2-1.5 kb were cloned into reporter vectors and co-transfected into trophoblast and nontrophoblast cell lines. Promoter activity generated by a 2-1.5-kb clone was significantly higher in trophoblasts than in nontrophoblasts. Selective deletion mutants showed that a clone encompassing the PGF (2-828/++34) region generated promoter activity similar to the 2-1.5-kb region in the trophoblast. However, deletion of another 131 bp from this subclone (2-698/++34) resulted in significantly less promoter activity in the trophoblast. The (2-828/2-698) region significantly enhanced activity of a minimal promoter construct in trophoblast but not in nontrophoblast cells, suggesting that this region contributes to regulating PGF transcription in the trophoblast. Site-directed mutagenesis of a glial cell missing 1 (GCM1) motif in the 131-bp region significantly decreased enhancer activity in the trophoblast. Furthermore, overexpression of GCM1 significantly increased PGF 2-1.5-kb promoter activity and PGF mRNA expression in trophoblast and nontrophoblast cells. Forced overexpression of GCM1 restored PGF expression in the hypoxic trophoblast. These data support a functional role for GCM1 contributing to constitutively high trophoblast PGF expression and is the first direct evidence of an oxygen-responsive, trophoblast-specific transcription factor contributing to the regulation of PGF expression.