Endoluminal approaches to bariatric surgery.

The practice of surgery is in a constant flux with evolving technology as new techniques are continually being developed. Obesity is a major health problem worldwide and is the second most common preventable cause of death in North America. Currently, bariatric surgery is the only modality that results in a sustained weight loss along with reversal of the comorbidities. The purpose of this manuscript is to review the current endoluminal options for the treatment of morbid obesity. Procedures such as intragastric balloons, endoluminal vertical gastroplasty, transoral gastroplasty and transluminal sleeve are discussed and their efficacy is analyzed.

The benefits of bariatric surgery in obese patients with hip and knee osteoarthritis: a systematic review.

Osteoarthritis is a common progressive disease leading to joint pain and severe disability. It is a complex multifactorial disease leading to damage of cartilage, deposition of subchondral bone matrix and release of pro-inflammatory cytokines. Obesity is an emerging epidemic and also an important risk factor for osteoarthritis. Weight loss has been shown to improve pain and function in hip and knee joints with osteoarthritis. Bariatric surgery currently is the only evidence-based approach to marked weight loss in obese individuals. However, there is currently limited literature to evaluate the role of bariatric surgery in hip and knee osteoarthritis. The objective of the present study was to systematically review the literature regarding the effectiveness of bariatric surgery in obese adult patients in improving large weight-bearing joint (hip and knee) osteoarthritis. Published English-language manuscripts were considered for review inclusion. A comprehensive search of electronic databases using broad search terms was completed. From a total of 400 articles, eight articles were identified. A total of six studies were included for qualitative analysis. A general trend was identified indicating improved hip and knee osteoarthritis following marked weight loss secondary to bariatric surgery. This systematic review demonstrates that bariatric surgery may benefit obese patients with hip or knee osteoarthritis. However, this review identifies the need for randomized controlled trials to clarify the role and indications for bariatric surgery.

Management of asymptomatic cholelithiasis for patients awaiting renal transplantation.

BACKGROUND: There is no consensus regarding the most appropriate management of asymptomatic cholelithiasis in patients awaiting renal transplantation. Cholecystectomy is considered before renal transplantation because of potential worsened complications from cholelithiasis with posttransplantation immunosuppression. This study reviewed the outcomes for operative and nonoperative management of asymptomatic cholelithiasis in patients awaiting renal transplantation. METHODS: A retrospective chart review of all patients who received renal transplant at the authors' institution during the period 1994 to 2000 was completed. All patients underwent pretransplantation abdominal ultrasound. RESULTS: Of the 411 patients receiving renal transplants (242 men and 169 women with a mean age of 45.7 years), 32 had cholelithiasis at the pretransplantation workup (7.8%), and 35 had gallbladder abnormalities (8.5%): polyps, thickened wall, sludge, bile duct dilation. Before transplantation, 12 of the 32 patients (38%) with cholelithiasis underwent uncomplicated cholecystectomy. None of the remaining 19 patients with cholelithiasis required cholecystectomy after renal transplantation (mean follow-up period 6.2 years). Of the 35 patients with gallbladder abnormalities, 2 required post transplantation elective cholecystectomy. CONCLUSIONS: No evidence was found for increased morbidity related to cholelithiasis or gallbladder abnormalities after renal transplantation. As in the general population, the risks associated with asymptomatic cholelithiasis do not appear to warrant prophylactic cholecystectomy for patients awaiting renal transplantation.

Octylcyanoacrylate tissue adhesive as an alternative to mechanical fixation of expanded polytetrafluoroethylene prosthesis.

In minimally invasive incisional hernia repair positioning and fixation of the expanded polytetrafluoroethylene (ePTFE) mesh prosthesis on the deep surface of the abdominal wall may be facilitated using tissue adhesives. Octylcyanoacrylate (OCTYL), a new adhesive, forms a strong flexible bond with antimicrobial properties. In a rabbit model for incisional hernia we investigated characteristics of the bond created by OCTYL between ePTFE and abdominal wall musculature. We studied initial bond strength and the postoperative host response to the adhesive over a 6-week period. We compared sutured, stapled, and glued mesh prostheses and examined the tissue-prosthesis interface. The ePTFE mesh was fixed successfully to the abdominal wall with OCTYL and remained tightly attached at 6 weeks. Prostheses fixed with OCTYL and spiral tacks induced few intra-abdominal adhesions compared with sutured mesh. All prostheses were completely reperitonealized at 2 weeks. The force required to displace mesh fixed with sutures and staples was greater than mesh fixed with OCTYL. Analysis of the ePTFE/tissue interface by light and scanning electron microscopy showed host cellular migration into the interstices of the mesh with fixation by tacks and suture, whereas an inflammatory infiltrate was seen on the muscular surface with OCTYL fixation of the mesh.

The development and implementation of a computerized database for clinical research in minimal access surgery. An international pilot study.

BACKGROUND: The measurement of outcomes after minimal access surgery (MAS) relies on the maintenance of an accurate, prospective clinical database. The development of a system for data management often proves to be challenging, expensive, and extremely time-consuming. METHODS: We developed a computerized relational database for MAS using Microsoft Access 97 to reside on a hospital server, taking advantage of existing network connections, security, and backup systems. The design of the database includes a point-and-click approach with dropdown boxes for diagnoses, procedures, and complications (limited free-text entry). A fundamental feature of this database allows surgeons and surgical trainees to record clinical information at the point and time of data acquisition. RESULTS: A "beta version" or fully functional draft of the database was presented to a group of surgeons from a variety of specialties (n = 8), and a structured interview based on a questionnaire was used to elicit the surgeon's evaluations of the database. Using the information from the interviews, the database was extensively revised and restructured. CONCLUSIONS: We have developed a relational database that reflects the needs of surgeons interested in clinical research. This database may serve as a template for other centers. It can be expanded to adopt new procedures or modified for other surgical specialties.

Laparoscopic wedge resection of a renal mass in a solitary kidney.

Laparoscopic radical nephrectomy has gained acceptance as a viable means of managing renal neoplasms. Partial nephrectomy has traditionally been performed through a flank or transabdominal incision, with its attendant morbidity and required hospitalization. Laparoscopic renal-sparing surgery may be more technically demanding, but remains beneficial to the patient if performed with adherence to oncological principles. We present a case of laparoscopic renal-sparing surgery in a patient with a renal mass in a solitary kidney. We discuss the technical and oncological challenges of this approach.

A pilot study of new approaches to teaching anatomy and pathology.

PURPOSE: Minimally Invasive Surgery (MIS) has impacted patient care as well as medical training. New medical education opportunities have emerged with MIS. In this pilot study we explore the role of live, interactive MIS to augment and strengthen specific segments of the undergraduate medical curriculum. METHODS: Laparoscopic cholecystectomy (LC) was selected to demonstrate upper abdominal anatomy and pathology. Second year medical students (n=100) in the course of their GI pathology classes attended live LC telesurgery-the telesurgery student group (TSG). Because of technical difficulties, a second class of medical students (n=90) was shown the tape of the MIS procedure one year later instead of the live surgery-the videotape surgery group (VSG). Background clinical information was provided by the program director and the durgeon. During the live and taped LC broadcast living anatomy was demonstrated and a diseased gallbladder was resected. TSG students were able to ask questions of the program director and the surgeon and vice versa using telesurgery technology. After the procedure, the surgeon met with the students for further discussion. VSG students were able to ask questions of the program director during and after the program. Both groups of students completed a pre- and posttest using remote audience responders. Students' responses from the two groups were compared for selected test and evaluation items. RESULTS: Pre-test (Cronbach's alpha=.10) and post-test (Cronbach's alpha =.28) data were obtained from 73 students in the TSG and.22 and.54 respectively from 69 students in the VSG. A significant increase in laparoscopic anatomy knowledge was observed from pretest to posttest for the VSG (31-55%) and from the TSG (30-61%). The majority of VSG students (68%) indicated the method used to teach was outstanding, and 87% indicated that the program was outstanding in keeping their interest. This is contrasted with only 24% of the TSG group responding that the teaching method was outstanding, and 41% indicated that the program was outstanding in keeping their interest. CONCLUSIONS: Medical students can productively be exposed to surgical methods and living anatomy using telesurgery. The high regard the TSG students had for this program suggests that it can be used effectively to teach and inspire medical students. The positive results have encouraged us to have a backup instructional method such as a tape of the MIS procedure, it apparently does not have the positive impact of live surgery.

Acute thermal injury to the canine jejunal free flap: electrocautery versus ultrasonic dissection.

Electrocautery-induced thermal injury contributes to morbidity and mortality after laparoscopic surgery. Ultrasonic dissection is an alternative technique that may produce less thermal injury. We compared the amount of acute thermal injury caused to jejunal free flaps isolated with laparoscopic electrosurgical instruments with that caused by ultrasonic dissection (laparoscopic coagulating shears). Canine jejunal free flaps were isolated by electrocautery or laparosonic coagulating shears and remained viable on a vascular pedicle. After a period of ischemia and reperfusion, the flaps were resected to simulate harvesting and reimplantation. Thermal injury was observed at the site of dissection and was graded histologically. At the margin of the jejunal free flaps, the laparosonic coagulating shears produced less thermal injury (score, 2.2 at level 3) than the electrocautery grasping forceps (score, 3.7 at 35 W and 4.1 at 70 W). The laparosconic coagulating shears produced less thermal injury to a jejunal free flap than did electrocautery. Ultrasonic dissection is an alternative to the complications produced by electrocautery during laparoscopic dissection.

Laparoscopic and open incisional hernia repair: a comparison study.

BACKGROUND: Techniques for performing laparoscopic incisional hernia repair have been described and some advantages over conventional open repair reported. However, most reported series of laparoscopic incisional hernia procedures are small, and only one has included a comparison with open repairs. METHODS: From December 1993 to January 1998, we prospectively collected operative and outcome data on 56 consecutive laparoscopic prosthetic repairs of large incisional hernias. The data were compared with those from a retrospective view of 49 open incisional hernia repairs done in January 1991 to December 1993. RESULTS: The open and laparoscopic repair groups were comparable in patient age, sex, preoperative American Society of Anesthesiologists score, hernia size, and history of previous repair. Operative time was significantly longer in the laparoscopic group; duration of hospitalization and number of perioperative complications were significantly greater in the open group. CONCLUSIONS: In this series, laparoscopic repair of incisional hernias took longer to perform than open repair but was associated with fewer perioperative complications and a shorter hospital stay.

Laparoscopic resection of an intra-abdominal cystic mass: a cystic mesothelioma.

The clinical features of a patient with an intra-abdominal cystic mass do not lead to a specific diagnosis. Aspiration is usually ineffective because the mass recurs and cytologic investigation is often non-diagnostic. Conservative management is unsuccessful because symptoms often persist. Surgical management of cystic masses is required for definitive management and pathologic diagnosis. A laparoscopic approach to the diagnosis and treatment can provide essential anatomic information and a complete resection with minimal morbidity. A laparoscopic technique using 3 trocars and maintaining the integrity of the mass allows complete excision and removal of large intra-abdominal cystic masses as reported in a 43-year-old patient with a large intra-abdominal cystic mass identified as a benign cystic mesothelioma.

Repeated infection of cats with Brugia pahangi: parasitological observations.

Cats were repeatedly inoculated with infective larvae of Brugia pahangi. On parasitological grounds they could be divided into 5 groups. Group I--most cats (some 70%) became microfilaraemic (mf+) and retained high levels of microfilariae (mf) in their blood for over 2 years. In some Group I cats mf counts stabilized at high levels whilst in others mf counts continued to increase. Large numbers of fecund adult worms were recovered from their lymphatics. Adult counts were not made on the cats in the current experiments but over 100 adults have been recovered from 'super-susceptible' cats. Large amounts of B. pahangi adult antigen were consistently present in the serum of all Group I cats. About 30% of cats became amicrofilaraemic (mf-). In these cats the peak mf levels were seldom above 10,000 mf/ml. Group II--these cats had less than 10,000 mf/ml and low antigen levels. After more than 1 year of being repeatedly infected B. pahangi adult antigen slowly declined and eventually could no longer be detected in their serum and the number of mf declined very slowly after the fall in antigen levels. This shows that in Group II cats the adult worms die and as the cats are resistant to the development of the continuing weekly inoculation of L3 no new adults can develop. Group III--these cats became mf--during the first year of infection but remained B. pahangi antigen-positive for many weeks after this and, at autopsy, had living adults in their lymphatics.(ABSTRACT TRUNCATED AT 250 WORDS)

Cats with single Brugia pahangi infections: relationship between parasitological status and humoral responses to somatic and surface parasite antigens.

Cats given a single inoculation of Brugia pahangi infective larvae (L3) were retrospectively allocated into three groups according to parasitological outcome of infection. Recognition of somatic and surface antigens of B. pahangi by sera from each group was compared by ELISA, immunoelectroblotting, and immunoprecipitation techniques. In cats that never became microfilaraemic mean serum IgG antibody levels against somatic extracts from adult male worms, L3, and microfilariae (mf) were higher than levels in cats that initially became microfilaraemic (mf + ve) then spontaneously became nonmicrofilaraemic (mf - ve). The lowest levels of antibody against each stage were found in cats that remained persistently mf + ve. Antigenic components of 18 kD and 22 kD in somatic extracts of adult worms and L3 were recognized by sera from cats that never became mf + ve and by spontaneously mf - ve cats, but not by sera of persistently mf + ve cats. When radioiodinated surface antigens of mixed adult worms and microfilariae were immunoprecipitated by sera from cats in the three groups, no correlation was observed between recognition of individual antigen components and parasitological outcome of infection.

Circulating filarial antigen in cats infected with Brugia pahangi is indicative of the presence of adult worms.

Using counterimmunoelectrophoresis with rabbit antisera raised against soluble extracts of adult females of Brugia pahangi parasite antigen was detected in the serum of all cats repeatedly infected with B. pahangi. Antigen was never detected in uninfected cats. The antigen was associated with the presence of adult worms. Antigen was detected consistently in a cat that was amicrofilaraemic but at autopsy harboured only two or three adult worms. Conversely, some cats showed slowly declining numbers of microfilariae and, in these, circulating antigen declined before the number of microfilariae. Eventually no antigen was detectable in circulation whereas microfilariae, although in diminishing numbers, were still present. At autopsy no adult worms were found in these cats. Antigen also appeared in several cats before they became microfilaraemic.

Morphologic changes and covalent binding of 1,1-dichloroethylene in Clara and alveolar type II cells isolated from lungs of mice following in vivo administration.

We have investigated the metabolism and covalent binding of 1,1-dichloroethylene (1,1-DCE) in isolated unseparated lung cells and in enriched fractions of Clara and alveolar type II cells from mice. Lung cells from control mice separated by centrifugal elutriation were viable and metabolically active as assessed by measurements of 7-ethoxycoumarin deethylase, NADPH cytochrome c reductase, and glutathione S-transferase activities, which were highest in fractions enriched in Clara cells. Mice were treated with [14C]1,1-DCE (125 mg/kg; 20 microCi/kg) in vivo and, 1 hr later, lung cells were isolated and binding of [14C]1,1-DCE determined. Covalent binding was highest in the Clara cell fraction (480 +/- 205 pmol/10(6) cells; 41% Clara cell purity) when compared to the levels present in the fractions containing type II cells (126 +/- 63 pmol/10(6) cells; 51% type II cell purity) and mixed cells from whole lung (29 +/- 13 pmol/10(6) cells). Ultrastructurally, alveolar type II cells from lungs of control and 1,1-DCE-treated mice exhibited normal morphology with well-preserved lamellar bodies. Whereas Clara cells isolated from lungs of control mice appeared structurally unimpaired, those from the lungs of 1,1-DCE-treated mice displayed severe damage and disruption of cellular organelles. The results of these experiments demonstrate the highest binding of [14C]1,1-DCE-metabolite(s) in Clara cells, whereas significantly lower binding was found in both alveolar type II and unseparated lung cells. The substantial binding of [14C]1,1-DCE in Clara cells correlated positively with the high monooxygenase capacity and the preferential damage sustained by this cell population.

Pulmonary toxicity of trichloroethylene in mice. Covalent binding and morphological manifestations.

We examined the time course of trichloroethylene (TCE)-induced pulmonary injury and focused on morphological changes and covalent binding of [14C]TCE soon after administration of a single dose of TCE (2000 mg/kg) to CD-1 male mice. At 1 hr after chemical treatment, Clara cells of the bronchiolar epithelium exhibited necrotic changes involving the mitochondria and endoplasmic reticulum. Dilatation of the endoplasmic reticulum became more severe at 2 hr after TCE administration and, by 4 hr, distended cisternae coalesced to form small vacuoles within the cytoplasmic matrix of the Clara cell. The severity of cellular damage increased progressively between 8 and 12 hr and, by 24 hr, the majority of Clara cells within an airway were severely vacuolated. Covalent binding of [14C]TCE to lung macromolecules was evident at 1 hr, peaked at 4 hr, declined thereafter, and reached a plateau between 12 and 24 hr. Peak binding (142.6 +/- 31.8 nmol/g of wet weight) represented approximately 20% of [14C]TCE distributed to the lung. Although the levels of binding in the liver were at all times greater than those in the lung, liver injury was relatively insignificant. The results demonstrate a positive correlation between the onset of Clara cell injury and the formation of reactive metabolites, as assessed by covalent binding of [14C]TCE.

Brugia pahangi infections in cats: antibody responses which correlate with the change from the microfilaraemic to the amicrofilaraemic state.

The humoral responses of eight cats infected with Brugia pahangi to somatic antigens from all life-cycle stages were examined quantitatively by ELISA and qualitatively by immunoblotting for almost a year post infection. Six cats spontaneously became amicrofilaraemic: their production of IgG antibodies against somatic antigens of microfilariae, adults, and infective larvae was not statistically higher than that of the two cats which remained microfilaraemic. However, immunoblotting revealed that those cats which spontaneously became amicrofilaraemic selectively recognized certain microfilarial, adult and infective larval somatic antigens prior to disappearance of microfilariae from the peripheral circulation. The data suggest that selective recognition of antigens by some cats is responsible for the production of antibodies which may then promote microfilarial death.