Approach to management of intussusception in adults: a new paradigm in the computed tomography era.

Intussusception has been considered an operative indication in adults as a result of the risk of ischemia and the possibility of a malignant lead point. Computed tomographic (CT) scans can reveal unsuspected intussusception. All CT reports from July 1999 to December 2005 were scanned electronically for letter strings to include the keyword intussusception. Identified CT scans were analyzed to characterize the intussusception and associated findings. Clinical, laboratory, pathological, and follow-up variables were gleaned from medical records. Findings were analyzed by treatment and findings at operation. Review of 380,999 CT reports yielded 170 (0.04%) adult patients (mean age, 41 years) with intussusceptions described as enteroenteric in 149 (87.6%), ileocecal in eight (4.7%), colocolonic in 10 (5.9%), and gastroenteric in three (1.8%). Radiological features included mean length of 4.4 cm (range, 0.8-20.5 cm) and diameter of 3.2 cm (range, 1.6-11.5 cm). Twenty-nine (17.1%) had a lead point, and 12 (7.1%) had bowel obstruction. Clinically, 88 (48.2%) patients reported abdominal pain, 52 (30.6%) had nausea and/or vomiting, and 74 (43.5%) had objective findings on abdominal examination. Thirty of 170 (17.6%) patients underwent operation, but only 15 (8.8%) patients had pathologic findings that correlated with CT findings. Seven had,enteroenteric intussusceptions from benign neoplasms (two), adhesions (one), local inflammation (one), previous anastomosis (one), Crohn's disease (one), and idiopathic (one). Three had ileocolic disease, including cecal cancer (one), metastatic melanoma (one) and idiopathic (one; whereas five patients had colocolonic intussusception from colon cancer (three), tubulovillous adenoma (one), and local inflammation (one). Of the 15 without intussusception at exploration, five had pathology related to trauma, four had nonincarcerated internal hernia after Roux-en-Y gastric bypass, four had negative explorations, one had adhesions, and one had appendicitis that did not correlate with CT findings. No patient in the observation group required subsequent operative exploration for intussusception at mean 14.1 months (range, 0.25-67.5 months) follow up. All operative patients demonstrated gastrointestinal symptoms versus 55.3 per cent of the observation group (P < 0.006). Analysis of CT features demonstrated differences among patients observed without operation, those without intussusception at exploration, and confirmed intussusception with regard to mean intussusception length 3.8 versus 3.8 versus 9.6 cm, diameter 3.0 versus 3.2 versus 4.8 cm, lead point 12.1 per cent versus 30 per cent versus 53.3 per cent, and proximal obstruction 3.8 per cent versus 0 per cent versus 46.7 per cent, respectively. Intussusceptions in adults discovered by CT scanning do not always mandate exploration. Most cases can be treated expectantly despite the presence of gastrointestinal symptoms. Close follow up is recommended with imaging and/or endoscopic surveillance. Length and diameter of the intussusception, presence of a lead point, or bowel obstruction on CT are predictive of findings that warrant exploration.

Incorporating laparoscopic fellowship does not increase morbidity or mortality in a university-based bariatric practice.

BACKGROUND: Minimally invasive surgery (MIS) fellowship is one of the most sought-after positions after residency. The increased use of bariatric operations has provided an abundance of advanced cases. The aim of this article is to determine if the addition of an MIS fellowship program has any impact on morbidity and mortality in a university-based bariatric program. STUDY DESIGN: Data from all laparoscopic gastric bypasses (LGBs) performed by one surgeon (RHC) from September 2001 until June 2006 were prospectively entered into a database, which was reviewed for morbidity and mortality before (group 1) and after (group 2) development of the MIS program. Mean operative time, length of hospital stay, anastomotic leaks and strictures, gastrointestinal bleeds, internal hernia, and mortality were compared between the two groups of patients using t-tests with significance of p = 0.05. RESULTS: A total of 761 (group 1, n = 397; group 2, n = 364) LGBs were performed. For the total population, operating room time was 104 +/- 24 minutes and length of hospital stay was 2 +/- 0.3 days. Incidences of morbidities are as follows: leaks, 0.53%; marginal ulcer, 5.0%; anastomotic stricture, 6.7%; incarcerated internal hernia, 2.2%; gastric outlet obstruction, 0.53%; gastrointestinal bleed, 0.09%; and mortality, 0.13%. Comparing groups 1 and 2, mean operating room time was longer in group 2, but there was no marked difference between any of the other variables. CONCLUSIONS: Addition of an MIS fellowship does not change the morbidity and mortality of LGB when developed in the context of a university-based bariatric practice that uses a systematic approach to preoperative evaluation, operative technique, and postoperative management.

The prevalence of nonalcoholic steatohepatitis is greater in morbidly obese men compared to women.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is a form of liver injury that is common in morbidly obese subjects. It has been shown that gender differences exist in the spectrum of nonalcoholic fatty liver disease (NAFLD). The focus of this study was to further characterize these gender differences based on ATP III criteria used to diagnose the metabolic syndrome (MS). METHODS: We retrospectively assessed NAFLD 58 men and 307 women who underwent gastric bypass, for the presence of NASH, MS, and positive predictors of NASH. RESULTS: There was no statistical difference in age, gender, or the presence of diabetes. The prevalence of NASH in men and women was 60.3% and 30.9%, respectively (P<0.001). Multivariate logistic analysis showed an association of male gender with NASH (2.7; 95% CI, 1.3-5.6, P=0.006) as well as age, AST, and diabetes. MS was diagnosed in 91.4% and 76.2% of men and women (P=0.008), and men tended to have more criteria for MS compared to women. The only positive predictor of MS that was statistically significant between genders was high triglycerides (P=0.003). Controlling for BMI and excess body weight produced similar results. CONCLUSIONS: Gender differences do exist within NAFLD and MS, that may be associated with free fatty acid flow to the liver.

Improvement in gastrointestinal symptoms and quality of life after cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the accepted treatment for symptomatic cholelithiasis but has been criticized as an overused procedure. This study assesses the effectiveness of LC on reduction in gastrointestinal (GI) symptoms and the impact on quality of life (QOL). METHODS: A prospective cohort of subjects evaluated for gallstone disease between August 2001 and July 2004 completed preoperative and postoperative GI gallbladder symptom surveys (GISS) and SF36 QOL surveys. The GISS was developed to quantify the magnitude, severity, and distressfulness of 16 GI symptoms. Surveys were scored and evaluated using paired t tests. RESULTS: Fifty-five subjects were included in the final analysis. The GISS revealed significant improvement in biliary type symptoms but not reflux or irritable bowel symptoms after LC (P > .05). Significant improvement was seen in QOL (P < .01). CONCLUSION: This study supports the utility of LC by showing not only a significant reduction of GI symptoms but also marked improvement in patients' general QOL.

Outcomes of cholecystectomy after endoscopic sphincterotomy for choledocholithiasis.

Laparoscopic cholecystectomy (LC) for treatment of symptomatic common bile duct stones (CBDS) after endoscopic sphincterotomy (ES) is associated with increased conversion and complications compared with other indications. We examined factors associated with conversion and complications of LC after ES. A retrospective study of 32 patients undergoing ES for CBDS followed by cholecystectomy was undertaken. Surgical outcomes for this group were compared with a control population of 499 LCs for all other indications. Factors associated with open cholecystectomy and complications in the ES group were analyzed. Patients undergoing LC preceded by ES had a significantly higher complication (odds ratio [OR] = 7.97; 95% CI, 2.84-22.5) and conversion rate (OR = 3.45; 95% CI, 1.56-7.66) compared with LC for all other indications. Pre-ES serum bilirubin greater than 5 mg/dL was predictive of conversion (positive predictive value = 63%, P < 0.005). Patients with symptomatic CBDS that undergo LC after ES have higher complication and conversion rates than patients undergoing LC without ES. Pre-ES serum bilirubin is useful in identifying patients who may not have a successful laparoscopic approach at cholecystectomy.

Incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting.

Vitamin deficiency after gastric bypass surgery is a known complication. The purpose of this study was to measure the incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting. All patients who underwent laparoscopic Roux-en-Y gastric bypass from January 2002 to December 2004 and completed a 1- and 2-year follow-up after surgery were selected. Of the total 493 patients, 318 (65%) had vitamin results at 1-year follow-up. Of the 366 eligible for the 2-year follow-up, 141 (39%) had vitamin results. Patients were further grouped based on gender, race, and Roux limb length, and incidence of vitamin deficiencies were studied. The incidence of vitamin A (retinol) deficiency was 11 per cent, vitamin C was 34.6 per cent, vitamin D25OH was 7 per cent, vitamin B1 was 18.3 per cent, vitamin B2 was 13.6 per cent, vitamin B6 was 17.6 per cent, and vitamin B12 was 3.6 per cent 12 months after surgery. There was no statistical difference in the incidence of vitamin deficiencies between 1 and 2 years. In univariate and multivariate logistic regression of 1- and 2-year follow up, black patients (vitamins A, D, and B1 for 1 year and B1 and B6 for 2 years) and women (vitamin C at 1 year) were more likely to have vitamin deficiencies. Vitamin deficiencies after laparoscopic Roux-en-Y gastric bypass are more common and involve more vitamins, even those that are water soluble, than previously appreciated. Black patients tend to have more deficiencies than other groups. The bariatric surgeon should be committed to the long-term follow-up and care of these patients. Further prospective and randomized studies are necessary to provide appropriate guidelines for supplementation.

Obesity status and use of general surgery resources.

Obesity is a rapidly growing epidemic. This study assesses the impact of obesity on surgeon workload for general surgical services. A retrospective study of patients undergoing cholecystectomy, unilateral mastectomy, and colectomy between January 2000 and December 2003 was undertaken. Obesity was defined as body mass index > or = 30. The proportion of obese patients was compared to the 2002 BRFSS obesity prevalence data for Alabama. Data were adjusted to control for potential confounders. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. A total of 1,385 patients were included in analysis. The prevalence of obesity in the study population was 35.5 per cent compared to the statewide prevalence of 25.2 per cent (OR = 1.73, 95% CI = 1.51, 1.98). These data were stratified by procedure, age, and gender. The cholecystectomy group had a significantly higher proportion of obese for all age groups and female gender. The mastectomy group had a higher proportion of obese in the 45-64 age group. The stratified colectomy group did not reach statistical significance. There was no evidence of referral bias to explain these findings. This study demonstrates there is a greater use of general surgery services, particularly cholecystectomy and mastectomy, in obese patients than predicted by the prevalence of obesity in the population.

Impact of obesity on resource utilization for general surgical procedures.

OBJECTIVE: To determine the impact of the obesity epidemic on workload for general surgeons. SUMMARY BACKGROUND DATA: In 2001, the prevalence of obesity in the United States reached 26%, more than double the rate in 1990. This study focuses on the impact of obesity on surgical practice and resource utilization. METHODS: A retrospective analysis was done on patients undergoing cholecystectomy, unilateral mastectomy, and colectomy from January 2000 to December 2003 at a tertiary care center. The main outcome variables were operative time (OT), length of stay (LOS), and complications. The key independent variable was body mass index. We analyzed the association of obesity status with OT, LOS, and complications for each surgery, using multivariate regression models controlling for surgeon time-invariant characteristics. RESULTS: There were 623 cholecystectomies, 322 unilateral mastectomies, and 430 colectomies suitable for analysis from 2000 to 2003. Multivariable regression analyses indicated that obese patients had statistically significantly longer OT (P < 0.01) but not longer LOS (P > 0.05) or more complications (P > 0.05). Compared with a normal-weight patient, an obese patient had an additional 5.19 (95% confidence interval [CI], 0.15-10.24), 23.67 (95% CI, 14.38-32.96), and 21.42 (95% CI, 9.54-33.30) minutes of OT with respect to cholecystectomy, unilateral mastectomy, and colectomy. These estimates were robust in sensitivity analyses. CONCLUSIONS: Obesity significantly increased OT for each procedure studied. These data have implications for health policy and surgical resource utilization. We suggest that a CPT modifier to appropriately reimburse surgeons caring for obese patients be considered.