Epidural analgesia and laparoscopic technique do not reduce incidence of prolonged ileus in elective colon resections.

BACKGROUND: This study evaluated the incidence and risk factors for prolonged ileus in patients undergoing elective colon resection. METHODS: Retrospective data were obtained in patients undergoing open colectomy with or without epidural analgesia and laparoscopic colectomy at a university-affiliated Veterans hospital. The incidence and risk factors of prolonged ileus as defined by no bowel movement before postoperative day 7 or placement of a nasogastric tube because of vomiting or abdominal distension were analyzed. RESULTS: Incidence of prolonged ileus was 15.2%, 22.4%, and 16.7% in epidural (92 patients), nonepidural (107 patients), and laparoscopic colectomy (48 patients), respectively (P = .39). Higher age, American Society of Anesthesiologists scores, and number of comorbidities, and lower postoperative potassium level were associated with the development of prolonged ileus. CONCLUSIONS: The incidence of prolonged ileus was similar in the 3 groups studied. However, the epidural and laparoscopic groups experienced earlier return of bowel function and toleration of diet than the nonepidural group.

Technique of resection of esophageal adenocarcinoma after Roux-en-Y gastric bypass and literature review of esophagogastric tumors after bariatric procedures.

BACKGROUND: The number of bariatric procedures has continued to increase worldwide. However, experience with tumors arising in the esophagus or stomach after gastric bypass is lacking. We report our technique for curative resection of esophageal adenocarcinoma in a patient who had undergone previous gastric bypass and review the reported data on esophagogastric tumors after bariatric surgery. METHODS: We have described the operative details of esophagectomy after gastric bypass and reviewed the published data regarding type of bariatric surgery, gender predilection, presentation, symptom duration, cancer stage, and prognosis of patients with esophagogastric tumors occurring after bariatric surgery. RESULTS: Only 22 esophagogastric tumors have been reported so far after bariatric surgery. The majority of them are locally advanced or metastatic at presentation. CONCLUSION: Esophagogastric tumors after bariatric surgery are uncommon. This operative technique pays particular attention to the altered anatomy, dissection of the gastric pouch, and preservation of the blood supply to the excluded stomach. This technique can also be applied to manage tumors arising in the gastric pouch after previous gastric bypass. Close collaboration with the bariatric surgeon during surgery is essential to achieve a successful oncologic outcome in this subset of patients.

Current management of adrenal tumors.

PURPOSE OF REVIEW: Adrenal tumors evoke considerable interest and diagnostic challenges. This rare group of tumors includes functional tumors with a gamut of clinical presentations, as well as adrenocortical carcinoma, with its advanced disease at presentation and dismal prognosis posing additional challenge. Increasing detection of incidentalomas adds further interest with the concomitant diagnostic and management dilemmas. RECENT FINDINGS: Significant advances have been made in diagnostic imaging modalities for identifying malignancy risk in adrenal incidentalomas. Considerable progress has occurred in understanding adrenocortical carcinoma pathogenesis from the study of genetics at the germline level in familial carcinomas, as well as at the somatic level by analyzing molecular alterations in sporadic tumors; this research supplies opportunities to develop novel therapeutic agents against a tumor with poor prognosis. SUMMARY: Laparoscopic adrenalectomy has emerged as standard of care in the treatment of functional benign adenomas and nonfunctional tumors larger than 4 cm when adrenocortical carcinoma is not suspected. Open adrenalectomy with en-bloc excision has been the mainstay for primary and recurrent adrenocortical carcinoma due to the lack of effective adjuvant therapy. International consensus conferences have attempted to standardize diagnostic and treatment approaches in the management of adrenal tumors; further research is necessary.

Bariatric surgery improves urinary incontinence in morbidly obese individuals.

BACKGROUND: Urinary incontinence is common in obese individuals. We report on the prevalence of urinary incontinence in patients undergoing bariatric surgery and the effect of surgically induced weight loss on urinary incontinence. METHODS: The prospectively collected data from 201 consecutive candidates for bariatric surgery were evaluated. The patients were surveyed using a questionnaire regarding the duration of incontinence, stress/urge incontinence symptoms, and incontinence severity before and after undergoing bariatric surgery. Severity was quantified using a validated index developed Data are presented as the mean +/- standard deviation. RESULTS: Of 201 patients, 65 (32%) reported urinary incontinence. Of the 65 patients, 44 women and 1 man (age 49 +/- 11 years, body mass index 48 +/- 7 kg/m(2)) underwent Roux-en-Y gastric bypass (n = 42) or laparoscopic-assisted gastric banding (n = 3). Of the 38 patients who reported mild (2%), moderate (48%), and severe (50%) urinary incontinence preoperatively who had complete follow-up at > or = 6 months postoperatively, 19 (50%) had demonstrated resolution of urinary incontinence and 19 had reported residual slight-moderate (37%) or severe (13%) urinary incontinence. The overall severity score improved from 5.4 +/- 2.3 to 2.3 +/- 2.8 postoperatively (P <.001); the percentage of excess body weight loss was 61% +/- 19%. The patients reported subjective improvement within 4 months postoperatively or after a 50-lb weight loss. CONCLUSION: Urinary incontinence is prevalent in bariatric surgery patients. Surgically induced weight loss results in improvement or resolution of urinary incontinence in 82% of patients. The findings from this large cohort warrant additional investigation with urodynamic studies.

Preoperative assessment and perioperative care of patients undergoing bariatric surgery.

The prevalence of morbid obesity in the United States and worldwide is increasing at an alarming rate. The number of bariatric surgical procedures also has steadily increased during the past decade. This article reviews the published literature and current practice trends for preoperative workup and assessment of patients undergoing bariatric surgery.