Biomarkers of NAFLD progression: a lipidomics approach to an epidemic.

The spectrum of nonalcoholic fatty liver disease (NAFLD) includes steatosis, nonalcoholic steatohepatitis (NASH), and cirrhosis. Recognition and timely diagnosis of these different stages, particularly NASH, is important for both potential reversibility and limitation of complications. Liver biopsy remains the clinical standard for definitive diagnosis. Diagnostic tools minimizing the need for invasive procedures or that add information to histologic data are important in novel management strategies for the growing epidemic of NAFLD. We describe an "omics" approach to detecting a reproducible signature of lipid metabolites, aqueous intracellular metabolites, SNPs, and mRNA transcripts in a double-blinded study of patients with different stages of NAFLD that involves profiling liver biopsies, plasma, and urine samples. Using linear discriminant analysis, a panel of 20 plasma metabolites that includes glycerophospholipids, sphingolipids, sterols, and various aqueous small molecular weight components involved in cellular metabolic pathways, can be used to differentiate between NASH and steatosis. This identification of differential biomolecular signatures has the potential to improve clinical diagnosis and facilitate therapeutic intervention of NAFLD.

Inpatient mortality and length of stay comparison of percutaneous endoscopic gastrostomy and percutaneous endoscopic gastrojejunostomy.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic gastrojejunostomy (PEGJ) are endoscopic procedures often performed by surgeons. No recent population-based study has compared inpatient mortality or length of stay between patients who undergo PEG or PEGJ placement during their hospitalization. METHODS: Patients undergoing inpatient PEG or PEGJ placement and who were at least 18 years old were identified from the 2006 Nationwide Inpatient Sample (NIS) database. Baseline characteristics of each group were compared, and outcomes of risk-adjusted inpatient mortality and length of stay were determined. Means were compared from using a complex sample t-test, and proportions were compared from using a complex sample chi-square test, with an alpha level of 0.05 for significance. Bivariate logistic regression was used to evaluate PEG or PEGJ placement as a risk factor for mortality. RESULTS: In the 2006 NIS, 187,597 discharges were identified, during which a PEG or PEGJ was placed. Ninety-six percent (179,587) of patients underwent PEG placement, and 4% (8010) had PEGJ tubes placed. Fifty-one percent were men, with the mean age for PEG and PEGJ placement of 71.3 +/- 0.3 (mean +/- standard error) and 64.8 +/- 0.8 years (P < 0.05). In the PEG group, 86% of admissions were nonelective, compared to 79% in the PEGJ group (P < 0.05). The primary discharge diagnoses for both groups of patients included acute cerebrovascular disease, aspiration pneumonitis, septicemia, respiratory failure, and intracranial injury. PEG patients had a higher cumulative incidence of congestive heart failure, chronic lung disease, and diabetes. Crude in-hospital mortality for death was 11% for both PEG and PEGJ patients. No difference in mortality was observed in risk-adjusted analyses accounting for patient severity. Mean length of stay was similar for both groups (PEG 20.9 +/- 0.4 days; PEGJ 22.5 +/- 1.1 days). Neither PEG nor PEGJ was identified as a risk factor for inpatient mortality. CONCLUSIONS: Comparative analyses of patients undergoing PEG versus PEGJ revealed no detectable difference between inpatient mortality and hospital length of stay in this large observational study. Both procedures can be performed safely in high-risk populations, with no increased mortality or length of stay incurred by jejunal feeding access. However, further analysis is required to compare more specific short-term outcomes between these populations as well as their respective cost-effectiveness.

Antegrade and retrograde endoscopy for treatment of esophageal stricture.

Total or near-total esophageal stricture results from multiple processes. Traditional treatment with wire cannulation followed by serial dilation is often contraindicated due to poor visualization and the risk of perforation. We seek to demonstrate that combined antegrade and retrograde endoscopy are useful for treatment of total or near-total esophageal strictures. The gastrostomy tube is removed and the tract dilated. A standard endoscope is passed retrograde to the stricture. An antegrade endoscope is advanced until transillumination across the stricture is visualized. A biopsy forceps or needle is used to traverse the stricture in an antegrade fashion. The tract is cannulated with a stiff wire that is then brought out through the gastrostomy site. The stricture is serially dilated. The gastrostomy tube is replaced, and a nasogastric tube is left across the stricture for 3 to 4 weeks. The endoscope is withdrawn and an 18 or 20 Fr gastrostomy tube is left in place. A total of three patients with total esophageal strictures were treated using combined antegrade and retrograde esophagoscopy. All three patients regained the ability to swallow secretions. Importantly, there were no instances of esophageal perforation. This technique has broader application, including combination with minilaparotomy for patients without retrograde access. Further research is needed to determine durability of stricture dilation.

Intraband pressure measurements describe a pattern of weight loss for patients with adjustable gastric bands.

BACKGROUND: Individuals with adjustable gastric bands experience plateaus in weight loss. Patients commonly attribute this to a "loosening" of their band with time. We sought to elucidate a physiologic mechanism for this pattern in patient behavior and describe the feasibility of a pressure-based adjustment algorithm for adjustable gastric bands. METHODS: Following IRB protocol, 100 consecutive patients undergoing placement of the Lap-Band (Inamed) were enrolled and followed prospectively for 12 months. Intraband pressure measurements at band volumes 0 to 4 mL were recorded intraoperatively and at each subsequent band adjustment. Band adjustments were made using the currently accepted volume-based postoperative protocol. RESULTS: Seventy-nine patients were included in analysis. Mean percent excess weight loss for the study cohort was 36 +/- 17% at a median followup of 347 days. During the time between adjustments, there was a statistically significant decrease (p < 0.001) in intraband pressure without a corresponding decrease in band volume. This was a result of a substantial change in the pressure-volume relationship of the Lap-Band. As time progressed, the Lap-Band developed less intraband pressure per unit volume. This change was not a result of changes in the elastic properties of the band material itself. CONCLUSIONS: Between adjustments, Lap-Band patients experience gradual loss of satiety and a loosening of their band, despite stable band volume. Their experience is substantiated by degradation in their intraband pressures with time. We have demonstrated that intraband pressures correlate with the patient's clinical history and have thereby established the foundation for a pressure-based adjustment protocol.

Liposarcoma of the spermatic cord masquerading as an incarcerated inguinal hernia.

We present a rare case of liposarcoma of the spermatic cord. There are only 61 reports in the literature. The presenting complaint is usually a painless bulge in the inguinal or scrotal region. Our patient presented with a new-onset inguinoscrotal swelling that was misdiagnosed preoperatively as an incarcerated indirect hernia. The treatment for a spermatic cord liposarcoma is radical orchiectomy with high ligation of the cord. Radiation therapy is recommended in addition to surgery in situations with evidence of tumor with propensity for more aggressive behavior (i.e., high-grade tumor, lymphatic invasion, inadequate margin, or recurrence). The current literature, diagnosis, and management of malignant tumors of the spermatic cord are reviewed.