A Single-Institution 5-Year Retrospective Analysis of Laparoscopic Sleeve Gastrectomy Staple-Line Reinforcement: Bioabsorbable Mesh Versus Oversewing.

Background: Staple-line reinforcement has been used to decrease complications such as staple-line bleeding (SLB) and staple-line leaks (SLLs) in patients undergoing laparoscopic sleeve gastrectomy (SG). There is little data comparing bioabsorbable mesh reinforcement (BMR) with oversewing the staple line (OSL). The aim of our study was to compare BMR with OSL in SG. Materials and Methods: This is a single-institution retrospective analysis comparing risks and benefits of BMR (group a) with those of OSL (group b) for SG staple-line reinforcement between 2015 and 2020. Results: In total, 857 patients were identified. There were 452 (52.74%) in group a and 405 (47.26%) in group b. SLB requiring transfusion occurred in 6 (1.32%) patients in group a and 6 (1.48%) patients in group b, NS (P = .848). Zero SLL was identified in either group. One-year mean direct cost of SG in group a was $7881 compared with $6677 in group b. Conclusion: This retrospective study showed that there was low risk of bleeding or leak with either technique of staple-line reinforcement and there was no significant difference in SLB or leak rate with bioabsorbable mesh versus oversewing. The use of bioabsorbable mesh was more expensive than oversewing.

Endoscopic Treatment of Gastroesophageal Reflux Disease.

There have been many devices and ideas to treat reflux disease endoscopically. Several devices have been tried and even FDA approved but now are no longer used. The push for these therapies is to find effective reflux control with lower risk and faster recovery. In this article we describe an endoscopic suturing device (TIF), radiofrequency device (Stretta) and a newer technique that has a lot of promise called antireflux mucosectomy. All these procedures seem to help control reflux at a minimum of morbidity given current information. As reflux is so prevalent a shift to these techniques for appropriate patients is likely to improve patient care.

Increased inflammatory low-density neutrophils in severe obesity and effect of bariatric surgery: Results from case-control and prospective cohort studies.

BACKGROUND: Low-density neutrophils (LDN) are increased in several inflammatory diseases and may also play a role in the low-grade chronic inflammation associated with obesity. Here we explored their role in obesity, determined their gene signatures, and assessed the effect of bariatric surgery. METHODS: We compared the number, function, and gene expression profiles of circulating LDN in morbidly obese patients (MOP, n=27; body mass index (BMI) > 40 Kg/m2) and normal-weight controls (NWC, n=20; BMI < 25 Kg/m2) in a case-control study. Additionally, in a prospective longitudinal study, we measured changes in the frequency of LDN after bariatric surgery (n=36) and tested for associations with metabolic and inflammatory parameters. FINDINGS: LDN and inflammatory markers were significantly increased in MOP compared to NWC. Transcriptome analysis showed increased neutrophil-related gene expression signatures associated with inflammation, neutrophil activation, and immunosuppressive function. However, LDN did not suppress T cells proliferation and produced low levels of reactive oxygen species (ROS). Circulating LDN in MOP significantly decreased after bariatric surgery in parallel with BMI, metabolic syndrome, and inflammatory markers. INTERPRETATION: Obesity increases LDN displaying an inflammatory gene signature. Our results suggest that LDN may represent a neutrophil subset associated with chronic inflammation, a feature of obesity that has been previously associated with the appearance and progression of co-morbidities. Furthermore, bariatric surgery, as an efficient therapy for severe obesity, reduces LDN in circulation and improves several components of the metabolic syndrome supporting its recognized anti-inflammatory and beneficial metabolic effects. FUNDING: This work was supported in part by grants from the National Institutes of Health (NIH; 5P30GM114732-02, P20CA233374 - A. Ochoa and L. Miele), Pennington Biomedical NORC (P30DK072476 - E. Ravussin & LSU-NO Stanley S. Scott Cancer Center and Louisiana Clinical and Translational Science Center (LACaTS; U54-GM104940 - J. Kirwan).

Duration of Nil Per Os is causal in hospital length of stay following laparoscopic bariatric surgery.

INTRODUCTION: A recent bariatric surgical study demonstrated an inverse relationship of intraoperative hydration with the incidence of extended hospital length of stay (ehLOS: >1 postoperative hospital day). In that study, a post hoc analysis of the preoperative duration of Nil Per Os (NPO) past midnight revealed a significant dose-response association on the incidence of ehLOS, with the lowest incidence (10-12 %) predicted within the 2-5-h NPO interval. As NPO is associated with a state of compensatory dehydration, the objectives of this study were to prospectively examine the role of decreasing preoperative NPO intervals on the incidence of ehLOS in a similar bariatric surgical population and to establish causality of this association. METHODS: Following IRB approval, 168 bariatric surgeries were analyzed following institution of a revised oral water ad libitum policy until 2 h prior to surgery on the incidence of ehLOS. The role of duration of NPO on the incidence of ehLOS was assessed by logistic fit graphs and misclassification rates on the two groups. A statistical process control chart monitored the efficacy of the revised NPO guidelines. RESULTS: There were statistically significant, but not clinical, differences in the incidences of histories of anemia, gastroesophageal reflux disease, previous percutaneous cardiac intervention/percutaneous transluminal coronary artery angioplasty, or preoperative albumin levels between the two groups. There were no perioperative pulmonary aspirations of gastric contents in either group. Following reduction of the oral hydration interval to ≥2 h, a 13-15 % incidence of ehLOS was observed within the 2-5-h NPO interval with similar misclassification rates observed between the two groups. CONCLUSIONS: Allowing bariatric patients access to ad libitum water for up to 2 h prior to surgery decreased the incidence of ehLOS. Comparison of the dose-response curves within the 2-5-h NPO intervals before and after introduction of the revised NPO guidelines was similar and confirms causality.

The evolution of early appendectomy as standard treatment from appendicitis: what we can learn from the past in adopting new medical therapies.

Dr. Reginald Fitz popularized early appendectomy for the treatment of appendicitis with his treatise, "Perforating Inflammation of the Vermiform Appendix," published in 1886 while he worked at the Massachusetts General Hospital along with Dr. Maurice Howe Richardson, the inventor of the Richardson retractor. Their collaboration over the ensuing years led to improvement in outcomes for patients with appendicitis. This historical article describes the importance of this collaboration with information from operative reports, letters, and manuscripts and echoes the discussion today of safely adopting new medical technologies.

Long-term outcomes of laparoscopic adrenalectomy for adrenal masses.

BACKGROUND: Laparoscopic adrenalectomy is the gold standard procedure for most adrenal masses. However, long-term data regarding this procedure are limited. We report our institution's experience with laparoscopic adrenalectomy, determine if this procedure results in durable weight loss and resolves hypertension, diabetes mellitus, or hyperlipidemia, and identify predictors of pathology in nonfunctioning tumors. MATERIALS AND METHODS: We retrospectively reviewed laparoscopic adrenalectomies performed for adrenal masses between May 2000 and September 2010 by nine surgeons at a single institution. Data gathered included demographics, body mass index (BMI), preoperative and postoperative imaging and biochemical testing results, length of stay, complications, pathology, medications, and resolution of hypertension, diabetes, or hyperlipidemia. RESULTS: We removed 96 adrenal glands in 95 patients. Their average age was 55.6 years. The average length of stay was 1.8 days. Average BMI was 32.9 kg/m(2) preoperatively and 31.9 kg/m(2) postoperatively (P=.46). We experienced no conversions to open procedure and no perioperative mortality. Minor complications occurred at a rate of 1.2%. Indications for adrenalectomy were nonfunctioning tumor (n=35), pheochromocytoma (n=18), aldosteronoma (n=17), subclinical Cushing's syndrome (n=15), Cushing's syndrome (n=9), and sex hormone-secreting tumor (n=1). Hypertension improved or resolved in 63% of patients with Cushing's syndrome, 56% with aldosteronoma, and 47% with pheochromocytoma. When adrenalectomy was performed for nonfunctioning tumors, neoplasia was identified in 22.9% of patients. The most predictive factors for neoplasia were previous history of cancer and abnormal appearance on computed tomography, magnetic resonance imaging, or positron emission tomography scan. CONCLUSIONS: Laparoscopic adrenalectomy is a safe procedure with a low complication rate and short hospital stay. Hypertension improves in the majority of patients with Cushing's syndrome and aldosteronoma and just under the majority of those with pheochromocytoma. In our study, abnormal radiologic appearance was a better predictor of neoplasia than size.

Role of intraoperative fluids on hospital length of stay in laparoscopic bariatric surgery: a retrospective study in 224 consecutive patients.

BACKGROUND: Studies are unclear regarding optimal intraoperative fluid management during laparoscopic bariatric surgery. The purpose of this 1-year study was to investigate the role of intraoperative fluid administration on hospital length of stay (hLOS) and postoperative complications in laparoscopic bariatric surgery. METHODS: Patient data analyzed included previously reported demographics, comorbidities, and intraoperative fluid administration on the duration of hLOS and incidence of postoperative complications. RESULTS: Logistic regression analysis of demographic and comorbidity variables revealed that BMI (P = 0.0099) and history of anemia (P = 0.0084) were significantly associated with hLOS (C index statistic, 0.7). Lower rates of intraoperative fluid administration were significantly associated with longer hLOS (P = 0.0005). Recursive partitioning observed that patients who received <1,750 ml of intraoperative fluids resulted in longer hLOS when compared to patients who received ≥ 1,750 ml (LogWorth = 0.5). When intraoperative fluid administration rates were defined by current hydration guidelines for major abdominal surgery, restricted rates (<5 ml/kg/h) were associated with the highest incidence of extended hLOS (>1 postoperative day) at 54.1 % when compared to 22.9 % with standard rates (5-7 ml/kg/h) and were lowest at 14.5 % in patients receiving liberal rates (>7 ml/kg/h) (P < 0.0001). Finally, lower rates of intraoperative fluid administration were significantly associated with delayed wound healing (P = 0.03). CONCLUSIONS: The amount of intravenous fluids administered during laparoscopic bariatric surgery plays a significant role on hLOS and on the incidence of delayed wound healing.

Pledgeted repair of giant hiatal hernia provides excellent long-term results.

BACKGROUND: Use of mesh in hiatal hernia repairs is a topic of debate. We present our experience in laparoscopic primary (nonmesh) repair of giant hiatal hernia. MATERIALS AND METHODS: All laparoscopic antireflux procedures done by a single surgeon from November 1997 to October 2006 were retrospectively reviewed. Inclusion criteria were primary crural closure with pledgets and giant hiatal hernia (greater than one-third of the stomach in the chest by esophagram, greater than 5 cm in length endoscopically, or greater than one-third of the stomach in the chest operatively). We attempted to reach all patients who met inclusion criteria and administered the Reflux Symptom Index (RSI) and Quality of Life Scale for Gastroesophageal Reflux Disease (QLSGR) questionnaires. RESULTS: In total, 89 patients met inclusion criteria. The male-to-female ratio was 32:57. Average age was 62.7 years. Average body mass index was 29.3 kg/m(2). Average length of stay was 2 days, and mean clinic follow-up was 161 days. At the most recent follow-up, 62% of patients were asymptomatic. The most common postoperative symptoms were dysphagia (16%), reflux/emesis (5%), bloating (5%), nausea (4%), epigastric pain (4%), and heartburn (3%). There were six (6.7%) recurrences on esophagogastroduodenoscopy or upper gastrointestinal examination. Five patients with recurrence were symptomatic. Of the 89 patients, 29 (33%) completed the questionnaire, with a mean follow-up of 69.7 months. Average RSI score was 12 (maximum possible score, 45). In six of nine categories, the average score was less than 1 (possible score, 0-5). Average QLSGR score was 12 (maximum possible score, 45). For satisfaction with the present condition, the average score was 4.34 (maximum score, 5), and 82.7% of respondents were satisfied or very satisfied with their present condition. CONCLUSIONS: Laparoscopic primary repair of giant hiatal hernia provides excellent long-term results. We found that 62% of patients were asymptomatic at the last follow-up and that 82% of respondents were satisfied or very satisfied. The recurrence rate was 6.7%.

Inhibition of notch signaling in combination with Paclitaxel reduces platinum-resistant ovarian tumor growth.

INTRODUCTION: Ovarian cancer (OvCa) is the most lethal gynecologic malignancy in the United States because of chemoresistant recurrent disease. Our objective was to investigate the efficacy of inhibiting the Notch pathway with a γ-secretase inhibitor (GSI) in an OvCa patient-derived xenograft model as a single agent therapy and in combination with standard chemotherapy. METHODS: Immunocompromised mice bearing xenografts derived from clinically platinum-sensitive human ovarian serous carcinomas were treated with vehicle, GSI (MRK-003) alone, paclitaxel and carboplatin (P/C) alone, or the combination of GSI and P/C. Mice bearing platinum-resistant xenografts were given GSI with or without paclitaxel. Gene transcript levels of the Notch pathway target Hes1 were analyzed using RT-PCR. Notch1 and Notch3 protein levels were evaluated. The Wilcoxon rank-sum test was used to assess significance between the different treatment groups. RESULTS: Expression of Notch1 and 3 was variable. GSI alone decreased tumor growth in two of three platinum-sensitive ovarian tumors (p < 0.05), as well as in one of three platinum-sensitive tumors (p = 0.04). The combination of GSI and paclitaxel was significantly more effective than GSI alone and paclitaxel alone in all platinum-resistant ovarian tumors (all p < 0.05). The addition of GSI did not alter the effect of P/C in platinum-sensitive tumors. Interestingly, although the response of each tumor to chronic GSI exposure did not correlate with its endogenous level of Notch expression, GSI did negatively affect Notch signaling in an acute setting. CONCLUSION: Inhibiting the Notch signaling cascade with a GSI reduces primary human xenograft growth in vivo. GSI synergized with conventional cytotoxic chemotherapy only in the platinum-resistant OvCa models with single agent paclitaxel. These findings suggest inhibition of the Notch pathway in concert with taxane therapy may hold promise for treatment of platinum-resistant OvCa.

Median arcuate ligament syndrome: a case report.

BACKGROUND: The median arcuate ligament passes superior to the origin of the celiac artery and is a continuation of the posterior diaphragm that wraps over the aorta. If it lies too low on the aorta, the ligament may cause symptoms of abdominal pain related to compression of the celiac artery. CASE REPORT: An abdominal ultrasound in a 22-year-old woman with longstanding abdominal pain after eating showed elevated celiac artery velocities of >300 cm/s upon inspiration. Computed tomography angiography of the abdomen showed stenosis of the origin of the celiac artery and confirmed the diagnosis of median arcuate ligament syndrome. Laparoscopic release of the median arcuate ligament resulted in relief of the patient's symptoms. CONCLUSION: The diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have a clearly established etiology.