Chueh Lien

Effect of vagotomy during Roux-en-Y gastric bypass surgery on weight loss outcomes

BACKGROUND During Roux-en-Y gastric bypasses (RYGB), some surgeons elect to perform a vagotomy to reduce symptoms of gastro-oesophageal reflux (GER). Routine vagotomy during RYGB may independently affect weight loss and metabolic outcomes following bariatric surgery. We aimed to determine whether vagotomy augments percent excess weight loss in obese patients after RYGB. METHODS We examined the effect of vagotomy in 1278 patients undergoing RYGB at our institution from 2003 to 2009. Weight and percent excess weight loss (%EWL) were modelled at three months and annually up to five years using a longitudinal linear mixed model controlling for differences in age, gender, initial body mass index (BMI), ideal body weight, and presence of vagotomy. RESULTS Vagotomy was performed on 40.3% of our cohort. Vagotomy patients had significantly lower initial BMI (46.4±6.2 vs. 48.3±7.7kg/m(2), p<0.001), but there were no other significant differences at baseline. The strongest predictor of %EWL over time was initial BMI, with lower BMI patients exhibiting greater %EWL (p<0.001). Age and gender effects were also significant, with younger patients (p<0.04) and males (p<0.002) attaining greater %EWL. Vagotomy had no effect on %EWL in either simple or multiple regression models. CONCLUSION Our series suggest that vagotomy does not augment %EWL when performed with RYGB.

Use of negative pressure wound therapy for abdominal wounds in neonates and infants

BACKGROUND Negative pressure wound therapy (NPWT) is an established and effective tool in the management of complicated abdominal wounds. This management approach has been used in infants, but few large series reports exist in the literature. METHODS The outcomes of infants with abdominal wounds receiving NPWT over the last 10 years at our institution were evaluated. Overall survival, time between initiation of NPWT, and discharge/death were examined. RESULTS We identified 18 infants who had abdominal wounds treated with NPWT. Diagnoses were varied, as was the duration of therapy. The median NPWT duration of treatment was 34.0 ± 92.1 days. Forty-four percent of the infants had a stoma before application of NPWT, and 22% of the infants had enterocutaneous fistulas before use of NPWT. There were only 2 cases in which a new fistula developed during the use of NPWT, and both of these omphalopagus conjoined twins had undergone the Bianchi procedure. No additional NPWT-related complications were identified. Of 18 infants, 6 died in this cohort. CONCLUSION Negative pressure wound therapy is an important therapeutic tool for the management of abdominal wounds in infants.

Postoperative Complications in Children With Crohn Disease Treated With Infliximab

Objectives: Infliximab (IFX) has become a mainstay of therapy for children with Crohn disease (CD). Despite medical advances, many children with CD, however, still require operative interventions. The risk of complications following resection in children treated with IFX remains largely unknown. We compare surgical outcomes stratified by IFX therapy in a cohort of children with CD who require bowel resection. Methods: We reviewed the postoperative complications in 123 children with CD who underwent bowel resection with primary anastomosis at our institution between 1977 and 2011. Demographics, medications, types of operations, and inpatient courses were analyzed. Complications and length of stay were compared based on medical therapy. Results: Overall, the postoperative complication rate was 13%. Of the 123 surgical cases, 24 children had received IFX before their operation. In the children treated with IFX, we identified 3 major complications, including anastomotic leak, acute renal failure, and intraabdominal abscess. There were 9 major complications in the non-IFX group, including infections (2), intraabdominal abscesses (2), bowel obstruction, shock, supraventricular tachycardia, phlegmon, and anastomotic stricture. No significant differences in complication rates or postoperative lengths of stay were identified between those who did or did not receive IFX. Conclusions: In this cohort, surgical procedures in children and young adults treated with IFX were not associated with an increased number of complications or prolonged length of stay. Given that postoperative complications are infrequent in children, larger multicenter studies may be required to determine whether IFX therapy increases the risk of surgical complications in pediatric CD.

A Modern Cohort of Duodenal Obstruction Patients: Predictors of Delayed Transition to Full Enteral Nutrition

Background. A common site for neonatal intestinal obstruction is the duodenum. Delayed establishment of enteral nutritional autonomy continues to challenge surgeons and, since early institution of nutritional support is critical in postoperative newborns, identification of patients likely to require alternative nutritional support may improve their outcomes. Therefore, we aimed to investigate risk factors leading to delayed establishment of full enteral nutrition in these patients. Methods. 87 patients who were surgically treated for intrinsic duodenal obstructions from 1998 to 2012 were reviewed. Variables were tested as potential risk factors. Median time to full enteral nutrition was estimated using the Kaplan-Meier method. Independent risk factors of delayed transition were identified using the multivariate Cox proportional hazards regression model. Results. Median time to transition to full enteral nutrition was 12 days (interquartile range: 9–17 days). Multivariate Cox analysis identified three significant risk factors for delayed enteral nutrition: gestational age (GA) ≤ 35 weeks (P < .001), congenital heart disease (CHD) (P = .02), and malrotation (P = .03). Conclusions. CHD and Prematurity are most commonly associated with delayed transition to full enteral nutrition. Thus, in these patients, supportive nutrition should strongly be considered pending enteral nutritional autonomy.

Early results of an objective feedback-directed system for the staged traction repair of long-gap esophageal atresia.

PURPOSE Treatment of long-gap esophageal atresia challenges pediatric surgeons. Dr. Foker described utilization of external traction sutures to promote in-vivo growth through tension-induced lengthening, but reproducibility of this technique is difficult. We describe a safe and reproducible traction system using transduction of hydrostatic pressure as a surrogate for tension. METHODS We conducted a multi-institutional review of patients treated with this system from 2005 to 2012. All children had sutures applied to both pouches with continuous measurement of associated hydrostatic pressures (tension). Main outcome measures were days to delayed primary repair and thoracotomies prior to primary repair. RESULTS Seven children were included. Median time to delayed repair was 15 days (range: 6-47 days). Three patients required repeat thoracotomies owing to mechanical entrapment of a pouch, all identified early by this system. All required postoperative dilations. Three had self-limited postdilation leaks, and there was one operation-related leak. CONCLUSIONS This system provides reproducible traction application, facilitating staged primary repair by preventing major failures through limiting excessive traction and guides re-exploration for trapped segments. Larger studies are needed to determine the optimal tension protocol, prevent postoperative leaks, while decreasing the need for dilations and time to enteral feeding.

A Single Institution's Overweight Pediatric Population and Their Associated Comorbid Conditions.

Background. Obesity studies are often performed on population data. We sought to examine the incidence of obesity and its associated comorbidities in a single freestanding childrens hospital. Methods. We performed a retrospective analysis of all visits to Boston Childrens Hospital from 2000 to 2012. This was conducted to determine the incidence of obesity, morbid obesity, and associated comorbidities. Each comorbidity was modeled independently. Incidence rate ratios were calculated, as well as odds ratios. Results. A retrospective review of 3,185,658 person-years in nonobese, 26,404 person-years in obese, and 25,819 person-years in the morbidly obese was conducted. Annual rates of all major comorbidities were increased in all patients, as well as in our obese and morbidly obese counterparts. Incidence rate ratios (IRR) and odds ratios (OR) were also significantly increased across all conditions for both our obese and morbidly obese patients. Conclusions. These data illustrate the substantial increases in obesity and associated comorbid conditions. Study limitations include (1) single institution data, (2) retrospective design, and (3) administrative undercoding. Future treatment options need to address these threats to longevity and quality of life.

A case report of the early results of laparoscopic bariatric surgery in six completely nonambulatory patients

A case report of the early results of laparoscopic bariatric surgery in six completely nonambulatory patients Sigrid Bairdain, M.D., M.P.H., Richard S. Flint, M.D., Chueh Lien, B.S., Mark Cleary, B.S., Bradley C. Linden, M.D., David B. Lautz, M.D., F.A.C.S.* Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts Department of Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts Department of Surgery, Emerson-Mass General Hospital, Harvard Medical School, Concord, Massachusetts Received March 7, 2013; accepted June 3, 2013

Laparoscopic adjustable gastric banding and hypoglycemia.

Obesity is commonplace, and surgical treatment usually includes Roux-en-Y gastric bypasses (RYGBs). RYGBs have the most documented side effects including vitamin deficiencies, rebound weight gain, and symptomatic hypoglycemia; fewer series exist describing hypoglycemia following other bariatric operations. We reviewed all patients undergoing laparoscopic adjustable gastric banding (LAGB) at our institution between 2008 and 2012. Three patients were identified to have symptomatic hypoglycemia following LAGB. Mean time from surgery was 33 months (range 14–45 months), and mean weight loss was 32.7 kg (range 15.9–43.1 kg). None of the patients had preexisting diabetes. Therefore, symptomatic hypoglycemia should be investigated irrespective of bariatric operation.