Go Miyano

Reversal of Type 2 Diabetes Mellitus and Improvements in Cardiovascular Risk Factors After Surgical Weight Loss in Adolescents

OBJECTIVES. Type 2 diabetes mellitus is associated with obesity, dyslipidemia, and hypertension, all well-known risk factors for cardiovascular disease. Surgical weight loss has resulted in a marked reduction of these risk factors in adults. We hypothesized that gastric bypass would improve parameters of metabolic dysfunction and cardiovascular risk in adolescents with type 2 diabetes mellitus. PATIENTS AND METHODS. Eleven adolescents who underwent Roux-en-Y gastric bypass at 5 centers were included. Anthropometric, hemodynamic, and biochemical measures and surgical complications were analyzed. Similar measures from 67 adolescents with type 2 diabetes mellitus who were treated medically for 1 year were also analyzed. RESULTS. Adolescents who underwent Roux-en-Y gastric bypass were extremely obese (mean BMI of 50 ± 5.9 kg/m2) with numerous cardiovascular risk factors. After surgery there was evidence of remission of type 2 diabetes mellitus in all but 1 patient. Significant improvements in BMI (−34%), fasting blood glucose (−41%), fasting insulin concentrations (−81%), hemoglobin A1c levels (7.3%–5.6%), and insulin sensitivity were also seen. There were significant improvements in serum lipid levels and blood pressure. In comparison, adolescents with type 2 diabetes mellitus who were followed during 1 year of medical treatment demonstrated stable body weight (baseline BMI: 35 ± 7.3 kg/m2; 1-year BMI: 34.9 ± 7.2 kg/m2) and no significant change in blood pressure or in diabetic medication use. Medically managed patients had significantly improved hemoglobin A1c levels over 1 year (baseline: 7.85% ± 2.3%; 1 year: 7.1% ± 2%). CONCLUSIONS. Extremely obese diabetic adolescents experience significant weight loss and remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass. Improvements in insulin resistance, β-cell function, and cardiovascular risk factors support Roux-en-Y gastric bypass as an intervention that improves the health of these adolescents. Although the long-term efficacy of Roux-en-Y gastric bypass is not known, these findings suggest that Roux-en-Y gastric bypass is an effective option for the treatment of extremely obese adolescents with type 2 diabetes mellitus.

Current Patterns of Practice and Technique in the Repair of Esophageal Atresia and Tracheoesophageal Fistua: An IPEG Survey

BACKGROUND Optimal surgical treatment of infants with esophageal atresia (EA) and tracheoesophageal fistula (TEF) remains controversial. In order to better understand variability in management, we surveyed the International Pediatric Endosurgery Group (IPEG) membership. MATERIALS AND METHODS An online-based survey, conducted in 2012, was sent to all IPEG members. RESULTS The survey was completed by 170 surgeons from 31 countries. A majority of respondents practiced in academic/university settings (86%) and performed one to three EA/TEF repairs annually (67%). Those practicing for over 15 years made up 39% of the study group, followed by those practicing 6-10 years (24%), 0-5 years (22%), and 11-15 years (15%). Utilization of a thoracoscopic approach was reported by half of the respondents with a frequency of 1-3 cases (76%), 4-6 cases (17%), and greater than 7 cases (7%) per year. Low birth weight, congenital heart disease, long gap length, and compromised physiologic status were identified as the most common exclusion criteria for thoracoscopic repair. The thoracoscopic repair was almost uniformly performed via an intrapleural approach (96%), in contrast with the open repair that was done extrapleurally in 89%. Preoperative bronchoscopy was routinely performed by 60%. Size 4-0 to 5-0 absorbable suture predominated for EA repair. Postoperative chest tube/drain and transanastomotic tube placement were used by 83%. A normal esophagram was required by 85% to initiate oral feeding. Sixty-six percent initiated transanastomotic feeds prior to obtaining an esophagram. Postoperative antibiotic use was common (76%) and varied from less than 1 to greater than 14 days. Acid suppression medication was used by 76% with duration ranging from 7 days to lifelong. For long gap EA, spiral myotomies were rarely performed (10%), and gastric transposition was the favored method for esophageal replacement (66%). CONCLUSIONS Considerable variability existed among the IPEG membership in treatment of patients with EA/TEF. The identification of variance is the first step in creating future studies to identify best practices.

Tubularized incised plate urethroplasty with dorsal inlay graft prevents meatal/neourethral stenosis: a single surgeon's experience

BACKGROUND/PURPOSE Snodgrass tubularized incised plate urethroplasty (SUP) is versatile and has good cosmesis. However, postoperative meatal/neourethral stenosis (M/N-S) is common enough for some surgeons to add a dorsal inlay graft (DIG) harvested from the inner prepuce and sutured to cover the longitudinal midline incision of the urethral plate. This is the first formal assessment of the effectiveness of DIG for preventing M/N-S. METHODS We reviewed the medical records of 100 consecutive SUP cases performed by a single surgeon between 2003 and 2010 comparing SUP + DIG (S + D group, n = 50) with SUP - DIG (S - D group, n = 50). Mean follow-up was 3.6 years. Data were analyzed statistically using the χ(2), 2-way ANOVA, and Mann-Whitney tests, with P < .05 considered significant. RESULTS Severity of hypospadias and type of SUP were similar. Mean age at SUP was 3.3 years in S + D and 3.6 years in S-D (P = NS). There were 4 complications in the S + D group: urethrocutaneous fistula (n = 3) and neourethral stenosis without diverticulum (n = 1). There were 15 complications in the S-D group : meatal stenosis (n = 2), neourethral stenosis with or without diverticulum (n = 6), urethrocutaneous fistula (n = 7) (P < .01). M/N-S was significantly less in the S + D group (1 vs 8; P < .05). CONCLUSIONS We strongly recommend that DIG be performed routinely during SUP.

Intraoperative measurement of rectourethral fistula: prevention of incomplete excision in male patients with high-/intermediate-type imperforate anus

INTRODUCTION We report a novel technique to measure the length of the rectourethral fistula (RUF) in male patients with high-/intermediate-type imperforate anus during laparoscopically assisted anorectal pull-through (LAARP) to prevent incomplete excision. METHOD During LAARP for RUF in 5 male patients (mean age, 4.6 months; prostatic in 3, bulbar in 2), the RUF was dissected carefully close to the urethra and opened; and a fine catheter with 10-mm calibrations was inserted by the laparoscopic surgeon until it was seen to emerge at or near the verumontanum by another surgeon performing cystoscopy. The laparoscopic surgeon then measured the distance from the point where dissection was ceased at the rectal end to the urethral orifice. The RUF was dissected free from the prostate for exactly this length, tied, and excised; and colon pull-through was performed to finish LAARP. RESULT Rectourethral fistulae ranged from 5 to 15 mm and were much longer than expected. All dissections were uncomplicated without any injury to the urethra, and postoperative courses were unremarkable. At mean follow-up of 11 months, urination is normal in all without evidence of residual fistula. CONCLUSION Knowing the exact length of the RUF facilitates safe and complete excision in an otherwise blind situation.

Perioperative outcome of Laparoscopic Roux-en-Y gastric bypass: A children's hospital experience

BACKGROUND/PURPOSE To evaluate the perioperative safety of laparoscopic Roux-en-Y gastric bypass (LRYGB) in a freestanding childrens hospital setting. PATIENTS AND METHODS Perioperative (<90 days) clinical complications of 77 consecutive patients (mean age 16.8 ± 2.1 years: mean BMI 59.4 kg/m(2), 68% female), who underwent LRYGB at Cincinnati Childrens Hospital from 2002 to 2007 were examined, using standardized data collection forms that were created specifically for use in this study. RESULTS No mortality or conversion to open surgery was observed. Intraoperative complications were uncommon (3%). No anesthetic complications or transfusion requirements were observed. Median hospital stay was 3 days. Twenty-two percent of subjects had a complication from discharge to 30 days, while 13% experienced a complication between 31 and 90 days. The common types of postoperative complications included gastrojejunal anastomotic stricture (17%), leak (7%), dehydration (7%), and small bowel obstruction (SBO; 5%). Reoperation was required in 9 subjects. Operating time significantly decreased as the number of cases performed increased. CONCLUSIONS LRYGB in this case series of adolescents was associated with a low rate of intraoperative complications, with an increased rate over the ensuing 90 days. These events can be successfully managed, even in super obese adolescents.

Comparison of anorectal angle and continence after Georgeson and Peña procedures for high/intermediate imperforate anus

AIM The anorectal angle (AA) influences defecation after pull-through (PT) for imperforate anus (IA). We compared postoperative AA and continence after Georgesons laparoscopy-assisted colon PT (GPT) and Peñas posterior sagittal anorectoplasty (PSARP) for high/intermediate-type IA. METHODS We reviewed 33 high/intermediate-type IA cases (20 GPTs and 13 PSARPs) prospectively. All had colostomy initially as neonates. Anorectal angle was measured as the angle between the rectum and the anal canal on barium enema. A fecal continence evaluation questionnaire (FCEQ) consisting of 5 parameters (frequency of defecation, staining/soiling, perianal erosion, anal shape, and requirement for medication; maximum score = 10) was evaluated in 28 cases (15 GPTs and 13 PSARPs) followed up for more than 3 years. RESULTS Mean age at PT was similar (6.6 months for GPT and 6.3 months for PSARP; P = not significant). There was no significant difference in mean AA. The FCEQ scores for GPT were generally higher throughout the study and significantly better from 3 years postoperatively (P < .05). CONCLUSIONS We are the first to confirm that effective AA similar to PSARP can be achieved after GPT, although FCEQ would suggest that GPT has less detrimental functional impact.

Laparoscopic splenopexy and gastropexy for wandering spleen associated with gastric volvulus.

Wandering spleen is not a common condition in childhood and has been described only rarely in association with gastric volvulus. The authors report the successful management of wandering spleen associated with gastric volvulus using laparoscopic splenopexy and gastropexy in a 4-year-old girl.

Open Versus Laparoscopic Treatment for Pan-Peritonitis Secondary to Perforated Appendicitis in Children: A Prospective Analysis

PURPOSE Reports on laparoscopic treatment (LT) of peritonitis secondary to perforated appendicitis (PA) in children often include localized peritonitis/appendiceal mass, without specifically referring to pan-peritonitis (PP). This study compared LT with open treatment (OT) in only those patients with PP secondary to PA. METHODS PP was defined as generalized abdominal rigidity on presentation with purulent material intraoperatively found throughout the entire abdominal cavity. Based on this definition, we identified 23 cases of PP secondary to PA from all our cases of appendicitis from 2004 to 2008 and prospectively collected data. RESULTS Surgical intervention was LT in 12 cases and OT in 11 cases. Appendectomy was successful in all cases without intraoperative complications. Mean age at surgery, sex ratio, preoperative mean white blood cell count, and C-reactive protein were similar. Mean operative time was 119 minutes for LT and 107 minutes for OT (P = NS). Mean volume of saline used for peritoneal lavage was 2730 mL for LT and 2950 mL for OT (P = NS). Duration of analgesic usage was significantly shorter in LT (P = 0.01). Postoperative wound infections were significantly less in LT (P = 0.04: LT 0, OT 4/11). Adhesive bowel obstruction occurred in one LT case and three OT cases (P = NS); none required surgery. There were two cases of intraabdominal abscess in each group, all were conservatively treated. Time taken to become afebrile, for white blood cell count and C-reactive protein to normalize, for intravenous antibiotics to be ceased, and for oral feeding to be commenced were not significantly different. Mean hospitalization was significantly shorter for LT (P = 0.04). CONCLUSIONS LT would appear to be superior for the treatment of PP secondary to appendicitis in children and would even seriously consider it as the procedure of choice.

A Prospective Analysis of Endoloops and Endostaples for Closing the Stump of the Appendix in Children

AIM The aim of this study was to compare endoloops and endostaples for closing the stump of the appendix during laparoscopic appendectomy (LA) for uncomplicated appendicitis in children. METHODS All LA performed for appendicitis from 2005 to 2009 were analyzed prospectively. Cases of complicated appendicitis such as perforated appendicitis or intra-abdominal abscess were excluded, leaving 75 cases closed with loops and 81 cases closed with staples. Choice of technique was determined by the attending surgeons preference. All patients were managed according to the same pre-, intra-, and postoperative protocols. RESULTS There were no significant differences between mean age at surgery, gender ratio, preoperative mean white blood cell count and mean C-reactive protein, histopathologic findings, mean duration of surgery, and mean hospitalization. There were no intra-operative complications in either group, but one loop case required conversion to open surgery (P = NS). There were no significant differences in the incidences of intra-abdominal abscess, transient ileus, small bowel obstruction, and wound infection. The postoperative readmission rate for management of complications was 4.0% for loop cases and 2.5% for staple cases (P = NS). Overall, using staples for a standard LA (anesthesia and stump closure) was U.S.

A Framework for Interactive Visualization of Digital Medical Images

405 more expensive than when loops were used. CONCLUSION This is the first prospective study comparing endoloops with endostaples for closing the stump of the appendix during LA for uncomplicated appendicitis in children. Although stapling proved to be more expensive, the choice of technique should reflect the surgeons experience and confidence to ensure that the patient has the safest possible LA.