Henry L. Laws

Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach

SummaryThis report describes a laparoscopic procedure for prosthetic repair of inguinal hernias using an extraperitoneal approach. A total of 51 primary direct and indirect hernias were repaired in this series, including 11 recurrent and 12 bilateral hernias. Operative time for this laparoscopic procedure was similar to that of the comparable open surgery and no unusual complications were noted. All patients were discharged the day following surgery and returned to work within 7 days.

Ascorbic acid dynamics in the seriously ill and injured

BACKGROUND In addition to the known beneficial effects of ascorbic acid on wound healing and the immune response, it is also a potent extracellular antioxidant. Recent work in septic rats suggests that high-dose ascorbic acid total parenteral nutrition (TPN) supplementation may protect cells from free radical injury and improve survival. In this study, we determined ascorbic acid levels in the immediate post-injury/illness period and evaluated the ability of early short-term high levels of ascorbic acid in TPN to normalize plasma levels. MATERIALS AND METHODS Ascorbic acid levels were determined in 12 critically injured patients and 2 patients with severe surgical infections. Each patient received TPN supplemented with increasing doses of ascorbic acid over a 6-day period. Therapeutic responses were determined by plasma and urine measurements using high-pressure liquid chromatography. RESULTS The initial mean +/- SEM baseline plasma ascorbic acid concentration was depressed (0.11 +/- 0.03 mg/dl) and unresponsive following 2 days on 300 mg/day supplementation (0.14 +/- 0.03; P = 1.0) and only approached low normal plasma levels following 2 days on 1000 mg/day (0.32 +/- 0.08; P = 0.36). A significant increase was noted following 2 days on 3000 mg/day (1.2 +/- 0.03; P = 0.005). CONCLUSION We confirmed extremely low plasma levels of ascorbic acid following trauma and infection. Maximal early repletion of this vitamin requires rapid pool filling early in the post-injury period using supraphysiologic doses for 3 or more days.

Gastrointestinal Symptoms are More Intense in Morbidly Obese Patients and are Improved with Laparoscopic Roux-en-Y Gastric Bypass

Background: Currently there are few reports comparing gastrointestinal (GI) symptoms in the morbidly obese versus control subjects or the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on such symptoms. Methods: A previously validated, 19-point GI symptom questionnaire was administered prospectively to each patient undergoing LRYGBP, and the questionnaire was re-administered 6 months postoperatively. Six symptom clusters (abdominal pain, irritable bowel [IBS], reflux, gastroesophageal reflux disease [GERD], sleep disturbances, and dysphagia) were compared in the following manner using Students t-test: 1) Control vs. Preop, 2) Control vs Postop, and 3) Preop vs Postop. Results are expressed as mean ± standard deviation, significance P=0.05. Results: 43 patients (40 female and 3 male, age 37.3 ± 8.6, BMI 47.8 ± 4.9) completed the questionnaire preoperatively, and 36 patients (34 female, 2 male, BMI 31.6 ± 5.3) completed the questionnaire 6 months postoperatively, for a response-rate of 84%. Abdominal pain, IBS, reflux, GERD and sleep disturbance symptoms were significantly worse in preop versus controls. Dysphagia was not different. Postop vs preop scores revealed abdominal pain, IBS, GERD, reflux, and sleep disturbance symptoms to be improved significantly. Dysphagia was not significantly different. Only dysphagia was worse when comparing postoperative to controls. No other symptom cluster was significantly different in controls vs postoperative. Conclusions: Morbidly obese patients experience more intense GI symptoms than control subjects, and many of these symptoms return to control levels 6 months after LRYGBP. Dysphagia is equivalent to control subjects preoperatively but increases significantly after LRYGBP. This data suggests another quality-of-life improvement (relief of GI symptoms) for morbidly obese patients. Further follow-up is needed to document the long-term reduction of GI symptoms.

Gastrointestinal symptomatic outcome after laparoscopic Roux-en-Y gastric bypass

Laparoscopic Roux-en-Y (RY) gastric bypass is an effective treatment for morbid obesity. However, little information is available regarding the gastrointestinal symptomatic outcome after laparoscopic RY gastric bypass for morbid obesity. The purpose of this study is to identify changes occurring in gastrointestinal symptoms after laparoscopic RY gastric bypass. A previously validated, 19-point gastrointestinal symptom questionnaire was administered prospectively to each patient seen for surgical consultation to treat morbid obesity. Patients rated the degree to which each symptom affected their lives on a 0 to 100 mm Liekert scale with 0 indicating absence of a symptom, 3 3 indicating the symptom was present occasionally, 67 indicating the symptom occurred frequently, and 100 indicating the symptom was continuous. The same survey was readministered 6 months postoperatively. The mean of each symptom (preoperative vs. postoperative value) was compared using Student’s t test with significance at P<0.05. Forty-three preoperative patients (age 37.3±8.6 years; body mass index 47.8 ± 4.9) and thirty-five, 6 months’ postoperative patients (81% follow-up; body mass index 31.6±5.3) completed the questionnaire. The result for each symptom is expressed as mean ± standard deviation of preoperative vs. postoperative scores. Significantly different symptoms include the following: abdominal pain 23.3±26.4 vs. 8.6 ± 13.5, P = 0.003; heartburn 34.0 ± 26.6 vs. 8.0 ± 14.0, P = 0.0001; acid regurgitation 28.1 ± 24.0 vs. 10.7±21.0, P=0.001; gnawing in epigastrium 19.3 ± 22.7 vs. 7.5 ± 16.0, P = 0.01; abdominal distention 38.2 ± 31.5 vs. 11.1 ± 19.2, P = 0.0001; eructation 27.7 ± 24.4 vs. 15.5 ± 16.9, P = 0.01; increased flatus 40.2 ± 25.7 vs. 25.2 ± 25.3, P = 0.005; decreased stools 5.4 ± 16.8 vs. 17.4 ± 20.0, P = 0.0005; increased stools 23.9 ± 26.7 vs. 6.5 ± 11.7, P = 0.0005; loose stools 29.7 ± 26.5 vs. 17.5 ± 20.0, P = 0.03; urgent defecation 34.3 ± 26.5 vs. 14.3 ± 19.3, P = 0.0009; difficulty falling asleep 44.1 ± 38.4 vs. 27.5 ± 32.9, P = 0.05; insomnia 42.4 ± 36.2 vs. 21.6 ± 30.5, P = 0.008; and rested on awakening 65.1 ± 33.8 vs. 30.5 ± 28.8, P = 0.0001. Symptoms that did not significantly change included the following: nausea/vomiting 17.2 ± 22.7 vs. 22.1 ± 19.9, P = 0.33; borborygmus 28.8 ± 25.2 vs. 26.8 ± 29.7, P = 0.75; hard stools 10.3 ± 22.9 vs. 7.1 ± 18.6, P = 0.56; incomplete evacuation of stool 17.2 ± 22.8 vs. 13.4 ± 21.7, P = 0.45; and dysphagia 10.9 ± 15.6 vs. 17.7 ± 28.4, P = 0.18. Laparoscopic RY gastric bypass significantly improves many gastrointestinal symptoms experienced by morbidly obese patients without adversely affecting any of the measured parameters. This information is useful in preoperative counseling to assure patients of overall symptomatic improvement after this operation in addition to significant weight loss and improvement of comorbid conditions.

Is the quality of surgical residency applicants deteriorating

BACKGROUND Among directors of general surgery residencies, there is a concern that the quality of medical students applying to surgical residencies is declining. METHODS Quality of surgical applicants was assessed by several methods including subjective opinions determined by survey and by objective data including student United States Medical Licensing Examination (USMLE) scores of matched candidates. The number of applicants interviewed, total interviews granted, proportion of Alpha Omega Alpha (AOA) students, and the rank order of the candidates matched was obtained by survey. The survey included data on postgraduate year 1 (PGY-1) residents from July 1996 to July 1999. Three mailings were made to 226 US surgical residency programs. RESULTS Data were obtained from 90 programs. Surgery program directors disagreed with a survey statement that overall quality of applicants had declined (P <0.01), but agreed with a statement that activities of medical schools to enroll graduating students into primary care had hurt recruitment (P <0.001). Objective data revealed no change in mean USMLE part I scores of PGY-1 residents over the 4 years (P = 0.265, power = 0.81). There was no change in proportion of matched residents who were AOA over time. The mean score of all new PGY-1 residents, the rank of the first matched resident, the rank of the last ranked resident, and proportion of AOA students was higher in programs with five or more categorical spots when compared with programs of at most four (P <0.001). Across all programs, there was a trend to go lower on the rank list to fill categorical positions over time (P <0.001). CONCLUSIONS There is a perception that medical school policies act to discourage recruitment of quality medical students into general surgery programs, and surgery programs are going deeper into their rank lists to fill categorical positions. However, the average USMLE part I score of applicants to surgical residencies and proportion of AOA applicants has not decreased.

Glutamine Supplementation of Enteral Nutrition: Impact on Whole Body Protein Kinetics and Glucose Metabolism in Critically Ill Patients

BACKGROUND Glutamine-supplemented parenteral nutrition has been reported to attenuate the early postoperative reduction in intracellular glutamine and improve protein synthesis and nitrogen balance. We investigated the effect of an enteral formula or protein and glucose kinetics and nitrogen balance in trauma patients. METHODS The enteral formula (AlitraQ) provided a mean intake of 0.35 g of glutamine/kg body weight per day to 16 trauma patients and was compared with an isonitrogenous formula that provided a mean of 0.05 g of glutamine/kg body weight per day in 14 trauma patients. After 3 days of feeding, protein kinetics were measured using a 4-hour prime-continuous infusion of L-[1-13C]leucine. Glucose kinetics were measured during the same time interval using prime-continuous infusion of [U-14C]- and [6-3H]glucose. RESULTS Nitrogen balance was not significantly different in the two groups. There were no significant differences in protein turnover, synthesis, and breakdown between the two groups. There were no significant differences in glucose turnover, oxidation, recycling, and percent of VCO2 from glucose oxidation between the two groups. CONCLUSIONS Glutamine-enriched enteral formulas are well tolerated by the severely injured patient but provide no additional nutritional advantage compared with standard enteral formulas during the first 3 days of feeding immediately after trauma.

Impact of enteral feeding of a glutamine-supplemented formula on the hypoaminoacidemic response in trauma patients

Plasma amino acid concentrations were measured during fasting and after 3 days of enteral feeding in 16 trauma patients on a glutamine-supplemented diet and 14 patients on an isonitrogenous control diet. During fasting, total amino acids, including glutamine, were depressed by 50% and this was attributed to a reduction in both essential and nonessential amino acids. The essential amino acid concentrations increased in both groups after feeding. The nonessential amino acid concentrations also increased in the control group but not in the glutamine group during feeding. Repletion of the glutamine extracellular pool was not evident after an average intake of 27.1 g per day of glutamine for 3 days. Nitrogen balance was similar for the two groups during feeding. We conclude that in this study, enteral glutamine did not increase the glutamine plasma concentration. In addition, both formulas improved the hypoaminoacidemia of essential amino acids but only the control diet improved the nonessential amino acids plasma concentration.

Gastrointestinal symptoms are more intense in morbidly obese patients.

Background: Laparoscopic Roux-en-Y gastric bypass is an effective treatment for morbid obesity. However, little information is available on gastrointestinal (GI) symptomatology in this population. This study compares GI symptoms in morbidly obese patients to that of control subjects. Methods: A previously validated, 19-point GI symptom questionnaire was administered prospectively to each patient seen for surgical consultation for morbid obesity. The symptoms were then grouped into 6 clusters as follows: (1) abdominal pain, (2) irritable bowel, (3) GERD, (4) reflux, (5) sleep disturbance, (6) dysphagia. The result of each cluster of symptoms expressed as mean ± standard deviation of obese versus control is compared using student’s t-test with significance p = 0.05. Results: Forty-three patients (40 female, 3 male) age 37.3 ± 8.6 with BMI 47.8 ± 4.9, and 36 healthy control subjects (23 female, 13 male), age 39.8 ± 11.2, completed the questionnaire. Results of each cluster for morbid obese vs control subjects are expressed as mean ± standard deviation: Abdominal pain 25.3 ± 18.0 vs 12.1 ± 11.4, p = 0.0002; irritable bowel 23.0 ± 14.8 vs 15.6 ± 13.3, p = 0.02; GERD 40.3 ± 18.9 vs 22.3 ± 16.1, p = 0.0001; reflux 29.9 ± 19.0 vs 11.8 ± 13.4, p = 0.0001; sleep disturbance 50.6 ± 28.9 vs 32.9 ± 26.8, p = 0.006; dysphagia 10.9 ± 15.6 vs 7.2 ± 10.6, p = NS. Conclusions: Morbidly obese patients experience more intense GI symptoms than normal subjects, whereas dysphagia is equivalent to normal subjects. These data may be important in counseling patients and understanding that their complaints are legitimate. Follow-up in the postoperative period is needed to determine if these symptoms are improved with an operation.

Successful management of heart rupture from blunt trauma

Seven patients with cardiac rupture from blunt trauma were encountered at the University Hospital, University of Alabama School of Medicine, in a 15-year period. Five of seven patients survived, including three with left atrial injuries and one each with right ventricular and left ventricular injuries. Useful diagnostic features included systolic hypotension, distended neck veins, and elevated central venous pressures. Associated injuries averaged four per patient. Successful management demands a high index of suspicion of cardiac injury, prompt diagnosis, and immediate median sternotomy. After repair of the heart the incision should usually be extended to allow exploratory laparotomy.

Regulation of Glucose Kinetics in Trauma Patients by Insulin and Glucagon

The current study was undertaken to evaluate the contribution of insulin and glucagon to regulation of glucose metabolism in man following severe, traumatic injury by manipulating concentrations of insulin and glucagon with infusions of somatostatin. Glucose kinetics were assessed with [U-14C, 6-(3)H]glucose in severely injured patients and compared with data obtained from patients recovering from minor, elective operative procedures. Glucose production was significantly increased in subjects with traumatic injury compared with control subjects (13.0 +/- 0.63 mumol/kg/min v 8.6 +/- 0.27 mumol/kg/min). There was no impairment in glucose oxidation by the injured patients. Modulation of insulin and glucagon with somatostatin indicated that non-insulin-mediated glucose uptake (NIMGU) was significantly elevated in injured patients (12.2 +/- 0.94 mumol/kg/min v 7.4 +/- 0.61 mumol/kg/min). Hepatic glucose output (HGO) in the absence of glucagon was also significantly elevated in injured patients (12.2 +/- 1.20 mumol/kg/min v 5.8 +/- 1.08 mumol/kg/min). Indirect calorimetry showed a 27% increase in resting energy expenditure (REE). Increased protein oxidation accounted for 56% of the increase in REE. Changes in carbohydrate and lipid oxidation accounted for 28% and 15% of the increase in REE. There was no correlation between the injury severity score of the injured patient and the degree of metabolic abnormality. It is concluded from these studies that (1) injured patients have a high rate of glucose turnover in the absence of glucagon and insulin; (2) the reliance on glucose as a source of energy is not diminished in injured subjects; and (3) increases in protein oxidation account for the majority of the increased REE found in injured patients.