Jeff W. Allen

Use of complementary and alternative medicine in patients with liver disease.

OBJECTIVES:Complementary and alternative medicine (CAM) is used by 42% of the U.S. population. Its use among patients with chronic liver disease has not been well defined. Toward that end, we surveyed patients in six geographically diverse liver disease clinics in the United States for use of CAM.METHODS:Patients attending six liver disease clinics were polled via a common questionnaire regarding their use of CAM. Demographic information was obtained to identify predictors of CAM use. Statistical analysis included univariate and multivariate analysis using logistic regression.RESULTS:A total of 989 patients completed the questionnaire. Of these, 389 (39%) admitted to using some form of CAM at least once during the preceding month; 21% admitted to using herbal preparations, and 13% used herbs to treat their liver disease. Five variables were found to be predictive of alternative therapy use: female sex, young age, level of education, annual income, and geographic location. In all, 74% of patients reported using CAM in addition to the medications prescribed by their physician, but 26% did not inform their physician of their CAM use.CONCLUSIONS:CAM use is as common among patients visiting liver disease clinics in the United States as in the general population (39% vs 42%). Many patients are using herbs to treat their liver disease but are declining to discuss this use with their physician.

A step-by-step guide to placement of the LAP-BAND adjustable gastric banding system

The early promise of laparoscopic adjustable gastric banding was tempered by reports of high rates of gastric herniation or prolapse. These complications are a function of the operative technique used early on. At the time, in the early 1990s, the LAP-BAND device (INAMED Health, Santa Barbara, CA) was placed lower on the stomach, near the first short gastric vessel. The required perigastric dissection was difficult and variable in its extent, depending on the width of the stomach and where the surgeon began the dissection. To combat these problems, a new surgical method for placement of the band has evolved. Called the pars flaccida technique, it emphasizes minimal dissection and placement of the LAP-BAND out of the lesser sac. This leads to a higher position of the band, away from the body of the stomach. The technique serves to make band placement simple, safe, reproducible, and easily teachable, as well as to decrease the rate of gastric herniation or prolapse. Keeping the band out of the lesser sac, away from the peristalsing stomach, minimizing dissection of the attachments to the stomach, paying strict attention to gastric-to-gastric suturing, and leaving all fluid out of the band until at least 6 weeks after surgery appear to be the most important factors in reducing the incidence of this complication.

Favorable early results of gastric banding for morbid obesity: the American experience

Background: In 2001 a new device for surgical weight loss was approved by the Food and Drug Administration (Lap-Band, Inamed Health). We describe initial results of laparoscopic gastric banding for morbid obesity in two American academic centers. Methods: Prospective data was collected on consecutive morbidly obese patients undergoing laparoscopic adjustable gastric banding, and evaluated retrospectively. Results: Four hundred forty-five consecutive patients underwent Lap-Band from May 2001 through December 2002. The 103 men and 341 women had an average age of 42.1 years (range 17–72 years) and an average body mass index (BMI) of 49.6 kg/m2 (range 35.2–92.2 kg/m2). One operation required conversion to laparotomy due to bleeding; the rest were completed laparoscopically. Mean length of stay was 1.1 days (range 1–10 days). There was one death. Additional complications included band slippage in 14 patients (3.1%), gastric obstruction without slip in 12 (2.7%), port migration in 2 (0.4%), tubing disconnections in 3 (0.7%), and port infection in 5 (1.1%). Two bands (0.4%) were removed due to intraabdominal abscess 2 months after placement. There was one band erosion (0.2%) and no clinically significant esophageal dilation. Ninety-nine patients have 1-year follow-up and have lost an average of 44.3% excess body weight. Conclusion: Laparoscopic gastric banding has much to offer the morbidly obese. We present data showing weight loss rivaling gastric bypass and acceptably low complications. These results parallel success with this device outside America.

Lessons learned from laparoscopic gastric banding for morbid obesity

BACKGROUND Laparoscopic gastric banding is a minimally invasive bariatric operation that is increasing in popularity at many centers worldwide. Although this procedure is not yet approved in the United States, clinical trials are ongoing. METHODS We report our results of a 3-year follow-up on 60 patients who underwent the laparoscopic gastric band procedure for the treatment of morbid obesity. The procedure was performed at the Wesley Obesity Clinic in Brisbane, Australia. RESULTS At follow-up, 51 of the 60 patients (85%) still had the laparoscopic gastric band in place. All of the patients had a lower body weight after undergoing the procedure. The average weight loss was 39 kg (range 2 to 98 kg), representing a loss of 65% of average excess body weight. Twenty-five of 51 patients (49%) regained some weight after their initial loss, but the average amount was only 5 kg. The remaining 26 patients have remained at their lowest body weight recorded after the procedure or are continuing to lose weight. There was no operative mortality. Complications predominantly were caused by band slippage (21%), which has been nearly eliminated in recent practice (1 slip in the last 225 cases). Subsequent modifications in the technique to prevent band slippage included placing the band near the level of the esophagus, with minimal disruption of the posterior gastric attachments and diligent suturing of the band in place. CONCLUSIONS We conclude that the laparoscopic gastric band is effective in short- and long-term weight loss. The high rate of reoperation for repositioning has been avoided in current practice.

Laparoscopic management of Meckel's diverticulum in adults.

Background: Meckels diverticulum is an uncommon entity. A high index of suspicion is necessary for opportune diagnosis and prompt treatment. Technetium (TC) 99m pertechnetate scintigraphy is a sensitive and specific test for Meckels diverticulum. In adults, the scan contributes little to clinical decision making and often will not change the need for surgical intervention. We describe our experience with four patients. Methods: Between August 2000 and August 2001, four patients were seen with Meckels diverticula. Three were male and one was female. The mean age was 39 years (range, 18–64). Three patients presented with anemia and one with an acute abdomen. A 99mTc pertechnetate scan was performed at a cost of

Totally laparoscopic feeding jejunostomy.

900 in the three anemic patients after other endoscopic and radiographic tests were nondiagnostic. Only one patient had a positive scan. All four patients underwent exploratory laparoscopy and small bowel resection. In one patient, a minilaparatomy had to be performed. Results: All patients had a satisfactory outcome without complications. Three patients were discharged within 3 days of surgery. The remaining patient had a prolonged hospital stay because of ongoing chemotherapy for small cell lung cancer. In the three anemic patients who underwent enterectomy, ulcerated small bowel outside the diverticulum was found by the pathologist. Conclusion:Laparoscopy is safe, cost-effective, and efficient for the diagnosis and definitive management of Meckels diverticulum. Technetium 99m pertechnetate scintigraphy scanning adds considerable time and expense to the care of the patient without significant benefits in adults. The practice of exploratory laparoscopy rather than scintigraphy is recommended.

Squamous cell carcinoma of the esophagus: a review and update.

Background: A feeding jejunostomy should be used for nutritional support in a small subset of patients. Minimal-access approaches for the placement of jejunal tubes have been described, but they often require special equipment not common to all operating theaters. We describe a technique of totally laparoscopic jejunostomy tube (LJT) placement using equipment found in most operating theaters. Methods: Thirty-five patients underwent LJT over a 12-month period. Indications included gastroparesis, anorexia nervosa, oral cancer, cerebral palsy, and Huntingtons chorea. The technique involved three incisions for trocars (one for a 10-mm camera and two for 5-mm working ports) and one small incision for the tube. A 16-Fr T-tube was passed transabdominally under direct vision, and a jejunotomy was made ~20 cm distal to the ligament of Trietz. Each limb of the T-tube was passed into the lumen of the bowel, and a purse-string suture was placed around the enterotomy and tied intracorporeally. After insertion, the serosa surrounding the insertion site is tacked to the anterior abdominal wall in four places with a reusable stainless steel suture passer. To test whether the tube was watertight, we injected methylene blue solution into the tube. Results: All of the patients tolerated the procedure well. There were no operative deaths. Five LJTs were electively removed in the office. One patient was reoperated on 10 days postoperatively because of intractable pain, but the source of pain was not found and the LJT was intact. Conclusions: LJT may be placed safely using the described technique. No significant morbidity or mortality occurred in our series. The results of this study have prompted us to consider LJT for any patient requiring access to the jejunum for feeding.

Proximal Sensor Data from Routine Dual-Sensor Esophageal pH Monitoring Is Often Inaccurate

Squamous cell carcinoma (SCC) of the esophagus is an often-lethal disease that most commonly presents in an advanced stage with dysphagia in elderly patients. Known risk factors include alcohol and tobacco abuse, lye stricture, and achalasia. Screening protocols for high-risk patients are practiced in Japan but not in the United States. The diagnosis usually is made based on the results of esophagogastroduodenoscopy and contrast upper gastrointestinal radiographs. Staging is determined using computed tomography scanning and esophageal ultrasound, the latter rapidly being accepted as a superior method. Treatment is based on the stage of disease at presentation. Lesions without metastatic spread or mediastinal invasion generally should be treated with esophagectomy. Dysphagia associated with advanced lesions is difficult to treat, but may be palliated by surgery, radiation therapy, chemotherapy, laser ablation, peroral dilation, or esophageal stenting. Despite numerous medical advances, little headway has been made in managing and treating SCC, and a multidisciplinary approach is recommended.

Hypopharyngeal pH monitoring artifact in detection of laryngopharyngeal reflux

Dual-sensor esophageal pH monitoring is routinely used to diagnose GERD. However, the proximal sensor may not be in proximal esophagus in patients with shortened esophagi. Our objective was to determine how often the proximal sensor was misplaced and to determine the effect on pH monitoring. Superior margins of the upper and lower esophageal sphincters (UES and LES) were determined prospectively in consecutive patients. Dual sensors were placed 20 and 5 cm above the LES with a fixed 15-cm spacing pH catheter. Patients were classified into subgroups based on the actual location of the proximal sensor. In 661 patients, the proximal pH sensor was in the hypopharynx in 9% of patients, within the UES in 36%, and in the proximal esophagus in 55%. Spearmans correlation for acid exposure was very good between the dual sensors when the proximal sensor was in the proximal esophagus (R=0.76) but was poor when the proximal sensor was misplaced in the hypopharynx (R=0.28). The proximal sensor was misplaced in 45% of patients undergoing dual-sensor esophageal pH monitoring. It is important to locate the UES by manometry before interpreting the proximal esophageal pH data.

Techniques for Repair of Gastric Prolapse After Laparoscopic Gastric Banding

Hypopharyngeal pH artifacts have been a concern in the detection of laryngopharyngeal reflux. Our purpose was to analyze and quantify artifacts from dual-sensor hypopharyngeal pH monitoring. In all, 42 hypopharyngeal and 58 esophageal pH studies were reviewed. Type 1 (out of range), type 2 (pH drift), and type 3 (isolated pH drop) artifacts were identified. The proportion of proximal-sensor pH drop to <4 that was artifactual was determined. The median number (range) of artifacts was 1 (0–17) and 2 (0–28) for hypopharyngeal and esophageal pH studies, respectively (P = NS). The median proportion of artifactual pH drop to <4 was 1% (0–84%) and 2% (0–74%) for hypopharyngeal and esophageal pH studies, respectively (P = NS). The diagnosis did not change in any patient after excluding pH artifacts. In all, 19% of the combined 2432 hypopharyngeal pH drops of <4 were artifacts. In conclusion, hypopharyngeal pH artifacts per study were uncommon but can be prominent in a few patients. One can identify these artifacts and exclude them from analysis.