Joel E. Goldberg

Non-Alcoholic Steatohepatitis: Effect of Roux-en-Y Gastric Bypass Surgery

OBJECTIVE:Non-alcoholic steatohepatitis (NASH) is an increasingly prevalent problem. Treatment options are still under investigation. The primary aim of the study was to determine whether weight loss, achieved through Roux-en-Y gastric bypass (RYGBP), improved histopathology in obese patients with biopsy proven NASH.METHODS:One hundred and forty-nine patients were identified from a surgical database as having RYGBP for obesity and concomitant intra-operative liver biopsies from October 2001 to September 2003. Thirty-five patients were found to have evidence of NASH at the time of surgery. Nineteen patients were contacted and underwent repeat percutaneous liver biopsies. Biopsies were evaluated and compared in blinded fashion by an experienced hepatopathologist. Fasting lipid panel, insulin and glucose, hemoglobin A1c (HgbA1c), and liver enzymes were obtained.RESULTS:Significant differences were noted in the following variables pre- and post-bypass surgery: body mass index 46.8–28.8 kg/m2 (p < 0.001); body weight in kilograms 132.1–79.7 (p < 0.001); glucose 102.9–94.1 mg/dL (p= 0.015); Hgb A1c 5.79–5.15% (p= 0.026); high density lipoprotein 45.7–64.4 mg/dL (p < 0.001); low density lipoprotein 112–88.6 mg/dL (p= 0.003); triglycerides 132.1–97 mg/dL (p= 0.013). Significant improvements in steatosis, lobular inflammation, portal, and lobular fibrosis were noted. Histopathologic criteria for NASH were no longer found in 17/19 patients (89%).CONCLUSIONS:Weight loss after gastric bypass surgery in obese patients with NASH results in significant improvement in glucose, HgbA1c. and lipid profiles. Furthermore, RYGBP results in significant improvement in the histological features of NASH with resolution of disease in a majority of these patients.

Rectal Carcinoid Tumors: Review of Results After Endoscopic and Surgical Therapy

OBJECTIVE To assess whether endoscopic treatment can clear local disease in patients with carcinoid tumor. DESIGN Retrospective cohort study. SETTING Tertiary care academic medical center. PATIENTS All patients diagnosed as having a neuroendocrine tumor or carcinoid tumor of the rectum who were evaluated at our institution between January 1, 1990, and December 31, 2006. MAIN OUTCOME MEASURE Margin status of tumor resection. RESULTS Eighty-five patients were identified (median age at diagnosis, 55 years). Thirty-three tumors (39%) were asymptomatic and diagnosed during screening colonoscopy. Eleven tumors (13%) were metastatic at presentation. Of the 85 tumors, 48 (56%) were smaller than 1.0 cm. Endoscopic therapy was performed in 46 patients (54%). Of these, 38 patients (83%) had tumors with positive or indeterminate margins on histologic examination; of whom 6 (16%) had residual tumor on subsequent endoscopy and 1 (3%) had recurrence as metastatic disease. One patient who had a negative margin had residual tumor on follow-up. Thirty-one patients (36%) underwent surgical resection; of these, 23 (74%) underwent transanal excision or transanal endoscopic microsurgery, 6 (19%) underwent low anterior resection, and 2 (6%) underwent abdominoperineal resection. Eight patients who did not receive local clearance of tumor had metastases on presentation, had another active malignant neoplasm, or refused further surgical treatment. Among the 85 patients, 4 metastases occurred during follow-up, including 2 from tumors smaller than 1.0 cm at presentation. CONCLUSIONS Endoscopic treatment is sufficient for tumors that are small, for tumors limited to the mucosa, and when a margin is negative for tumor. Transanal excision should be considered when margins of endoscopic resection are positive. We recommend rectal resection for tumors that are 1.0 to 1.9 cm and have high-risk features.

Rectal Foreign Bodies

Rectal foreign bodies present a difficult diagnostic and management dilemma because of delayed presentation, a variety of objects, and a wide spectrum of injuries. An orderly approach to the diagnosis, management, and post-extraction evaluation of the patient with a rectal foreign body is essential. This article outlines and describes the stepwise evaluation and management of the patient with a rectal foreign body. The authors also describe the varied techniques needed to successfully remove the different foreign bodies that may be encountered.

Low-Dose 18F-FDG PET/CT Enterography: Improving on CT Enterography Assessment of Patients with Crohn Disease

The purpose of this study was to evaluate the diagnostic efficacy of low-dose, combined 18F-FDG PET/CT enterography (PET/CTE), compared with CT enterography (CTE) alone, in the assessment of patients with Crohn disease. Methods: Thirteen patients with Crohn disease were prospectively enrolled in this pilot study and underwent abdominal–pelvic 18F-FDG PET/CTE using neutral oral and intravenous contrast medium. The effective dose from PET/CTE was 17.7 mSv for the first 4 patients and 8.31 mSv for the last 9 patients. Six patients underwent surgical resection of the bowel, and 7 patients underwent colonoscopy with biopsies within 27 d (mean, 12 d) of PET/CTE. PET/CTE and CTE images were each visually assessed for Crohn disease involvement in 54 bowel segments with pathology correlation. Extraintestinal findings were recorded. A CTE severity score, maximum standardized uptake value (SUVmax), SUVmax ratio, simplified endoscopic score, and clinical parameters were correlated with pathology inflammation grade, on a per-patient basis and on a per-bowel-segment basis, using Spearman correlation. Results: In 3 (23.1%) of 13 patients, 18F-FDG uptake using PET/CTE revealed active inflammation in a bowel segment not evident using CTE (n = 2) or revealed an enterocolic fistula missed with CTE (n = 1). Visual interpretation of both PET/CTE and CTE images detected the presence of disease in all bowel segments with more than mild inflammation (sensitivity, 100%; specificity, 89.7%; positive predictive value, 78.9%; and negative predictive value, 100%). Correlation to inflammation grade per patient was the strongest for the SUVmax ratio (0.735, P = 0.004) and SUVmax (0.67, P = 0.013), as compared with the CTE score (0.62, P = 0.024). Correlation with inflammation per bowel segment was higher for the CTE score (0.79, P < 0.0001) than the SUVmax ratio (0.62, P < 0.0001) or SUVmax (0.48, P < 0.0001). SUVmax correlated strongly with serum C-reactive protein (0.82, P = 0.023), but CTE score did not. Conclusion: Low-dose 18F-FDG PET/CTE, compared with CTE, may improve the detection and grading of active inflammation in patients with Crohn disease. PET/CTE also may reveal clinically significant findings, such as enterocolic fistula, not evident on PET or CTE alone.

Rethinking Priorities: Cost of Complications After Elective Colectomy.

Objective: To compare incremental costs associated with complications of elective colectomy using nationally representative data among patients undergoing laparoscopic/open resections for the 4 most frequent diagnoses. Summary Background Data: Rising healthcare costs have led to increasing focus on the need to achieve a better understanding of the association between costs and quality. Among elective colectomies, a focus of surgical quality-improvement initiatives, interpretable evidence to support existing approaches is lacking. Methods: The 2009 to 2011 Nationwide Inpatient Sample (NIS) data were queried for adult (≥18 years) patients undergoing elective colectomy. Patients with primary diagnoses for colon cancer, diverticular disease, benign colonic neoplasm, and ulcerative colitis/regional enteritis were included. Based on system-based complications considered relevant to long-term treatment of elective colectomy, stratified differences in risk-adjusted incremental hospital costs and complications probabilities were compared. Results: A total of 68,462 patients were included, weighted to represent 337,887 patients nationwide. A total of 16.4% experienced complications. Annual risk-adjusted incremental costs amounted to >

Titanium-tethered vancomycin prevents resistance to rifampicin in Staphylococcus aureus in vitro.

150 million. Magnitudes of complication prevalences/costs varied by primary diagnosis, operative technique, and complication group. Infectious complications contributed the most (

The Boston AIDS Survival Score (BASS): a multidimensional AIDS severity instrument.

55 million), followed by gastrointestinal (

The impact of Medicare eligibility on cancer screening behaviors

53 million), pulmonary (

Do the advantages of a minimally invasive approach remain in complex colorectal procedures? A nationwide comparison.

22 million), and cardiovascular (

Data on Medicare eligibility and cancer screening utilization

11 million) complications. Total annual costs for elective colectomies amounted to >