Pradeep K. Pallati

Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: Review of the Bariatric Outcomes Longitudinal Database☆

BACKGROUND The prevalence of gastroesophageal reflux disease (GERD) in the morbidly obese population is as high as 45%. The objective of this study was to compare the efficacy of various bariatric procedures in the improvement of GERD. METHODS The Bariatric Outcomes Longitudinal Database is a prospective database of patients who undergo bariatric surgery by a participant in the American Society of Metabolic and Bariatric Surgery Center of Excellence program. GERD is graded on a 6-point scale, from 0 (no history of GERD) to 5 (prior surgery for GERD). Patients with GERD severe enough to require medications (grades 2, 3, and 4) from June 2007 to December 2009 are identified; the resolution of GERD is noted based on 6-month follow-up. RESULTS Of a total of 116,136 patients, 36,938 patients had evidence of GERD preoperatively. After excluding patients undergoing concomitant hiatal hernia repair or fundoplication, there were 22,870 patients with 6-month follow-up. Mean age was 47.6±11.1 years, with an 82% female population. Mean BMI was 46.3±8.0 kg/m(2). Mean preoperative GERD score for patients with Roux-en-Y gastric bypass (RYGB) was 2.80±.56, and mean postoperative score was 1.33±1.41 (P<.0001). Similarly, adjustable gastric banding (AGB, 2.77±.57 to 1.63±1.37, P<.0001) and sleeve gastrectomy (SG, 2.82±.57 to 1.85±1.40, P<.0001) had significant improvement in GERD score. GERD score improvement was best in RYGB patients (56.5%; 7955 of 14,078) followed by AGB (46%; 3773 of 8207) and SG patients (41%; 240 of 585). CONCLUSION All common bariatric procedures improve GERD. Roux-en-Y gastric bypass is superior to adjustable gastric banding and sleeve gastrectomy in improving GERD. Also, the greater the loss in excess weight, the greater the improvement in GERD score.

Do you need a computed tomographic scan to evaluate suspected appendicitis in young men: an administrative database review

BACKGROUND The purpose of this study was to evaluate the impact of computed tomographic (CT) scans of the abdomen on clinical outcomes and costs in young male patients presenting with suspected appendicitis. METHODS Discharge data from the University HealthSystem Consortium was accessed for all male patients between 18 and 55 years of age from October 2007 to June 2011. RESULTS Of a total of 13,228 patients who met the inclusion criteria, 11,340 (85%) were assessed using a CT scan of the abdomen, whereas 1,888 (15%) did not undergo CT evaluation. Patients undergoing CT imaging compared with those without a CT scan had less morbidity (.86% vs 2.2%, P < .0001) and fewer 30-day readmissions (1.8% vs 5.13%, P < .0001). However, CT imaging resulted in a higher overall length of hospital stay and a higher total cost. CONCLUSIONS This study suggests that in young men with suspected appendicitis, the use of an abdominal CT scan is associated with improved immediate postoperative complications, lower readmission rates with observed higher length of stay, and increased cost of care.

Increased expression of triggering receptor expressed on myeloid cells-1 in the population with obesity and insulin resistance

Triggering receptor expressed on myeloid cells (TREM)−1 has recently been recognized as one of the potent amplifiers of acute and chronic inflammation. However, the exact role of TREM‐1 in regard to insulin insensitivity is unknown.

Perioperative outcomes after adrenalectomy for malignant neoplasm in laparoscopic era: A multicenter retrospective study

Background: This study aims to review perioperative outcomes of adrenalectomy for malignant neoplasm performed by open or laparoscopic technique and comparing them with benign diseases. Methods: This study is a multicenter, retrospective analysis utilizing a large administrative database. The University Health System Consortium is an alliance of over 100 academic medical centers and 250 affiliate hospitals. The University Health System Consortium database was accessed using International Classification of Diseases codes. Results: A total of 6157 patients underwent adrenalectomy between January 2008 and June 2011. Of these, 5101 patients underwent open adrenalectomy (OA) and 1056 underwent adrenalectomy by laparoscopic technique (LA). Comparison between LA and OA showed lower morbidity (4.8% vs. 7.2%, P=0.0007), hospital length of stay (d) (3.23±5.66 vs. 4.35±6.59, P<0.0001), ICU admission rate (18.19% vs. 23.75%, P<0.0001), and cost (

Incarcerated intrathoracic stomach with antral ischemia resulting in gastric outlet obstruction: a case report

) (9250±14306 vs. 11634±16547, P<0.0001) for LA, with no statistical difference in observed mortality or 30-day readmission rate. We then compared open and laparoscopic procedures performed for benign and malignant diagnoses. Conclusions: Overall, LA had better outcomes than OA. When comparisons were made between LA and OA for benign adrenal diseases, all outcomes were significantly better in the laparoscopic group. There were, however, no statistical differences when LA was compared with OA for malignant diagnoses.

Individualisierte Chirurgie des Thoraxmagens und Antirefluxchirurgie

A 73-year-old man underwent laparoscopic repair of intrathoracic gastric volvulus after presenting with chest discomfort and inability to belch. After a few weeks, he developed early satiety, nausea and postprandial bloating and was found to have developed a tight stenosis 2 cm proximal to the pylorus. He underwent a series of endoscopies with balloon dilation with full resolution of symptoms and is doing well at 1-year follow-up. Gastric volvulus with ischemia resulting in a stricture has not been previously reported.

Surgical Technique and Difficult Situations from Sumeet K. Mittal

Die chirurgische Behandlung der gastroosophagealen Refluxkrankheit (GERD) kennt zahlreiche technische Varianten und Modifikationen. Die wesentlichen Phasen der Operation sind: Dissektion des Lig. phrenicooesophageale und des His-Winkels; Eroffnung der Pars flaccida und retrokardiale Mobilisierung mit anschliesendem Anschlingen des Osophagus; Mobilisierung des Fundus mit Durchtrennung der kurzen Magenarterien (nicht obligat); Hiatoplastik; Fundoplikation. Die ersten vier Schritte bieten nicht so viele technische Variationsmoglichkeiten wie die Rekonstruktion des kardioosophagealen Uberganges durch eine Fundoplikation. Die Etablierung der laparoskopischen Techniken fuhrte zu einer Zunahme der operativen Behandlung der GERD. Damit stieg aber auch die Zahl der GERD-Rezidive nach entsprechenden Eingriffen.

Comment on: Worthy or not? Six Year Experience of Revisional Bariatric Surgery from an Asian Centre of Excellence1

Intrathoracic stomach represents herniation of greater than 75 % of the stomach through the esophageal hiatus into the thoracic cavity. The most common symptoms include intermittent dysphagia for solids, abdominal and chest pain secondary to visceral torsion, gastrointestinal bleeding from mucosal ischemia resulting in iron deficiency anemia, and heartburn. A high incidence of acute volvulus with possible gangrene, perforation, or hemorrhage requiring emergent surgery has been reported, and elective repair has been recommended [1] though not universally accepted for asymptomatic patients. All symptomatic PEH should be repaired especially if they have symptoms suggesting incarceration. The operative repair was traditionally via left thoracotomy and subsequently via laparotomy though laparoscopic repair is feasible in nearly all patients. Cuscheri first reported laparoscopic repair of paraesophageal hernia in 1992 [2]. Operative strategy includes sac and hernia reduction with hiatus closure along with or without fundoplication.

Laparoscopic Versus Open Repair for the Uncomplicated Unilateral Inguinal Hernia

As primary bariatric surgery is increasing in magnitude across the world, the need for revisions is also increasing. At present, inadequate weight loss or weight regain after primary bariatric surgery is a vexing problem. It is dependent on the type of initial procedure, the patient’s initial weight and other unexplained patient factors [1]. In cases of primary restrictive bariatric surgery, the option of conversion to a combination restrictive and malabsorptive Roux-en-Y gastric bypass (RYGB) has shown very promising results. However, in cases of primary RYGB, any revision is associated with only moderate weight loss. Haung et al. [2] present their experience of revisional bariatric surgery from a high-volume Asian bariatric center between July 2006 and June 2012. The authors do not include their initial 50 procedures, citing a learning curve. Also, patients with a minimum of 6 months follow-up after the revisional bariatric surgery are included. This resulted in 52 revisional bariatric procedures out of a total of 1578 bariatric operations. The indications were primarily weight loss failure in 21 patients and complications related to the primary operation in 31 patients. Weight loss failure was defined as excess weight loss (EWL) of less than 50% at 2 years, or weight regain 415% from baseline following primary bariatric surgery. The authors had good response in patients who had a primary restrictive bariatric operation with a mean body mass index (BMI) change of 8.9 kg/m. But, patients who had a revision of RYGB for inadequate weight loss had only a mean BMI change of 3.2 kg/m. Authors from Cleveland clinic [3] also noted a similar success with mean EWL of 53.7% after revision of a primary restrictive procedure, but only 37.6% after revision of RYGB at 41-year follow-up. However, when you consider the total weight loss from initial primary bariatric surgery, these patients still achieved greater than 50% mean EWL. Similarly, in the present study as noted in Fig. 2, the final BMI was similar in both primary restrictive and primary RYGB patients after revision. Hence, this small change in BMI after revision should not be totally discouraging.

589 Reoperative Intervention in Patients With Mesh At Hiatus Is Associated With High Morbidity and High Incidence of Esophageal Resection - Single Center Experience

Most authorities agree that laparoscopic inguinal herniorrhaphy is an excellent option for patients with recurrent hernias after a failed conventional operation in the anterior space or for patients whose hernias are bilateral. However, there is lack of agreement as to the best approach for the uncomplicated unilateral hernia as many feel there is not enough benefit in this group to justify the added expense and the slight possibility of serious complications or even a fatal operative accident with laparoscopy. In this chapter, we present the current available literature on the pros and cons of open versus laparoscopic repair of a unilateral, nonrecurrent inguinal hernia.