Pratibha Vemulapalli

Intestinal Malrotation in a Patient Undergoing Laparoscopic Gastric Bypass

Intestinal malrotation is an anomalous disorder resulting from the incomplete rotation and fixation of the midgut during embryonic development. Although most patients present early in life with symptoms of bowel obstruction, others remain asymptomatic throughout their lives. We report the case of a 40-year-old morbidly obese woman with no significant past medical history, found to have intestinal malrotation on initial laparoscopic exploration for gastric bypass.

Adipocyte-Specific IKKβ Signaling Suppresses Adipose Tissue Inflammation through an IL-13-Dependent Paracrine Feedback Pathway

SUMMARY Adipose tissue inflammation is one pathway shown to mediate insulin resistance in obese humans and rodents. Obesity induces dynamic cellular changes in adipose tissue to increase proinflammatory cytokines and diminish anti-inflammatory cytokines. However, we have found that anti-inflammatory interleukin-13 (IL-13) is unexpectedly induced in adipose tissue of obese humans and high-fat diet (HFD)-fed mice, and the source of IL-13 is primarily the adipocyte. Moreover, HFD-induced proinflammatory cytokines such as tumor necrosis factor alpha (TNF-α) and IL-1β mediate IL-13 production in adipocytes in an IKKβ-dependent manner. In contrast, adipocyte-specific IKKβ-deficient mice show diminished IL-13 expression and enhanced inflammation after HFD feeding, resulting in a worsening of the insulin-resistant state. Together these data demonstrate that although IKKβ activates the expression of proinflammatory mediators, in adipocytes, IKKβ signaling also induces the expression of the anti-inflammatory cytokine IL-13, which plays a unique protective role by limiting adipose tissue inflammation and insulin resistance.

Single-incision laparoscopic cholecystectomy learning curve experience seen in a single institution.

Introduction: Single-incision laparoscopic surgery (SILS) is laparoscopic surgery done by one incision through the umbilicus. Cholecystectomy lends itself well to a SILS approach. As these procedures have become more widely adapted, it is important to determine the approximate learning curve to decrease two surgical endpoints: (1) time to completion of the procedure; and (2) decreased incidence of conversion. Methods: We prospectively reviewed our series of 50 cholecystectomies done using the SILS approach between May 2008 to September 2008. All cases were performed by two advanced laparoscopic surgeons at a single institution. Data was collected immediately after the case and entered into an Excel database. Cases were performed by insufflating the abdomen with a Veress needle through the umbilicus followed by placement of 5-mm ports at the umbilicus. Results: Patient ages ranged between 21 and 82 years with a median age of 45 years. Body mass index (BMI) range was 21 to 42 kg/m2 with a mean of 30 kg/m2. Average length of time for cases was 1 hour 9 minutes with a range between 55 minutes and 120 minutes. The average length of time for the first 25 cases was 80 minutes. When compared with cases 26 to 50 the average length of time was 60 minutes (P<0.05). The conversion rate to conventional laparoscopic cholecystectomy was 10%. Conversion was accomplished through the addition of a 5-mm port elsewhere on the abdominal cavity. After the tenth case, the incidence of conversion went down to zero. When conversions were further stratified, they occurred within each individual surgeon’s first ten cases. Conclusions: The learning curve for successful consistent completion of SILS cholecystectomy cases appears to be after 25 cases. In addition, conversion rates drop dramatically after the first ten cases.

Single-incision laparoscopic-assisted right colon resection for cancer.

The authors suggest that laparoscopic right colectomy utilizing a single port may be performed with excellent cosmetic results.

Revisional sleeve gastrectomy can be a safe and efficacious procedure.

Laparoscopic adjustable gastric band (LAGB) was once the most popular bariatric procedure in the world. However, inadequate postoperative weight loss and dissatisfaction with postoperative dysphagia have encouraged patients to seek band removal and conversion to another bariatric procedure. However, revisional laparoscopic sleeve gastrectomy (RLSG) after LAGB has been associated with an increased risk of complications such as staple line leak, gastric hemorrhage, or hematoma. In an effort to decrease this complication rate, it is unclear whether to perform this operation as a 1-stage or 2-stage procedure. In a series of 90 patients where it was performed as a 1-stage procedure, the rates of staple line leak and a gastric hemorrhage were 5.5% and 4.4%, respectively [1]. Another series by Berende et al. [2] found a leak rate of 14% and a bleeding rate of 20% for the 1-stage approach. However, with a 2-stage approach major complication rates dropped between 0–3.7% [2–7]. Yet others have attempted to reduce these complications by using surgical adjuncts such as buttress reinforcement agents [8–13]. While the use of these agents has been found to be effective in preventing staple line hemorrhage, the evidence supporting their role in preventing staple line dehiscence is lacking [12,13]. In several studies, complication rates after RLSG have been higher than those seen after primary laparoscopic sleeve gastrectomy (LSG) and therefore call for caution [3,14,15]. It is difficult to explain the inverse phenomena of complication rates in this report between primary and RLSG seen in this series, namely that complication rates were lower in the revisional group than the primary RLSG cohort. Furthermore, no deaths were reported in this series after surgical revisions. This is rather unusual after revisional bariatric surgery. These findings may speak more to the low numbers than to the safety of the procedure. RSLG is more difficult after LAGB for several factors such as thinning out of gastric tissue secondary to capsular scar removal. In addition, band placement at the left crus often causes a dense inflammatory scar reaction in this portion of the stomach, which abuts the crus and is most likely to be the area of leak after RLSG. Dissection around such unfavorable inflammatory tissue does not allow for