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Consolidation of physician practices is well-documented in recent years, yet minimal data exist regarding consolidation in general surgery. This study evaluates current trends in general surgery practice consolidation.Data were obtained through the CMS Physician Compare database. Surgeons and practices were categorized by size, and trends were analyzed using the Cochran-Armitage test. Data were stratified by US region.From 2012 to 2020, practicing general surgeons increased from 20,044 to 20,637 (+3%). Unique general surgery practices declined from 8178 to 6489 (-21%). The percentage of surgeons in practices of 1 or 2 declined from 19% to 12%, while surgeons in groups of 500 or more grew from 20% to 31%. Tests for trends towards consolidation at both the individual surgeon and unique practice levels were significant (p .001). The Midwest region demonstrated the highest degree of consolidation.Consistent with trends in medicine overall, general surgery is experiencing substantial practice consolidation.

Eosinophils have been widely investigated in asthma and allergic diseases. More recently, new insights into the biology of these cells has illustrated eosinophils contribute to homeostatic functions in health such as regulation of adipose tissue glucose metabolism. Human translational studies are limited by the difficulty of obtaining cells taken directly from their tissue environment, relying instead on eosinophils isolated from peripheral blood. Isolation techniques for tissue-derived eosinophils can result in unwanted cell or ribonuclease activation, leading to poor cell viability or RNA quality, which may impair analysis of effector activities of these cells. Here we demonstrate a technique to obtain eosinophils from human adipose tissue samples for the purpose of downstream molecular analysis. From as little as 2 g of intact human adipose tissue, greater than 104 eosinophils were purified by fluorescence-activated cell sorting (FACS) protocol resulting in ≥ 99% purity and ≥ 95% viable eosinophils. We demonstrated that the isolated eosinophils could undergo epigenetic analysis to determine differences in DNA methylation in various settings. Here we focused on comparing eosinophils isolated from human peripheral blood vs human adipose tissue. Our results open the door to future mechanistic investigations to better understand the role of tissue resident eosinophils in different context.

Background The mechanisms of weight loss and metabolic improvements following bariatric surgery in skeletal muscle are not well known; however, epigenetic modifications are likely to contribute. The aim of our study was to investigate skeletal muscle DNA methylation after weight loss induced by Roux-en-Y gastric bypass (RYGB) surgery. Muscle biopsies were obtained basally from seven insulin-resistant obese (BMI > 40 kg/m2) female subjects (45.1 ± 3.6 years) pre- and 3-month post-surgery with euglycemic hyperinsulinemic clamps to assess insulin sensitivity. Four lean (BMI 2) females (38.5 ± 5.8 years) served as controls. We performed reduced representation bisulfite sequencing next generation methylation on DNA isolated from the vastus lateralis muscle biopsies. Results Global methylation was significantly higher in the pre- (32.97 ± 0.02%) and post-surgery (33.31 ± 0.02%) compared to the lean (30.46 ± 0.02%), P versus pre-surgery (Benjamini–Hochberg q versus the lean controls (Benjamini–Hochberg q versus the lean controls, 2885 DMCs were altered (Benjamini–Hochberg q ITGB3) promoter and KIAA0284 exon, respectively. ITGB3 methylation was significantly decreased in the post-surgery (0.5 ± 0.5%) and lean controls (0 ± 0%) versus pre-surgery (13.6 ± 2.7%, P ITGB3 gene expression (fold change + 1.52, P = 0.0087). In addition, we showed that ITGB3 promoter methylation in vitro significantly suppressed transcriptional activity (P ITGB3 chr17.45,330,989 identified three putative transcription factor binding motifs; PAX-5, p53 and AP-2alphaA. Conclusions These results demonstrate that weight loss after RYGB alters the epigenome through DNA methylation. In particular, this study highlights ITGB3 as a novel gene that may contribute to the metabolic improvements observed post-surgery. Future additional studies are warranted to address the exact mechanism of ITGB3 in skeletal muscle.

Introduction. Obesity is a common comorbidity seen in the perioperative setting and is associated with many diseases including cardiovascular disease and obstructive sleep apnea. Laparoscopic Roux-en-Y gastric bypass is the gold standard surgical treatment for patients whose weight is refractory to diet and exercise. Caring for these patients perioperatively presents unique challenges to anesthesiologists and is associated with an increased risk of adverse respiratory events. In our study, we hypothesize that a low-dose perioperative ketamine infusion will reduce opioid consumption and improve analgesia when compared to standard therapy. Methods. This is a single-center, prospective randomized controlled study enrolling 35 patients in total. Patients were randomized equally into the ketamine and control group. Preop, intraop, and postop management regimens were standardized. The ketamine group received a 0.3 mg/kg ideal body weight ketamine bolus after induction followed by a 0.2 mg/kg/hr ketamine infusion continued into the postop setting for up to 24 hours. Data collected included total perioperative opioids used converted to oral morphine equivalents (ME), pain scores, side effects, hospital length of stay, and patient satisfaction captured via postoperative questionnaires. Results. The use of perioperative opioid consumption was significantly lower in the ketamine group when compared with the control group (179.9 ME versus 248.7 ME, P = 0.03 ). There was no statistically significant difference in pain scores or hospital length of stay postoperatively between the two groups. There were also no reported adverse respiratory events, prolonged sedation, agitation, or other side effects reported in either group. The patient satisfaction questionnaires showed a significant difference with the ketamine group reporting lower maximum pain scores, a decrease in how pain limited activities of daily living once discharged, and increased hospital pain management satisfaction scores. Conclusions. Perioperative low-dose ketamine infusions significantly reduced opioid consumption in morbidly obese patients undergoing laparoscopic gastric bypass surgery.

Background Long chain omega-3 polyunsaturated fatty acids (ω-3PUFA) supplementation in animal models of diet-induced obesity has consistently shown to improve insulin sensitivity. The same is not always reported in human studies with insulin resistant (IR) subjects with obesity. Objective We studied whether high-dose ω-3PUFA supplementation for 3 months improves insulin sensitivity and adipose tissue (AT) inflammation in IR subjects with obesity. Methods Thirteen subjects (BMI = 39.3 ± 1.6 kg/m2) underwent 80 mU/m2·min euglycemic-hyperinsulinemic clamp with subcutaneous (Sc) AT biopsy before and after 3 months of ω-3PUFA (DHA and EPA, 4 g/daily) supplementation. Cytoadipokine plasma profiles were assessed before and after ω-3PUFA. AT-specific inflammatory gene expression was evaluated on Sc fat biopsies. Microarray analysis was performed on the fat biopsies collected during the program. Results Palmitic and stearic acid plasma levels were significantly reduced (P P P Conclusion High dose of long chain ω-3PUFA supplementation modulates significant changes in plasma fatty acid profile, AT, and systemic inflammation. These findings are associated with significant improvement of insulin-stimulated glucose disposal. Unbiased microarray analysis of Sc fat biopsy identified APOE as among the most differentially regulated gene after ω-3PUFA supplementation. We speculate that ω-3PUFA increases macrophage-derived APOE mRNA levels with anti-inflammatory properties.

Surgeon workload is significant both mentally and physically and may differ by procedure type. When comparing laparoscopic surgery and open surgery, studies have reported contrasting results on the physical and mental workload assessed.Wearable posture sensors and pre-/post-surgical questionnaires were employed to assess intraoperative workload and to identify risk factors for surgeons using objective and subjective measures.Data from 49 cases (27 open and 22 laparoscopic surgeries performed by 13 male and 11 female surgeons) were assessed. More than half the surgeons reported a clinically relevant post-surgical fatigue score. The surgeons also self-reported a significant increase in pain for the neck, upper back, and lower back during/after surgery. Procedural time had significant impacts on fatigue, body part pain, and subjective (NASA-TLX) workload. The objectively assessed intraoperative work postures using wearable sensors showed a high musculoskeletal risk for neck and lower back based on their posture overall. Open surgeries had significantly larger neck angles (median [IQR]: 40 [28-47]°) compared with laparoscopic surgeries (median [IQR]: 23 [16-29]°), p 0.001) and torso (median [IQR]: 17 [14-22]° vs. 13 [10-17]°, p = 0.006).Surgeons reported significantly higher levels of fatigue and pain in the neck and lower back during or after performing a surgical case. Longer procedural time resulted in more self-rated fatigue, pain, and subjective workload. Open surgery had higher postural risk. Overall, surgeons spent a disturbingly high percentage of time during surgery in high-risk musculoskeletal postures, especially the neck. These results show that intraoperative postural risk is very high and that interventions are necessary to protect surgeon musculoskeletal health for optimal surgeon performance and career longevity.

Upper age limits for bariatric surgery are questioned on the merits of increased complication rates in the elderly and questionable efficacy. This study evaluates outcomes of bariatric surgery in patients ≥ 70 years of age. Retrospective review was performed of patients ≥ 70 years of age who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) between 2001 and 2018. Primary endpoints were 30-day readmission, Clavien-Dindo grade III–V (CD III–IV) complications, and mortality. Secondary data included were weight loss, long-term outcomes, comorbidity resolution, hemoglobin A1C, and lipid panels. A total of 23 patients with an average age of 72 years (range 70–80 years) and mean BMI of 43.3 (range 37.3–56.0) were reviewed. Average length-of-stay was 2.4 days (range 1–6 days), with the only acute complication being aspiration pneumonia in one patient. Median follow-up was 69.3 weeks (range 9–875 weeks). One-year follow-up rate was 96%, during which no deaths or CD III-IV complications occurred. Subsequently, one patient experienced failure-to-thrive requiring temporary enteral nutrition. Average 1 year percent total weight loss (%TWL) was 29%, and this was maintained on subsequent follow-ups. Average 1 year percent excess weight loss (%EWL) was 60%, maintained long-term at 61%. Significant serum biochemical improvements included hemoglobin A1C (6.9 ± 1.4% to 5.6 ± 1.3%, p = 0.001), triglycerides (155 ± 49 mg/dL to 102 ± 41 mg/dL, p = 0.0003), and high-density lipoprotein cholesterol (48 ± 14 mg/dL to 58 ± 22 mg/dL, p = 0.004). Laparoscopic RYGB is a safe and effective treatment for obesity and obesity-related comorbidities in septuagenarians.

Objective Enhanced recovery has been utilized to decrease length of stay and cost in bariatric surgery. We have recently focused efforts on pre-operative education with regards to discharge on the first post-operative day. The aim of this study was to determine the effectiveness of pre-operative education on discharge timing and readmission rates. Methods A retrospective review was conducted after revising discharge expectation education. Patients undergoing first time bariatric operations were included. Early group education focused on average patient stay of 2 postoperative days. Revised education informed patients they could go home on the first post-operative day. Results A total of 125 patients met inclusion criteria. Implementation of preoperative education was associated with a decrease in mean LOS and greater percentage of patients discharged on post-operative day one. There was no difference in readmission and complication rates. Conclusion Effective pre-operative education can decrease length of stay in first time laparoscopic bariatric surgery.

Objective To characterize reasons for discordance between administrative data and registry data in the determination of postoperative infectious complications. Background Data regarding the occurrence of postoperative surgical complications are identified through either administrative or registry data. Rates of complications vary significantly between these two types of data; the reasons for this are not well-understood. Methods The occurrence of 30-day inpatient infectious complications (pneumonia, sepsis, surgical site infection, and urinary tract infection) was compared between the NSQIP and administrative mechanisms at 4 academic hospitals between 2012 and 2014. In each situation where the NSQIP and administrative data were discordant regarding the occurrence of a specific complication, a 2-clinician chart abstraction was performed to characterize the reasons for discordance as (i) administrative coding error, (ii) NSQIP coding error, (iii) "question of criteria", where the discordance was the result of differences in criteria, or (iv) "dually incorrect", where both data sources coded the complication incorrectly. Results The cohort included 19,163 patients undergoing surgery in 4 different academic hospitals. Rates of infectious complications varied up to 5-fold between the two data sources. A total of 717 discordant complications were identified. Of these, the greatest portion (43%) was due to "question of criteria," followed by administrative coding error (37%), NSQIP error (15%), and dually incorrect (5%). Conclusions With a goal of improving existing mechanisms for measuring surgical quality, definitions for the occurrence of a postoperative complication need to be developed and applied consistently. Progress toward this goal will enable patients and payers to better take advantage of recent advances in healthcare data transparency.

Bariatric surgery is an effective procedure to achieve weight loss in obese patients. However, homeostasis of essential metals may be disrupted as the main absorption site is bypassed. In this study, we determined Cu, Fe and Zn isotopic compositions in paired serum and whole blood samples of patients who underwent Roux-en-Y gastric bypass (RYGB) surgery for evaluation of longitudinal changes and their potential relation to mineral element concentrations and relevant clinical parameters used for monitoring the patient's condition. Samples from eight patients were collected pre-surgery and at 3, 6 and 12 months post-surgery. Multi-collector inductively coupled plasma-mass spectrometry (MC-ICP-MS) was used for high-precision isotope ratio measurements. Alterations in metal homeostasis related to bariatric surgery were reflected in the serum and whole blood Cu, Fe and Zn isotopic compositions. The serum and whole blood Cu became isotopically lighter (lower δ65Cu values) after bariatric surgery, reaching statistical significance at 6 months post-surgery (p < 0.05). The difference between the serum and the whole blood Zn isotopic composition increased after surgery, reaching significance from 6 months post-surgery onwards (p < 0.05). Those changes in Cu, Fe and Zn isotopic compositions were not accompanied by similar changes in their respective concentrations, making isotopic analysis more sensitive to physiological changes than elemental content. Furthermore, the Zn isotopic composition correlates with blood glycaemic and lipid parameters, while the Fe isotopic composition correlates with glycaemic parameters. Graphical Abstract.

Eosinophils (EOS) have been shown to play a major role in animal adipose tissue (AT) metabolism by promoting insulin sensitivity (IS) through an increase in alternatively activated macrophages (M2). Additionally, AT EOS are known to be decreased in obese mice. Currently, translational evidence is lacking for the role of EOS in human AT metabolism and IS. We investigated whether human AT-resident EOS numbers, as in animal models, are decreased in obese subjects and correlate with their degree of insulin resistance (IR). To date, we have studied 16 lean subjects (F15/M1, age 43 +2 years old; BMI 22.5+0.4kg/m2; HOMA-IR: 0.99 +0.38) and 22 obese, IR subjects (17F/5M, age 42 +1.3 years old; BMI: 38.9 +1.0kg/m2; HOMA-IR:5.0 +1.6) undergoing elective laparoscopic surgery. During surgical procedure, subcutaneous (SC) and omental (OM) fat was harvested. Stromal vascular fraction (SVF) was isolated after collagenase digestion of the fat samples. SVF was subjected to FACS analysis using BD Biosciences FACSAria III Cell Sorter with EOS count normalized as percent of CD45+ cells. Viable EOS were isolated and cytospin preparation was stained with a Diff-Quik. EOS isolated from SC AT of lean(L) subjects were found to significantly outnumber those obtained from obese (Ob) subjects by a 2.1:1 ratio (SC L:2.34 +0.29 vs. SC Ob: 1.11 +0.21, P Disclosure J.D. Hernandez: None. T. Li: None. C. Rau: None. M.Y. Masuda: None. J.A. Madura: None. E.A. Jacobsen: None. E. DeFilippis: None. Funding Arizona Department of Health Services (14-00003606); Arizona Biomedical Research Commission; Kathryn H. and Roger Penske Career Development Award

Nontuberculous mycobacteria are ubiquitous environmental organisms that are infrequently implicated as pathogens. Peritoneal infection with nontuberculous mycobacteria is rare and published reports are most commonly associated with peritoneal dialysis. This study describes a case of a 41-year-old woman with cirrhosis who had Mycobacterium abscessus peritonitis and an abdominal abscess resulting from infection of a remotely placed gastric band (Lap-Band; Apollo Endosurgery, Inc).

Loss of skeletal muscle in patients that have undergone gastric bypass is a consistent observation. Skeletal muscle constitutes the largest protein/amino acid pool in the body, and loss of skeletal muscle has important implications in health and disease. Sustaining a given level of muscle protein requires a balance between the rates of muscle protein synthesis and breakdown. Current evidence suggests that reduced rate of protein synthesis is implicated in the loss of muscle after gastric bypass. This is not surprising given a less than optimal dietary protein intake following the gastric bypass and because, unlike other macronutrients, protein/amino acids are not stored in the body. Ingesting essential amino acids, which cannot be synthesized de novo and have the primary role in the regulation of muscle protein synthesis, can potentially ameliorate loss of muscle protein after gastric bypass. At the same time, ingestion of essential amino acids provides a more efficient nutritional approach (i.e., greater stimulation of protein synthesis relative to the amount of amino acids ingested) to enhance muscle protein synthesis compared to the ingestion of intact protein in the gastric bypass patient. Changing current dietary practices towards increasing ingestion of essential amino acids provides an approach that can potentially prevent loss of lean body tissue and ultimately achieve a more sustained level of health in patients that have undergone gastric bypass.

Background Obesity is a disease that is caused by genetic and environmental factors. However, epigenetic mechanisms of obesity are less well known. DNA methylation provides a mechanism whereby environmental factors can influence gene transcription. The aim of our study was to investigate skeletal muscle DNA methylation of sorbin and SH3 domain containing 3 (SORBS3) with weight loss induced by Roux-en-Y gastric bypass (RYGB). Results Previously, we had shown increased methylation (5.0 to 24.4%) and decreased gene expression (fold change − 1.9) of SORBS3 with obesity (BMI > 30 kg/m2) compared to lean controls. In the present study, basal muscle biopsies were obtained from seven morbidly obese (BMI > 40 kg/m2) female subjects pre- and 3 months post-RYGB surgery, in combination with euglycemic-hyperinsulinemic clamps to assess insulin sensitivity. We identified 30 significantly altered promoter and untranslated region methylation sites in SORBS3 using reduced representation bisulfite sequencing (RRBS). Twenty-nine of these sites were decreased (− 5.6 to − 24.2%) post-RYGB compared to pre-RYGB. We confirmed the methylation in 2 (Chr.8:22,423,690 and Chr.8:22,423,702) of the 29 decreased SORBS3 sites using pyrosequencing. This decreased methylation was associated with an increase in SORBS3 gene expression (fold change + 1.7) post-surgery. In addition, we demonstrated that SORBS3 promoter methylation in vitro significantly alters reporter gene expression (P

Gastric pneumatosis is a radiographic finding that represents a spectrum of conditions ranging from benign disease to abdominal sepsis and death. Along with portal venous gas, it is generally considered an ominous sign prompting emergent operative intervention. We report a rare case showing that diagnostic laparoscopy can be used to confirm or refute full thickness ischemic necrosis and that conservative management can be considered in some patients, recognizing the possibility of a benign process.

Bariatric surgery is increasingly being performed in the medically complicated obese population as convincing data continue to mount, documenting the success of surgery not only in achieving meaningful weight loss but also in correcting obesity-related illnesses. Several surgical procedures with varying degrees of success and complications are currently being performed. This article discusses the short- and long-term gastrointestinal complications for the 4 most common bariatric surgical procedures: laparoscopic adjustable gastric banding, vertical sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch.

Obesity is a growing worldwide epidemic, increasingly addressed through surgical options for weight loss. Benefits of these operations, such as weight loss and improvement or reversal of obesity-related comorbidities, are well established; however, postoperative complications do occur. This article will evaluate common causes for hospital admissions in the post-bariatric surgery population as they relate to the hospitalist who is often responsible for their care. Here we provide an overview of the most common bariatric procedures currently performed, early postoperative complications, late medical complications (ie, abdominal complaints, weight fluctuations, nutritional deficiencies, and metabolic bone disease), and late surgical complications that often affect these patients and result in hospital admissions. Special attention will be paid to radiologic pearls that can assist in the initial evaluation and diagnosis of these patients.

Resection and drainage operations achieve long-term pain relief in approximately 85% of patients with chronic pancreatitis (CP). In patients who develop recurrent pain, a few data exist on the long-term results of remedial operations. Over an 18-year period (1988–2006), 316 patients with CP had primary resection or drainage operations at our institution. Thirty-nine developed recurrent pain and were treated by a remedial resection or drainage operation. Patient demographics, time to symptom recurrence, radiographic anatomic abnormalities, type of remedial operation, postoperative morbidity, and long-term outcomes were analyzed. Thirty-nine patients, 56% female with a mean age of 41 years (range 16–61 years) had either remedial resection: total pancreatectomy (TP; N = 8), pancreaticoduodenectomy (PD; N = 6), distal pancreatectomy (DP; N = 5), or drainage operation: duodenal preserving pancreatic head resection (DPPHR; N = 8), revision of pancreaticojejunostomy (N = 12). TP achieved pain relief in 88% with postoperative complications greater than or equal to grade III in 38% and diabetes in 100%. Drainage operations achieved pain relief in 67% of patients with postoperative complications greater than or equal to grade III in only 8%. Partial parenchymal resections (DPPHR, PD, DP) as a remedial procedure achieved pain relief

Background Chemotherapy has been largely unsuccessful in pancreatic cancer. Measurement of cell-specific biological endpoints may clarify the evaluation of a newer generation of compounds. Perillyl alcohol has shown chemotherapeutic activity in preclinical systems through enhancing apoptosis. Aims To pilot a new trial template for testing novel agents in pancreatic cancer and to assess the biological activity of perillyl alcohol in patients with resectable pancreatic cancer. Methods Apoptosis was quantified with ApopTag in situ , Bak staining, and light microscopy. Tumor size, serum CA 19–9 level, and survival were also measured. Results Eight patients enrolled. Toxicity was mild and perillyl alcohol was generally well tolerated. Tumor size and CA 19–9 level were unchanged with perillyl alcohol treatment. Survival time was longer in patients who received full perillyl alcohol treatment (288 ± 32 days) compared to those who did not (204 ± 96 days), but this result did not achieve statistical significance ( P = 0.2). There was a trend toward greater apoptosis in patients receiving perillyl alcohol compared to fresh operative controls; there was also a suggestion of greater apoptosis in tumor compared to normal pancreatic tissue in the same patient. Conclusions Incorporation of cell-specific biological endpoints is challenging but feasible and should be used in clinical studies of pancreatic cancer treatment. Our pilot study suggests that perillyl alcohol may indeed have effects on biological endpoints. This study will serve as a useful template for examining cell-specific biological endpoints in the testing of future agents that are thought to induce apoptosis in pancreatic cancer.

The mechanisms of metabolic improvements after Roux-en-Y gastric bypass (RYGB) surgery are not entirely clear. Therefore, the aim of our study was to investigate the role of obesity and RYGB on the human skeletal muscle proteome. Basal muscle biopsies were obtained from seven obese (BMI >40 kg/m2) female subjects (45.1 ± 3.6 years) pre- and 3 months post-RYGB, and euglycemic-hyperinsulinemic clamps were used to assess insulin sensitivity. Four age-matched (48.5 ± 4.7 years) lean (BMI

In patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PC), conversion to total pancreatectomy (TP) may be necessary to achieve R0 resection. Hypothesis We sought to examine the oncologic benefit of conversion of PD to TP to achieve an R0 resection in patients with an isolated positive neck margin. Methods We conducted a retrospective analysis of prospectively collected data at Indiana University and Johns Hopkins Medical Institutions. A review of 1,579 patients who underwent PD or TP for PC at these institutions between 1992 and 2006 was performed. Sixty-one patients were eligible. Results Twenty-eight patients underwent PD with an isolated positive neck margin found on pathologic examination; 33 patients had conversion to TP for isolated neck margin involvement to achieve R0 resection. Patients undergoing TP versus PD had a greater median survival (18 vs 10 months; P = .04). Mortality (6% vs 7%) and morbidity (36% vs 54%; P = .20) for TP versus PD were comparable. Multivariate analysis revealed PD and greater tumor size as the only independent predictors of poor long-term survival (hazard ratio [HR], 2.2; P = .01 and HR, 1.3; P = .005). Conclusions Conversion of PD to TP to achieve an R0 resection in patients with pancreatic adenocarcinoma is associated with a survival benefit.

Background Traditional retrorectus techniques for ventral hernia repair often produce abdominal wall pain related to transfascial suture placement. This report details results of a retrorectus mesh herniorrhaphy technique avoiding transfascial suture fixation. Methods A retrospective review of 90 patients who underwent retrorectus ventral hernia repair between 2009 and 2015 was performed. All were treated with primary posterior rectus fascial closure and retrorectus mesh placement. Standard weight polypropylene mesh was used with polypropylene tacking sutures to the posterior rectus sheath with medialization of the rectus muscles and primary closure of the anterior rectus sheath over the mesh repair. Results The overall complication rate was 19.6%. Hernia recurrence occurred in 2 patients (2.2%) with mean follow-up of 3.0 years. There were 4 cases of superficial infection (4.3%). Two patients (2.2%) developed hematomas and 2 patients developed seromas (2.2%). Late abdominal pain occurred in 6 (6.5%) patients, eventually resolving in all but 2. Conclusions Retrorectus ventral hernia repair avoiding transfascial suture placement produces a functional repair with minimal chronic pain and a low rate of complications.

Pancreatic cancer has a poor prognosis with complete surgical resection being the only therapy to offer a realistic chance for long-term survival. The aim of this study is to identify surgery-related variables that influence long-term survival. Between 1990 and 2002, 226 consecutive patients (mean age of 64+/-11 years) had resection for pancreatic adenocarcinoma. Prognostic variables in these patients were analyzed using univariate and multivariate analysis. Two hundred four patients (90%) had pancreaticoduodenectomy, 13 patients (6%) had distal pancreatectomy, and 9 patients (4%) had a TP. Stage I disease was present in 50 (22%), stage II disease in 170 (75%), and stage III disease in 6 (3%). R0 resections were achieved in 70%. Operative morbidity was 36% and 30-day mortality was 6%. Actual 1-year, 3-year, and 5-year survival rates were 49% (n=111), 14% (n=31), and 4% (n=9). Using multivariate analysis: tumor size, tumor differentiation, obtaining an R0 resection, and lack of postoperative complications were variables associated with long-term survival. Long-term survival in patients with pancreatic cancer after resection remains poor. Achieving a margin negative resection (R0) with no postoperative complications are prognostic variables that can be affected by the surgeon.

Ninety per cent of pancreatic cysts are inflammatory pseudocysts. The other 10 per cent are congenital or neoplastic and include congenital true cysts, retention cysts, lymphoepithelial cysts, the mucinous cystadenoma, mucinous cystadenocarcinoma, and serous microcystic cystadenomas and the more recently described intraductal papillary mucin-secreting neoplasms. The advent of computerized tomographic scanning, endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasonography (EUS) has brought many of these lesions to light when they are minimally symptomatic or are incidentally found while investigating unrelated problems. If there is any suspicion of actual or potentially malignant disease, then total excision of the lesion with part of or the entire pancreas is indicated to achieve a likely cure, as survival is better than for the more common ductal adenocarcinomas. There are few reliable preoperative studies to distinguish accurately the etiology and prognosis of this spectrum of cystic lesions, and usually the actual diagnosis is made only at the time of operation or histopathologic examination after the cystic lesion has been biopsied or excised. If a cyst is confirmed to be totally benign, as in the congenital true cyst, lymphoepithelial cyst, or a benign mucinous cyst, they may lend themselves to nonoperative observation or excision without sacrifice of pancreatic parenchyma. However, many mucin-producing cystic lesions may evolve into a dysplastic or invasive malignant lesion requiring more aggressive resective treatment, and it is important not to miss that diagnosis early when cure is still possible. This report presents four benign mucin-secreting cysts treated by local excision. All four were in the head of the pancreas and communicated with the main pancreatic duct and lacked ovarian-type stroma, thus categorizing them as side-branch intraductal papillary mucinous neoplasms. These lesions were able to be easily dissected out of the pancreas with only one patient developing a transient pancreatic fistula. Intraoperative and final histopathology confirmed the benign status, and these patients have remained disease free 3 to 5 years postoperatively. A review of benign tumors reported to have been treated by cyst enucleation in the literature confirms the rationale of this approach in highly selected lesions.

Bile reflux gastritis has been recognized since the first successful gastric operations and has persisted for more than a century. Diagnosis has been difficult and non-operative therapy largely ineffective. Early attempts at surgical correction resulted in stomal ulceration and it was not until the advent of flexible endoscopy and other techniques that diagnosis became more secure. Operative attempts at correction have included the Roux-en-Y procedure, the Braun enteroenterostomy, and Henley jejunal interposition. None of the procedures has been uniformly successful, and the Roux-en-Y has resulted in a disabling stasis syndrome in most patients. The diagnosis of bile reflux without previous gastric surgery has been even more elusive and seems to be associated with previous cholecystectomy. Thirty-one patients diagnosed with primary bile reflux, having typical symptoms of epigastric pain, nausea, and bilious vomiting have been treated by diverting bile flow through a Roux-en-Y choledochojejunostomy without accompanying gastric resection or vagotomy. There were no operative deaths and no long-term problems, such as anastomotic stricture. Two patients had self-limited bile leaks. Twenty-seven of the 31 patients (87%) have achieved complete relief of symptoms and have no gastrointestinal complaints. Serial gastric emptying has demonstrated no alteration in 9 of 12 patients who were normal before operation, and improvement in 12 of the 19 (63%) patients with abnormal preoperative studies.

Malpositioned peritoneal dialysis catheters may be repositioned laparoscopically with a testicular prosthesis used as an anchoring weight., Background: A 66-year-old male with a history of severe ischemic myopathy and renal failure underwent a combined heart and kidney transplant. Postoperative failure of the transplanted kidney eventually led to the need for peritoneal dialysis (PD). Methods: After one month, the PD catheter was laparoscopically repositioned after it was found to have migrated from its correct position in the pelvis and twisted and clogged in the omentum. After one more month, the same complication recurred. Laparoscopy was again used to clear the clogged catheter and reposition it. This time, a testicular prosthesis was sewn to the catheter and used as an anchoring weight for the proper position in the pelvis. Results: Six months after anchoring with the testicular prosthesis, the peritoneal dialysis catheter continues to function appropriately, and the patient has no complaints. Conclusions: Mal-positioned peritoneal dialysis catheters may be repositioned and anchored by using a testicular prosthesis in the event that weighted catheters are not available.

Primary bile reflux gastritis is an unusual and elusive problem. Postgastrectomy bile reflux has been long recognized and treated variously with Roux-en-Y gastrojejunostomy, Braun enteroenterostomy, and Henley jejunal interposition. All of these procedures have been fraught with postoperative side effects, the worst of which is stasis. A new procedure utilizing biliary diversion has been proposed to divert bile from the gastric lumen without vagotomy or gastric resection. This procedure was used for 16 patients with diagnosed bile reflux, and results were compared with those of a previous group of 21 patients who had been treated with Roux-en-Y gastrojejunostomy. The patient groups were similar in age, sex, weight, symptoms, and results of investigative studies. The earlier group all had vagotomy, antrectomy, and gastrojejunal anastomosis to a 45-cm Roux limb. The later group all had an end-to-side choledochojejunostomy to a 45-cm Roux limb, taken 45 cm from the ligament of Treitz. The patients in the bile diversion group had fewer complications and shorter hospital stays. In addition, they had few postoperative complaints, no further operations for either bile reflux or upper gastrointestinal stasis, and no long-term deaths due to gastrointestinal problems or malnutrition. Their eventual postoperative gastric emptying improved significantly when compared with the Roux-en-Y patients, suggesting that the dysmotility observed preoperatively may well have been a result of the bile injury to the stomach, rather than an underlying gastric dysmotility.

Background: The management of perforations after endoscopic sphincterotomy (ES) is controversial. The purpose of this study was to analyze the treatments and outcome of patients with ES perforations. Methods: Between January 1994 and July 1998, in a series of 6040 endoscopic retrograde cholangiopancreatographies, 2874 (48%) ESs were performed: 40 patients (0.6%) with perforation were identified and retrospectively reviewed. Results: All patients (n = 14) with guidewire perforation (group I) were recognized early, managed medically, and discharged after a mean hospital stay of 3.5 days. Twenty of 22 patients with periampullary perforation (group II) were identified early; 18 patients (90%) had aggressive endoscopic drainage, and none required operation. Of the 2 patients identified late, 1 patient required operation and subsequently died. Mean hospital stay for this group was 8.5 days. Only 1 of 4 patients with duodenal perforations (group III) was identified early; all required operation; 1 patient died, and the mean hospital stay was 19.5 days. Conclusions: ES perforation has 3 distinct types: guidewire, periampullary, and duodenal. Guidewire perforations are recognized early and resolve with medical treatment. Periampullary perforations diagnosed early respond to aggressive endoscopic drainage and medical treatment. Postsphincterotomy perforations diagnosed late (particularly duodenal) require surgical drainage, which carries a high morbidity and mortality rate. (Surgery 1999:126:658-65.)

Background. We initiated a pancreatic islet transplantation program using fresh, single-donor tissue. Methods. Group 1 (n=3) received cadaver kidney and islets from the same donor; islets were placed beneath the capsule of the transplanted kidney. Group 2 (n=6) received islets via percutaneous portal vein puncture subsequent to successful kidney transplant. Group 1 and 2 recipients had type 1 diabetes mellitus. Group 3 (n=6) received autologous islet transplantation after total or near-total pancreatectomy (for chronic pancreatitis and intractable pain). Implantation and graft function was considered successful if C-peptide exceeded 0.10 ng/ml. Sustacal challenge test was done before and after transplant at day 1, week 1, and months 1, 3, 6, and 12. We also measured glycated hemoglobin and insulin requirements at regular time intervals. Results. Post-Ficoll yield was 402,000 (SD 174,000) equivalent islet number, average purity of 67% (range, 50-90%). Group 1 had initial primary nonfunction followed by occasional evidence of C-peptide at months 3 and 6. Group 2 recipients had significant C-peptide levels early after transplantation which gradually declined over several months. However, all recipients had graft function at 6 months and 50% recipients still maintained graft function at 1 year. Group 3 recipients are off exogenous insulin (mean follow-up of 5.5 months). Insulin requirement was unchanged in group 1, while a reduction of approximately 20% was noted in four of six patients in group 2. Glycated hemoglobin was reduced in four out of six recipients of group 2, while in group 3, glycated hemoglobin remained within normal limits. Pain relief was sustained when patients (group 3) received total pancreatectomy ; near-total pancreatectomy resulted in recurrence of pain within 3 months. Conclusions. Autologous islet transplantation is uniformly successful ; total excision of pancreas was superior to partial pancreatectomy for pain relief. For allogeneic islet transplantation, the intrahepatic site is superior to the renal subcapsular site. Insulin independence was not achieved in allogeneic islet transplants ; however, continued graft function resulted in reduction of glycated hemoglobin in some recipients.

Background: Optimal treatment strategies for patients with external pancreatic fistulas have evolved with improved radiographic imaging and the development of transpapillary pancreatic duct stents. The aim of this study was to examine factors affecting fistula closure and develop a classification scheme to guide therapeutic interventions. Methods: Retrospective chart review was made of all patients with external pancreatic fistulas treated at our institution from January 1991 to January 1997. Side (partial) fistulas maintained continuity with the gastrointestinal tract; end (complete) fistulas had no continuity with the gastrointestinal tract. Results: Postoperative side fistulas resolved with medical treatment in 13 (86%) of 15 patients after a mean of 11 weeks of conservative management. Inflammatory side fistulas resolved with medical treatment in only 8 (53%) of 15 patients after a mean of 22 weeks; those that did not close initially did so with transpapillary stenting. End pancreatic fistulas never closed with medical treatment and were unable to be stented; therefore internal drainage or pancreatic resection was necessary to achieve closure. There were no differences in sepsis rates, Acute Physiology and Chronic Health Evaluation II scores, fistula site, total parenteral nutrition, somatostatin treatment, or initial fistula output between groups. Conclusions: Classifying external pancreatic fistulas as to their pancreatic duct relationship and cause provides important prognostic and therapeutic information. (Surgery 1998;124:627-33.)

Complicated pancreatic pseudocysts, including multiple pseudocysts, those that have failed prior internal or external drainage, those with associated biliary or pancreatic duct strictures, and those where the diagnosis of cystic neoplasm cannot be excluded, pose unique problems in terms of treatment by standard internal or external drainage techniques. In the series reported herein, pancreatic resection (pylorus-sparing pancreaticoduodenectomy or distal pancreatectomy) was used to treat patients with these complicated pseudocysts resulting in a 59% morbidity rate, 3% mortality rate, and 6% recurrence rate. Results from a collective series of 152 patients from the literature support these findings. Although pancreatic resection has a limited role in the management of patients with uncomplicated pancreatic pseudocysts, it is the treatment of choice in patients with complicated pancreatic pseudocysts.

Purpose: Smooth muscle cell (SMC) migration and proliferation are prominent features of intimal hyperplasia. Previous studies have shown that inhibition of c- myb inhibits arterial SMC proliferation. Our goal was to evaluate the effect of an antisense oligonucleotide targeted to c- myb on the proliferation and migration of SMC explanted from synthetic vascular grafts. Methods: SMCs were enzymatically removed from aortas and Dacron grafts explanted from dogs (n = 5). For proliferation studies, quiescent SMCs were incubated with either 0.0, 0.5, 5.0, or 10.0 μM antisense (GTGTCGGGGTCTCCGGGC) or sense (GCCCGGAGACCCCGACAC) oligonucleotides to c- myb . Proliferation was measured after 24 hours by incorporation of [ 3 H]thymidine. Migration was assessed 24 hours after a razor injury. Results: Antisense to c- myb consistently inhibited proliferation and migration of both native aortic and graft SMCs in a dose-dependent fashion. At a concentration of 10 μM antisense oligonucleotide, aortic and graft SMC proliferation rates were 32% ± 20% and 56% ± 9% of control samples, respectively. At 25 μM antisense, the number of migrating aortic and graft SMCs decreased to 41.9% ± 26.8% and 51.9% ± 34.1% of control samples, respectively. Conclusions: Our results suggest that antisense oligonucleotides to c- myb may be useful in the inhibition of SMC proliferation and migration associated with development of intimal hyperplasia. (J Vasc Surg 1996;23:783-91.)

Platelet-derived growth factor (PDGF) is a potent mitogen and chemotactic agent which may be involved in the formation of proliferative lesions of the arterial system, such as intimal hyperplasia and atherosclerosis. To examine the regional variation in vessel wall production of this mitogen, PDGF production and PDGF A chain mRNA expression by normal arterial wall was studied as a function of vessel location. PDGF production by canine aortic segments was measured after 72 h in organ culture, revealing significantly more PDGF produced by the distal compared to proximal aorta at 77 +/- 10 versus 14 +/- 6 pg/cm2/72 h (p0.05). Endothelial cells (EC) and smooth muscle cells (SMC), isolated from analogous aortic sites, were grown in tissue culture and the conditioned medium was assayed for PDGF. EC in vitro demonstrated a similar geographic trend in PDGF production (distal=1,501 +/- 389 pg/microgram DNA/72 h, proximal=759 +/- 230 pg/microgram DNA/72 h; p=0.17). PDGF production by SMC in cell culture had a similar pattern with cells from the distal aorta producing 58 +/- 28 pg PDGF/microgram DNA/72 h, compared to cells from the proximal aorta producing 37 +/- 15 pg PDGF/microgram DNA/72 h (p=0.13). Freshly harvested EC and SMC, isolated from the same aortic sites, were subjected to quantitation of PDGF mRNA levels using a coupled reverse transcriptase and polymerase chain reaction amplification method, with glyceraldehyde-phosphate dehydrogenase (GAPDH) as a control. The ratio of PDGF A chain:GAPDH mRNA was significantly greater in distal aortic SMC, 2.30 +/- 0.99, compared to proximal aortic SMC, 1.27 +/- 0.46 (p=0.05), but was not significantly different between proximal and distal aortic EC (p=0.86). These findings demonstrate significant regional differences in PDGF production in the normal canine aorta. Additionally, SMC are implicated as a significant contributor to the regional variation in PDGF production.

Background. Unlike chronic calcific pancreatitis, obstructive pancreatitis occurs as a consequence of an obstruction or stricture in the main pancreatic duct. The purpose of this paper is to identify the best method of surgical treatment for patients with obstructive pancreatitis. Methods. Retrospective analysis of 224 patients surgically treated for chronic pancreatitis during a 7-year period (1988 through 1994) identified 23 patients with obstructive pancreatitis. Patients were classified by surgical treatment into pancreaticoduodenectomy (five patients), side-to-side pancreaticojejunostomy (nine patients), or distal pancreatectomy (nine patients) groups and analyzed. Results. Despite similar demographics, patients treated with distal pancreatectomy had significantly better outcomes (seven of nine) than those treated with either pancreaticoduodenectomy (zero of four) or side-to-side pancreaticojejunostomy (two of eight) at a mean follow-up of 26 months (chi-squared, p=0.009). Multivariate analysis revealed stricture location, cause of pancreatitis, maximal duct dilatation, exocrine insufficiency, or continued alcohol intake had no influence on surgical outcome in this series (p=0.698, logistic regression analysis). Conclusions. At 2 years of follow-up, distal pancreatectomy provided superior relief from pain and recurrent pancreatitis compared with pancreaticoduodenectomy or side-to-side pancreaticojejunostomy. Obstructive pancreatitis is best treated by distal rather than proximal pancreatic resection or drainage.

Nonocclusive mesenteric ischemia (NOMI) is a poorly understood condition marked by progressive intestinal ischemia leading to infarction, sepsis, and death in a high proportion of patients. The mortality rate for this intestinal disorder remains high, even when the diagnosis is made early in the disease course. This paper presents a comprehensive review of NOMI with a detailed discussion of its history, pathophysiology, diagnosis, and treatment.

The past decade has seen an enormous increase in the number of bariatric, or weight loss, operations performed. This trend is likely to continue, mirroring the epidemic of obesity around the world and its rising prevalence among children. Bariatric surgery is considered by many to be the most effective treatment for obesity in terms of maintenance of long-term weight loss and improvement in obesity-related comorbid conditions. Although overly simplified, the primary mechanisms of the surgical interventions currently utilized to treat obesity are the creation of a restrictive or malabsorptive bowel anatomy. Operations based on these mechanisms include the laparoscopic adjustable gastric band and laparoscopic vertical sleeve gastrectomy (considered primarily restrictive operations), the laparoscopic biliopancreatic diversion with or without a duodenal switch (primarily malabsorptive operation), and the laparoscopic Roux-en-Y gastric bypass (considered a combination restrictive and selective malabsorptive procedure). Each operation has pros and cons. Important considerations, for the patient and surgeon alike, in the decision to proceed with bariatric surgery include the technical aspects of the operation, postoperative complications including long-term nutritional problems, magnitude of initial and sustained weight loss desired, and correction of obesity-related comorbidities. Herein, the pros and cons of the contemporary laparoscopic bariatric operations are reviewed and ongoing controversies relating to bariatric surgery are discussed: appropriate patient selection, appropriate operation selection for an individual patient, surgeon selection, and how to measure success after surgery.

Advances in imaging, minimally invasive techniques, and regionalization have changed pancreatic surgery. Therefore, the aims of this report are to determine whether the pancreatic operations or the spectrum of disease have evolved at a high-volume center.From 1996 through 2009, 2,004 pancreatic operations were performed at Indiana University Hospital. The operations, pathology, and outcomes for 1996-2003 were compared with 2004-2009.In 2004-2009, more operations/year were performed (215 vs 89; P.01) and patients were older (58.8 years vs 55.8 years; P.01). In recent years, more pancreatoduodenectomies (55.0% vs 50.4%) and fewer pancreatojejunostomies (6.2% vs 12.6%) and Beger/Frey procedures (2.6% vs 4.8%) were performed (P.05). In 2004-2009, pylorus preservation (81.1% vs 64.4%), laparoscopic distal pancreatectomy (33.9% vs 0%), and splenic preservation (25.3% vs 2.2%) were carried out more frequently (P.001). Pathology review revealed more tumors (68.8% vs 60.4%) and less pancreatitis (29.2% vs 34.4%; P.01). Thirty-day mortality improved from 2.5% to 1.8%.At a high-volume pancreatic surgery center, the number and age of the patients, the percentage of pancreatic resections, preservation of the pylorus and spleen as well as laparoscopic procedures, and the percentage of patients with tumors all have increased, whereas the outcomes continued to improve.

Mesh hernioplasty is the preferred surgical procedure for large abdominal wall hernias. Infection remains one of the most challenging complications of this operation. Salvaging infected prosthetic material after ventral hernia repair is rarely successful. Most cases require mesh excision and complex abdominal wall reconstruction, with variable success rates. In this article, we report 3 cases of mesh salvage after laparoscopic ventral herniorrhapy with a novel use of percutaneous drainage and antibiotic irrigation.Three patients developed infected seromas after laparoscopic ventral hernia repair. The fascial defect of the first patient was repaired with a commercially available 20 x 18 cm polytetrafluoroethylene (PTFE) mesh. A complex fluid collection developed the following month in the anterior abdominal wall overlying the patient's mesh. The cultures grew Staphylococcus aureus. The second patient had a 30 x 20 cm PTFE mesh placed, which developed a fluid collection with Enterococcus faecalis and Escherichia coli. The third case underwent repair, using a another commercially available 22 x 28 cm PTFE mesh. A fluid collection measuring 20 x 10 cm in the anterior abdominal wall developed, growing Staphylococcus lugdunensis. In all 3 cases, a percutaneous drain was placed within the fluid collection and long-term intravenous (i.v.) access was obtained. I.v. antibiotics were initiated. In addition, gentamicin (80 mg) with 20 mL of saline was infused through the drain 3 times a day. All patients have remained free of clinical signs of infection following the completion of therapy.Infected mesh after laparoscopic ventral herniorrhapy without systemic sepsis may be amenable to nonoperative treatment. A conservative approach that includes percutaneous drainage followed by antibiotic irrigation is a potential alternative to prosthetic removal in carefully selected patients. Further evaluation of this technique is warranted to define the most appropriate management strategies for these patients.

We evaluated 224 consecutive patients referred for severe constipation prospectively by strict criteria to determine their candidacy for subtotal colectomy. Eighteen patients had insufficient symptoms to warrant evaluation. Two hundred six patients had anorectal manometry and defecography, and 182 had colonic transit measurement. Forty-nine patients had normal or minimally abnormal studies. One-hundred twenty-nine patients had abnormalities such as outlet obstruction, mild colonic inertia, diffuse gut dysfunction, or combinations of factors not favoring subtotal colectomy. Twenty-eight patients had colonic inertia without outlet obstruction and with disabling symptoms; 19 of these patients underwent subtotal colectomy. Follow-up > or = 12 months was available in 14 patients from this group. Of these patients, 12 (86%) were clinically improved. Preoperative evaluation accurately predicted postoperative fecal incontinence and likely reduced postoperative constipation. Small-bowel obstruction occurred postoperatively in 4 patients (29%), and remains a major risk of subtotal colectomy even in carefully selected candidates.

This article reviews the use of minimally invasive surgical and endoscopic techniques in the field of surgical oncology. It reviews the indications and techniques of the use of minimally invasive surgery for several oncologic indications in general surgery. In particular, it reviews the currently published literature discussing the oncologic outcomes of these techniques.

Pancreatic fistula continues to be a common complication following PD. This study seeks to identify clinical factors which may predict pancreatic fistula (PF) and evaluate the effect of PF on outcomes following pancreaticoduodenectomy (PD). We performed a retrospective analysis of a clinical database at an academic tertiary care hospital with a high volume of pancreatic surgery. Five hundred ten consecutive patients underwent PD, and PF occurred in 46 patients (9%). Perioperative mortality of patients with PF was 0%. Forty-five of 46 PF (98%) closed without reoperation with a mean time to closure of 34 days. Patients who developed PF showed a higher incidence of wound infection, intra-abdominal abscess, need for reoperation, and hospital length of stay. Multivariate analysis demonstrated an invaginated pancreatic anastomosis and closed suction intraperitoneal drainage were associated with PF whereas a diagnosis of chronic pancreatitis and endoscopic stenting conferred protection. Development of PF following PD in this series was predicted by gender, preoperative stenting, pancreatic anastomotic technique, and pancreas pathology. Outcomes in patients with PF are remarkable for a higher rate of septic complications, longer hospital stays, but in this study, no increased mortality.

Background and aims Recent studies have shown an association between obstructive sleep apnea (OSA) and elevated liver enzymes in patients with nonalcoholic fatty liver disease (NAFLD). The aim of the current study was to compare biochemical and histologic findings in patients with NAFLD as a function of OSA status. Methods Subjects consisted of 85 patients who had a sleep study followed by a liver biopsy performed at the time of obesity surgery. The diagnosis of OSA was based on an apnea hypopnea index of >/=15. Demographic and laboratory data were collected retrospectively. Liver biopsies were systematically evaluated for features of NAFLD including degree of steatosis, inflammation, and fibrosis. Results All but one patient had histologic evidence of NAFLD and 51% of the study population had OSA. A higher proportion of patients with OSA had elevated alanine aminotransferase levels (13/39) compared with those without OSA (3/34) (P=0.01). Only 19% of subjects had fibrosis on liver biopsy and still fewer (5%) had bridging fibrosis or cirrhosis. There was a trend toward a higher prevalence of OSA in patients with evidence of progressive liver disease, as indicated by inflammation plus fibrosis (11/15), compared with those with inflammation alone (22/48) (P=0.06). Conclusions In obese patients with NAFLD, OSA was associated with elevated alanine aminotransferase levels and a trend toward histologic evidence of progressive liver disease.

Sphincter of Oddi dysfunction and pancreas divisum are very distinct anatomic abnormalities, yet are diagnosed in similar clinical situations. While both entities are uncommon, they are most often discovered during the evaluation of postcholecystectomy syndrome, recurrent idiopathic pancreatitis, and biliary or pancreatic pain when first line studies are normal. Treatment consists of surgical sphincteroplasty or endoscopic sphincterotomy for both diagnoses, which result in reliable relief of symptoms for most sphincter of Oddi dysfunction patients but less predictable response in pancreas divisum.

The aim of this study was to correlate the bactibilia found after preoperative biliary stenting with that of the bacteriology of postoperative infectious complications in patients with obstructive jaundice. One hundred thirty-eight patients (83% malignant and 17% benign etiologies) with obstructive jaundice had both their bile and all postoperative infectious complications cultured. Eighty-six (62%) had preoperative biliary stents (stent group) and 52 (38%) did not (no-stent group). There were no differences for age, sex, incidence of malignancy, type of operation, estimated blood loss, transfusion requirements, hospital length of stay, morbidity, or mortality rates between the two groups. Of 31 infectious complications, 23 were in the stent group and eight were in the no-stent group (P > 0.05), but only 13 (42%) infectious complications had bacteria that were also cultured from the bile. Only wound infection (P = 0.03) and bacteremia (P = 0.04) were more likely to occur in stented patients. Taken together, these data show that preoperative biliary stenting increases the incidence of bactibilia, bacteremia, and wound infection rates but does not increase morbidity, mortality, or hospital length of stay. Jaundiced patients can undergo preoperative biliary stenting while maintaining an acceptable postoperative morbidity rate.

Background Accurate preoperative detection and staging of pancreatic cancer may identify patients with locoregional disease that is amenable to surgical resection. Objective To compare endoscopic ultrasonography and multidetector computed tomography (CT) for the detection, staging, and resectability of known or suspected locoregional pancreatic cancer. Design Prospective, observational, cohort study. Setting Single, tertiary referral hospital in Indianapolis, Indiana. Patients 120 participants with known or suspected locoregional pancreatic cancer. Interventions Endoscopic ultrasonography followed by multidetector CT was performed in all patients. Patients with known or suspected pancreatic cancer deemed potentially resectable by 1 or both tests were considered for surgery. Measurements Detection, staging, and resectability of pancreatic cancer. Surgically resected pancreatic cancer with negative microscopic histologic margins was considered resectable. Results Of 120 patients enrolled, 104 (87%) underwent endoscopic ultrasonography and CT. Of the 80 patients with pancreatic cancer, 27 (34%) were managed nonoperatively, and 53 (66%) treated surgically had resectable (n = 25) or unresectable (n = 28) cancer. For the 80 patients with cancer, the sensitivity of endoscopic ultrasonography (98% [95% CI, 91% to 100%]) for detecting a pancreatic mass was greater than that of CT (86% [CI, 77% to 93%]; P = 0.012). For the 53 surgical patients, endoscopic ultrasonography was superior to CT for tumor staging accuracy (67% vs. 41%; P 0.2). Of the 25 resectable pancreatic tumors in patients recommended for surgery, endoscopic ultrasonography and CT correctly identified 88% and 92%, respectively, as resectable. Of the 28 unresectable pancreatic tumors in patients recommended for surgery, endoscopic ultrasonography and CT correctly identified 68% and 64%, respectively, as unresectable. Limitations Radiologists who read the scans and endosonographers were not blinded to previous radiographic information. Because of the modest sample size, CIs of the sensitivity estimates were sometimes wide. Conclusion Compared with multidetector CT, endoscopic ultrasonography is superior for tumor detection and staging but similar for nodal staging and resectability of preoperatively suspected nonmetastatic pancreatic cancer.

Background Inguinal nerve entrapment is a debilitating postoperative problem. Patients and methods One hundred patients were treated for inguinal nerve entrapment, including 52 men and 48 women with an average age of 45 ± 14 years. Most patients had inguinal hernia repairs or Pfannenstiel incisions. Mesh was found in 27% of patients. Symptoms included pain (100%), radiation of pain to the thigh and/or genital area (59%), and postural pain (59%). Diagnosis was made by physical examination, postural maneuvering, and inguinal nerve block. Proximal nerve resection was followed by Mersiline (Ethicon, Inc., Somerville, NJ) ligature and absolute alcohol or phenol application to prevent neuromas. Results Five percent of patients had minor complications. There was abnormal nerve histopathology in 18%. Total pain relief was attained in 72% of patients, partial relief in 25%, and no relief in 3%. Two patients complained of numbness postoperatively. Multifactorial analysis showed recurrent hernia repair as a significant predictive factor.