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Objective To investigate whether there was a difference in morbidity, recurrence rate, and length of hospital stay between patients undergoing open or laparoscopic incisional hernia repair. Design and Setting Single-institution cohort study. We compared prospectively collected patient cohorts undergoing laparoscopic or open intraperitoneal onlay mesh repair. Statistical analysis was performed by Fisher exact test and analysis of variance. Patients Between October 1995 and December 2005, data from 360 consecutive patients who had undergone open or laparoscopic intraperitoneal onlay mesh repair of a ventral hernia were prospectively collected in a database and were supplemented by record review. Main Outcome Measures Morbidity, hernia recurrence, and length of hospital stay. Postoperative complications of Clavien grade II or greater were considered major complications. Results Intraperitoneal onlay mesh repair was performed in 233 patients by the open approach and in 127 patients using the laparoscopic approach. The groups were similar for sex and body mass index (calculated as the weight in kilograms divided by the height in meters squared); the mean age of the laparoscopic group was 3 years younger; and the mesh was larger in the laparoscopic group. Mean follow-up was 30 and 36 months for the laparoscopic and open groups, respectively; the conversion rate was 4%. Major morbidities were 15% in the open group vs 7% in the laparoscopic group ( P = .01). Recurrence rates were 9% in the open group vs 12% in the laparoscopic group ( P = .36). Postoperative inpatient admission was more frequent after the open procedure than after the laparoscopic procedure (28% vs 16%, respectively; P Conclusions Outcomes did not differ with respect to recurrence rates after long-term follow-up; however, the lower rate of major morbidity and increased outpatient-based procedure rates favor laparoscopic repair in this study.

Hypothesis Laparoscopic cholecystectomy (LC) has known physiological benefits and positive socioeconomic effects over the open procedure. Although recent studies have questioned the technique's efficacy in elderly patients (>65 years), we hypothesize that LC is safe and efficacious in that patient group. Methods Five thousand eight hundred eighty-four consecutive patients (mean age, 40 years; 26% male) underwent an attempted LC (conversion rate, 5.2%) from 1991 to 2001 at a teaching institution. Of these, 395 patients (6.7%) were older than 65 years. Analysis included patient age, sex, American Society of Anesthesiologists classification, conversion rate, morbidity, mortality, and assessment of results over time. Results Elderly patients were predominantly male (64%). Septuagenarians had a 40% incidence of complicated gallstone disease, such as acute cholecystitis, choledocholithiasis, or biliary pancreatitis, and octogenarians had a 55% incidence. Overall mortality was 1.4%. The conversion rate was 17% for the first 5 years of the study period and 7% for the second half. The conversion rate was 22% for patients with complicated disease and 2.5% for patients with chronic cholecystitis. Average hospital stay decreased from 10.2 days to 4.6 days during the first and second half of the study period, respectively. Conclusions The results of LC in patients aged 65 to 69 years are comparable with those previously reported in younger patients. Patients older than 70 years had a 2-fold increase in complicated biliary tract disease and conversion rates, but a low mortality rate (2%) compared with results of other authors (12%), despite an increase in American Society of Anesthesiologists classification. Increased technical experience with LC favorably affected outcomes over time. Early diagnosis and treatment prior to onset of complications are necessary for further improvement in the outcomes of elderly patients undergoing LC.

The incidence of gallstone disease in patients with cirrhosis is greater than that in healthy patients. Previous surgical literature reported greater morbidity and mortality in patients with cirrhosis with both open and laparoscopic cholecystectomy (LC). We compared our recent experience with LC in patients with cirrhosis and controls. A retrospective review was performed using the search terms, “cirrhosis” and “laparoscopic cholecystectoaiy” Forty-eight patients with cirrhosis were identified and randomly matched with healthy controls by age and sex. Four controls were assigned per patient with cirrhosis. Outcomes assessed included mortality, duration of surgery, length of hospital stay, blood transfusion requirement, postoperative complications, and need for conversion to open cholecystectomy. Forty-eight patients with cirrhosis and 187 healthy controls underwent LC. Child-Pugh classification of severity of liver disease was as follows: Child's class A, 38 of 48 patients; Child's class B, 10 of 48 patients; and Child's class C, 0 of 48 patients. Patients with cirrhosis had statistically significantly lower albumin levels (P = .0001) and prolonged prothrombin times (P = .05). Average duration of surgery for patients with cirrhosis was 1.71 versus 1.57 hours (P = .57) for controls. Average length of hospital stay for patients with cirrhosis was 6.47 versus 4.77 days (P = .152) for controls. Average number of units of blood transfused in patients with cirrhosis was 0.156 versus 0.0 units (P = .025) in controls. Complications occurred in 6 of 48 patients with cirrhosis (12.5%) and 8 of 187 controls (4.2%; P < .05). No child's class C patient underwent LC. Four patients with cirrhosis (8.3%) and no controls were converted to open cholecystectomy. No postoperative infections were noted. There was no mortality in either group. LC in patients with Child's class A and B cirrhosis is reasonably safe and shows no increase in morbidity or mortality or worsening of outcome. Further studies are required to evaluate the management of acute gallbladder disease in Child's class C patients.

Objective To evaluate the efficacy and safety of a combined approach to the treatment of biliary pancreatitis using laparoscopic cholecystectomy and selective endoscopic retrograde cholangiopancreatography (ERCP). Design Consecutive case series. Setting Tertiary care center. Patients All patients undergoing primary operations for biliary pancreatitis during 2 time periods were included. In the open era (June 1982 through May 1988), there were 276 patients; in the laparoscopic era (January 1996 through June 1997), there were 114 patients. Interventions Open cholecystectomy with or without common bile duct exploration (CBDE); laparoscopic cholecystectomy with selective ERCP and/or laparoscopic CBDE. Main Outcome Measures Two periods were compared for morbidity, mortality, the duration of preoperative and postoperative stays, and the total length of hospitalization. Results Both groups were demographically similar and had the same mortality (1.9%). Laparoscopic cholecystectomies provided a preoperative stay comparable to open cholecystectomy (6.4 vs 5.8 days), a shorter postoperative stay (1.5 vs 8.5 days), a lower incidence of CBDE (6.6% vs 26%), and a lower morbidity (8% vs 13.7%). The addition of an ERCP to laparoscopic cholecystectomy was associated with prolongation of the preoperative stay (7.4 vs 5.0 days), a comparable postoperative stay, a lower conversion rate (7.5% vs 13%), and fewer CBDEs (3% vs 13%). In 27 (42%) of the 64 ERCP cases, no stones were found. Conclusions Treatment of biliary pancreatitis with combined laparoscopic cholecystectomy and selective ERCP is safe and effective and is associated with a shorter hospitalization and fewer CBDEs than open cholecystectomy. Unnecessary ERCPs can be reduced by improved selection criteria or greater dependence on operative CBDE.

BACKGROUND Subepithelial lesions are incidentally found during routine endoscopy of the gastrointestinal (GI) tract. Endoscopic ultrasonography (EUS) has become the preferred non-invasive technique in evaluating these subepithelial lesions. It is assumed that it provides valuable information such as size, echotexture, layer of origin and features of invasion which may correlate with a particular histopathological diagnosis. Available published data seems to indicate that there is an incongruency between sonographic diagnosis and the actual surgical pathology of gastric subepithelial lesions with a reported accuracy that ranges between 20% and 84%. AIM To compare the diagnosis suggested by sonographic evaluation of various subepithelial lesions throughout the GI tract with the histological description of tissue specimens obtained by endoscopic mucosal resection (EMR). METHODS Patients who underwent endoscopic mucosal resection for a suspected subepithelial lesion were retrospectively identified from 2009 to 2012 at two university hospitals. The diagnosis made at the time of the endoscopic ultrasound prior to EMR was compared with the diagnosis made from the specimen obtained after EMR. RESULTS Twenty-three patients (12M, 11F) with a mean age of 58yrs (range 36 -82 yrs) were identified who underwent both EUS and EMR for subepithelial lesions of the GI tract. The location of the lesions were: esophagus 1, stomach 13, duodenum 6, rectum 3. EUS based diagnosis was only 61% accurate when compared with the histopathological diagnosis obtained via EMR. (Table 1) CONCLUSION Except for the rectum, there is poor correlation between the sonographic and histopathological diagnosis of subepithelial lesions of the GI Tract. Based on these findings, clinical decision making protocols that rely solely on endoscopic sonographic findings for pathologic diagnosis are flawed and may lead to unnecessary surgical procedures. All subepithelial lesions of the GI Tract should undergo endoscopic mucosal resection for a definitive histopathological diagnosis to direct appropriate treatment.

The efficacy of meropenem was compared to that of the combination of tobramycin plus clindamycin (TIC) in a multiinstitutional clinical trial of treatment for patients suffering intraabdominal infection. Among the 177 patients enrolled and randomized, 127 were clinically evaluable and 86 were microbiologically evaluable. Analysis of data on an intent-to-treat basis for all randomized patients and on the basis of a successful outcome (absence of any infection) for clinically evaluable patients failed to detect any difference in efficacy between the two treatments. Infection was cleared in 92% of meropenem- and 89% of T/C-treated clinically evaluable patients. Eradication of pathogens also was similar in the two treatment groups. Overall, adverse drug experiences were comparable between the two treatment groups, with the exception of an increase in serum creatinine level (which occurred more frequently in patients receiving TIC). Meropenem appears to be efficacious for the treatment of intraabdominal infections.

Hypothesis A selective surgical approach using either a 1- or a 2-stage resection is relatively safe and effective in the management of acute complicated colonic diverticulosis. Design A consecutive cohort study. Setting A university hospital. Patients Eighty-nine consecutive patients who underwent emergency operations for diverticular disease between July 1, 1984, and June 30, 1999. There were 53 male and 36 female patients (mean age, 47 years). The ethnic background was predominantly Mexican American (58 patients [65.2%]). Interventions Resections of the affected colon (n=83) plus construction of a Hartmann pouch or mucous fistula (n=72) or primary anastomosis (n=11). Main Outcome Measures Morbidity, mortality, and length of hospital stay. Results Sixty-eight operations were performed for perforation at an annual rate that has increased greater than 75% in the past 15 years. Another 14 patients underwent operations for obstruction, and 7 underwent operations to control unremitting hemorrhage. Surgical therapy included resection of the affected segment of the bowel in 83 (93%) of the 89 patients, and a Hartmann pouch or mucous fistula was added in 72 (81%). A primary anastomosis was performed in 4 (80%) of 5 right-sided lesions but in only 7 (8%) of 84 left-sided lesions. Morbidity occurred in 38 (43%) of the 89 patients, and the mortality was 4%, with 4 deaths occurring secondary to sepsis in high-risk patients with perforations (n=3) or obstructions (n=1). The average length of hospital stay was 19.7 days (range, 5-80 days). Conclusions Emergency operations for diverticular disease are uncommon but may be associated with substantial morbidity and occasional mortality. Complicated diverticulosis may present at a relatively young age, and perforated forms appear to be increasing rapidly in prevalence. Most diverticular lesions can be satisfactorily managed using a selective approach based on resection with either a primary anastomosis or a temporary colostomy.

Pancreatic islet peptides, as well as other gastrointestinal hormones, have been implicated in both the pathogenesis of obesity and the etiology of associated metabolic derangements. This study evaluated the pancreatic islet and gastrointestinal (GI) hormone response to oral glucose in 20 morbidly obese (151% above ideal body weight) patients. Glucose intolerance, hyperinsulinism, and exaggerated gastric inhibitory polypeptide (GIP) release occurred following glucose ingestion. Significant release of PP occurred in 14 patients, while only six patients had release of somatostatin. No significant changes in plasma concentrations of glucagon occurred. Since GIP is insulinotropic in the presence of hyperglycemia, the hyperinsulinism of morbid obesity may be secondary to the abnormally high glucose-stimulated GIP levels in these patients. Failure of glucagon suppression in response to oral glucose many contribute to the hyperglycemia noted. Somatostatin and pancreatic polypeptide may be responsible for some of the metabolic derangements of morbid obesity.