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Abstract: Background: Obstructive sleep apnea (OSA) is prevalent in the morbidly obese population. The need for routine preoperative testing for OSA has been debated in bariatric surgery publications. Most investigators have advocated the use of continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) in the postoperative setting; however, others have reported pouch perforations or other gastrointestinal complications as a result of their use. From a review of our experience, we present an algorithm for the safe postoperative treatment of patients with OSA without the use of CPAP or BiPAP. Methods: From January 2003 to December 2007, 1095 laparoscopic Roux-en-Y gastric bypasses were performed at our institution. Preoperative testing for OSA was not routinely performed. A prospective database was maintained. The data included patient demographics, co-morbidities (including OSA and CPAP/BiPAP use), perioperative events, complications, and follow-up information. Patients with known OSA were not given CPAP/BiPAP after surgery. They were observed in a monitored setting during their inpatient stay, ensuring continuous oxygen saturation of >92%. All patients used patient-controlled analgesia, were trained in the use of incentive spirometry, and ambulated within a few hours of surgery. The outcomes were compared between the OSA patients using preoperative CPAP/BiPAP versus those with OSA without preoperative CPAP/BiPAP versus patients with no history of OSA. Results: A total of 811 patients were included in the study group with no known history of OSA. Of the 284 patients with a confirmed diagnosis of OSA, 144 were CPAP/BiPAP dependent. Statistically significant differences were present in age distribution and gender, with men having greater CPAP/BiPAP dependency. No significant differences were found in body mass index, length of stay, pulmonary complications, or deaths. One pulmonary complication occurred in the OSA, CPAP/BiPAP-dependent group, three in the OSA, non-CPAP group, and six in the no-known OSA group. No anastomotic leaks or deaths occurred in the series. Conclusion: Postoperative CPAP/BiPAP can be safely omitted in laparoscopic Roux-en-Y gastric bypass patients with known OSA, provided they are observed in a monitored setting and their pulmonary status is optimized by aggressive incentive spirometry and early ambulation. [Copyright &y& Elsevier]

A letter to the editor is presented in response to an article about oblique excision and primary closure of pilonidal disease published in previous issue.

Background and Objectives: Hepatic artery chemoembolization (HACE) used to treat neuroendocrine tumors metastatic to the liver has shown both survival benefit and improvement in symptoms. The development of hepatic necrosis after HACE is rare, but the consequences can be devastating. We report the first case of laparoscopic management of extensive hepatic necrosis occurring after HACE., Case Report: A 58-year-old man with neuroendocrine tumor metastatic to the liver underwent HACE in addition to medical management. He had undergone previous biliary stenting for biliary obstruction. After HACE was performed via the right hepatic artery, the patient developed sepsis due to right hepatic lobe infarction. Percutaneous drainage and antibiotics were attempted for 2 months, but hepatic debridement was ultimately required due to repeated drain malfunction and septic complications. Laparoscopic necrosectomy was performed with ease and with little blood loss. The patient quickly recovered without any further infectious complications., Conclusion: Infected hepatic necrosis resulting from HACE that fails percutaneous management can be successfully managed with laparoscopic necrosectomy. This report adds to the growing evidence that minimally invasive techniques can be used to manage complicated hepatic conditions.