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Background Carbon dioxide pneumoperitoneum during laparoscopy changes cardiorespiratory physiology and contributes to post-op pain. We studied outcomes before and after implementing low-pressure pneumoperitoneum QI project. Methods Forty-two patients were insufflated at standard pressures (15 mmHg) while 41 were insufflated using low (8-12 mmHg) during laparoscopic procedures. These variables were obtained from the patient chart: pain scores, intravenous morphine milligram equivalents (MME), peak inspiratory pressures (PIP), end-tidal CO2 (EtCO2), surgery duration, and patient demographics. The study was conducted after IRB approval. Results Low-pressure pneumoperitoneum is feasible and the surgeon can increase to 10-12 mmHg as needed. The mean post-op IV MME was significantly decreased in the low-pressure group (11.75 ± 10.41) compared to the standard pressure group (17.36 ± 18.1) (t-test, P = .047). Mean peak inspiratory pressures during insufflation were significantly higher for procedures conducted at standard pressure (31.40 ± 4.82) compared to the 8 mmHg (24.68 ± 4.19) and 12 mmHg (27.33± 3.85) low pressure groups (one-way ANOVA, P < .0001). During insufflation, there was a significant increase in the average EtCO2 in the standard pressure group (42.07 ± 5.60) compared to the 8 mmHg low pressure group (37.59 ± 5.05) (ANOVA, P = .0096). Constant flow insufflation was more likely to be performed at low pressure than demand mode (58% v. 33%). Conclusion Low pressure pneumoperitoneum decreases PIP pressure and CO2 absorption evidenced by lower ETCO2 intra-operatively. Patients have significant improvement in postoperative pain evidenced by decreased narcotics needed. Low pressure pneumoperitoneum using a constant flow insufflator is safe and results in improved patient outcomes.

In 1982 Dean Warren delivered the presidential address “Not for the Profession… For the People” in which he identified substandard surgical residency programs graduating residents who were unable to pass American Board of Surgery exams. Drs. Warren and Shires as members of the independent ACGME began to close the substandard programs in order to improve surgical care for average Americans i.e. “for the people”. By 2003 these changes dramatically reduced the failure rate for the ABS exams and trained good surgeons who could operate independently however the residents were on duty for every other or every third night. In 2003 the ACGME mandated duty hour restrictions in order improve resident wellness and improve the training environment for the profession. However, work hour restrictions reduced the time surgical residents spent in the hospital environment primarily when residents had more autonomy and had exposure to emergency cases which degraded readiness for independent practice. Surgical educators in the 2 decades after the work hour restrictions have improved techniques of training so graduates could not only pass the board exams but also be prepared for independent practice. Surgical residency training has improved by both the changes implemented by the independent ACGME in 1981 and by the work hour restrictions mandated in 2003. Five recommendations are made to ensure that Dr Warren's culture of excellence in surgical training continues in an environment that enhances wellbeing of the trainee i.e. “For the People and the Profession”.

Purpose: Recently, poor function after Hirschprung Surgery has become more common. We hypothesized that accurate construction of the anorectal cuff and inclusion of certain technical in the procedure elements would correlate with improved long-term function.Methods: Anoscopy was performed on dysfunctional patients to measure the Anorectal cuff assigning a cuff score (CS) to assess the distance from the dentate line to the suture line. Using content analysis, a blinded observer abstracted nine originally described technical elements from operative reports. Function was evaluated from 1-3 years post-operative and classified as a) normal bowel function (NBF), b) constipation or c) incontinence. The outcomes were recorded as a function of each technical element found in the operative report.Results: CS in 12 incontinent and 8 constipated patients measured 8.75[0-22) and 60.77 (32-160) respectively. 92 operative reports were reviewed resulting in 58 patients being included. Overall, NBF was found in 36 (62%), 11 (20%) had constipation and 11 (20%) had incontinence. The presence of 5 elements in the operative reports corelated with NBF. When all 5 were documented, 23/26 (89%) reported NBF while if none were recorded only 3/19 (16 %) had NBF. Conclusion: Low CS (32mm) is associated with constipation. Procedural components identified by content analysis are key to preventing incontinence.

Purpose: Recently, poor function after Hirschprung’s Surgery has become more common. We hypothesized that accurate construction of the anorectal cuff and inclusion of certain technical elements would correlate with improved long-term function.Methods:: Anoscopy was performed in dysfunctional patients to measure Anorectal cuff area (CA) reported as the distance from the dentate line to the suture line. Using content analysis, a blinded observer abstracted nine technical elements from operative reports. Function was recorded from 1-3 years post-operative and classified as a) normal bowel function (NBF), b) constipation or c) incontinence. The association the outcomes was determined for each technical element.Results: CA in 12 incontinent and 8 constipated patients measured 8.75mm2 [0-22) and 60.75mm2 (32-160) respectively. 92 charts were reviewed resulting in 58 patients. NBF was found in 36 (62%), 11 (20%) had constipation and 11 (20%) had incontinence. 5 elements in the operative reports corelated with NBF. When all 5 were documented, 23/26 (89%) reported NBF while if none were recorded only 3/19 (16 %) had NBF. Conclusion: Short CA (2) is associated with incontinence while long CA (>32mm2) is associated with constipation. Procedural components identified by content analysis are key to provide an optimal anorectal cuff preventing incontinence.

Background Acute mesenteric ischemia represents a life-threatening gastrointestinal condition. A noninvasive diagnostic modality that identifies mesenteric ischemia patients early in the disease process will enable early surgical intervention. Previous studies have identified significant changes in the small-bowel electrical slow-wave parameters during intestinal ischemia caused by total occlusion of the superior mesenteric artery. The purpose of this study was to use noninvasive biomagnetic techniques to assess functional physiological changes in intestinal slow waves in response to partial mesenteric ischemia. Methods We induced progressive intestinal ischemia in normal porcine subjects (n = 10) by slowly increasing the occlusion of the superior mesenteric artery at the following percentages of baseline flow: 50%, 75%, 90%, and 100% while simultaneous transabdominal magnetoenterogram (MENG) and serosal electromyogram (EMG) recordings were being obtained. Results A statistically significant serosal EMG amplitude decrease was observed at 100% occlusion compared with baseline, whereas no significant change was observed for MENG amplitude at any progressive occlusion levels. MENG recordings showed significant changes in the frequency and percentage of power distributed in bradyenteric and normoenteric frequency ranges at 50%, 75%, 90%, and 100% vessel occlusions. In serosal EMG recordings, a similar percent power distribution (PPD) effect was observed at 75%, 90%, and 100% occlusion levels. Serosal EMG showed a statistically significant increase in tachyenteric PPD at 90% and 100% occlusion. We observed significant increase in tachyenteric PPD only at the 100% occlusion level in MENG recordings. Conclusions Ischemic changes in the intestinal slow wave can be detected early and noninvasively even with partial vascular occlusion. Our results suggest that noninvasive MENG may be useful for clinical diagnosis of partial mesenteric ischemia.

Dr Dean Warren was born in 1924 and died prematurely from cancer in 1989. He was a man of uncommon intelligence, wit, collegiality, integrity, honesty, and a true leader in American surgery. In 1966, he and his colleagues (Drs Zeppa and Fomon) presented a new concept for surgical shunts to control variceal hemorrhage while maintaining portal perfusion or hepatopetal blood flow. He termed this new shunt the distal splenorenal shunt (DSRS), which was the first selective shunt invented. The DSRS selective shunt was a brilliant improvement over the total shunt concept proposed by Nicolai Eck and was practiced worldwide during the 1980s. In a space of 2 decades, Dr Warren’s pioneering work would show that the selective DSRS was superior to total shunts for treatment of portal hypertension, but that endoscopic sclerotherapy was a better first-line treatment for variceal hemorrhage than his own creation. His absolute adherence to the principles he espoused in his presidential address to the Society for Surgery of the Alimentary Tract in 1973 were employed in his research and treatment of patients. This paper details Dr Warren’s extraordinary research accomplishments and sets a lesson for us that well-designed clinical trials including randomization are essential in the advancement of the care of surgical patients.

We have recently introduced laparoscopic magnetic sphincter augmentation (MSA) combined with hiatal hernia repair for treatment of patients with medically refractory gastroesophageal reflux disease (GERD). MSA is a novel surgical approach to the treatment of severe GERD, in which magnetic beads are secured around the lower esophageal sphincter, augmenting the lower esophageal sphincter function as an anti-reflux barrier. We hypothesize that patients undergoing MSA will achieve GERD relief, equal to that obtained after laparoscopic Nissen fundoplication. The GERD Health Related Quality of Life (GERD HRQL) Questionnaire is a validated clinical tool that was used to quantify patient outcomes in terms of GERD-related symptoms both on and off proton pump inhibitors and after acute radiation syndrome. We retrospectively reviewed data from patients at our institution enrolled in a prospective institutional review board–approved database “Registry Outcomes Anti-Reflux Surgery” that applies objective and subjective information about patients undergoing anti-reflux surgery. Information from both the database and patient HRQL scores were used to compare the effectiveness of medical intervention with acute radiation syndrome (laparoscopic Nissen fundoplication and MSA) in decreasing GERD-related symptoms in patients. Results are expressed as mean ± SE, and single-factor ANOVA test was used to compare groups. We found that MSA and laparoscopic fundoplication both lead to a comparable decrease in HRQL score and an increase in patient satisfaction when compared with patient's preoperative symptoms with maximum proton pump inhibitor use. In addition, our study shows that MSA is a safe minimally invasive anti-reflux procedure without the negative side-effects, such as gas bloat, inability to belch, and inability to vomit, commonly associated with NF.

Our prior randomized controlled trial of Heller myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term. We actively engaged participants from the prior randomized cohort, making up to six contact attempts per person using telephone, mail, and electronic messaging. We collected patient-reported measures of dysphagia and gastroesophageal reflux using the Dysphagia Score and the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) instrument. Patient-reported re-interventions for dysphagia were verified by obtaining longitudinal medical records. Among living participants, 27/41 (66%) were contacted and all completed the follow-up study at a mean of 11.8 years postoperatively. Median Dysphagia Scores and GERD-HRQL scores were slightly worse for Heller than Heller plus Dor but were not statistically different (6 vs 3, p = 0.08 for dysphagia, 15 vs 13, p = 0.25 for reflux). Five patients in the Heller group and 6 in Heller plus Dor underwent re-intervention for dysphagia with most occurring more than five years postoperatively. One patient in each group underwent redo Heller myotomy and subsequent esophagectomy. Nearly all patients (96%) would undergo operation again. Long-term patient-reported outcomes after Heller alone and Heller plus Dor for achalasia are comparable, providing support for either procedure.

We have recently introduced laparoscopic magnetic sphincter augmentation (MSA) combined with hiatal hernia repair for treatment of patients with medically refractory gastroesophageal reflux disease (GERD). MSA is a novel surgical approach to the treatment of severe GERD, in which magnetic beads are secured around the lower esophageal sphincter, augmenting the lower esophageal sphincter function as an anti-reflux barrier. We hypothesize that patients undergoing MSA will achieve GERD relief, equal to that obtained after laparoscopic Nissen fundoplication. The GERD Health Related Quality of Life (GERD HRQL) Questionnaire is a validated clinical tool that was used to quantify patient outcomes in terms of GERD-related symptoms both on and off proton pump inhibitors and after acute radiation syndrome. We retrospectively reviewed data from patients at our institution enrolled in a prospective institutional review board-approved database "Registry Outcomes Anti-Reflux Surgery" that applies objective and subjective information about patients undergoing anti-reflux surgery. Information from both the database and patient HRQL scores were used to compare the effectiveness of medical intervention with acute radiation syndrome (laparoscopic Nissen fundoplication and MSA) in decreasing GERD-related symptoms in patients. Results are expressed as mean ± SE, and single-factor ANOVA test was used to compare groups. We found that MSA and laparoscopic fundoplication both lead to a comparable decrease in HRQL score and an increase in patient satisfaction when compared with patient's preoperative symptoms with maximum proton pump inhibitor use. In addition, our study shows that MSA is a safe minimally invasive anti-reflux procedure without the negative side-effects, such as gas bloat, inability to belch, and inability to vomit, commonly associated with NF.

Objective: The propagation of electrophysiological activity measured by multichannel devices could have significant clinical implications. Gastric slow waves normally propagate along longitudinal paths that are evident in recordings of serosal potentials and transcutaneous magnetic fields. We employed a realistic model of gastric slow wave activity to simulate the transabdominal magnetogastrogram (MGG) recorded in a multichannel biomagnetometer and to determine characteristics of electrophysiological propagation from MGG measurements. Methods: Using MGG simulations of slow wave sources in a realistic abdomen (both superficial and deep sources) and in a horizontally-layered volume conductor, we compared two analytic methods (second-order blind identification, SOBI and surface current density, SCD) that allow quantitative characterization of slow wave propagation. We also evaluated the performance of the methods with simulated experimental noise. The methods were also validated in an experimental animal model. Results: Mean square errors in position estimates were within 2 cm of the correct position, and average propagation velocities within 2 mm/s of the actual velocities. SOBI propagation analysis outperformed the SCD method for dipoles in the superficial and horizontal layer models with and without additive noise. The SCD method gave better estimates for deep sources, but did not handle additive noise as well as SOBI. Conclusion: SOBI-MGG and SCD-MGG were used to quantify slow wave propagation in a realistic abdomen model of gastric electrical activity. Significance: These methods could be generalized to any propagating electrophysiological activity detected by multichannel sensor arrays.

The prevalence of GERD is estimated to be between 10% and 20% in the Western world, with a higher predilection in developed countries. Obesity itself has been shown to be an independent risk factor for GERD, with an observed dose-response relationship between frequency of heartburn or regurgitation and higher BMI. A report of the US National Health and Education Survey (NHANES) found that approximately 66% of the US adult population is either overweight or obese, with this number on the rise annually. Roughly 5% of the total global health-care cost is allocated toward treating obese patients, as there is clearly a rising economic burden associated with obesity. The direct health-care costs associated with GERD in all patient populations are estimated to be around $9–$10 billion annually. Indirect costs such as decrease in work productivity, disability, and absent workdays should also be considered. Given the limited effectiveness of lifestyle modifications and medications, bariatric surgery has been shown to be the only modality with long-term sustained weight loss, reduction in morbidity, and improvement in all-cause mortality.

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R2 = 0.525, De Backer R2 = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of micro-circulatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.

Chronic mesenteric ischemia (CMI) is a challenging clinical problem that is difficult to diagnose noninvasively. Diagnosis early in the disease process would enable life-saving early surgical intervention. Previous studies established that superconducting quantum interference device (SQUID) magnetometers detect the slow wave changes in the magnetoenterogram (MENG) noninvasively following induction of mesenteric ischemia in animal models. The purpose of this study was to assess functional physiological changes in the intestinal slow wave MENG of patients with chronic mesenteric ischemia. Pre- and postoperative studies were conducted on CMI patients using MENG and intraoperative recordings using invasive serosal electromyograms (EMG). Our preoperative MENG recordings showed that patients with CMI exhibited a significant decrease in intestinal slow wave frequency from 8.9 ± 0.3 cpm preprandial to 7.4 ± 0.1 cpm postprandial ( P < 0.01) that was not observed in postoperative recordings (9.3 ± 0.2 cpm preprandial and 9.4 ± 0.4 cpm postprandial, P = 0.86). Intraoperative recording detected multiple frequencies from the ischemic portion of jejunum before revascularization, whereas normal serosal intestinal slow wave frequencies were observed after revascularization. The preoperative MENG data also showed signals with multiple frequencies suggestive of uncoupling and intestinal ischemia similar to intraoperative serosal EMG. Our results showed that multichannel MENG can identify intestinal slow wave dysrhythmias in CMI patients.

A retrospective analysis of a prospective observational study of a cohort of patients who required prolonged foregut/midgut decompression/intraluminal stenting and/or enteral nutritional support was conducted. Those patients were intolerant of protracted nasogastric intubation. They also manifested hostile peritoneal cavities and therefore were not candidates for a laparoendoscopic gastrostomy or jejunostomy. Accordingly, they underwent insertion of a pharyngogastric or pharyngojejunal tube. With patients properly positioned and anesthetized and with attention to the anatomy of the superior carotid cervical triangle, those pharyngostomies and cannulations were performed safely and efficiently. The tubes remained indefinitely or were changed/removed ad libitum. Morbidity was nil and no mortality attributable to the procedure was observed. Pharyngostomy should be part of the armamentarium of all general surgeons.

Background Diagnosing the extremes of superficial burns and full-thickness burns is straightforward. It is in the middle ground of partial-thickness burns where the diagnostic difficulties emerge; it can take up to 3 to 5 days for signs of healing to appear. We hypothesize that cooling partial-thickness burns and tracking the rate of rewarming will immediately reflect the condition of the burn: shallow partial-thickness burns that retain cell health and blood flow will rewarm rapidly, and deeper burns with damaged microvessels will rewarm slowly. Study Design We enrolled 16 patients with isolated, partial-thickness burns on their extremities who were diagnosed as indeterminate by our burn surgeon. Within 24 hours after presentation, room-temperature saline was poured over the burn as a cooling challenge. An infrared camera that was sensitive to body temperature produced false-color images showing pixel-by-pixel temperatures. A time-lapse recording from the infrared camera images taken as the burn rewarmed produced a time-temperature curve that reflected the kinetics of rewarming. The outcomes variable was whether or not the patient received a skin graft, which was determined 72 hours after presentation. Results The method correctly predicted whether or not the patient required a skin graft. Conclusions Here we report a new technique that permits determination of wound viability much earlier than clinical examination. Due to the simplicity of the method, non-experts can successfully perform the technique on the first day of the burn and make the correct diagnosis and decision to graft or not to graft.

Many members of the medical profession in Mobile, Alabama, have exemplified a strong commitment to the education of their colleagues and successors, a tradition (L., traditio, “to hand over”) that dates from the early 18th century. The Mobile General (city/county) Hospital (1830 to 1970) and its successor, the Medical Center, University of South Alabama (1971 to the present), were the institutional foci of those endeavors. Because it is individuals who create, design, and vitalize institutions, this monograph is an acknowledgment of the accomplishments of those who gave that endeavor purpose, direction, and meaning, particularly with reference to the evolution of surgical education. Numerous clinical and societal forces—cultural, economic, political, and social—influenced that evolution. This compilation gives attribution to a legacy of commitment to health and medical/surgical care, education, and research within southern Alabama.

The slow wave activity was measured in the magnetoenterogram (MENG) of normal porcine subjects ( N = 5) with segmental intestinal ischemia. The correlation changes in enteric slow wave activity were determined in MENG and serosal electromyograms (EMG). MENG recordings show significant changes in the frequency and power distribution of enteric slow-wave signals during segmental ischemia, and these changes agree with changes observed in the serosal EMG. There was a high degree of correlation between the frequency of the electrical activity recorded in MENG and in serosal EMG (r = 0.97). The percentage of power distributed in brady- and normoenteric frequency ranges exhibited significant segmental ischemic changes. Our results suggest that noninvasive MENG detects ischemic changes in isolated small bowel segments.

Background Gastroparesis is characterized by delayed gastric emptying without mechanical obstruction, but remains difficult to diagnose and distinguish from other gastrointestinal (GI) disorders. Gastroparesis affects the gastric slow wave, but non-invasive assessment has been limited to the electrogastrogram (EGG), which reliably characterizes temporal dynamics but does not provide spatial information. Methods We measured gastric slow wave parameters from the EGG and magnetogastrogram (MGG) in patients with gastroparesis and in healthy controls. In addition to dominant frequency (DF) and percentage power distribution (PPD), we measured the propagation velocity from MGG spatiotemporal patterns and the percentage of slow wave coupling (%SWC) from EGG. Key Results No significant difference in DF was found between patients and controls. Gastroparesis patients had lower percentages of normogastric frequencies (60 ± 6% vs 78 ± 4%, p < 0.05), and higher brady (9 ± 2% vs 2 ± 1%, p < 0.05) and tachygastric (31 ± 2% vs 19 ± 1%, p < 0.05) frequency content postprandial, indicative of uncoupling. Propagation patterns were substantially different in patients and longitudinal propagation velocity was retrograde at 4.3 ± 2.9 mm/s vs anterograde at 7.4 ± 1.0 mm/s for controls (p < 0.01). No difference was found in %SWC from EGG. Conclusions & Inferences Gastric slow wave parameters obtained from MGG recordings distinguish gastroparesis patients from controls. Assessment of slow wave propagation may prove critical to characterization of underlying disease processes. Future studies should determine pathologic indicators from MGG associated with other functional gastric disorders, and whether multichannel EGG with appropriate signal processing also reveals pathology.

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R(2) = 0.525, De Backer R(2) = 0.576, P0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of microcirculatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.

BackgroundPostoperative pancreatic fistula (POPF) is the most common significant complication after distal pancreatectomy (DP) and results in substantial morbidity. Many different methods are available to divide the pancreatic parenchyma and achieve stump closure, but demonstrating an improvement in the incidence of POPF has been difficult.MethodsA single-institution, retrospective review was conducted to evaluate all hand-assisted laparoscopic DP performed from October 2008 to July 2011 utilizing saline-coupled radiofrequency ablation (RFA) as the exclusive method of achieving division of the pancreatic parenchyma and closure of the proximal pancreatic remnant. All significant complications within the perioperative period were noted.ResultsThirty-four patients met the criteria for inclusion in the study. One patient was lost to follow-up and thus excluded. Three patients (9.1%) demonstrated a POPF; two were treated with prolonged placement of the intraoperative drain (grade A: 6.1%) and the third was treated with endoscopic cystogastrostomy (grade C: 3.0%). One other significant complication (3.0%) of a perforated gastric ulcer that required partial gastrectomy occurred.ConclusionsThe use of saline-coupled RFA alone for pancreatic parenchymal division and closure after DP is safe and effective. This study found an overall significant complication rate of 6.1%, and a rate of clinically significant POPF of 3.0%.

We measured gastric slow wave activity simultaneously with a Superconducting Quantum Interference Device (SQUID) magnetometer, mucosal electrodes and cutaneous electrodes in 18 normal human subjects (11 women and 7 men). We processed signals with Fourier spectral analysis and SOBI blind-source separation techniques. We observed a high waveform correlation between the mucosal electromyogram (EMG) and multichannel SQUID magnetogastrogram (MGG). There was a lower waveform correlation between the mucosal EMG and cutaneous electrogastrogram (EGG), but the correlation improved with the application of SOBI. There was also a high correlation between the frequency of the electrical activity recorded in the MGG and in mucosal electrodes (r = 0.97). We concluded that SQUID magnetometers noninvasively record gastric slow wave activity that is highly correlated with the activity recorded by invasive mucosal electrodes.

Disordered gastric motility represents a spectrum of dysfunction ranging from delayed gastric emptying to abnormally rapid gastric transit, commonly referred to as the "dumping syndrome." Both extremes of gastric motility disorders can arise from similar pathologic processes, and produce remarkably identical symptoms. This fact underscores the need to attain a precise diagnosis to ensure the institution of optimal therapy. Disordered gastric motility is primarily managed with dietary modification followed by pharmacotherapy, as traditional surgical interventions tend to be fraught with complications. However, continued improvements in minimally invasive diagnostic and therapeutic modalities promise novel options for earlier and more effective treatment.

Background & Aims Visceral adipose tissue (VAT) is an important risk factor for the metabolic complications associated with obesity. Therefore, a reduction in VAT is considered an important target of obesity therapy. We evaluated whether reducing VAT mass by surgical removal of the omentum improves insulin sensitivity and metabolic function in obese patients. Methods We conducted a 12-month randomized controlled trial to determine whether reducing VAT by omentectomy in 22 obese subjects increased their improvement following Roux-en-Y gastric bypass (RYGB) surgery in hepatic and skeletal muscle sensitivity to insulin study 1. Improvement was assessed by using the hyperinsulinemic-euglycemic clamp technique. We also performed a 3-month, longitudinal, single-arm study to determine whether laparoscopic omentectomy alone, in 7 obese subjects with type 2 diabetes mellitus (T2DM), improved insulin sensitivity study 2. Improvement was assessed by using the Frequently Sampled Intravenous Glucose Tolerance Test. Results The greater omentum, which weighed 0.82 kg (95% confidence interval: 0.67–0.97), was removed from subjects who had omentectomy in both studies. In study 1, there was an approximate 2-fold increase in muscle insulin sensitivity (relative increase in glucose disposal during insulin infusion) and a 4-fold increase in hepatic insulin sensitivity 12 months after RYGB alone and RYGB plus omentectomy, compared with baseline values ( P P > .87) or group × time interactions ( P > .36). In study 2, surgery had no effect on insulin sensitivity ( P = .844) or use of diabetes medications. Conclusions These results demonstrate that decreasing VAT through omentectomy, alone or in combination with RYGB surgery, does not improve metabolic function in obese patients.

High resolution (HR) multi-electrode mapping is increasingly being used to evaluate gastrointestinal slow wave behaviors. To create the HR-activation maps from gastric serosal electrode recordings that quantify slow wave propagation, it is first necessary to identify the activation time (AT) of each individual slow wave event. Identifying these ATs has been a time consuming task, because there has previously been no reliable automated detection method. We have developed an automated AT detection method termed falling-edge, variable threshold (FEVT) detection. It computes a detection signal transform to accentuate the high ‘energy’ content of the falling edges in the serosal recording, and uses a running median estimator of the noise to set the time-varying detection threshold. The FEVT method was optimized, validated, and compared to other potential algorithms using in-vivo HR recordings from a porcine model. FEVT properly detects ATs in a wide range of waveforms, making its performance substantially superior to the other methods, especially for low signal-to-noise ratio (SNR) recordings. The algorithm offered a substantial time savings (>100 times) over manual-marking whilst achieving a highly satisfactory sensitivity (0.92) and positive-prediction value (0.89).

Hyperglycemic effects on the gastric slow wave are not well understood, and no studies have examined the effects that hyperglycemia has on gastric slow wave magnetic fields. We recorded multichannel magnetogastrograms (MGGs) before and after intravenous administration of glucagon and subsequent modest hyperglycemia in 20 normal volunteers. Normal slow waves were evident in baseline MGG recordings from all 20 subjects, but within 15 min after glucagon had been given, we noted significant effects on MGG signals. In addition to an overall decrease in the slow wave frequency from 2.9 ± 0.5 cycles per min (cpm) to 2.2 ± 0.1 cpm ( P < 0.05), we observed significant changes in the number and range of spectral peaks recorded. Furthermore, the propagation velocity determined from surface current density maps computed from the multichannel MGG decreased significantly (7.1 ± 0.8 mm/s to 5.0 ± 0.3 mm/s, P < 0.05). This is the first study of biomagnetic effects of hyperglycemia in normal subjects. Our results suggest that the analysis of the MGG provides parameter quantification for gastric electrical activity specific to and characteristic of slow wave abnormalities associated with increased serum glucose by injection of glucagon.

The Residency Review Committee for Surgery (RRC-S) re-cently mandated a 293% increase in required flexible gastroin-testinalendoscopyexperienceforgeneralsurgeryresidents.De-spite this heightened accreditation emphasis, resident exposureto flexible endoscopy remains erratic even in volume-adequatesettings. A successful endoscopy training program requiresplanning, educator and resident buy-in, and proper trainingtools. So, how does the program director in surgery change thecurriculum to prepare trainees for successful completion of theprogram?Stepstowardamoreuniformandappropriatetrainingexpe-rienceshouldincludeaddressingcurrentAccreditationCouncilforGraduateMedicalEducation(ACGME)policies,efficientlyusing available resources, including simulators, and institutinga validated, standardized endoscopy curriculum incorporatingrecommendations from surgery and gastrointestinal societies.Trainees also may benefit from structured experiences with ru-ral surgeons or other high-volume endoscopy providers. Incor-poration of multidisciplinary initiatives focused on expandingandstandardizingendoscopytrainingalsomaybehelpful.Suchinitiativesincludedevelopmentofstandardizednationalcurric-ula and proficiency-oriented skills assessment. Another bur-geoning initiative is natural orifice translumenal endoscopicsurgery (NOTES), which lends itself to novel technology de-sign, expansion and application of fundamental endoscopicskills,multidisciplinarytrainingandresearchmodels,plusout-comes assessment.Along with reviewing the aforementioned issues, this ar-ticle articulates the perspective that flexible endoscopy is anintegral part of general surgery and that alimentary tractsurgery will involve increasing utilization of endoscopictechniques in the future. If gastrointestinal surgeons are toprovide integrated and current patient care, it will be neces-sary to incorporate intralumenal and potentially translume-nal endoscopic techniques as they evolve. This article detailsthe available strategies to prepare general surgery residentsfor the scope of contemporary practice.

IN BRIEF Bariatric surgery is becoming increasingly common as a means to control weight in the United States. This article reviews the most common forms of bariatric surgery and their effects on diabetes and other components of the metabolic syndrome.

Metabolic bone disease is a potential complication of bariatric surgery. The aims of our study were to evaluate the effects of laparoscopic gastric bypass on calcium and vitamin D metabolism, and to identify patients at high risk to develop secondary hyperparathyroidism (HPT).Serum calcium, alkaline phosphatase, intact parathyroid hormone (PTH), and 25-hydroxy (OH) vitamin D were measured at 3, 6, 12, and 24 months after laparoscopic gastric bypass in a cohort of morbidly obese women. Logistic regression was used in both univariate and multivariate models to identify independent preoperative variables associated with secondary HPT.The study enrolled 193 morbidly obese women. During the 2-year follow-up period, the incidence of elevated PTH levels (65 pg/ml) was 53.3%. The mean time elapsed between surgery and detection of secondary HPT was 9.1 months (range, 3-24 months). Vitamin D deficiency was observed in 39 patients (20.2%). On univariate analysis, the preoperative factors associated with secondary HPT were race (high PTH levels were detected in 70% of African Americans versus 50% of Caucasians; p0.05), preoperative body mass index (BMI; high PTH: 52.5 +/- 10.8 versus normal PTH: 48.9 +/- 7.5 kg/m2; p0.01), and age (high PTH: 44.9 +/- 9.2 versus normal PTH: 42.3 +/- 9 years, p0.05). Race and age remained independent risk factors for secondary HPT in the multivariate logistic regression model after adjusting for the covariate Roux-limb length. African Americans were at more than 2.5 times greater risk to develop secondary HPT as Caucasian (RR 2.5; 95% CI: 1.03-6.17, p0.05). Patients older than 45 years were at 1.8 times higher risk of developing secondary HPT as their younger counterparts (RR 1.8; 95% CI: 1.01-3.32, p0.05).Morbidly obese women have a high incidence of elevated PTH levels after gastric bypass surgery. Low vitamin D levels did not constitute the only reason behind this finding. African-American women and women older than 45 years of age were at significantly higher risk of developing secondary HPT. In these populations, aggressive supplementation with calcium citrate and vitamin D should be implemented.

Several cultures, including the Egyptians, Greeks, Romans, and Arabs, made attempts to view accessible human body cavities using a variety of instruments such as spatulas and specula. The first endoscope was created in 1806 when Phillip Bozzini, a German-born urologist, constructed the lichtleiter, which used concave mirrors to reflect candlelight through an open tube into the esophagus, bladder, or rectum. Maximilian Carl-Friedrich Nitze, another German urologist, produced the first usable cystoscope in 1877 by using series of lenses to increase magnification. He was also the first to place light inside the organ of interest to aid visualization. In 1880 Mikulicz made the first gastroscope using a system similar to Nitze's cystoscope. Modern endoscopy was born with the introduction of the fiberoptic endoscope in the late 1950s. Over the ensuing 50 years endoscopy revolutionized many aspects of the surgeon's practice. Endoscopy can now be used to diagnose and often treat gastrointestinal cancer, hemorrhage, obstruction, and inflammatory conditions. This review was initiated by the SAGES Flexible Endoscopy Committee to chronicle the role of the surgeon in the development and introduction of flexible endoscopy into clinical practice, historically and in contemporary surgery. Flexible endoscopy evolved out of surgeons' need to overcome diagnostic and therapeutic challenges. There have been many recent technological advances that facilitate endoluminal therapies, and flexible endoscopy is now traversing new ground. Surgeons have been major contributors in the development of all aspects of endoscopy. There is a continually expanding list of therapeutic options available to patients. The difficult questions of which procedure, on which patient, and when can be answered best by the surgeon versed in endoscopic, laparoscopic, and open surgical techniques.

The electrical control activity of the large intestine was recorded in six pigs using a SQUID magnetometer. The study was performed in pre- and post-colectomy/sham-colectomy conditions. The biomagnetic field associated with colonic ECA changed drastically in subjects that underwent the colectomy procedure, whereas the signal for the control animals was nearly unchanged. Power spectral analysis was used to determine the average changes of dominant frequency and amplitude between baseline versus colectomy and sham-colectomy conditions. The dominant frequency was increased by 68 +/- 24% (versus 2 +/- 3% in control). The amplitude was decreased by 69 +/- 24% (versus 13 +/- 17% in control). This is the first study of transabdominal magnetic fields associated with colonic ECA, suggests some of the side effects generated in colectomy surgery and shows the utility of the biomagnetic technique in studies of the large intestine.

Obesity surgery is becoming one of the most common general surgery procedures done in the United States. Internal hernias are a known and increasingly more common occurrence after laparoscopic roux-en-Y gastric bypass (LRYGB). Increased clinical awareness of this complication will lead to decreased surgical morbidity and mortality. We retrospectively reviewed our database of 529 patients who had undergone LRYGB from 2000 to 2005 and identified those presenting with intestinal obstruction from an internal hernia. The type of internal hernia (jejunojejunostomy, transverse mesocolon, roux limb mesentery [Peterson's hernia]), length of time from presentation to operative intervention, and length of stay were obtained for all patients. Of 529 laparoscopic retrocolic retrogastric LRYGBs, 13 internal hernias (2.5%) were identified in 13 different patients. Eight of the hernias were at the mesenteric defect created by the jejunojejunostomy (62%), 3 originated from the transverse mesocolon defect (23%), and 2 were a Peterson's hernia (15%). The median time from initial operation to repair was 150 days. The average time from presentation to operative repair was 29.2 hours (range, 5–67.5 hours). The median length of stay was 3 days (range, 1.5–45 days). Eleven hernias were repaired laparoscopically (85%). There were no mortalities associated with obstruction from the internal hernia. Intestinal obstruction from an internal hernia after LRYGB is becoming increasingly more common. General awareness of this condition and high clinical suspicion allow for prompt surgical intervention with decreased morbidity and mortality.

Laparoscopic gastric bypass (LGB) has proven efficacy in causing significant and durable weight loss. However, the degree of postoperative weight loss and metabolic improvement varies greatly among individuals. Our study is aimed to identify independent predictors of successful weight loss after LGB. Socioeconomic demographics were prospectively collected on patients undergoing LGB. Primary endpoint was percent of excess weight loss (EWL) at 1-year follow-up. Insufficient weight loss was defined as EWL ≤−1 SD from mean EWL. Logistic regression was used in both univariate and multivariate models to identify independent preoperative demographics associated with successful weight loss. A total of 180 consecutive patients were enrolled over 30 months. Mean preoperative body mass index (BMI) was 48. Mean EWL was 70.1 ± 17.3% (1 SD); therefore, success was defined as EWL ≥52.8%. According to this definition, 147 patients (81.7%) achieved successful weight loss 1 year after LGB. On univariate analysis, preoperative BMI had a significant effect on EWL, with patients with BMI