Stress and corticotropin releasing factor (CRF) promote necrotizing enterocolitis in a formula-fed neonatal rat model.

The etiology of necrotizing enterocolitis (NEC) is not known. Alterations in gut microbiome, mucosal barrier function, immune cell activation, and blood flow are characterized events in its development, with stress as a contributing factor. The hormone corticotropin-releasing factor (CRF) is a key mediator of stress responses and influences these aforementioned processes. CRF signaling is modulated by NEC's main risk factors of prematurity and formula feeding. Using an established neonatal rat model of NEC, we tested hypotheses that: (i) increased CRF levels-as seen during stress-promote NEC in formula-fed (FF) newborn rats, and (ii) antagonism of CRF action ameliorates NEC. Newborn pups were formula-fed to initiate gut inflammation and randomized to: no stress, no stress with subcutaneous CRF administration, stress (acute hypoxia followed by cold exposure-NEC model), or stress after pretreatment with the CRF peptide antagonist Astressin. Dam-fed unstressed and stressed littermates served as controls. NEC incidence and severity in the terminal ileum were determined using a histologic scoring system. Changes in CRF, CRF receptor (CRFRs), and toll-like receptor 4 (TLR4) expression levels were determined by immunofluorescence and immunoblotting, respectively. Stress exposure in FF neonates resulted in 40.0% NEC incidence, whereas exogenous CRF administration resulted in 51.7% NEC incidence compared to 8.7% in FF non-stressed neonates (p<0.001). Astressin prevented development of NEC in FF-stressed neonates (7.7% vs. 40.0%; p = 0.003). CRF and CRFR immunoreactivity increased in the ileum of neonates with NEC compared to dam-fed controls or FF unstressed pups. Immunoblotting confirmed increased TLR4 protein levels in FF stressed (NEC model) animals vs. controls, and Astressin treatment restored TLR4 to control levels. Peripheral CRF may serve as specific pharmacologic target for the prevention and treatment of NEC.

Safety, tolerability, and pharmacokinetic evaluation of single- and multiple-ascending doses of a novel kappa opioid receptor antagonist LY2456302 and drug interaction with ethanol in healthy subjects.

Accumulating evidence indicates that selective antagonism of kappa opioid receptors may provide therapeutic benefit in the treatment of major depressive disorder, anxiety disorders, and substance use disorders. LY2456302 is a high-affinity, selective kappa opioid antagonist that demonstrates >30-fold functional selectivity over mu and delta opioid receptors. The safety, tolerability, and pharmacokinetics (PK) of LY2456302 were investigated following single oral doses (2-60 mg), multiple oral doses (2, 10, and 35 mg), and when co-administered with ethanol. Plasma concentrations of LY2456302 were measured by liquid chromatography-tandem mass spectrometry method. Safety analyses were conducted on all enrolled subjects. LY2456302 doses were well-tolerated with no clinically significant findings. No safety concerns were seen on co-administration with ethanol. No evidence for an interaction between LY2456302 and ethanol on cognitive-motor performance was detected. LY2456302 displayed rapid oral absorption and a terminal half-life of approximately 30-40 hours. Plasma exposure of LY2456302 increased proportionally with increasing doses and reached steady state after 6-8 days of once-daily dosing. Steady-state PK of LY2456302 were not affected by coadministration of a single dose of ethanol. No clinically important changes in maximum concentration (Cmax ) or AUC of ethanol (in the presence of LY2456302) were observed.

Complications of transvaginal natural orifice transluminal endoscopic surgery: a series of 102 patients.

OBJECTIVE: To review the complications encountered in our facility and in previously published studies of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) to date. BACKGROUND: TV NOTES is currently observed with critical eyes from the surgical community, despite encouraging data to suggest improved short-term recovery and pain. METHODS: All TV NOTES procedures performed in female patients between 18 and 65 years of age were included. The median follow-up was 90 days. The TV appendectomies and ventral hernia repairs were pure NOTES, through a SILS port in the vagina, whereas TV cholecystectomies were hybrid procedures with the addition of a 5-mm port in the umbilicus. RESULTS: A total of 102 TV NOTES procedures, including 72 TV cholecystectomies, 24 TV appendectomies, and 6 TV ventral hernia repairs, were performed. The average age was 37 years old and body mass index was 29 kg/m. Three major and 7 minor complications occurred. The first major complication was a rectal injury during a TV access port insertion. The second major complication was an omental vessel bleed after a TV cholecystectomy. The third complication was an intra-abdominal abscess after a TV appendectomy. Seven minor complications were urinary retention (4), transient brachial plexus injury, dislodgement of an intrauterine device, and vaginal granulation tissue. CONCLUSIONS: As techniques in TV surgery are adopted, inevitably, complications may occur due to the inherent learning curve. Laparoscopic instruments, although adaptable to TV approaches, have yet to be optimized. A high index of suspicion is necessary to identify complications and optimize outcomes for patients.

Pure transvaginal ventral hernia repair in humans.

INTRODUCTION: Transvaginal natural orifice transluminal endoscopic surgery procedures are at the forefront of minimally invasive innovation, remarkable for shorter recovery times and decreased postoperative pain. We aim to demonstrate a novel technique of pure transvaginal laparoscopic ventral hernia repair in a series of patients performed in our institution. TECHNIQUE DESCRIPTION: The patient was placed in lithotomy position and steep Trendelenburg. A 2-cm transverse colpotomy incision was made and a SILS port was introduced. One 12-mm trocar and two 5-mm trocars were placed through the SILS port and standard straight laparoscopic instruments were used. An appropriately sized round mesh was deployed within a specimen retrieval bag into the peritoneal cavity. Complete anterior circumferential fixation of the mesh was achieved using an AbsorbaTack device. The colpotomy incision was closed. RESULTS: There were a total of 6 pure transvaginal ventral hernia repair procedures performed in our institution between November 2010 and February 2012. The first case was converted to an open procedure after a rectal injury was recognized and repaired. Two patients had transient urinary retention that resolved after 24 hours. One patient had vaginal wound granulation noted at 2 months postoperatively. No long-term complications or recurrences were noted with a median follow-up of 9 months. The mean operative time was 107 minutes. CONCLUSION: Our initial experience with transvaginal ventral hernia repair in humans suggests that this procedure is feasible, safe, and associated with improved cosmetic results.

Determining pharmacological selectivity of the kappa opioid receptor antagonist LY2456302 using pupillometry as a translational biomarker in rat and human.

BACKGROUND: Selective kappa opioid receptor antagonism is a promising experimental strategy for the treatment of depression. The kappa opioid receptor antagonist, LY2456302, exhibits ~30-fold higher affinity for kappa opioid receptors over mu opioid receptors, which is the next closest identified pharmacology. METHODS: Here, we determined kappa opioid receptor pharmacological selectivity of LY2456302 by assessing mu opioid receptor antagonism using translational pupillometry in rats and humans. RESULTS: In rats, morphine-induced mydriasis was completely blocked by the nonselective opioid receptor antagonist naloxone (3mg/kg, which produced 90% mu opioid receptor occupancy), while 100 and 300 mg/kg LY2456302 (which produced 56% and 87% mu opioid receptor occupancy, respectively) only partially blocked morphine-induced mydriasis. In humans, fentanyl-induced miosis was completely blocked by 50mg naltrexone, and LY2456302 dose-dependently blocked miosis at 25 and 60 mg (minimal-to-no blockade at 4-10mg). CONCLUSIONS: We demonstrate, for the first time, the use of translational pupillometry in the context of receptor occupancy to identify a clinical dose of LY2456302 achieving maximal kappa opioid receptor occupancy without evidence of significant mu receptor antagonism.

Transvaginal cholecystectomy: effect on quality of life and female sexual function.

IMPORTANCE: Transvaginal cholecystectomy (TVC) is the leading natural orifice transluminal endoscopic surgery to date and has the potential to offer improved cosmesis, less pain, and shorter recovery times for female patients. OBJECTIVE: To investigate quality of life and female sexual function in our patients undergoing TVC. DESIGN: A prospective cohort study from August 14, 2009, to June 12, 2012, of TVCs performed at our institution to date. SETTING: Tertiary academic referral center. PARTICIPANTS: The first 47 consecutive female patients (aged 18-65 years) who received a TVC by a single surgeon. INTERVENTIONS: A hybrid TVC was performed by a 5-mm umbilical trocar and a 12-mm transvaginal trocar with standard laparoscopic instruments. MAIN OUTCOMES AND MEASURES: Quality-of-life index (36-Item Short Form Health Survey) and female sexual function (Female Sexual Function Index) scores. RESULTS: A total of 47 TVCs were performed, with a mean age of 39 years, mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 31, and mean operative time of 65 minutes. No difference was noted in overall female sexual function from preoperatively to 1 and 3 months postoperatively. When comparing quality of life preoperatively vs 1 and 3 months postoperatively, there were significant improvements in physical function (P = .02), energy and fatigue (P = .001), emotional well-being (P = .01), pain (P < .001), and general health (P = .03). No significant changes were noted in physical limitations (P = .18), emotional problems (P = .72), and social function (P = .12). CONCLUSIONS AND RELEVANCE: In our experience to date, female sexual function is unchanged and quality of life either is unchanged or improves at 1 and 3 months following TVC. Undergoing TVC does not appear to negatively affect female sexual function or quality of life in the short term.

Pure transvaginal umbilical hernia repair.

BACKGROUND: Transvaginal natural orifice transluminal endoscopic surgery (NOTES) procedures are at the forefront of minimally invasive innovation, remarkable for shorter recovery times and decreased postoperative pain [1, 2]. Most transvaginal procedures are performed as hybrid procedures [3]. To our knowledge, this is the first video depiction of a pure transvaginal umbilical hernia repair in a human. METHODS: This is a 38-year-old woman, body mass index 36.4 kg/m(2), with a symptomatic port site hernia in the umbilical region after a previous laparoscopic cholecystectomy. The patient was positioned in stirrups in a steep Trendelenburg position. Sterilization of vaginal cavity was performed with 10 % povidone-iodine solution. A 2 cm transverse incision at the posterior fornix was made, and a SILS port (Covidien, North Haven, CT) was introduced. One 12 mm trocar and two 5 mm trocars were placed through SILS port. Standard straight laparoscopic instruments were used. A 12 cm round Parietex mesh (Covidien) was placed in a specimen retrieval bag and deployed into the peritoneal cavity. The mesh was extracted, unfolded in the abdominal cavity, and circumferentially fixated to the abdominal wall with an AbsorbaTack device (Covidien). The colpotomy incision was closed with a running absorbable suture. RESULTS: The procedure lasted 103 min and was performed on an outpatient basis. No intraoperative complications occurred. The patient was doing well and had no pain or recurrence at 2, 6, and 9 months' follow-up. CONCLUSIONS: Our initial experience with transvaginal ventral hernia repair in humans suggests that this procedure is feasible and safe. This approach may improve cosmesis and decrease the risk of future ventral hernias. Potential cons may include a longer operative time, mesh infection, and risk of visceral injury with a pure transvaginal approach. As transvaginal surgery evolves, techniques and devices will become increasingly refined to tackle these challenges.

Transvaginal natural orifice transluminal endoscopic surgery in the morbidly obese.

BACKGROUND: The objective of this study is to assess the safety and efficacy of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) operations in morbidly obese patients. METHODS: One hundred seven NOTES operations have been performed at our institution to date, of which 17 were completed in patients with body mass index (BMI) between 35 and 45 kg/m(2). These included 14 cholecystectomies, one appendectomy, and two ventral hernia repairs. The patients had average age of 36.2 years (range 19-62 years) and average BMI of 38.9 kg/m(2) (range 35.2-44.9 kg/m(2)). The mean number of previous abdominal operations was 1. The TV cholecystectomies were hybrid NOTES procedures, while TV appendectomy and ventral hernia repair were pure NOTES. All operations were completed with standard straight laparoscopic instruments. RESULTS: The mean operative time was 60 min for cholecystectomy, 41 min for TV appendectomy, and 90 min for ventral hernia repair. No significant difference was encountered between the operative time for NOTES cholecystectomies in obese versus nonobese (60 vs. 61 min, p = 0.86). No conversions to traditional laparoscopy or open surgery were made, and no major complications were encountered. CONCLUSIONS: NOTES is an attractive alternative to laparoscopy in female patients with morbid obesity. The procedures are safe and have short operative times, good postoperative outcomes, and improved cosmesis compared with laparoscopy.

Eating disorder examination-questionnaire factor structure and construct validity in bariatric surgery candidates.

BACKGROUND: The Eating Disorder Examination-Questionnaire (EDE-Q) is increasingly used in studies with bariatric surgery patients although little is known about psychometric properties of this self-report measure in this clinical group. The current study evaluated the factor structure and construct validity of the EDE-Q in bariatric surgery candidates. METHODS: Participants were a consecutive series of 174 obese bariatric surgery candidates who completed the EDE-Q and a battery of behavioral and psychological measures. RESULTS: Confirmatory factor analysis (CFA) revealed an inadequate fit for the original EDE-Q structure but revealed a good fit for an alternative structure suggested by recent research with obese samples. CFA supported a seven-item, three-factor structure; the three factors were interpreted as dietary restraint, shape/weight overvaluation, and body dissatisfaction. The three factors converged with other relevant collateral measures. CONCLUSIONS: These factor analytic findings, which replicate recent findings from studies with diverse obese samples, demonstrated convergent validity. Implications of these findings for clinical assessment and research with bariatric surgery patients are discussed.

Prognostication for body contouring surgery after bariatric surgery.

OBJECTIVE: Body contouring surgery has become a steadily increasing part of weight loss treatment in the population of patients electing to undergo bariatric surgery. This study aims to elicit factors that can be used to prognosticate which bariatric surgery patients will choose to undergo body contouring procedures. METHODS: A database of 381 patients who underwent gastric bypass surgery between August 2002 and December 2005 was retrospectively reviewed. All patients with subsequent body contouring surgery (group I) were identified and compared with those without it (group II). Variables studied were age, gender, preoperative excess body weight, percent excess weight loss at 6 and 12 months, preoperative body mass index, and change in body mass index at 6 and 12 months. RESULTS: We identified 24 patients for group I and 168 patients for group II. Group I was significantly younger with a mean age of 36 ± 9 years than group II with a mean age of 41 ± 10 years (P = .023). Change in body mass index was significantly greater in group I with changes of 16.1 ± 4 and 13.82 ± 3 (P = .001) at 6 months and changes of 21.4 ± 6.6 and 17.39 ± 4.6 (P < .0001) at 12 months in group I and group II, respectively. Lastly, the percent excess weight loss at 12 months was significantly greater in group I with a mean percent excess weight loss of 70.1 ± 13.3 than in group II with a mean percent excess weight loss of 62 ± 16.6 (P = .0052). CONCLUSIONS: Age, change in body mass index at 6 and 12 months, and percent excess weight loss at 12 month follow-up were useful predictive factors to determine which bariatric surgery patients ultimately underwent body contouring procedures.

Mental and physical impact of body contouring procedures on post-bariatric surgery patients.

OBJECTIVE: The rapid rate of weight loss following bariatric surgery leads to areas of excessive skin that can cause physical ailments and distortion of body image. Dissatisfaction with the excessive skin can lead patients to seek plastic surgery. This study aims to assess the changes in mental and physical quality of life after body contouring procedures in the post-bariatric surgery population. METHODS: In this cross-sectional study, the 36-Item Short Form Health Survey was given to 104 patients divided into 4 groups consisting of a control group, obese patients, post-bariatric surgery patients, and post-bariatric and -body contouring surgery patients. Scores from each survey question were individually averaged, scaled, and converted to the corresponding 8 scales that make up the 36-Item Short Form Health Survey. Scale comparisons were accomplished by analysis of variance and t test. RESULTS: Compared with the obese group, both post-bariatric surgery patients and post-body contouring surgery patients had improved quality of life. When comparing the post-body contouring and post-bariatric surgery patients, the post-body contouring group did not show significant quality of life improvement and actually scored significantly lower in 2 measures, Role Emotional and Social Functioning, indicating a decreased mental component of quality of life. When compared with the control group, the post-body contouring surgery group had statistically significant lower scores in 6 of the 8 scales. CONCLUSIONS: The functional impairment caused by excessive skin following massive weight loss interferes with quality of life. Patients electing to have body contouring after bariatric surgery show decreased quality of life even after plastic surgery compared to those patients who do not.

Construct and face validity of a virtual reality-based camera navigation curriculum.

INTRODUCTION: Camera handling and navigation are essential skills in laparoscopic surgery. Surgeons rely on camera operators, usually the least experienced members of the team, for visualization of the operative field. Essential skills for camera operators include maintaining orientation, an effective horizon, appropriate zoom control, and a clean lens. Virtual reality (VR) simulation may be a useful adjunct to developing camera skills in a novice population. No standardized VR-based camera navigation curriculum is currently available. We developed and implemented a novel curriculum on the LapSim VR simulator platform for our residents and students. We hypothesize that our curriculum will demonstrate construct and face validity in our trainee population, distinguishing levels of laparoscopic experience as part of a realistic training curriculum. METHODS: Overall, 41 participants with various levels of laparoscopic training completed the curriculum. Participants included medical students, surgical residents (Postgraduate Years 1-5), fellows, and attendings. We stratified subjects into three groups (novice, intermediate, and advanced) based on previous laparoscopic experience. We assessed face validity with a questionnaire. The proficiency-based curriculum consists of three modules: camera navigation, coordination, and target visualization using 0° and 30° laparoscopes. Metrics include time, target misses, drift, path length, and tissue contact. We analyzed data using analysis of variance and Student's t-test. RESULTS: We noted significant differences in repetitions required to complete the curriculum: 41.8 for novices, 21.2 for intermediates, and 11.7 for the advanced group (P < 0.05). In the individual modules, coordination required 13.3 attempts for novices, 4.2 for intermediates, and 1.7 for the advanced group (P < 0.05). Target visualization required 19.3 attempts for novices, 13.2 for intermediates, and 8.2 for the advanced group (P < 0.05). Participants believe that training improves camera handling skills (95%), is relevant to surgery (95%), and is a valid training tool (93%). Graphics (98%) and realism (93%) were highly regarded. CONCLUSIONS: The VR-based camera navigation curriculum demonstrates construct and face validity for our training population. Camera navigation simulation may be a valuable tool that can be integrated into training protocols for residents and medical students during their surgery rotations.

Pure transvaginal laparoscopic appendectomy.

BACKGROUND: Natural orifice transluminal endoscopic surgery has been at the forefront of minimally invasive surgery. Benefits include no visible scars, less pain, and shorter recovery time. We describe a video of a 37-year-old female who underwent a pure transvaginal appendectomy (TVA) for acute appendicitis. This is 1 of 18 successfully performed TVAs at Yale-New Haven Hospital. Appropriate Institutional Review Board was obtained preoperatively. METHODS: The patient was positioned in steep Trendelenburg and then a weighted speculum was introduced into the vagina allowing exposure of the posterior vaginal fornix. The cervix was grasped with a single-toothed tenaculum on the posterior cervical lip and the posterior vaginal fornix was visualized. Access to the peritoneum was achieved by electrocautery and then sharp dissection. A SILS™ port (Covidien, Mansfield, MA, USA) was introduced and pneumoperitoneum up to 15 mmHg was achieved. Two 5-mm trocars and one 12-mm trocar were used. A 5-mm 30° angled endoscope, a flexible reticulating endograsper, and straight standard instruments were used. The identified appendix was dissected and a stapler was used to divide the mesoappendix from the appendix. Following confirmation of good hemostasis and no spillage of bowel contents, the appendix was removed from the abdomen within a retrieval bag and the culdotomy was closed with a running absorbable suture. The patient tolerated the 27 min procedure well and was discharged home in good condition on postoperative day 1.

Transvaginal cholecystectomy versus single-incision laparoscopic cholecystectomy versus four-port laparoscopic cholecystectomy: a prospective cohort study.

OBJECTIVE: This report describes the first prospective cohort study comparing transvaginal cholecystectomies (TVC) with single incision laparoscopic cholecystectomies (SILC) and four-port laparoscopic cholecystectomies (4PLC). METHODS: Between May 2009 and August 2010, 14 patients underwent a TVC. These patients were compared with patients who underwent SILC (22 patients) or 4PLC (11 patients) in a concurrent, randomized, controlled trial. Demographic data, operative time, numerical pain scales, complications, and return to work were recorded. RESULTS: Mean age (TVC: 33.5 ± 3.0 year; SILC: 38.4 ± 3.3 year; 4PLC: 35.5 ± 4.1 year; p = 0.58) and mean BMI (TVC: 28.8 ± 1.5 kg/m(2); SILC: 31.8 ± 1 kg/m(2); 4PLC: 31.4 ± 2.2 kg/m(2); p = 0.35) were not statistically significant. However, mean operative time (TVC: 67 ± 3.9 min; SILC: 48.9 ± 2.6 min; 4PLC: 42.3 ± 3.9 min; p < 0.001) was significantly longer for TVC. Numerical pain scales showed significantly lower pain scores on POD 1 and 3 for TVC compared with SILC and 4PLC (TVC: 4.1 ± 0.5 and 2.9 ± 0.7; SILC: 6.1 ± 0.5 and 5.3 ± 0.5; 4PLC: 5.7 ± 0.4 and 4.7 ± 0.3; p = 0.02) with equilibration of pain scores by days 14 and 30. Return to work (TVC: 6.4 ± 1.5 days; SILC: 13.1 ± 1.3 days; 4PLC: 14.1 ± 1.4 days; p < 0.001) also was significantly faster for patients in the TVC group. One conversion in the TVC group to a 4PLC was necessary due to adhesions within the pelvis. One dislodged IUD was seen and immediately replaced in the TVC group. One hernia was observed in the SILC group. CONCLUSIONS: Transvaginal cholecystectomy is a safe and well-tolerated procedure with statistically significantly less pain at 1 and 3 days after surgery, with a faster return to work but longer operative times compared with single incision and four-port laparoscopic cholecystectomy.

Pure transvaginal appendectomy versus traditional laparoscopic appendectomy for acute appendicitis: a prospective cohort study.

OBJECTIVE: This report describes the first cohort study comparing pure transvaginal appendectomies (TVAs) to traditional 3-port laparoscopic appendectomies (LAs). METHODS: Between August 2008 and August 2010, 42 patients were offered a pure TVA. Patients who did not wish to undergo a TVA underwent a LA and served as the control group. Demographic data, operative time, length of stay, patient controlled analgesia (PCA) 12-hour-morphine utilization, complications, return to normal activity, and return to work were recorded. RESULTS: Eighteen of 40 enrolled patients underwent a pure TVA. Two patients refused to participate in this study. Mean age (TVA: 31.3 ± 2.5 years vs. LA: 28.2 ± 2.3 years, P = 0.36), mean body mass index (TVA: 23.7 ± 1.2 kg/m2 vs. LA: 23.6 ± 0.7 kg/m2, P = 0.96) mean operative time (TVA: 44.4 ± 4.5 minutes vs. LA: 39.8 ± 2.6 minutes, P = 0.38), and mean length of hospital stay (TVA: 1.1 ± 0.1 days vs. LA: 1.2 ± 0.1 days, P = 0.53) were not statistically significant. However, mean postoperative morphine-use (TVA: 8.7 ± 2.0 mg vs. LA: 23.0 ± 3.4 mg, P < 0.01), return to normal activity (TVA: 3.3 ± 0.4 days vs. LA: 9.7 ± 1.6 days, P < 0.01), and return to work (TVA: 5.4 ± 1.1 days vs. LA: 10.7 ± 1.5 days, P = 0.01) were statistically significant. One conversion in the TVA group to a LA was necessary because of inability to maintain adequate pneumoperitoneum. Four complications were observed: 1 intraabdominal abscess and 1 case of urinary retention in the TVA group; 1 early postoperative bowel obstruction and 1 case of urinary retention in the LA group. CONCLUSIONS: Pure TVA is a safe and well-tolerated procedure with significantly less pain and faster recovery compared to traditional LA.

Transvaginal NOTES hybrid cholecystectomy.

BACKGROUND: Initial reports confirm the safety and feasibility of natural orifice transluminal eendoscopic surgery (NOTES) transvaginal hybrid cholecystectomy (TVC). Benefits of TVC include no visible scars, less pain, and shorter recovery. The authors describe a single surgeon's initial experience with TVC through his first 20 cases. METHOD: Under direct visualization from a 5-mm umbilical trochar, a 12-mm trocar, or in 2 cases a SILS port was introduced through the posterior vagina into the cul-de-sac. The gallbladder was visualized using an endoscope introduced through the vaginal port. Using extracorporeal stay sutures for retraction, the cystic duct and artery were dissected free, clipped, and divided. The gallbladder was then removed through the vaginal port. RESULTS: Twenty patients underwent a successful TVC. The average age was 34.9 years (21-55 years), average body mass index was 29.9 kg/m2 (18.3-38.1 kg/m2), and the mean operative time was 71.4 minutes (42-116 minutes). CONCLUSION: TVC is a safe, feasible, and attractive alternative to traditional 4-port laparoscopic cholecystectomy.

Female sexual function after pure transvaginal appendectomy: a cohort study.

BACKGROUND: The impact of transvaginal natural orifice transluminal endoscopic surgery (NOTES) on female sexual function is unknown. We therefore performed a prospective cohort study of women undergoing pure transvaginal appendectomies (TVA) versus traditional laparoscopic appendectomies (LA). Using a validated, 19-point, female sexual function index questionnaire (FSFI) assessing six domains of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and pain with intercourse), pre- and postoperative sexual function was compared. METHODS: Between August 2008 and August 2010, 42 patients with acute appendicitis were offered a pure TVA. Patients who did not wish to undergo a TVA underwent an LA and served as controls. Both groups were provided with an FSFI before surgery and at regular intervals for up to 1 year. Pre- and postoperative FSFI results were compared between cohorts using unpaired t tests, and between individuals within each cohort pre- and postoperatively using paired t tests. RESULTS: Twenty-two underwent LA, 18 patients underwent a pure TVA, and 2 refused participation in this study. Preoperative and >60 days postoperative FSFI data were available for 21 patients (10 LA and 11 TVA). Baseline FSFI scores were not significantly different between groups (LA, 19.3 ± 0.9; TVA, 19.3 ± 0.8, p = 0.99). FSFI scores at greater than 60 days postoperatively did not differ significantly from FSFI scores preoperatively in either group (LA, 19.3 ± 0.9 to 19.7 ± 0.7; p = 0.87; TVA, 19.3 ± 0.8 to 19.4 ± 0.9; p = 0.97). No FSFI domain in either cohort was significantly changed postoperatively. CONCLUSIONS: Neither LA nor TVA affected female sexual function scores. This suggests that TVA does not have negative effects on female sexual function. The results of this study may prove beneficial in consultations with patients concerning the sexual sequelae of transvaginal surgery.

Stump appendicitis: a surgeon's dilemma.

BACKGROUND: Stump appendicitis is defined by the recurrent inflammation of the residual appendix after the appendix has been only partially removed during an appendectomy for appendicitis. Forty-eight cases of stump appendicitis were identified in the English literature. DATABASE: The institutional CPT codes were evaluated for multiple hits of the appendectomy code, yielding a total of 3 patients. After appropriate approval from an internal review board, a retrospective chart review was completed and all available data extracted. All 3 patients were diagnosed with stump appendicitis, ranging from 2 months to 20 years after the initial procedure. Two patients underwent a laparoscopic and the one an open completion appendectomy. All patients did well and were discharged home in good condition. CONCLUSION: Surgeons need a heightened awareness of the possibility of stump appendicitis. Correct identification and removal of the appendiceal base without leaving an appendiceal stump minimizes the risk of stump appendicitis. If a CT scan has been obtained, it enables exquisite delineation of the surrounding anatomy, including the length of the appendiceal remnant. Thus, we propose that unless there are other mitigating circumstances, the completion appendectomy in cases of stump appendicitis should also be performed laparoscopically guided by the CT findings.

Completion of a novel, virtual-reality-based, advanced laparoscopic curriculum improves advanced laparoscopic skills in senior residents.

INTRODUCTION: Virtual reality simulators contribute to basic laparoscopic skill acquisition. These trainers have not yet been shown to contribute to the acquisition of more advanced laparoscopic skills as measured by the Fundamentals of Laparoscopic Surgery (FLS). We have customized novel basic and advanced curricula for the LapSim trainer (Surgical Science, Göteborg, Sweden). Successful completion of these programs is required of our residents. We hypothesize that the successful completion of our advanced curriculum will result in the significant improvement of our residents' advanced laparoscopic skills as measured by the FLS skills scores. METHODS: In all, 23 surgical residents (PGY 1-4), who had already passed our basic skills curriculum, completed our advanced LapSim curriculum. All individuals underwent FLS skills testing before and after completing the training. Laparoscopic case experience during the training period was documented for all trainees. FLS scores were analyzed by t test and controlled for case experience. RESULTS: Posttraining FLS scores demonstrate a significant increase for all residents from a mean of 57-66 (p < 0.02), especially for seniors (PGY 3-4): 56-68 (p < 0.01). The operative laparoscopic case volume ranged from 1-90 (mean, 30) for juniors (PGY 1-2) and 12-76 (mean 50) for seniors during the training period. Junior resident FLS improvement was dependent on case volume during the period of training; residents with less than 30 cases had a mean improvement of 0, whereas those with at least 30 cases had a 15 point improvement (p < 0.01). Senior resident FLS score improvement was independent of case numbers during the training period. CONCLUSIONS: Completion of our advanced LapSim curriculum results in improved advanced laparoscopic skills in senior residents as measured by FLS scores. This skill improvement is independent of laparoscopic case experience. Continuing to mandate the use of this skills curriculum should improve our residents' performance in advanced laparoscopic surgical procedures.

Does Preoperative Weight Change Predict Postoperative Weight Loss after Laparoscopic Roux-en-Y Gastric Bypass in the Short Term?

Background. Many institutions mandate preoperative weight loss prior to bariatric surgery. This study examines the correlation between preoperative weight change and postoperative success following laparoscopic Roux-en-Y gastric bypass. Methods. We retrospectively studied the correlation between change in BMI before surgery and change in BMI postoperatively, using linear regression analyses and one-way ANOVA, in 256 consecutive gastric bypass patients with 1-year followup. Results. Of 256 patients, 125 lost weight preoperatively (mean -1.7% BMI), while 131 maintained or gained weight (mean +1.2% BMI). Postoperatively, there was no significant difference in percent BMI loss between the two groups (34.6% and 34.5%). The percent change in BMI preoperatively did not predict postoperative BMI change after 1 year (P = n.s.). Conclusions. Our study did not show any correlation between preoperative weight change and postoperative weight loss after Roux-en-Y gastric bypass. Therefore, we do not believe that potential patients should be denied bariatric surgery on the basis of their inability to lose weight preoperatively.