Causes and Timing of Nonelective Reoperations After Bariatric Surgery: A Review of 1304 Cases at a Single Institution.

As the number of patients undergoing bariatric procedures for weight loss increases, an understanding of the causes and timing of complications requiring reoperation is critical. The aim of our study was to characterize the type and timing of nonelective (NE) reoperations in these patients. Over five years, 1304 patients undergoing index procedures were identified: 769 laparoscopic Roux-en-Y gastric bypasses (LRYGB), 301 laparoscopic sleeve gastrectomies, and 234 laparoscopic adjustable gastric bands. We identified 117 NE reoperations, which were grouped by index procedure as well as whether they occurred early (≤90 days) or late (>90 days). In the laparoscopic adjustable gastric bands group, slipped gastric band was the most common indication for early (n = 2) and late (n = 2) reoperations. Biliary disease was the most common cause for early reoperations (n = 4), and the only cause for late reoperations (n = 2) after laparoscopic sleeve gastrectomies. For LRYGB, diagnoses differed between the early and late groups, with the most common early indications being bowel obstruction (n = 8) and anastomotic leak (n = 4) of the 18 early reoperations, and internal hernia (n = 36) and biliary disease (n = 17) of the 82 late reoperations. The vast majority of NE reoperations were performed laparoscopically (92%), with conversions and primarily open procedures only occurring in the LRYGB group.

Ruptured abdominal aortic aneurysm: does trauma center designation affect outcome?

Ruptured abdominal aortic aneurysm (RAAA) continues to be a major cause of mortality in the United States. Rapid diagnosis and uncomplicated surgical repair remain paramount to improving survival in this population. We proposed that the addition of an organized trauma service and subsequent improved management of critically ill patients who present with RAAA would positively impact overall mortality. A retrospective analysis was performed on all patients treated for RAAA at Santa Barbara Cottage Hospital for the years 1985-2004. Patients treated before level II trauma center designation (1985-1999) were compared to those treated after the trauma center was instituted. A total of 76 patients were included in this analysis. The two groups were similar with regard to demographics. However, significant decreases in transport time from the emergency department to the operating room and overall 30-day mortality were seen in patients after the trauma center designation. This designation also led to an increase in the number of cases performed per year, centralizing the treatment for these critically ill patients. Institution of a well-prepared and organized service, such as trauma, improved the outcome for patients treated with RAAA, with a particular benefit in the unstable patient.

Insulin stimulates endogenous angiotensin II production via a mitogen-activated protein kinase pathway in vascular smooth muscle cells.

OBJECTIVE: The present study was designed to determine the effects of insulin on cytosolic angiotensin II production and proliferation in cultured rat vascular smooth muscle cells. DESIGN AND METHODS: Vascular smooth muscle cells were incubated with insulin for 48 h. Cytosolic angiotensin I and II were determined by radioimmunoassays of purified cell homogenates. Angiotensin II was also detected by immunohistochemistry of intact cells. Cell proliferation was determined by pulse labeling with radiolabeled thymidine. Angiotensinogen mRNA expression was determined by slot-blot analysis. RESULTS: Insulin significantly increased cytosolic angiotensin II concentration in vascular smooth muscle cells. Lisinopril, omapatrilat and irbesartan inhibited this increase of angiotensin II, but had no effect on angiotensin I levels. Immunohistochemical staining confirmed the presence of angiotensin II in control and insulin-treated vascular smooth muscle cells. Insulin increased cell proliferation, and addition of lisinopril, omapatrilat or irbesartan inhibited this effect. Insulin also increased expression of angiotensinogen mRNA in cultured vascular smooth muscle cells, but PD98059, a mitogen-activated protein kinase inhibitor, prevented the rise in angiotensinogen expression. CONCLUSION: These results support the concept that insulin stimulates angiotensin II production in cultured vascular smooth muscle cells through a mitogen-activated, protein kinase-dependent pathway that might be a factor in the progression of atherosclerosis. Agents that block the renin-angiotensin system have direct protective effects, reducing vascular angiotensin II and growth of vascular smooth muscle cells and are thus of cardiovascular benefit.

Essential techniques for intraoperative composite endograft (CEG) formation in the treatment of abdominal aortic aneurysm.

The development of an ideal aortic stent graft continues to progress. New devices and techniques are expanding the use of endovascular repair in the treatment of abdominal aortic aneurysms (AAA). We present data with intraoperative composite endograft (CEG) techniques evaluating immediate and short-term compatibility of components and patients outcome. Twenty-five of 66 patients (38%) received intraoperative CEGs for AAA treatment. A total of 50 components were used to treat type I endoleaks, prevent graft limb kinking or treat associated iliac aneurysm. Nine of the components were used to manage type I proximal endoleaks. Forty-one components were used at the iliac limb for distal type I endoleak, hostile iliac anatomy, or graft limb support or to treat an associated iliac aneurysm. Two patients were left with a type I endoleaks at the iliac attachment site on completion of graft placement. With a mean follow-up of 11 months. Two of 25 patients had a type II endoleak at 6 months. One patient had type I endoleak at 1 year follow-up. CEGs are essential to treat endoleaks with a high technical success rate and expand the indications for treating infrarenal AAA. The component's short-term compatibility makes this method of stent graft placement safe.