Protective effect of black relative to white race against non-alcoholic fatty liver disease in patients with severe obesity, independent of type 2 diabetes.

Severe obesity (body mass index ⩾35 kg m-2) and type 2 diabetes (T2D) are potent and additive risk factors for non-alcoholic fatty liver disease (NAFLD), including non-alcoholic steatohepatitis (NASH). Scant available evidence indicates that black relative to white patients with severe obesity are less susceptible to NAFLD, but it is unclear if T2D abolishes this apparent racial disparity. Therefore, we compared biopsy-proven NAFLD and its progression between black (n=71) and white (n=155) patients with severe obesity stratified by presence or absence of T2D. Although prevalence of T2D was similar between races (37%, P>0.9), whites were significantly more likely than blacks to have NAFLD, NASH and advanced fibrosis (defined as bridging fibrosis and/or cirrhosis). Importantly, T2D was associated with increased odds of NAFLD, NASH and advanced fibrosis (defined as bridging fibrosis or cirrhosis) in whites only (P<0.05). In turn, a higher proportion of blacks than whites with T2D were free of NAFLD (58 versus 22%, P<0.01). These preliminary findings question translation of the powerful interconnection between T2D and NAFLD in whites with severe obesity to blacks and point to an important role of race in the pathophysiology and treatment of these diseases.

Esophageal verrucous carcinoma arising from hyperkeratotic plaques associated with human papilloma virus type 51.

Esophageal verrucous carcinoma is a rare variant of esophageal squamous cell carcinoma. We report a case of esophageal verrucous carcinoma associated with human papilloma virus (HPV) type 51. The patient had long-standing dysphagia and odynophagia, and white esophageal plaques showing hyperkeratosis on biopsy. At repeat endoscopy, the esophagus was covered with verrucous white plaques and areas of nodular mucosa with white fronds, with a distal 10-cm smooth mass protruding into the lumen. Biopsies demonstrated an atypical squamoproliferative lesion but no frank malignancy. HPV type 51 DNA was detected in endoscopic biopsy specimens by polymerase chain reaction. Because the size of the lesion favored an underlying verrucous carcinoma, our patient underwent minimally invasive esophagectomy with gastric pull-up and cervical anastomosis. The pathologic diagnosis was a well-differentiated esophageal verrucous carcinoma. One year after esophagectomy, the patient feels well and is free of disease. Although HPV DNA was not detected in the cancer tissue obtained at surgery, our case suggests an association between HPV type 51 and esophageal verrucous carcinoma. The clinical evolution in this case highlights the importance of endoscopic surveillance in patients with exuberant esophageal hyperkeratosis, and of definitive surgical resection when malignancy is suspected even if frank malignancy is not demonstrated on superficial biopsies.

Giardia spp. e Cryptosporidium spp. em água de manancial superficial de abastecimento contaminada por dejetos humano e animal / Giardia spp. and Cryptosporidium spp. in a fresh water supply source contaminated with human and animal excreta and waste water

Estudou-se ocorrência de cistos de Giardia spp. e oocistos de Cryptosporidium spp. - (oo)cistos - na bacia hidrográfica do Ribeirão São Bartolomeu, localizada no município de Viçosa, MG. O estudo incluiu as populações humana e animal existentes na área da bacia, bem como no efluente de uma estação de tratamento de esgoto (ETE) e de duas instalações para suínos. Os resultados indicam presença de (oo)cistos no manancial (médias geométricas: 3,92 e 3,62 (oo)cistos/l para Giardia spp. e Cryptosporidium spp., respectivamente). Propriedades com exploração bovina foram positivas ao longo de todo período (prevalência média de propriedades positivas 36,4 por cento para Giardia spp. e 18,0 por cento para Cryptosporidium spp.). O efluente da ETE apresentou elevada concentração de cistos de Giardia spp. (média geométrica na ordem de 10(4)/l), mas não foram encontrados oocistos de Cryptosporidium spp. A ocorrência de (oo)cistos apresentou comportamento sazonal, sendo que os valores médios de (oo)cistos e de pluviosidade do trimestre de coleta revelaram bom ajuste de correlação (R²=98,3 por cento; P=0,0087 para Giardia spp. e R²=91,8 por cento; P=0,0421 para Cryptosporidium spp.). A significativa ocorrência de (oo)cistos no manancial sugere que a forma de ocupação do solo interfere na qualidade parasitológica da água bruta. Os resultados apontam para a importância de adoção de medidas preventivas, como proteção de áreas de mananciais, objetivando reduzir riscos de transmissão de protozoários via água de consumo humano.

The occurrence of Giardia spp. cysts and Cryptosporidium spp. oocysts - (oo)cysts - was studied in a watershed (São Bartolomeu Stream-SB), at Viçosa city, MG. In the studied area, characterization of animal farms and identification of sewage and animal wastes discharges were undertaken. In addition, a sewage treatment plant (STP) and effluents of two swine farms were sampled. The results presented protozoan contamination (geometric averages: 3.92 and 3.62 (oo)cysts/l for Giardia spp. and Cryptosporidium spp., respectively). Positive cattle farms were detected during all the period, and the correspondent mean prevalences were: 36.4 percent for Giardia spp. and 18.0 percent for Cryptosporidium spp. STP effluent presented high concentration of Giardia spp. (geometric average of cysts in the order of 10(4)/l). However, Cryptosporidium spp. oocysts were not detected. The results showed that (oo)cysts concentration were influenced by climate factors. Precipitation and (oo)cysts concentration data were well correlated (R²=98.3 percent; P=0.0087 for Giardia spp. and R²=91.8 percent; P=0.0421 for Cryptosporidium spp.). Cysts and oocysts levels were remarkably high in the raw water source, pointing out the role of land use in an unprotected watershed as a source of protozoa. The results demonstrate the importance of preventive measures rather than relying on, sometimes unreliable, corrective measures such as water treatment, in order to minimize human health risks.

Routine upper GI series after gastric bypass does not reliably identify anastomotic leaks or predict stricture formation.

BACKGROUND: Many surgeons who perform Roux-en-Y gastric bypass (RYGB) for morbid obesity routinely obtain an upper gastrointestinal (GI) series in the early postoperative period to search for anastomotic leaks and signs of stricture formation at the gastrojejunostomy. We hypothesized that this practice is unreliable. METHODS: We analyzed 654 consecutive RYGBs, of which 63% were completed laparoscopically. An upper GI series was obtained in 634 (97%) patients. The radiographic findings (leak or delayed emptying) were compared with clinical outcomes (leak or stricture formation) to calculate the sensitivity and specificity. Univariate analysis identified risk factors for leaks or stricture formation; events were too few for multivariate analysis. RESULTS: Of 634 routine upper GI series, anastomotic leaks at the gastrojejunostomy were diagnosed in 5 (0.8%); 2 of these 5 were later reinterpreted as artifacts. Four leaks were not seen on the initial upper GI series, yielding an overall sensitivity of 43% and a positive predictive value (PPV) of 60%. Univariate analysis showed that cases done early (odds ratio [OR] 5.4 for the first 100 cases, p = 0.02) and prolonged operating time (OR 7.8 for cases >or= 300 min, p = 0.01) were associated with leaks. Emptying into the Roux-en-Y limb was delayed in 127 (20%) of the upper GI series. Strictures requiring dilatation developed in 16 (2.4%) patients. The PPV of delayed emptying for stricture formation was 6%. Risk factors for stricture formation included stapled anastomosis (OR 7.8, p = 0.002), surgeon inexperience (OR 2.9 for first 50 cases, p = 0.04), and delayed emptying (OR 3.3; p = 0.02). CONCLUSIONS: Because the incidence of anastomotic complications and the sensitivity of upper GI series were both low, routine upper GI series did not reliably identify leaks or predict stricture formation. A selective approach, whereby imaging is reserved for patients with clinical evidence of a leak or stricture, may be more appropriate.

Predictive factors of Barrett esophagus: multivariate analysis of 502 patients with gastroesophageal reflux disease.

HYPOTHESIS: Risk factors for the presence and extent of Barrett esophagus (BE) can be identified in patients with gastroesophageal reflux disease (GERD). DESIGN: Case-comparison study. SETTING: University tertiary referral center. PATIENTS: Five hundred two consecutive patients with GERD documented by 24-hour esophageal pH monitoring and with complete demographic, endoscopic, and physiological evaluation, divided in groups according to the presence and extent of BE (328 patients without BE and 174 with BE [67 short-segment BE and 107 long-segment BE]). MAIN OUTCOME MEASURES: Clinical, endoscopic, and physiological data, studied by multivariate analysis, to identify the independent predictors of the presence and extent of BE. RESULTS: Seven factors were identified as predictors of BE. They were abnormal bile reflux (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.9-9.7), hiatal hernia larger than 4 cm (OR, 4.1; 95% CI, 2.1-8.0), a defective lower esophageal sphincter (OR, 2.7; 95% CI, 1.4-5.4), male sex (OR, 2.6; 95% CI, 1.6-4.3), defective distal esophageal contraction (OR, 2.2; 95% CI, 1.4-3.5), abnormal number of reflux episodes lasting longer than 5 minutes (OR, 2.2; 95% CI, 1.1-4.6), and GERD symptoms lasting for more than 5 years (OR, 2.1; 95% CI, 1.4-3.2). Only abnormal bile reflux (OR, 4.8; 95% CI, 1.7-13.2) was identified as a predictor of short-segment BE (baseline, no BE). Three factors were identified as predictors of long-segment BE (baseline short-segment BE). They were hiatal hernia larger than 4 cm (OR, 17.8; 95% CI, 4.1-76.6), a defective lower esophageal sphincter (OR, 16.9; 95% CI, 1.6-181.4), and an abnormal longest reflux episode (OR, 8.1; 95% CI, 2.8-24.0). CONCLUSIONS: Among patients with GERD, specific factors are associated with the presence and extent of BE. Elimination of reflux with an antireflux operation in patients with 1 or more of these factors may prevent the future development of BE.

Dermatophytes and saprobe fungi isolated from dogs and cats in the city of Fortaleza, Brazil

The possible involvement of saprobe fungi in dermatomycoses, as well as the determination of the incidence of dermatophytes in dogs and cats were studied. During a period of one year, 74 dogs and 18 cats, with cutaneous lesions suggesting mycoses were included in this study. The mycological analyses were conducted by direct microscopy and by fungal culture on Sabouraud agar, chloramphenicol Sabouraud agar and mycosel agar. Of the 92 samples, 21 resulted in positive cultures for dermatophytes. Dematophyte fungi pure cultures were obtained from 13 samples. A simultaneous growth of dermatophytes plus saprobe fungi was observed in 8 of the samples. Of the remaining 71 samples, no fungal growth was observed in 10 samples, and at minimum the growth of one saprobe fungi in 61. One, two and three genera of saprobe were isolated in 29, 30 and 2 samples, respectively. Microsporum canis was isolated in 6 (28.6 per cent) and 10 samples (47.6 per cent) from cats and dogs, respectively, and Trichophyton mentagrophytes in 2 (9.5 per cent) and 3 samples (14.3 per cent) from cats and dogs, respectively. The following genera of saprobe fungi were also isolated: Alternaria sp (1.9 per cent), Chaetomium sp (1.9 per cent), Rhizopus sp (2.9 per cent), Curvularia sp (3.9 per cent), Candida sp (6.8 per cent), Trichoderma sp (6.8 per cent), Fusarium sp (7.8 per cent), Cladosporium sp (8.7 per cent), Penicillium sp (21.4 per cent) and Aspergillus sp (37.9 per cent)

[Hantavirus pulmonary and cardiovascular syndrome: epidemiology, clinical presentation, laboratory diagnosis and treatment]. / Síndrome pulmonar e cardiovascular por Hantavirus: aspectos epidemiológicos, clínicos, do diagnóstico laboratorial e do tratamento.

The Hantavirus pulmonary and cardiovascular syndrome (HPCVS) is an emerging disease in Brazil. In this study, eight confirmed cases of HPCVS were studied. All the patients presented fever and dyspnea as well as thrombocytopenia and hypoxemia. Tachycardia, malaise, hypotension and lung rales occurred in 75 to 87.5% of the cases. Hemoconcentration, blood cell count increased and immature neutrophils, and high levels of creatinine were observed in 75 to 87.5%. Intravenous liquid infusion, the use of drugs for increasing systemic vascular resistance and inotropism, and mechanic ventilation were used for the patients. Mechanical ventilation and volume administration should be started precociously, preferable in intensive care units employing recommended universal and respiratory precautions. Careful volume administration should be limited if signs of pulmonary edema develop. Mortality (50%) is high and probably related to the severity of the disease as well as to a delayed attending of the patients for intensive management. It is important to report hantaviruses and HPCVS to the Brazilian medical community considering that many cases could be undiagnosed.

Síndrome pulmonar e cardiovascular por Hantavirus: aspectos epidemiológicos, clínicos, do diagnóstico laboratorial e do tratamento / Hantavirus pulmonary and cardiovascular syndrome: epidemiology, clinical presentation, laboratory diagnosis and treatment

The Hantavirus pulmonary and cardiovascular syndrome (HPCVS) is an emerging disease in Brazil. In this study, eight confirmed cases of HPCVS were studied. All the patients presented fever and dyspnea as well as thrombocytopenia and hypoxemia. Tachycardia, malaise, hypotension and lung rales occurred in 75 to 87.5% of the cases. Hemoconcentration, blood cell count increased and immature neutrophils, and high levels of creatinine were observed in 75 to 87.5%. Intravenous liquid infusion, the use of drugs for increasing systemic vascular resistance and inotropism, and mechanic ventilation were used for the patients. Mechanical ventilation and volume administration should be started precociously, preferable in intensive care units employing recommended universal and respiratory precautions. Careful volume administration should be limited if signs of pulmonary edema develop. Mortality (50%) is high and probably related to the severity of the disease as well as to a delayed attending of the patients for intensive management. It is important to report hantaviruses and HPCVS to the Brazilian medical community considering that many cases could be undiagnosed.

A síndrome pulmonar e cardiovascular por Hantavirus (SPCVH), é doença emergente com descrição crescente de casos no Brasil. Neste trabalho, estudou-se 8 casos confirmados da doença. Todos apresentaram febre e dispnéia. Taquicardia, astenia, hipotensão e estertoração pulmonar ocorreram em 75 a 87,5% dos casos. Plaquetopenia e hipoxemia ocorreram em 100% dos casos, hemoconcentração, leucocitose com desvio à esquerda e elevação de uréia e creatinina séricas em 75 a 87,5%. Assistência respiratória, hidratação endovenosa e utilização de aminas vasoativas foram as medidas utilizadas nos pacientes. Ressalta-se que o suporte ventilatório e cardiovascular deve ser precocemente instituído, preferencialmente em unidades de terapia intensiva, com precauções universais e respiratórias de isolamento. Deve-se ter cuidados com infusão excessiva de líquidos para não agravar o edema pulmonar. A mortalidade observada, de 50%, é elevada, deveu-se à gravidade da doença e ao comparecimento tardio para tratamento intensivo. Deve-se informar sobre a SPCVH aos profissionais de saúde, considerando que casos de SPCVH, provavelmente, vêm passando desapercebidos.

Laparoscopic extraperitoneal inguinal hernia repair. A safe approach based on the understanding of rectus sheath anatomy.

We have devised a reproducible approach to the preperitoneal space for laparoscopic repair of inguinal hernias that is based on an understanding of the abdominal wall anatomy. Laparoscopic totally extraperitoneal herniorrhaphy was performed on 99 hernias in 90 patients at the Los Angeles County-University of Southern California Medical Center, using a standardized approach to the preperitoneal space. Operative times, morbidity, and recurrence rates were recorded prospectively. The median operative time was 37 min (range, 28-60) for unilateral hernias and 46 min (range, 35-73) for bilateral hernias. There were no conversions to open repair, and there was only one conversion to a laparoscopic transabdominal approach. Complications were limited to urinary retention in two patients, pneumoscrotum in one patient, and postoperative pain requiring a large dose of analgesics in one patient. All patients were discharged within 23 h. There were no recurrences or neuralgias on follow-up at 2 years. A standardized approach to the preperitoneal space based on a thorough understanding of the abdominal wall anatomy is essential to a satisfactory outcome in hernia repair.

Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication.

Laparoscopic Nissen fundoplication has been applied with increasing frequency in the treatment of gastroesophageal reflux disease. The aim of this study was to determine the variables that predict outcome of laparoscopic Nissen fundoplication. A multivariate analysis was performed on data from 199 consecutive patients undergoing laparoscopic Nissen fundoplication. Variables included age, sex, body mass index, primary symptoms, clinical response to acid suppression therapy, erosive esophagitis, 24-hour esophageal pH score, and the percentage of time the esophageal pH was less than 4 on 24-hour pH monitoring, lower esophageal sphincter competence, status of the esophageal body motility, hiatal hernia, carditis, intestinal metaplasia of cardiac epithelium limited to the gastroesophageal junction, and Barrett's esophagus of any length. Clinical outcome was obtained from all patients at a median follow-up of 15 months (range 6 to 74 months) after surgery. One hundred seventy-three patients had an excellent or good outcome (87%) and 26 had a fair or poor outcome. Three factors were significantly predictive of a successful outcome: an abnormal 24-hour pH score (odds ratio = 5.4; 95% confidence interval [CI] = 1. 9-15.3), a typical primary symptom (odds ratio = 5.1; 95% CI = 1. 9-13.6), and a clinical response to acid suppression therapy (odds ratio = 3.3; 95% CI = 1.3-8.7). We conclude that 24-hour pH monitoring provides the strongest outcome predictor of laparoscopic Nissen fundoplication and that outcome is based more on the correct identification of the disease than on its severity.

Laparoscopic repair of perforated duodenal ulcers: outcome and efficacy in 30 consecutive patients.

HYPOTHESIS: Laparoscopic management of perforated duodenal ulcers is safe and effective. DESIGN: Prospective nonrandomized controlled trial. SETTING: Tertiary care academic center. PATIENTS AND METHODS: Between October 1993 and October 1997, 30 patients underwent laparoscopic Graham patch repair of perforated duodenal ulcers and 16 had an open repair. MAIN OUTCOME MEASURES: Morbidity, operating time, analgesic requirements, length of hospital stay, and time to return to work. RESULTS: There was no difference in morbidity between the 2 groups. Operating time was longer in the laparoscopy group (106 vs. 63 minutes; P = .001). Patients with shock on admission or symptoms for more than 24 hours had a higher conversion rate (P<.05). The laparoscopy group required fewer analgesics, had a shorter stay, and a quicker recovery. CONCLUSIONS: Laparoscopic repair for perforated ulcers is safe and maintains benefits of the minimally invasive approach. Laparoscopy is not beneficial in patients with shock.

The pattern of esophageal acid exposure in gastroesophageal reflux disease influences the severity of the disease.

HYPOTHESIS: There is an independent association between the different patterns of esophageal acid exposure in gastroesophageal reflux disease and the severity of the disease. DESIGN: Case-comparison study. SETTING: Department of surgery at a university hospital. PATIENTS: A group of 401 patients with increased esophageal acid exposure divided into 4 groups according to the pattern of reflux: postprandial (n = 41), upright (n = 74), supine (n = 129), and bipositional (n = 157). MAIN OUTCOME MEASURES: The prevalence of mucosal injury and the status of the lower esophageal sphincter and esophageal motility were assessed in each group. RESULTS: The likelihood of having indicators of the severity of gastroesophageal reflux disease increases progressively from postprandial to upright, supine, and bipositional reflux. CONCLUSIONS: The pattern of esophageal acid exposure in gastroesophageal reflux disease is an objective predictor of the severity of disease and could be used for therapeutic decisions.

Short esophagus: analysis of predictors and clinical implications.

HYPOTHESIS: Preoperative assessment can identify the predictors of esophageal shortening in patients with gastroesophageal reflux disease. DESIGN AND SETTING: Patient comparison study in a university-based tertiary care center. PATIENTS: A total of 236 patients with gastroesophageal reflux disease underwent primary antireflux procedures. Sixty-five patients were suspected of having a short esophagus and underwent a transthoracic approach. In 37 patients, a lengthening procedure was necessary to avoid tension on the repair. The remaining 28 patients were thought-after complete esophageal mobilization-to have sufficient length for a repair without needing a gastroplasty. An abdominal approach (laparoscopic Nissen fundoplication) was performed on 171 patients judged to have normal esophageal length. MAIN OUTCOME MEASURES: Univariate and multivariate analyses of preoperative variables were performed to identify predictors of a short esophagus. RESULTS: On univariate analysis, manometric esophageal length below the fifth percentile of normal was associated with esophageal shortening. On multivariate analysis, only the presence of an esophageal stricture predicted the need for a Collis gastroplasty (odds ratio, 7.5). The presence of Barrett's esophagus of 3 cm or greater identified patients in whom the transthoracic esophageal mobilization alone was sufficient (odds ratio, 3.4). CONCLUSIONS: The presence of a stricture was associated with esophageal shortening sufficient to require a gastroplasty. Transthoracic esophageal mobilization alone was usually sufficient to perform a safe repair without tension in patients with a Barrett's esophagus of 3 cm or greater.

A multivariate model to determine prognostic factors in gastrointestinal fistulas.

BACKGROUND: Some studies have identified and selected factors that were associated with prognosis in patients with gastrointestinal fistulas, but a multivariate analysis to determine their relative importance and independent predictive value has not been done. The aim of this study was to determine independent prognostic factors for fistula closure and death in patients with gastrointestinal fistulas using a multivariate model. STUDY DESIGN: Several variables were assessed related to spontaneous closure, surgical closure, and mortality in 188 patients with digestive fistulas (duodenal 22.3%, jejunoileal 28.7%, colonic 23.9%, biliopancreatic 25%). Selection of the variables was done through a forward stepwise logistic regression procedure; the final models were used to estimate the probability of closure, either spontaneous or surgical, and the probability of death. RESULTS: Variables significant for spontaneous closure were: cause of the fistula (p = 0.027), fistula output (p = 0.037), institutional origin of the patient (p = 0.026), and occurrence of complications (p<0.001). Organ of origin of the fistula was only marginally significant (p = 0.068). Successful surgical closure was significantly associated with the presence of complications (p = 0.001) and was marginally associated with age (p = 0.069). Variables significant for death were fistula output (p = 0.009) and the presence of complications (p<0.001). CONCLUSIONS: We conclude that the likelihood of spontaneous fistula closure is higher for fistulas with surgical causes, low output, and with no complications. Mortality is higher in patients with complications and with high-output fistulas.

Node status in transmural esophageal adenocarcinoma and outcome after en bloc esophagectomy.

OBJECTIVE: Adenocarcinoma has replaced squamous cell as the most common esophageal cancer in the United States. The purpose of this study was to determine the prevalence and location of lymph node metastases, the feasibility of performing an R0 resection, and disease recurrence and survival in patients with transmural adenocarcinoma of the lower esophagus and gastroesophageal junction. METHODS: Forty-four patients with transmural adenocarcinoma underwent en bloc esophagectomy with systematic thoracic and abdominal lymphadenectomy. They were followed up for a median of 23 months. RESULTS: Actuarial survival for the entire group was 26% at 5 years. The most important predictors of the likelihood of recurrent disease and 5-year survival were the presence and number of lymph node metastases and the ratio of involved to total removed nodes. Seven patients (16%) were found to have no lymph node metastases and had an 85% 5-year survival. In contrast, patients with more than 4 involved nodes or a node ratio greater than 0.1 had a high likelihood of recurrence and death. Location of involved lymph nodes did not predict the likelihood of recurrence or death. Despite all patients having transmural tumors, recurrence within the field of the en bloc resection occurred in only 1 patient (2%). CONCLUSIONS: En bloc esophagectomy in patients with transmural esophageal adenocarcinoma is required to obtain the survival benefit of an R0 resection, to adequately assess lymphatic tumor burden, and to be able to predict the likelihood of recurrence and death and thereby guide the use of postoperative adjuvant therapy.

Laparoscopic management of benign solid and cystic lesions of the liver.

OBJECTIVE: The authors present their experience in the laparoscopic management of benign liver disease. The aim of the study is to analyze technical feasibility and evaluate immediate and long-term outcome. SUMMARY BACKGROUND DATA: Indications for the laparoscopic management of varied abdominal conditions have evolved. Although the minimally invasive treatment of liver cysts has been reported, the laparoscopic approach to other liver lesions remains undefined. METHODS: Between September 1990 and October 1997, 43 patients underwent laparoscopic liver surgery. There were two groups of benign lesions: cysts (n = 31) and solid tumors (n = 12). Indications were solitary giant liver cysts (n = 16), polycystic liver disease (n = 9), hydatid cyst (n = 6), focal nodular hyperplasia (n = 3), and adenoma (n = 9). Only solid tumors, hydatid cysts, and patients with polycystic disease and large dominant cysts located in anterior liver segments were included. All giant solitary liver cysts were considered for laparoscopy. Patients with cholangitis, cirrhosis, and significant cardiac disease were excluded. Data were collected prospectively. RESULTS: The procedures were completed laparoscopically in 40 patients. Median size was 4 cm for solid nodules and 14 cm for solitary liver cysts. Conversion occurred in three patients (7%), for bleeding (n = 2) and impingement of a solid tumor on the inferior vena cava (n = 1). The median operative time was 179 minutes. All solitary liver cysts were fenestrated in less than 1 hour. There were no deaths. Complications occurred in 6 cases (14.1%). Two hemorrhagic and two infectious complications were noted after management of hydatid cysts. There were no complications after resection of solid tumors. Three patients received transfusions (7%). The median length of stay was 4.7 days. Median follow-up was 30 months. There was no recurrence of solitary liver or hydatid cysts. One patient with polycystic disease had symptomatic recurrent cysts at 6 months requiring laparotomy. CONCLUSION: Laparoscopic liver surgery can be accomplished safely in selected patients with small benign solid tumors located in the anterior liver segments and giant solitary cysts. The laparoscopic management of polycystic liver disease should be reserved for patients with a limited number of large, anteriorly located cysts. Hydatid disease is best treated through an open approach.

The extent of Barrett's esophagus depends on the status of the lower esophageal sphincter and the degree of esophageal acid exposure.

OBJECTIVE: The purpose of this study was to assess whether the extent of intestinal metaplasia is related to the severity of the gastroesophageal reflux disease. METHODS: A total of 556 consecutive patients with symptoms suggestive of foregut disease had upper gastrointestinal endoscopy with extensive biopsies from the gastroesophageal junction and the esophagus. All patients had esophageal motility and 24-hour pH monitoring. In 411 patients, cardiac-type mucosa was identified; in 147 patients, the cardiac-type mucosa showed intestinal metaplasia. They were divided into 3 groups based on the extent of intestinal metaplasia commonly seen clinically: long segments (>3 cm), short segments (<3 cm), and limited to the gastroesophageal junction. The duration of symptoms, the status of the lower esophageal sphincter, the degree of esophageal acid exposure, and the time to clear a reflux episode were assessed in each group. RESULTS: The presence of intestinal metaplasia in cardiac-type mucosa was associated with the hallmarks of gastroesophageal reflux disease. The extent of intestinal metaplasia correlated strongly with the degree of esophageal acid exposure (r = 0.711; P <.001) and inversely with the lower esophageal sphincter pressure (r = 0.351; P <.001) and length (r = 0. 259; P =.002). Patients with a long segment of intestinal metaplasia (>3 cm) had longer duration of symptoms (16 years) than those patients with a segment of intestinal metaplasia less than 3 cm (10 years; P =.048) or those patients with intestinal metaplasia limited to the gastroesophageal junction (10 years; P =.01). CONCLUSION: The extent of intestinal metaplasia, that is, Barrett's esophagus, is related to the status of the lower esophageal sphincter and the degree of esophageal acid exposure.

Is laparoscopic approach to lumbar spine fusion worthwhile?

BACKGROUND: Laparoscopic lumbar spine fusion has been recently described. The aim of this study is to evaluate the safety and efficacy of this procedure for single- and multiple-level degenerative disc disease. METHODS: Twenty-four consecutive laparoscopic interbody lumbar fusions were evaluated prospectively (18 single-level were compared with 6 multiple-level procedures). Results of the laparoscopic multiple-level procedures were further compared with 12 open multiple-level operations. RESULTS: Twenty procedures were completed laparoscopically. The conversions were related to iliac vein lacerations (3 cases) and a mesenteric tear. Single-level cases had lower morbidity (22% versus 83%), shorter hospital stay (2 versus 10 days), and higher fusion rate (88% versus 50%) than multiple-level procedures. Overall results in the latter group were worse than in the matched open group. CONCLUSIONS: Laparoscopic single-level fusion (L5-S1) is safe and carries the benefits of minimal access surgery. Morbidity after multiple level approach is high, and this procedure cannot be advocated at this time.