Salivary cortisol increases after bariatric surgery in women.

Cortisol increases have been associated with psychological and physiological stress; however, cortisol dynamics after weight loss (bariatric) surgery have not been defined. Obese participants not using exogenous glucocorticoids were eligible to participate. Female participants (n=24) provided salivary cortisol samples at bedtime, upon awakening the following morning, and 30 min after awakening before, and at 6 or 12 months after bariatric surgery. The Medical Outcomes Study Short Form-12 version 2 questionnaire regarding health-related quality of life was also completed. Preoperatively, mean body mass index was 45.1±8.1 kg/m2. Mean late night (1.8±1.1 nmol/l), awakening (10.7±7.4 nmol/l), and after-awakening (11.5±7.9 nmol/l) salivary cortisol values were within normal ranges. The cortisol awakening response (mean 21.1±79.7%, median 13.7%) was at the low end of normal. Preoperatively, participants had lower mental and physical health-related quality of life scores than US adult norms (p<0.001). Salivary cortisol was not correlated with measures of health-related quality of life. Mean BMI decreased over time (p<0.001) and participants experienced improved physical and mental health-related quality of life (p≤0.011). Postoperative late night salivary cortisol was not different from preoperative values. Awakening and after-awakening cortisol levels were higher than preoperative values (15.3±7.7 nmol/l, p=0.013; 17.5±10.2 nmol/l, p=0.005; respectively), but the cortisol awakening response was not changed (mean 26.7±66.2%; median 7.8%). Morning salivary cortisol increased at long-term follow-up after bariatric surgery. Although self-evaluated mental and physical health improved after surgery, the cortisol awakening response is at the low end of normal, which may indicate continued physiological stress.

Telementored laparoscopic cholecystectomy: a pilot study.

Few laparoscopic surgical experts exist relative to the number of surgeons needing training in laparoscopic surgical techniques. This study tested application of telemedicine technology in the mentoring of surgeons during laparoscopic cholecystectomy. Our Surgical Telementoring Suite provided real-time audio and video telecommunication to the operating room. Data points for telementored laparoscopic cholecystectomy (TLC, n = 6) were compared to age and sex-matched controls having standard laparoscopic cholecystectomy (SLC, n = 6) with mentors physically present in the operating room. TLC data were also compared between cases performed with a staff surgeon and resident as mentorees (SRM, n = 3), versus two residents as mentorees (RRM, n = 3). Data were analyzed with chi-square testing. The level of statistical significance was set at p < 0.05. No major operative complications occurred in either group (p > 0.05). Total operative times were similar (92.2 +/- 18.4 minutes SLC vs. 94.7 +/- 25.3 minutes TLC, p > 0.05). Additional data compared between SRM and RRM groups included time to establishment of a pneumoperitoneum of 12-15 mm Hg (7.0 +/- 6.1 minutes SRM vs. 6.7 +/- 2.9 minutes RRM), time to placement of all four trocars (13.0 +/- 3.6 minutes SRM vs. 10.3 +/- 3.1 minutes RRM, time to isolation and proximal clipping of the cystic duct (38.0 +/- 12.1 minutes SRM vs. 55.7 +/- 29.0 minutes RRM), and time to removal of the gallbladder (77.3 +/- 25.4 minutes vs. 77.7 +/- 27.5 minutes RRM). For all data points, p > 0.05. We conclude that telementoring is a safe, effective method for teaching the techniques of LC. This is true for operating teams composed of surgical residents, with or without staff surgeons present.

Biliary dyskinesia: a study of more than 200 patients and review of the literature.

The diagnosis and treatment of biliary dyskinesia, defined as symptoms of biliary colic in the absence of gallstones, remains controversial and has been the subject of several previous retrospective reviews. The diagnosis and treatment of biliary dyskinesia based on the CCK-HIDA scan, and the outcome with cholecystectomy for billary dyskinesia, are reviewed. We add more than 200 cases of cholecystectomy for biliary dyskinesia, and compare our results with those of previous reports. We retrospectively reviewed 295 patients with biliary dyskinesia who underwent cholecystectomy at three military hospitals between 1988 and 1995. All patients had symptoms consistent with biliary colic and preoperative evaluations that revealed no evidence of cholelithiasis. Pathology specimens were reviewed for cholelithiasis and pathologic changes. Data were retrieved by chart review and clinic evaluation of new patients. Individual follow-up of each patient was attempted. Follow-up was achieved in 218 of the 295 patients for a rate of 74%. The mean duration of follow-up was 506 days with a range of 22 days to 6 years. Two hundred patients (92%) had CCK-HIDA scans with an ejection fraction (EF) >=<50%. Eighteen patients (8%) had an EF >50% but did have reproduction of their symptoms with CCK injection. In the group with an EF <50%, 94.5% were improved or cured with cholecystectomy. In the group with an EF >50% and pain reproduction, the improved or cured rate was 83.4%. CCK-HIDA scans are useful for diagnosing biliary dyskinesia and predicting improvement after cholecystectomy. Patients presenting with biliary dyskinesia and an EF <50% on CCK-HIDA scan have 94% improvement or resolution of their symptoms after cholecystectorny. CCK-HIDA scans should be employed early in the evaluation of billary colic with no evidence of cholelithiasis (i.e., with a normal ultrasound scan). When test results are abnormal, cholecystectomy should be performed, since the results in this setting approach those of cholecystectomy for stone disease (>90% cured/improved). In the current climate of cost containment, these excellent results would obviate the need for extensive and expensive medical testing before surgical therapy is recommended.