Human primary gastric dendritic cells induce a Th1 response to H. pylori.

Adaptive CD4 T-cell responses are important in the pathogenesis of chronic Helicobacter pylori gastritis. However, the gastric antigen-presenting cells that induce these responses have not yet been identified. Here we show that dendritic cells (DCs) are present in the gastric mucosa of healthy subjects and are more prevalent and more activated in the gastric mucosa of H. pylori-infected subjects. H. pylori induced gastric DCs isolated from noninfected subjects to express increased levels of CD11c, CD86 and CD83, and to secrete proinflammatory cytokines, particularly interleukin (IL)-6 and IL-8. Importantly, gastric DCs pulsed with live H. pylori, but not control DCs, mediated T-cell secretion of interferon-gamma. The ability of H. pylori to induce gastric DC maturation and stimulate gastric DC activation of Th1 cells implicates gastric DCs as initiators of the immune response to H. pylori.

Influence of complications and extent of weight loss on quality of life after laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: Obesity decreases health-related quality of life, but bariatric surgery improves it. This study evaluates the effect of laparoscopic Roux-en-Y gastric bypass, postoperative complications, and percentage of excess body weight loss on quality of life. METHODS: SF-36v.1 questionnaires were administered preoperative (n = 505), 1 year (n = 237) and 2 years (n = 106) following laparoscopic Roux-en-Y gastric bypass. Analysis was performed using Student's t-test and multiple logistic regression analysis. Complications were defined as requiring additional intervention or hospitalization. SF-36 responses were normalized to 1998 US norms. RESULTS: Bariatric patients scored significantly lower on all scales compared to the normal population. Health-related quality of life notably improves after surgery. At 1 year, scores not only improved from baseline, but were higher than those of the non-obese reference population regardless of complications. Compared to patients at 2 years without complications, patients experiencing complications reported decreased scores, but scores remained higher than preoperative scores in five scales. At 1 and 2 years, < or = 50% excess body weight loss decreased scores; however, scores were significantly improved from baseline. CONCLUSIONS: Health-related quality of life in bariatric patients is worse than in controls, but it improves 1 and 2 years after laparoscopic Roux-en-Y gastric bypass. Complications or < or = 50% excess body weight loss slightly decreases this improvement.

Water-soluble upper GI based on clinical findings is reliable to detect anastomotic leaks after laparoscopic gastric bypass.

Anastomotic leak after laparoscopic Roux-en-Y gastric bypass (LGB) is a major complication that must be recognized and treated early for best results. There is controversy in the literature regarding the reliability of upper GI series (UGI) in diagnosing leaks. LGB was performed in patients meeting NIH criteria for the surgical treatment of morbid obesity. All leaks identified at the time of surgery were repaired with suture and retested. Drains were placed at the surgeon's discretion. Postoperatively, UGI was performed by an experienced radiologist if there was a clinical suspicion of leak. From September 2001 until October 2004, a total of 553 patients (age 40.4 +/- 9.2 years, BMI 48.6 +/- 7.2) underwent LGB at UAB. Seventy-eight per cent (431 of 553) of patients had no clinical evidence suggesting anastomotic leak and were managed expectantly. Twenty-two per cent (122 of 553) of patients met at least one inclusion criteria for leak and underwent UGI. Four of 122 patients (3.2%) had a leak, two from anastomosis and two from the perforation of the stapled end of the Roux limb. No patient returned to the operating room without a positive UGI. High clinical suspicion and selectively performed UGI based on clinical evidence is reliable in detecting leaks.

Incidence of clinically evident deep venous thrombosis after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Advanced age, major orthopedic surgery, neoplastic disease, prolonged operations, varicose veins, immobilization, estrogen-containing medications, and obesity are known risk factors for the development of postoperative thromboembolic complications. Perioperative heparin is useful for reducing the incidence of deep venous thrombosis (DVT), but it is associated with a discrete bleeding rate. The purpose of this study was to determine the incidence of clinically evident DVT in morbidly obese patients after laparoscopic Roux-en-Y gastric bypass when a pneumatic compression hose is used as the only prophylaxis against DVT instead of anticoagulants. METHODS: From April 2000 to April 2003, 380 patients underwent laparoscopic Roux-en-Y gastric bypass for morbid obesity by one surgeon (R.H.C.). Prospectively, each patient was clinically evaluated for the presence of DVT during the postoperative period. Calf-length pneumatic compression stockings were placed before the procedure began, and remained in place until the patient was ambulatory. Ambulation was encouraged on the evening of the operation. No pharmacologic anticoagulant was used as a prophylaxis against DVT. RESULTS: Of the 380 patients, 346 were women and 34 were men with a mean age of 39.3 +/- 9.4 years (range, 14-65 years). The mean weight of these patients was 299.5 +/- 53.6 lb (range, 188-483 lb), and their mean body mass index was 48.5 +/- 6.6 (range, 36-70). The mean operative time was 103. 3 +/- 24.3 min (range, 62-227 min), and mean American Society of Anesthesiology (ASA) score was 2.6. Nine patients had clinical evidence of severe, chronic venous disease preoperatively. One patient (0.26%) experienced a clinically evident DVT limited to the popliteal vein on duplex ultrasonography. The clot resolved completely, as evidenced by follow-up duplex ultrasonography after 2 weeks of subcutaneously injected fractionated heparin. No clinically evident pulmonary thromboembolism occurred in this study group. CONCLUSIONS: The incidence of clinically evident DVT after laparoscopic Roux-en-Y gastric bypass is low when the procedure is accomplished with a relatively short operative time, with the initiation of calf-length pneumatic compression hose before the induction of anesthesia, and with routine early ambulation. No form of heparin anticoagulation is mandatory when these conditions can be met.

Gastrointestinal symptoms are more intense in morbidly obese patients.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass is an effective treatment for morbid obesity. However, little information is available on gastrointestinal (GI) symptomatology in this population. This study compares GI symptoms in morbidly obese patients to that of control subjects. METHODS: A previously validated, 19-point GI symptom questionnaire was administered prospectively to each patient seen for surgical consultation for morbid obesity. The symptoms were then grouped into 6 clusters as follows: (1) abdominal pain, (2) irritable bowel, (3) GERD, (4) reflux, (5) sleep disturbance, (6) dysphagia. The result of each cluster of symptoms expressed as mean +/- standard deviation of obese versus control is compared using student's t-test with significance p = 0.05. RESULTS: Forty-three patients (40 female, 3 male) age 37.3 +/- 8.6 with BMI 47.8 +/- 4.9, and 36 healthy control subjects (23 female, 13 male), age 39.8 +/- 11.2, completed the questionnaire. Results of each cluster for morbid obese vs control subjects are expressed as mean +/- standard deviation: Abdominal pain 25.3 +/- 18.0 vs 12.1 +/- 11.4, p = 0.0002; irritable bowel 23.0 +/- 14.8 vs 15.6 +/- 13.3, p = 0.02; GERD 40.3 +/- 18.9 vs 22.3 +/- 16.1, p = 0.0001; reflux 29.9 +/- 19.0 vs 11.8 +/- 13.4, p = 0.0001; sleep disturbance 50.6 +/- 28.9 vs 32.9 +/- 26.8, p = 0.006; dysphagia 10.9 +/- 15.6 vs 7.2 +/- 10.6, p = NS. CONCLUSIONS: Morbidly obese patients experience more intense GI symptoms than normal subjects, whereas dysphagia is equivalent to normal subjects. These data may be important in counseling patients and understanding that their complaints are legitimate. Follow-up in the postoperative period is needed to determine if these symptoms are improved with an operation.

Incidence and significance of pneumomediastinum after laparoscopic esophageal surgery.

BACKGROUND: Pneumomediastinum can be a sign of esophageal perforation. During laparoscopic esophageal surgery, the mediastinum is exposed to carbon dioxide gas under pressure that can cause pneumomediastinum. METHODS: Forty-five patients undergoing laparoscopic esophageal procedures had erect, inspiratory, single-view chest radiographs (CXR) performed in the recovery room (RR). Patients with extraabdominal gas underwent daily erect, inspiratory, single-view CXR until resorption of the gas or discharge from the hospital. Insufflation time and pressure were recorded, and morbidity was evaluated. Results are expressed as mean +/- SEM. RESULTS: Twenty-five men (56%)and 20 women (44%) aged 33.0 +/- 2.9 years underwent 10 Heller myotomies (22.2%), 27 Nissen fundoplications (60.0%), six Toupet fundoplications (13.3%), and two paraesophageal hernia repairs (4.4%). Twenty-four patients (53.3%) had normal CXR in RR, and 21 (46.7%) had extraabdominal gas. Eighteen (85.7%) of the 21 had pneumomediastinum, three (14.3%) had pneumothorax, and 12 (57.1%) had subcutaneous emphysema in RR. Sixteen of these 21 remained hospitalized and had repeat CXR on postoperative day 1. Of these 16, five (31.3%) had normal CXR, 11 (68.8%) had pneumomediastinum, and seven (43.8%) had subcutaneous emphysema. There were no esophageal perforations and no chest tube insertions, and there was no morbidity related to pneumomediastinum. CONCLUSION: Pneumomediastinum is observed frequently following laparoscopic esophageal operations and often persists past 24 h. After these operations, pneumomediastinum is not necessarily indicative of esophageal perforation. In this group, it caused no clinically significant events that altered the course of the patients.

Critical decisions in the management of endoscopic perforations of the colon.

The ideal management of suspected colon perforation following colonoscopy remains elusive because the incidence is only 0.1 to 2.0 per cent. The patient with obvious perforation deserves immediate exploration, but the patient with equivocal findings poses a diagnostic dilemma. We propose an algorithm based on the results of water-soluble contrast enema that allows for rapid, definitive surgical decision-making. If perforation is confirmed, early operation allows for primary repair without resection or colostomy, or if no perforation is identified, medical management can be undertaken with confidence. This algorithm should ensure that the surgical management of this potentially lethal complication is not unnecessarily delayed.

An objective scoring system for laparoscopic cholecystectomy.

BACKGROUND: Direct observation with structured criteria for performance is the most reliable and valid method of assessing technical skill during operative procedures. We developed such a system to evaluate technical performance during a laparoscopic cholecystectomy. The reliability and validity of the system were tested by analyzing the correlation among three observers in a multicenter study and comparing performance with years of surgical experience. STUDY DESIGN: Thirty consecutive cases of laparoscopic cholecystectomy were recorded on videotape, 10 from each of 3 institutions. Independent scores were generated by three observers examining each of the videotapes, providing a total of 90 scores. Points were awarded for successful completion of each of 23 different steps required to perform a laparoscopic cholecystectomy. Error points were tabulated based on the frequency and relative severity of each of 21 potential technical mistakes during the operation. The final score was assumed to be a relative measure of technical skill and was derived by subtracting error points from points awarded for completion of each step of the procedure. Pearson correlation coefficients were used to assess agreement among examiners and correlation with year of surgical experience. RESULTS: Agreement in final scores among the three observers was excellent (r = 0.74-0.96) despite the fact that one observer assigned significantly fewer error points. Correlation between year of experience and two-handed technique scoring was good (r = 0.5, p = 0.057), but the correlation between experience and one-handed technique scores was poor (r = 0.02). CONCLUSIONS: The technical skills required to perform laparoscopic cholecystectomy can reliably be measured using this tool. This method can be used to track the learning curve of surgeons in training, evaluate the efficacy of alternative training tools, and provide a means of self-assessment for the trainee.

Prevalence of gastroesophageal reflux after laparoscopic Heller myotomy.

BACKGROUND: There is still some controversy over the need for antireflux procedures with Heller myotomy in the treatment of achalasia. This study was undertaken in an effort to clarify this question. METHODS: To determine whether Heller myotomy alone would cause significant gastroesophageal reflux (GER), we studied 16 patients who had undergone laparoscopic Heller myotomy without concomitant antireflux procedures. Patients were asked to return for esophageal manometry and 24-h pH studies after giving informed consent for the Institutional Review Board (IRB)-approved study at a median follow-up time of 8.3 months (range, 3-51). Results are expressed as the mean +/- SEM. RESULTS: Fourteen of the 16 patients reported good to excellent relief of dysphagia after myotomy. They were subsequently studied with a 24-h pH probe and esophageal manometry. These 14 patients had a significant fall in lower esophageal sphincter (LES) pressure from 41.4 +/- 4.2 mmHg to 14.2 +/- 1.3 mmHg, after the myotomy (p < 0.01, Student's t-test). The two patients who reported more dysphagia postoperatively had LES pressures of 20 and 25 mmHg, respectively. Two of 14 patients had DeMeester scores of >22 (scores = 61.8, 29.4), while only one patient had a pathologic total time of reflux (percent time of reflux, 8%). The mean percent time of reflux in the other 13 patients was 1.9 +/- 0.6% (range, 0.1-4%), and the mean DeMeester score was 11.7 +/- 4.6 (range, 0.48-19.7). CONCLUSIONS: Laparoscopic Heller myotomy is effective for the relief of dysphagia in achalasia if the myotomy lowers the LES pressure to <17 mmHg. If performed without dissection of the entire esophagus, the laparoscopic Heller myotomy does not create significant GER in the postoperative period. Clearance of acid refluxate from the aperistaltic esophagus is an important component of the pathologic gastroesophageal reflux disease (GERD) seen after Heller myotomy for achalasia. Furthermore, GERD symptoms do not correlate with objective measurement of GE reflux in patients with achalasia. Objective measurement of GERD with 24 h pH probes may be indicated to identify those patients with pathologic acid reflux who need additional medical treatment.

Laparoscopic left adrenalectomy for pheochromocytoma in a child.

Although uncommon, adrenalectomy occasionally is indicated in children. To date, this procedure has required either a laparotomy or a flank incision. The authors report the case of a child with episodic palpitations, diaphoresis, chest discomfort, and occipital headache who underwent laparoscopic adrenalectomy for pheochromocytoma without complication.

Insulin's anabolic effect is influenced by route of administration of nutrients.

OBJECTIVE: To determine if the anabolic effects of intravenous insulin on protein kinetics could be exploited in the enterally fed trauma victim. DESIGN: Randomized, crossover control protocol. SETTING: Level I trauma center. PATIENTS: Ten trauma patients with an Injury Severity Score higher than 20. Exclusion criteria included diabetes mellitus, pregnancy, steroid use, and aged younger than 18 years or older than 65 years. INTERVENTIONS: Within the first 24 hours of admission to the intensive care unit, each patient had a transpyloric feeding tube inserted radiographically. Enteral nutrition was provided with a protein supplement (Ensure, Ross Laboratories, Columbus, Ohio) and Promod, supplemented with protein powder to supply 1.5 g/kg per day of protein and 156.9 kJ/kg per day. Intravenous insulin was provided at 0.043 U/kg per hour beginning on the second or fourth day. MAIN OUTCOME MEASURES: Urinary nitrogen balance and 3-methylhistidine excretion rates were measured at the end of the third and fifth days. Plasma glucose, insulin, and C-peptide levels were obtained at these same times. RESULTS: Urinary nitrogen balance was not significantly different with or without the administration of insulin (-4.58+/-50.1 mg/kg per day vs -9.38+/-50.9 mg/kg per day, respectively). 3-Methylhistidine excretion rates did not change significantly with or without the administration of insulin (5.77+/-0.67 micromol/kg per day vs 6.15+/-0.43 micromol/kg per day, respectively). Serum insulin levels did not differ significantly when exogenous infusions were added (57.8+/-17.9 microU/mL vs 82.1+/-44.9 microU/mL), but serum C-peptide levels did decrease significantly when exogenous insulin was added (5.11+/-3.2 microU/mL vs 10.28+/-3.5 microU/mL; P = .04). Serum glucose levels decreased significantly when insulin was administered (5.8+/-0.4 mmol/L [104.6+/-7.2 mg/dL] vs 7.7+/-0.4 mmol/L [138.1+/-7.4 mg/dL; P =.004). CONCLUSION: The anabolic effect of intravenous insulin on protein kinetics is not evident when nutrition is provided enterally in the trauma victim.

Adhesion formation is reduced after laparoscopic surgery.

BACKGROUND: Adhesion formation after abdominal operations causes significant morbidity. METHODS: Adhesion formation in pigs was compared after placement of prosthetic mesh during celiotomy (group 1), laparoscopy with large incision (group 2), and laparoscopy (group 3). After peritoneum was excised, polypropylene mesh was fixed to the abdominal wall, then to the opposite abdominal wall in the preperitoneal space followed by peritoneal closure. Adhesion area, grade, and vascularity were measured. RESULTS: More adhesions (p < 0.02) covered intraperitoneal mesh (7.57 +/- 1.89 cm2) than covered reperitonealized mesh (2.16 +/- 1.13 cm2), and adhesion grade was significantly greater (p < 0.02). Adhesion areas were significantly greater in groups 1 and 2 than in group 3 (p = 0.001 and 0.03, respectively). Adhesion grade was significantly greater in groups 1 and 2 than in group 3 (p = 0.02 and p = 0.04, respectively). Groups 1 and 2 had more vascular adhesions than group 3 (p < 0.01 and p = 0.02, respectively) CONCLUSIONS: A foreign body within the peritoneum stimulates more numerous and denser adhesions. Tissue trauma distant from the site of adhesions increases their formation. A major advantage of laparoscopic surgery is decreased adhesion formation.

Hemangioma of the rib: a rare diagnosis.

Hemangioma of the rib is an exceedingly rare tumor with less than ten cases reported in the literature. Wide local resection without preoperative needle biopsy is the preferred treatment. The case of a 76-year-old man with a right chest mass that was discovered on chest X-ray obtained for asbestos exposure is reported to demonstrate the presentation, diagnosis, and treatment of this distinctly uncommon tumor.

Laparoscopic cholecystectomy.

Cholelithiasis is being recognized more frequently in the pediatric population. Although hemolytic diseases have an identifiable etiology, the origin of gallstones in approximately 80% of pediatric patients remains unknown. Infants with cholelithiasis can be managed expectantly unless symptoms develop because many of these stones will resolve spontaneously. The 2- to 12-year age group is more likely to present with chronic cholecystitis and will require cholecystectomy at some point, since there is little chance of spontaneous resolution of these gallstones. Teenagers tend to present in a similar manner to adults and are managed much the same way. Although plain radiographs are more useful in children than in adults, abdominal ultrasonography remains the most useful tool to document cholelithiasis. Safe access to the abdominal cavity is the first step to successful laparoscopic cholecystectomy, and the arrangement of secondary ports varies with the age and size of the patient. Choledocholithiasis can be managed laparoscopically in experienced hands, and endoscopic retrograde cholangiopancreatography plays a diagnostic as well as therapeutic role for this problem. Laparoscopic cholecystectomy has become the standard of care for all children in whom cholecystectomy is required.

The outcome of laparoscopic Heller myotomy without antireflux procedure in patients with achalasia.

We retrospectively reviewed 30 patients with achalasia (18 males, 12 females) undergoing laparoscopic Heller myotomy without antireflux procedure to determine relief of dysphagia and prevalence of postoperative gastroesophageal reflux. Preoperative symptoms were obtained by history alone before 1996 and by standardized questionnaire after September 1996. Twenty-nine patients (97%) had dysphagia, 22 patients (73%) had regurgitation, 21 patients (70%) had weight loss, 7 patients (23%) had heartburn, and 4 patients (13%) had nocturnal aspiration. The first 3 patients were done thoracoscopically, with the subsequent 27 patients performed laparoscopically; 4 cases (13%; 1 thoracoscopic and 3 laparoscopic) were converted. The mean postoperative stay was 1.9 days (1-6 days). One patient underwent repeat laparoscopic myotomy for persistent dysphagia. Twenty-eight patients (93%) were available for follow-up. Patients were asked on a standardized questionnaire to grade their relief of dysphagia, regurgitation, and heartburn. Good to excellent relief of dysphagia was obtained in 25 patients (89%), whereas 3 patients (11%) continued to have significant dysphagia postoperatively. Twenty-four patients (86%) had little or no regurgitation. Four patients (14%) had frequent regurgitation. Twenty-four patients (89%) reported little or no heartburn. Three patients (11%) reported significant postoperative heartburn. Laparoscopic Heller esophagomyotomy without antireflux procedure provides excellent symptomatic relief of dysphagia in patients with achalasia. Early follow-up suggests that minimal occurrence of symptomatic postoperative reflux can be achieved without performing an antireflux procedure.

Blunt intrapericardial rupture of the pulmonary artery in a surviving patient.

Blunt chest trauma can produce a number of potentially lethal injuries, including pulmonary artery rupture. Survivors of pulmonary artery injuries are rare. Most previously reported surviving patients presented with hemothorax from a hilar injury. We report a patient who survived a blunt rupture of the intrapericardial portion of the pulmonary artery and thus presented with pericardial tamponade. The interventions that led to her survival are discussed.