What Should I Use? Impact of Adhesion Barriers on Postoperative Abdominal Complications: A Systematic Review.

BACKGROUND: Adhesions are a feared complication of abdominal surgery. There have been many new adhesion barriers developed and tested; however, there is no recent systematic review analyzing all the published literature. To address this, we aimed to analyze the different types of adhesion barriers, and determine their effects on postoperative outcomes in patients. METHODS: A total of 14,038 articles utilizing adhesion barriers in abdominal surgery were retrieved from the PubMed, EMBASE, and Scopus databases. Inclusion criteria were: patients undergoing abdominal surgery, patients receiving an adhesion barrier, and reported postoperative outcomes. Two reviewers independently screened titles/abstracts and full-text articles using Covidence. The ROBINS-I tool was used to assess the quality of the included studies. Study protocol: Prospero CRD42023458230. RESULTS: A total of 20 studies, with no overall high risk of bias, with 171,792 patients were included. Most studies showed an equivocal benefit for adhesion barriers, with no singular adhesion barrier type that had definitive superior outcomes compared to the others. Bioresorbable barriers emerged as the most extensively researched adhesion barrier type, exhibiting promising results in colorectal surgery. Starch-based adhesion barriers also exhibited a reduction in overall postoperative bowel obstructions and may be beneficial for stoma sites and port closures. On the other hand, many studies raised concerns regarding complications, including risk of abscess formation, fistula development, peritonitis, and anastomotic leakage. CONCLUSIONS: Adhesion barriers should be considered on a case-by-case basis, however, they should not be utilized prophylactically in all abdominal surgeries due to their risk of complications.

Endoscopic thyroidectomy: the development in a Chinese center.

BACKGROUND: Endoscopic thyroidectomy (ET) precludes the long cervical incision of the open procedure. Although endoscopy is an essential tool taught to almost every surgeon, its effective use with regard to thyroidectomy requires understanding its limitations pertaining to trauma and cancer, as well as an understanding of the advantages and disadvantages of the different endoscopic approaches. The development of an ET center in China is discussed here. METHODS: Overall, 235 patients who had undergone attempted ET in Qilu Hospital of Shandong University in China from August 2001 to September 2010 were evaluated. RESULTS: Of the 11 men and 224 women on whom the procedure had been attempted, all but seven successfully underwent ET, 145 (63.6%) via a modified anterior chest approach, and 83 (36.4%) via a breast approach. Age ranged from 17 to 52 years, with a mean of 34.5 years. Surgery was limited, in the case of masses, to lesions smaller than 6 cm ultrasonographically. All patients were followed for at least 3 months. The 24 and 48 hours Visual Analog Scale postoperative measurements were low. Complications included four cases of cutaneous emphysema, five seromas, four episodes of anterior chest discomfort, three transient laryngeal nerve palsies, and four episodes of hypocalcemia. The seven procedures that had been converted to an open procedure comprised two patients discovered at frozen section to have poorly differentiated thyroid carcinoma, two with tumors larger than 5 cm, and three with thyroiditis. CONCLUSIONS: ET is readily learned, provided the surgeon is competent at both laparoscopic technique and open thyroidectomy. Procedural advantages of an endoscopic approach include superior cosmesis and decreased invasiveness.

A cost-benefit analysis of bariatric surgery on the South Plains region of Texas.

The regional economic burdens of obesity have not been fully quantified. This study incorporated bariatric surgery demographics collected from a large university hospital with regional economic and employment data to evaluate the cost of obesity for the South Plains region of Texas. Data were collected from patients who underwent laparoscopic gastric bypass and laparoscopic banding between September 2003 and September 2005 at Texas Tech University Health Sciences Center. A regional economic model estimated the economic impact of lost productivity due to obesity. Comparisons of lost work days in the year before and after surgery were used to estimate the potential benefit of bariatric surgery to the South Plains economy. Total output impacts of obesity, over $364 million, were 3.3% of total personal income; total labor income impacts neared $60 million: the losses corresponded to $2,389 lost output and $390 lost labor income per household. Obesity cost the South Plains over 1,977 jobs and decreased indirect business tax revenues by over $13 million. The net benefit of bariatric surgery was estimated at $9.9 billion for a discount rate of 3%, $5.0 billion for a discount rate of 5%, and $1.3 billion for a discount rate of 10%. Potential benefits to the South Plains economy of performing bariatric surgery more than outweigh its costs.

Metabolic syndrome: a new multidisciplinary service line.

That obesity in the USA has reached epidemic proportions is undeniable: one in three American adults is obese. High levels of obesity yield adverse microeconomic and macroeconomic effects, but assessing the viability of bariatric surgery in this respect requires careful consideration of its efficacy, its economic costs, and the benefits of the surgery. Metabolic syndrome is a microcosm of multiple disease states; the diseases that fall under the umbrella of the metabolic syndrome are, like obesity, becoming more prevalent. Epidemic obesity in part reflects inadequate utilization of bariatric surgery and inadequate coordination of efforts by the healthcare system. An integrated delivery network (IDN) is the best current model to achieve healthcare goals for patient subsets that are deemed important. Our overweight population, both with and without the metabolic syndrome, constitutes such a group because of the fraction of the general population they compose, the inherent costs to the healthcare system that their comorbid conditions generate, and the lost productivity to our economy that the treatment of these conditions entail. In this paper, we show a metabolic syndrome service line that will benefit both the individual hospital and the healthcare system. Pathways accepted for bariatric practices can be used, with modification, for the creation of a metabolic syndrome IDN. Implementation of such a system would benefit patients, caregivers, and society.

Hepatocyte infusions improve the results of liver transplantation in rats.

BACKGROUND/AIMS: The results of liver transplantation were influenced by miscellaneous factors. The aim was the notion that hepatocyte infusions might improve results of liver transplantation in rats. METHODOLOGY: Survival, serum analytes, FasL production, and histologic degree of rejection of transplanted rats pretreated with hepatocyte infusions (Hepatocyte) was compared to that of rats pretreated with either bone marrow cell infusions (Marrow) or saline infusions (Control). RESULTS: Hepatocyte rats had longer median survivals, less biochemical evidence of liver damage, more albumin production, a lower degree of histologic rejection, and increased FasL production than did either Marrow or Control rats (p < 0.05 for each analysis), which did not differ from one another (p > 0.05 for each analysis). CONCLUSIONS: Hepatocyte infusions improve the results of liver transplantation in rats.

Thyroid surgery without cut and tie: the use of Ligasure for total thyroidectomy.

Total thyroidectomy is the surgical preferred procedure for the treatment of benign and malignant disease. The purpose of this research was to evaluate total thyroidectomy operation by Ligasure in comparison with total thyroidectomy by the traditional technique that uses clamp and tie. We evaluated 256 patients. In 144 patients (56%), we used Ligasure without tie for total thyroidectomy; in the remaining 112 patients (44%), we used clamp and tie. The middle values of the variables examined were inferior (P < 0.0005) in the Ligasure group compared with the clamp and tie group. Only the middle value of operating room costs was higher in the first group than in the second, balanced by a decreased hospital stay of two days. Ligasure can be safely used for total thyroidectomy, because there is a meaningful difference in the distribution of variance between the two groups. There are decreasing risks of parathyroid gland and laryngeal nerve injury in the Ligasure group.

Value of routine postoperative gastrographin contrast swallow studies after laparoscopic gastric banding.

HYPOTHESIS: Laparoscopic adjustable gastric banding (LAGB) effectively treats morbid obesity and yields improved quality of life with low morbidity and mortality rates. The current standard of care is to perform a postoperative gastrographin study. This study evaluated a series of patients to determine the usefulness of this routine procedure. DESIGN: Retrospective analysis. SETTING: Texas Tech University Health Sciences Center, Lubbock. PATIENTS: A series of 100 patients who had undergone LAGB between August 1, 2006, and February 28, 2007, were evaluated by medical record review and a blinded examination of the upper gastrointestinal tract. MAIN OUTCOME MEASURES: Laboratory test results and patient vital signs. RESULTS: The mean age of the patients was 42 years. The mean initial body mass index (calculated as weight in kilograms divided by height in meters squared) was 50.0. Median excess weight loss was 49.0% after 12 months. Three patients did not undergo gastrographin studies because of a history of allergic reactions to the dye. No differences between the opinion of the surgeon and that of the original radiologist were uncovered. The 97 patients who underwent gastrographin studies lacked leaks; the only radiologic abnormalities were slow passage and reflux in 23 patients. No alteration in patient care resulted. The total cost for the 97 patients was $49 470. The 95% confidence interval for 0 useful results for 97 studies is 0.00 to 0.03; at best, 3.2% of patients undergoing this expensive study would have garnered some benefit. CONCLUSION: Routine postoperative upper gastrointestinal tract studies are expensive and of limited value. Instead of relying on them to detect leaks, which are extremely rare after LAGB, reliance should be given to the presence or absence of tachypnea and tachycardia, as is currently done for Roux-en-Y gastric bypass. In this way there will be a cost savings and the potential to make LAGB a same-day procedure.

Is there any role of resecting the stomach to ameliorate weight loss and sugar control in morbidly obese diabetic patients?

BACKGROUND: Among the restrictive procedures the role of restrictive vs. resecting the stomach is still ambiguous. This study evaluate which is the role of the stomach with respect to blood glucose levels (BG) and percent excess weight loss (EWL) over the 18 months after restrictive procedures in morbid obese diabetic patients. METHODS: We retrospectively compared a group of patients who underwent partial gastrectomy (just part of the gastric body) with gastric banding (GBSR; n=27), sleeve gastrectomy (part of gastric body and complete fundus resection; LSG; n=53) to laparoscopic gastric banding (LAGB; n=100). Differences among groups at 3, 6, 12, and 18 months were evaluated by analysis of variance. The three cohorts were diabetic patients similar in BMI, age, and gender. RESULTS: At 12 and 18 months, LSG had higher EWL (P<0.05) and lower BG (P<0.05) than did either LAGB or GBSR. There were no operative deaths. COMPLICATIONS: LAGB-two staple-line oozing, two wound infections; LSG-one hemorrhage, two staple-line oozing, two leaks; GBSR-one hemorrhage, two wound infections. All complications were readily treated. CONCLUSIONS: LSG provides better weight loss and glucose control at 1 year and 1.5 years after surgery than does either LAGB or GBSR, suggesting that gastric fundus resection plays an important, not yet well-defined, role.

Is surgery the next answer to treat obesity-related hypertension?

Obesity is related to multiple comorbidities, including hypertension, diabetes, hypercholesterolemia, and sleep apnea. Comorbidities burden the health care system, such that in the United States, 6% to 8% of health care costs are related to obesity. Obesity-induced hypertension has multiple potential etiologic pathways, the most well established being increased renal sodium reabsorption with impaired pressure natriuresis via (1) activation of the renin-angiotensin system, (2) stimulation of the sympathetic nervous system, and (3) altered intrarenal physical forces. Weight loss is the best means to reduce obesity-related hypertension. For every 3 patients who lose 10 pounds of weight and maintain the weight loss for 4 years, 1 of them will eliminate the use of antihypertensive medication. Whereas nonsurgical therapy ineffectually treats extreme obesity, bariatric surgery yields durable weight loss, as well as resolution of some of the comorbidities associated with obesity, including hypertension. Increase in anti-inflammatory factors secreted by adipocytes may explain some of the improvement in blood pressure in the first 3 years post-procedure. Bariatric surgery safely and effectively improves and may improve or eliminate obesity-related hypertension. More data need to be collected to substantiate the same results over periods of time longer than 3 years.

Complications after sleeve gastrectomy for morbid obesity.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an increasingly used bariatric surgical procedure. METHODS: We report our complications after LSG and compared to 17 other published LSG series. The individual types of complications for the published series were evaluated, with sample size calculations being performed to determine the number of patients required for a study that would detect halving the odds of the most common complications. RESULTS: Of 53 patients who underwent LSG, 42 were women. Mean age was 51 years with a mean initial body mass index of 53.5 kg/m2 and mean of eight comorbidities. Mean excess weight loss was 52.2% at 12 months and 59.2% at 18 months. No patients died. Five patients (9.4%) developed complications which included two staple line leaks that required reoperations, one preceded by a salmonella infection associated with vomiting, the other by postoperative pneumonia associated with coughing. Of the three staple line hemorrhages, one required hospitalization. The median complication rate for the 17 articles was 4.5%. With the number of patients for each series taken into account, the current series had a complication rate of 1.24 (95% CI 0.45-2.87) times that of the 17 published series. Published LSG complications were diverse, with the most common being reoperation, occurring after 3.6% of procedures. A study designed to detect halving the odds of reoperation would require more than 3,000 procedures. CONCLUSION: LSG is a safe procedure with low morbidity. Because leaks and reoperation in this series were preceded by large increments in intraabdominal pressure, attention to staple line reinforcements that increase burst pressure may be warranted.

Laparoscopic sleeve gastrectomy after gastric banding removal: a feasibility study.

BACKGROUND AND OBJECTIVES: Laparoscopic adjustable gastric banding (LAGB) is a commonly performed bariatric procedure. When LAGB fails, restrictive procedures such as gastric bypass have been performed. Laparoscopic sleeve gastrectomy (LSG) has been suggested as an alternative, but it has not yet been fully studied. Evaluated in this report are the experiences of patients who underwent LSG, a restrictive procedure, as a rescue procedure for failed LAGB. METHODS: From June 2002 to June 2007, charts of patients who underwent LAGB were reviewed to find those who had undergone LSG as a rescue procedure. RESULTS: Of 294 patients who underwent LAGB, 10 later underwent LSG. Median excess weight loss (EWL) prior to LSG had been 34%; after LSG, median EWL was 55%. Before LSG was performed, patients had a median 11.5 comorbidities, all of which improved after LSG. No major complications or deaths resulted. CONCLUSION: The results suggest LSG might be a reasonable choice for patients who fail LAGB. A formal study comparing LSG with other rescue procedures should be performed.

Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is an accepted bariatric procedure, with an advantaged by a low complication rate. A feared complication is stapler line leak. Buttressing materials have been suggested as a means of reducing staple line leak rates. We analyzed the leak rates from published series to help in demonstrating a potential cause. METHODS: The study was institutional review board (IRB) approved retrospectively. A Medline search using the key words sleeve gastrectomy and bariatric surgery obtained 54 articles. Attention was restricted to 11 articles written in English that listed numbers of gastrectomy procedures and leaks. Poisson regression assessed the possibility that patients who received buttressing materials had a reduced rate of leaks. RESULTS: Thirty-five patients were evaluated from Greece (15) and the United States (20); two patients developed staple line leaks that appeared to be related to problems associated with buttressing materials. Eleven prior studies and the present series yielded 1,589 procedures, 15 (0.94%) of which were complicated by leaks. The leak rate for patients who were known to have received reinforcement of some sort was 1.45 (95% confidence interval 0.41-3.43) times that for other patients. To detect a difference between 1% and 0.5% as statistically significant in 80% of cases, with a two tailed test and alpha set at 0.05, would require 9,346 procedures. CONCLUSIONS: There is no reason to believe, at this point, that reduction in leak rates occur because reinforcement is used. Because the leak rate is small, the routine reinforcement of the staple line after sleeve gastrectomy is questionable at best, although a decrease in hemorrhage has been reported.

Adipose tissue: the new endocrine organ? A review article.

Fat is either white or brown, the latter being found principally in neonates. White fat, which comprises adipocytes, pre-adipocytes, macrophages, endothelial cells, fibroblasts, and leukocytes, actively participates in hormonal and inflammatory systems. Adipokines include hormones such as leptin, adiponectin, visfatin, apelin, vaspin, hepcidine, chemerin, omentin, and inflammatory cytokines, including tumor necrosis factor alpha (TNF), monocyte chemoattractant protein-1 (MCP-1), and plasminogen activator protein (PAI). Multiple roles in metabolic and inflammatory responses have been assigned to adipokines; this review describes the molecular actions and clinical significance of the more important adipokines. The array of adipokines evidences diverse roles for adipose tissue, which looms large in the mediators of inflammation and metabolism. For this reason, treating obesity is more than a reduction of excess fat; it is also the treatment of obesity's comorbidities, many of which will some day be treated by drugs that counteract derangements induced by adipokine excesses.

Economic considerations for bariatric surgery and morbid obesity.

The obesity epidemic is also an economic tragedy. This analysis evaluates the economic effects and the potential to improve the well-being of both individual and societal wealth. Econometric techniques should carefully assess the degree to which obesity affects declines in business output, employment, income, and tax revenues at the regional and national levels. Microeconomics assesses lost productivity and associated wages and profit. Macroeconomics assesses trends associated with employment, inflation, interest rates, money supply, and output. To decrease the adverse economic consequences of the obesity epidemic, policy makers must emphasize bariatric surgery as a cost-effective option for qualified patients. Early intervention, education, and tax rebates for obese individuals who undergo bariatric surgery and for medical centers and doctors would likely have positive economic effects on the whole economy in a few years.

Loss expression of active fragile sites genes associated with the severity of breast epithelial abnormalities.

BACKGROUND: WWOX and FHIT are two candidate tumor suppressor genes located in active fragile sites, the damage of which has been associated with the development of breast cancer. The association of the expression of these genes and the development of breast cancer has not been fully explored. We evaluated mRNA and protein expression of WWOX and FHIT in breast tissue with normal histological appearances, atypical ductal hyperplasia, ductal carcinoma in situ, and invasive cancer to see if a progressive decline in expression was present. METHODS: Reverse transcription-polymerase chain reaction and Western blotting were used to evaluate the specimens for mRNA and protein expression, including 28 specimens with normal tissue, 28 specimens with atypical ductal hyperplasia, 33 specimens with ductal carcinoma in situ, and 51 specimens with invasive ductal carcinoma. RESULTS: Compared with in situ and invasive cancer specimens, both normal and atypical hyperplasia specimens had greater rates of detectable mRNA (WWOX rate ratio = 2.95, 95% CI 1.24 - 7.08; FHIT rate ratio = 4.58, 95% CI 1.82 - 11.81) and Western blotting detectable protein (WWOX rate ratio = 4.12, 95% CI 1.63 - 10.73; FHIT rate ratio = 3.76, 95% CI 1.44 - 10.06). For both proteins, differences between normal and atypical hyperplasia specimens and between in situ and invasive carcinoma specimens were explainable by chance (P > 0.05 for each analysis). Within each histological category, differences among fractions of specimens showed that FHIT and WWOX mRNA and protein expression were explainable by chance (P > 0.05 for each analysis). CONCLUSION: Expression of FHIT and WWOX decreases along with breast tissue progress from a normal histological appearance to atypical ductal hyperplasia, in situ cancer, and the final invasive cancer.

Microwave ablation with cooled-tip electrode for liver cancer: an analysis of 160 cases.

A novel microwave electrode with a cooled tip (FORSEA MTC-3 type, China) was devised to better enable microwave ablation of liver cancers. The efficacy of this technology was evaluated. The records of 160 patients (97 with hepatoma, 63 with metastatic cancer of the liver) who had undergone microwave ablation with this new device were reviewed. One-year survival in 86 patients whose follow-up had been more than one year was determined. Pre-operative and post-operative contrast-enhanced CT scans were performed to assess completion of therapy and the presence or absence of recurrent tumor. For patients with hepatoma, serum alpha-fetoprotein (AFP) levels were evaluated pre-operatively and, if elevated, post-operatively. A median two (range one to five) applications were required per session. All patients exhibited initial radiographic resolution of their lesions after therapy. The ablated areas were not enhanced in any phases of contrast CT scan. Eight patients required a second microwave therapy for recurrent tumor; two patients required a third treatment. Twenty-five patients with hepatoma had elevated AFP (104.2+/-22.5 ng/ml), which, after microwave ablation, recovered to normal or almost normal (24.6+/-3.6 ng/ml) (t = 2.1, p<0.05). There were no post-operative deaths. Complications included fever in three of four patients, successfully treated with indomethacin, elevated transaminases in four of five patients, requiring no treatment except for those with pre-operative ascites (who were dialyzed), pleural effusions in fourteen patients, only one of whom required drainage, and obstructive jaundice requiring drainage in two patients. The one-year survival rate was 91.9%. Microwave ablation with this novel cooled-tip electrode is safe, minimally invasive and effective. The tool may greatly expand the fraction of patients with liver cancer who might be candidates for microwave ablation.

Sperm protein 17 is a suitable target for adoptive T-cell-based immunotherapy in human ovarian cancer.

For ovarian cancer (OC) patients with advanced or metastatic disease, standard treatments (chemotherapy and radiotherapy) are not very effective and have undesirable side effects. Newer and more promising approaches in cancer treatment use components of the immune system. In this study, we applied an adoptive immunotherapy-based approach using a cancer testis antigen, sperm protein 17, as a target for the treatment of human metastatic OC in a NOD.CB17-PrkDCcid/J (nonobese, diabetic severe combined immunodeficient) mouse model. We used the human SK-OV-3A2.A3 OC cell line, endogenously expressing sperm protein 17, to induce tumor growth in mice. We provide direct evidence, for the first time, that in vitro cultured, monoclonal, cytotoxic T lymphocytes (derived either from advanced OC patients or from healthy donors), specific for sperm protein 17, can eradicate human metastatic OC cells. In addition, we observed no evidence of autoimmunity after histologic examination of the tissue sections adding to the safety profile of our approach.