The association of new-onset diabetes with subsequent diagnosis of pancreatic cancer-novel use of a large administrative database.

BACKGROUND: Screening options for pancreatic ductal adenocarcinoma (PDAC) are limited. New-onset type 2 diabetes (NoD) is associated with subsequent diagnosis of PDAC in observational studies and may afford an opportunity for PDAC screening. We evaluated this association using a large administrative database. METHODS: Patients were identified using claims data from the OptumLabs® Data Warehouse. Adult patients with NoD diagnosis were matched 1:3 with patients without NoD using age, sex and chronic obstructive pulmonary disease (COPD) status. The event of PDAC diagnosis was compared between cohorts using the Kaplan-Meier method. Factors associated with PDAC diagnosis were evaluated with Cox's proportional hazards modeling. RESULTS: We identified 640 421 patients with NoD and included 1 921 263 controls. At 3 years, significantly more PDAC events were identified in the NoD group vs control group (579 vs 505; P < 0.001). When controlling for patient factors, NoD was significantly associated with elevated risk of PDAC (HR 3.474, 95% CI 3.082-3.920, P < 0.001). Other factors significantly associated with PDAC diagnosis were increasing age, increasing age among Black patients, and COPD diagnosis (P ≤ 0.05). CONCLUSIONS: NoD was independently associated with subsequent diagnosis of PDAC within 3 years. Future studies should evaluate the feasibility and benefit of PDAC screening in patients with NoD.

Correction to: Partitioning of adipose lipid metabolism by altered expression and function of PPAR isoforms after bariatric surgery.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Partitioning of adipose lipid metabolism by altered expression and function of PPAR isoforms after bariatric surgery.

BACKGROUND: Bariatric surgery remains the most effective treatment for reducing adiposity and eliminating type 2 diabetes; however, the mechanism(s) responsible have remained elusive. Peroxisome proliferator-activated receptors (PPAR) encompass a family of nuclear hormone receptors that upon activation exert control of lipid metabolism, glucose regulation and inflammation. Their role in adipose tissue following bariatric surgery remains undefined. MATERIALS AND METHODS: Subcutaneous adipose tissue biopsies and serum were obtained and evaluated from time of surgery and on postoperative day 7 in patients randomized to Roux-en-Y gastric bypass (n=13) or matched caloric restriction (n=14), as well as patients undergoing vertical sleeve gastrectomy (n=33). Fat samples were evaluated for changes in gene expression, protein levels, ß-oxidation, lipolysis and cysteine oxidation. RESULTS: Within 7 days, bariatric surgery acutely drives a change in the activity and expression of PPARγ and PPARδ in subcutaneous adipose tissue thereby attenuating lipid storage, increasing lipolysis and potentiating lipid oxidation. This unique metabolic alteration leads to changes in downstream PPARγ/δ targets including decreased expression of fatty acid binding protein (FABP) 4 and stearoyl-CoA desaturase-1 (SCD1) with increased expression of carnitine palmitoyl transferase 1 (CPT1) and uncoupling protein 2 (UCP2). Increased expression of UCP2 not only facilitated fatty acid oxidation (increased 15-fold following surgery) but also regulated the subcutaneous adipose tissue redoxome by attenuating protein cysteine oxidation and reducing oxidative stress. The expression of UCP1, a mitochondrial protein responsible for the regulation of fatty acid oxidation and thermogenesis in beige and brown fat, was unaltered following surgery. CONCLUSIONS: These results suggest that bariatric surgery initiates a novel metabolic shift in subcutaneous adipose tissue to oxidize fatty acids independently from the beiging process through regulation of PPAR isoforms. Further studies are required to understand the contribution of this shift in expression of PPAR isoforms to weight loss following bariatric surgery.

Obesity and bariatric surgery: a systematic review of associations with defecatory dysfunction.

BACKGROUND: Obesity rates are rapidly growing in the developed world. While upper gastrointestinal disturbances and urinary incontinence are independently associated with obesity, the relationship between obesity and defecatory dysfunction is less well defined. OBJECTIVES: To summarize the literature on faecal incontinence, diarrhoea and constipation in obese patients and its effects of bariatric surgery. SEARCH STRATEGY: A Medline search was carried out on articles published from January 1966 to March 2010. SELECTION CRITERIA: Original articles on adult obese or morbidly obese patients were identified, including results following bariatric surgery that reported faecal incontinence, diarrhoea or constipation. Other forms of pelvic floor dysfunction were excluded. Main outcome measures included faecal incontinence, diarrhoea and constipation rates and their severity in obese patients and following bariatric surgery. RESULTS: Twenty studies reported defecatory outcomes in obese patients (n = 14) and after bariatric surgery (n = 6). While constipation rates were similar, the rates of faecal incontinence and diarrhoea were higher in obese patients compared with non-obese patients. The exact rates of these conditions, and the correlations between body mass index (BMI) and faecal incontinence, diarrhoea and constipation, were not clear. Faecal incontinence improved after Roux-en-Y gastric bypass in studies with preoperative data. The effects of bariatric surgery on diarrhoea were unclear. CONCLUSION: Few studies have assessed the correlations between obesity and defecatory function and the effect of bariatric surgery. Studies were often not well controlled and used non-uniform instruments to assess bowel function. Obesity appears to be correlated with higher rates of faecal incontinence and diarrhoea. The effects of bariatric surgery on these conditions are not well defined. Well-controlled studies correlating outcome with physiological pelvic floor function are needed.

Laparoscopic conversion of vertical banded gastroplasty to a Roux-en-Y gastric bypass.

The vertical banded gastroplasty was the mainstay of bariatric surgery for over a decade. Though this procedure is now rarely performed many of these patients will present with failure or maladaptive eating and its sequelae. Some of these patients who demonstrate the motivation for lifestyle modification as well as many of these with complications will be candidates for revisional surgery. This article reviews the technical challenges in performing these revisions using minimally invasive techniques. In addition it reviews outcomes of laparoscopic conversion and tips for patient selection and success.

Situs inversus totalis: giant hiatal hernia repair by laparoscopic Collis gastroplasty and Nissen fundoplication.

We report the repair of a giant hiatal hernia by laparoscopic Collis gastroplasty and Nissen fundoplication in a patient with situs inversus totalis, highlighting the unique anatomic challenges in this case. The 52-year old female patient had Kartageners syndrome, a giant hiatal hernia, and a history of chronic severe gastroesophageal reflux disease with uncontrolled regurgitation. The laparoscopic procedure was accomplished with five ports placed in a mirror-image configuration, reversed from our standard positions. After visual confirmation of the complete reversal of the intraabdominal anatomy, we performed a modified Collis gastroplasty and Nissen fundoplication. Significant technical challenges were encountered intraoperatively. To the best of our knowledge, this report is the first of its kind in the literature. The use of advanced laparoscopic techniques is highly adaptable to unusual anatomy. Laparoscopic hiatal hernia surgery is feasible in patients with situs inversus.

Endoscopic balloon dilation of gastroenteric anastomotic stricture after laparoscopic gastric bypass.

BACKGROUND AND STUDY AIMS: Laparoscopic gastric bypass is a recently introduced treatment option for morbid obesity, with promising initial results. Stenosis of the gastroenterostomy is a recognized complication. The efficacy and safety of endoscopic balloon dilation for the management of this type of anastomotic stenosis has not been studied. PATIENTS AND METHODS: 450 patients who underwent laparoscopic gastric bypass at our institution were followed prospectively. All patients had a 15 ml gastric pouch and either a 75 cm or 150 cm jejunal Roux limb depending on whether obesity was morbid (body mass index (BMI) < 50 kg/m 2) or super-morbid (BMI > 50 kg/m 2). Patients who developed symptoms compatible with stenosis of the gastrojejunostomy were referred for upper gastrointestinal endoscopy. RESULTS: 14 patients, 11 women and three men, underwent a total of 27 endoscopies, with 23 balloon dilations. Their average age was 46 years (range 33 - 59 years), average preoperative BMI was 47 kg/m 2, and they presented an average of 2.7 months after surgery (range 0.3 - 15.7 months). Of the 14 patients, 13 had a stricture of the gastrojejunostomy and one patient had edema. For initial dilation, a 15 mm hydrostatic balloon was used in 12 patients and an 18 mm balloon in two patients. There was response to treatment with the 15 mm balloon in seven of the 12 patients (58 %), and they required no further dilation; in one there was a response to a further 15 mm balloon dilation; in three patients a response to subsequent 18 mm balloon dilation; and one patient required 18 mm and 25 mm balloon dilations. The two patients treated with an initial 18 mm balloon dilation required no further dilations. The average length of follow-up after successful dilation was 18 months (range 7 - 30 months). There were no complications with any of the 23 dilations performed. CONCLUSION: Stenosis of the gastroenterostomy after laparoscopic gastric bypass occurred in 3.1 % of the patients in this series. It can be successfully and safely treated with endoscopic balloon dilation with good long-term follow-up.

The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases.

BACKGROUND: The purpose of this study was to determine the effect of operative experience on perioperative outcomes for laparoscopic Roux-en-Y gastric bypass (LGB). METHODS: Between July 1997 and September 2001, 750 patients underwent LGB for the treatment of morbid obesity at our center. We evaluated the perioperative outcomes of the first 150 consecutive patients to determine if a learning curve effect could be demonstrated. The patients were divided into three groups (1, 2, and 3) of 50 consecutive patients, and outcomes for each group were compared. RESULTS: The patients in group 3 had a larger body mass index (BMI), were more likely to have had prior abdominal surgery, and were more likely to have secondary operations at the time of LGB. Operating time decreased from a mean of 311 min in group 11 to 237 min in group 3, and technical complications were reduced by 50% after an experience of 100 cases. CONCLUSIONS: Operative time and technically related complications decreased with operative experience even though heavier patients and higher-risk patients were more predominant in the latter part of our experience. LGB is a technically challenging operation with a long learning curve. To minimize morbidity related to the learning curve, strategies for developing training programs must address these challenges.

Outcomes of laparoscopic Toupet compared to laparoscopic Nissen fundoplication.

BACKGROUND: Recent reports suggest that partial fundoplications such as the laparoscopic Toupet (LT) ultimately suffer from a higher recurrence rate compared to complete wraps such as the laparoscopic Nissen fundoplication (LNF). This article summarizes our experience with LT and LNF. METHODS: Over a 45-month period (February 1995 to November 1998), 206 patients underwent laparoscopic antireflux operations. The LNF group included 163 patients and the LT group included 43 patients. Global quality of life was measured using the Medical outcomes short form 36 (SF36). RESULTS: There were no differences in disease severity, except that the LT group had a higher incidence of esophageal dysmotility (37.2% 8.6%, p < 0.05). Early outcomes were similar, with no perioperative deaths and morbidity occurring in 15 (9.2%) LNF and 5 (11.6%) LT patients (p = not significant). Long-term follow-up was available in 142 patients at a mean of 19.7 months. A greater number of LT patients required proton pump inhibitors (38 vs 20%) and were dissatisfied (21 vs 7%) with their surgery (p < 0.05). SF36 physical function scores were better in the LNF group (85 vs 74; p < 0.05). Significantly more (p < 0.05) of the LT patients complained of dysphagia (34.5 vs 15%) on follow-up. There were no differences in the incidence of symptoms related to the gas-bloat syndrome. The observed differences between the LT and LNF groups did not appear to be related to differences in esophageal motility. CONCLUSIONS: Short-term results were similar for LT and LNF, but with longer follow-up, better results were seen with LNF. Even in the setting of moderate decreases of esophageal motility, complete fundoplication yields superior results.

Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The purpose of this study was to determine the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on symptomatic control of gastroesophageal reflux disease (GERD). METHODS: Morbidly obese patients (n = 435) who underwent LRYGBP for morbid obesity were assessed for changes in GERD symptoms, quality of life, and patient satisfaction after surgery. RESULTS: A total of 238 patients (55%) had evidence of chronic GERD, and 152 patients (64%) voluntarily participated in the study. The mean body mass index (BMI) was 48 kg/m2. The mean excess weight loss was 68.8% at 12 months. There was a significant decrease in GERD-related symptoms, including heartburn (from 87% to 22%, p<0.001); water brash (from 18% to 7%, p<0.05); wheezing (from 40% to 5%, p<0.001) laryngitis (from 17% to 7%, p<0.05); and aspiration (from 14% to 2%, p<0.01) following LRYGBP. Postoperatively, the use of medication decreased significantly both for proton pump inhibitors (from 44% to 9%, p<0.001) and for the H2 blockers (from 60% to 10%, p<0.01). SF-36 physical function scores and the mental component summary scores improved after the operation (87 vs 71; p<0.05 and 83 vs 66; p<0.05, respectively). Overall patient satisfaction was 97%. CONCLUSION: LRYGBP results in very good control of GERD in morbidly obese patients with follow-up as late as 3 years. Morbidly obese patients who require surgery for GERD may be better served by LRYGBP than fundoplication because of the additional benefit of significant weight loss.

Laparoscopic resection of a large periadrenal nonmalignant pheochromocytoma.

This is, to our knowledge, the first case description of an extraadrenal pheochromocytoma located in the periadrenal fat. Pheochromocytoma is a tumor that originates in the chromaffin tissue. Extraadrenal pheochromocytomas have been described commonly in locations such as the organ of Zuckerkandle (29%); the bladder (12%); the sacrum, testis, rectum, and pelvic floor (2%); the upper abdomen in association with celiac, superior mesenteric, and inferior mesenteric ganglia (43%); the thorax (12%); and the neck (2%), most commonly in association with the ninth or tenth cranial nerve ganglion. Our patient was a 40-year-old woman known to have had an adrenal mass for the last 4 years. She was referred for surgery because of an increase in the size of the mass to 11 cm. Laparoscopic adrenalectomy was performed via a posterior flank approach. The pathology report was of periadrenal fat pheochromocytoma, with positive staining for synaptophysin, chromogranin, and vimentin. The patient was discharged on postoperative day 3. The unique feature in this case was the uncommon location of the extraadrenal tumor: the supraadrenal fat. The other unique finding in this case was that the pheochromocytoma was neither symptomatic nor malignant, common features of extraadrenal masses.

Laparoscopic surgery for morbid obesity.

Minimally invasive approaches to bariatric surgery offer significant advantages over those of open surgery. The potential of laparoscopic approaches to reduce the morbidity of these operations may exceed that of laparoscopic cholecystecomy and laparoscopic Nissen fundoplication because the access incisions for open bariatric operations have relatively greater potential for harming the morbidly obese patient. Early results of laparoscopic VBG suggest a significant decrease in perioperative morbidity compared to the open approach, with similar weight-loss results. LGB may have the lowest perioperative morbidity and mortality of all current bariatric operations. However, the reoperation rate for device-related complications or failure of the patient to lose sufficient weight appears significant. Long-term esophageal motility also remains questionable for the LGB. It is hoped that the FDA trial will address many of the issues regarding LGB. Results of Lap RYGBP are accumulating and appear promising. The early experience suggests that it is technically feasible and safe in the hands of surgeons who have appropriate training. It is associated with low perioperative morbidity, short hospital stay, and rapid recovery compared to expected results of open RYGBP. Weight loss for Lap RYGBP after 5 years is excellent. It is, however, a technically formidable operation requiring long operating times and a steep learning curve. Early results indicate that technical complications may be greater than those experienced with open RYGBP because of the learning curve. Lap RYGBP is a promising bariatric procedure with potentially significant advantages over open RYGBP. Thus, for patients in the United States, Lap RYGBP may become the preferred weight-reduction procedure. The value of hand-assisted bariatric procedures and laparoscopic malabsorption procedures must await further study.

Surgical management of gastroesophageal reflux disease in obese patients.

Obesity or morbid obesity is common among patients who are seeking surgery for refractory gastroesophageal reflux disease (GERD). Several surgical options for treating GERD in obese patients are available. Fundoplications may be effective, at least in the short-term, but have no effect on weight loss and comorbidity reduction. Silicone-adjustable gastric banding and Roux-en-Y gastric bypass have different antireflux mechanisms, but also have proven efficacy against GERD and result in significant weight loss and comorbidity reduction. Vertical banded gastroplasty is not an effective antireflux procedure, and it may induce GERD in some patients. The malabsorbtion operations have no proven efficacy against GERD. Patients with severe obesity who are seeking surgical treatment for GERD should be considered for silicone adjustable gastric banding or Roux-en-Y gastric bypass because of the added benefit of weight loss and consequent comorbidity reduction.

Outcomes after minimally invasive esophagomyotomy.

BACKGROUND: Thoracic surgeons traditionally performed thoracotomy and myotomy for achalasia. Recently minimally invasive approaches have been reported with good success. This report summarizes our single-institution experience using video-assisted thoracoscopy (VATS) or laparoscopy (LAP) for the treatment of achalasia. METHODS: A review of 62 patients undergoing minimally invasive myotomy for achalasia was performed. There were 27 male and 35 female patients. Mean age was 53 years (range 14 to 86). Thirty-seven (59.7%) had failed prior treatments (balloon dilation, botulinim toxin injection, or prior surgery). Outcomes studied were dysphagia score (1 = none, 5 = severe), Short-Form 36 quality of life (SF36 QOL) score, and heartburn-related QOL index (HRQOL). RESULTS: Surgery included myotomy and partial fundoplication (5 VATS and 57 LAP). Mortality was zero, and complications occurred in 9 (14.5%) patients. There were 6 perforations (4 repaired by LAP and 2 open). Median length of stay was 2 days, time to oral intake was 1 day. At a mean of 19 months follow-up, 92.5% of patients were satisfied with outcome. Dysphagia scores improved from 3.6 to 1.5 (p < 0.01) but 3 patients ultimately required esophagectomy for recurrent dysphagia. HRQOL scores for heartburn and SF-36 QOL scores were comparable with control populations. CONCLUSIONS: Minimally invasive myotomy and partial fundoplication for achalasia improved dysphagia in 92.5% of patients with heartburn and QOL scores were comparable with normal values at 19-month follow-up. The laparoscopic approach offers excellent results and was the preferred approach by our thoracic group for treating achalasia. Thoracic residency training should strive to include laparoscopic esophageal experience.

Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity.

OBJECTIVE: To evaluate the short-term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with a follow-up of 1 to 31 months. SUMMARY BACKGROUND DATA: The Roux-en-Y gastric bypass is a highly successful approach to morbid obesity but results in significant perioperative complications. A laparoscopic approach has significant potential to reduce perioperative complications and recovery time. METHODS: Consecutive patients (n = 275) who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass between July 1997 and March 2000. A 15-mL gastric pouch and a 75-cm Roux limb (150 cm for superobese) was created using five or six trocar incisions. RESULTS: The conversion rate to open gastric bypass was 1%. The start of an oral diet began a mean of 1.58 days after surgery, with a median hospital stay of 2 days and return to work at 21 days. The incidence of early major and minor complications was 3.3% and 27%, respectively. One death occurred related to a pulmonary embolus (0.4%). The hernia rate was 0.7%, and wound infections requiring outpatient drainage only were uncommon (5%). Excess weight loss at 24 and 30 months was 83% and 77%, respectively. In patients with more than 1 year of follow-up, most of the comorbidities were improved or resolved, and 95% reported significant improvement in quality of life. CONCLUSION: Laparoscopic Roux-en-Y gastric bypass is effective in achieving weight loss and in improving comorbidities and quality of life while reducing recovery time and perioperative complications.

Pulmonary embolism following laparoscopic antireflux surgery: a case report and review of the literature.

Deep venous thrombosis and pulmonary embolism are concerning causes of morbidity and mortality in patients undergoing general surgical procedures. Laparoscopic surgery has gained rapid acceptance in the past several years and is now a commonly performed procedure by most general surgeons. Multiple anecdotal reports of pulmonary embolism following laparoscopic cholecystectomy have been reported, but the true incidence of deep venous thrombosis and pulmonary embolism in patients undergoing laparoscopic surgery is not known. We present a case of pulmonary embolism following laparoscopic repair of paraesophageal hernia. The literature is then reviewed regarding the incidence of pulmonary embolism following laparoscopic surgery, the mechanism of deep venous thrombosis formation, and the recommendations for deep venous thrombosis prophylaxis in patients undergoing laparoscopic procedures.

Minilaparoscopy.

Minilaparoscopy is an emerging aspect of laparoscopic surgery involving the use of miniaturized scopes and instruments to further reduce perioperative morbidity and enhance cosmesis. Recent improvements in optical technology and instrument design have enabled relatively broad applications of minilaparoscopy to include diagnostic and therapeutic procedures in both inpatient and outpatient settings. Early results suggest that minilaparoscopic procedures in the hands of experienced laparoscopic surgeons appear to be similarly safe and effective with minimally perceptive scarring. Although promising, clear advantages in reducing perioperative pain and morbidity have yet to be determined.

Laparoscopic Roux-en-Y gastric bypass: a case report at one-year follow-up.

Surgery is the only treatment for morbid obesity that has been proven to achieve a significant long-term weight loss. The Roux-en-Y gastric bypass procedure has been performed for the treatment of morbid obesity over the past two decades with excellent results. Wound complications and perioperative morbidity remain unresolved problems of the procedure. A laparoscopic approach to this procedure has great potential to minimize the complications of this highly effective technique. We describe a laparoscopically performed Roux-en-Y gastric bypass in a 28-year-old woman with morbid obesity. The technique described here preserves the anatomic construct of the operation but introduces the benefit of the laparoscopic approach.

Detection of aerosolized cells during carbon dioxide laparoscopy.

Laparoscopic surgery for malignancy has been complicated by port-site recurrences. The exact mechanism has yet to be defined. In vitro studies suggest that carbon dioxide-induced tumor cell aerosolization may play a role. We have attempted to document this in a human model. Patients scheduled for elective laparoscopy underwent port placement and abdominal insufflation with carbon dioxide. A suction trap was then filled with 40 cc of normal saline solution and attached to an insufflation site on the port. The carbon dioxide effluent was directed through the saline. The specimen was concentrated, resuspended, and transferred to a slide. A Papanicolaou stain was used. Thirty-five specimens were obtained. Fifteen patients (37%) had malignant disease, which was metastatic in eight. Five patients had carcinomatosis. In two of those with carcinomatosis, staining revealed a large number of malignant cells. Malignant cells were not found in any other patients. In two patients, however, aerosolized mesothelial cells were identified. Follow-up ranged from 2 to 7 months. One patient who displayed cellular aerosolization developed a port-site recurrence. We conclude that malignant cells are aerosolized but only during laparoscopy in the presence of carcinomatosis. It is unlikely that tumor cell aerosolization contributes significantly to port-site metastasis.