Metabolic Pancreatitis: Pancreatic Steatosis, Hypertriglyceridemia, and Associated Chronic Pancreatitis in 3 Patients with Metabolic Syndrome.

Obesity, insulin resistance, and metabolic syndrome continue to increase in prevalence. Hypertriglyceridemia is commonly associated and represents a valuable marker of metabolic syndrome. An increase in subcutaneous fat deposition places patients at risk for visceral adipose deposition in sites such as the liver, heart, and pancreas. Pancreatic steatosis in the setting of metabolic syndrome is a rapidly emerging entity whose clinical spectrum remains to be defined. Hypertriglyceridemia is an accepted cause of acute pancreatitis but its role in chronic pancreatic injury remains to be explored. We present 3 patients with chronic abdominal pain and pancreatic steatosis in the setting of underlying metabolic syndrome with hypertriglyceridemia. These cases were identified in one endoscopic ultrasonographer's practice over a 12-month period. Each patient had documented hypertriglyceridemia but no history of acute hypertriglyceride-induced pancreatitis. A history of significant alcohol exposure was carefully excluded. Each patient underwent endoscopic ultrasonography (EUS) which proved critical in delineating the spectrum of chronic pancreatic injury. Each of our patients had EUS documentation of pancreatic steatosis and sufficient criteria to establish a diagnosis of chronic pancreatitis. Intraductal pancreatic calculi were identified in all 3 patients. Our series suggests that in the setting of metabolic syndrome, chronic hypertriglyceridemia and pancreatic steatosis may be associated with chronic pancreatitis. We hypothesize that hypertriglyceridemia may provide a pathogenic role in the development of chronic pancreatic microinjury. In addition, each of our patients had EUS-documented pancreatic ductal lithiasis. To our review, these are novel findings which have yet to be reported. We believe that with an enhanced awareness, it is likely that the entity of metabolic syndrome with features of pancreatic steatosis and hypertriglyceridemia with their associated manifestations of chronic pancreatitis, including ductal lithiasis, will be widely appreciated.

Laparoscopic revision of failed fundoplication and hiatal herniorraphy.

OBJECTIVE: The aim of this study was to evaluate the mechanisms of failure after laparoscopic fundoplication and the results of revision laparoscopic fundoplication. BACKGROUND: Laparoscopic Nissen fundoplication has become the most commonly performed antireflux procedure for the treatment of gastroesophageal reflux disease, with success rates from 90 to 95%. Persistent or new symptoms often warrant endoscopic and radiographic studies to find the cause of surgical failure. In experienced hands, reoperative antireflux surgery can be done laparoscopically. We performed a retrospective analysis of all laparoscopic revision of failed fundoplications done by the principle author and the respective fellow within the laparoscopic fellowship from 1992 to 2006. METHODS: A review was performed on patients who underwent laparoscopic revision of a failed primary laparoscopic fundoplication. RESULTS: Laparoscopic revision of failed fundoplication was performed on 68 patients between 1992 and 2006. The success rate of the laparoscopic redo Nissen fundoplication was 86%. Symptoms prior to the revision procedure included heartburn (69%), dysphagia (8.8%), or both (11.7%). Preoperative evaluation revealed esophagitis in 41%, hiatal hernia with esophagitis in 36%, hiatal hernia without esophagitis in 7.3%, stenosis in 11.74%, and dysmotility in 2.4%. The main laparoscopic revisions included fundoplication alone (41%) or fundoplication with hiatal hernia repair (50%). Four gastric perforations occurred; these were repaired primarily without further incident. An open conversion was performed in 1 patient. Length of stay was 2.5 +/- 1.0 days. Mean follow-up was 22 months (range, 6-42), during which failure of the redo procedure was noted in 9 patients (13.23%). CONCLUSION: Laparoscopic redo antireflux surgery, performed in a laparoscopic fellowship program, produces excellent results that approach the success rates of primary operations.

The Plicator procedure for the treatment of gastroesophageal reflux disease: a registry study.

BACKGROUND: Endoscopic full-thickness plication of the gastric cardia using the Plicator is shown to be effective for the treatment of symptomatic gastroesophageal reflux disease (GERD) in both prospective and randomized controlled trials. This registry study aimed to evaluate Plicator procedure safety and efficacy among GERD patients treated in routine clinical practice at multiple academic and nonacademic centers. METHODS: An open-label, prospective multicenter trial was conducted at seven centers under institutional review board approval. Patients with symptomatic GERD completed a series of questionnaires at baseline to assess GERD symptoms, heartburn/regurgitation scores, antisecretory medication use, and treatment satisfaction. All the patients then underwent the Plicator procedure with placement of a single transmural pledgeted suture in the anterior gastric cardia. The patients were reevaluated at 12 months after plication. RESULTS: The 12-month follow-up assessment was completed by 81 patients. At 12 months, the mean GERD Health-Related Quality-of-Life score had improved significantly compared with the baseline score (12.0 vs 26.6; p < 0.001), with 66% of the subjects showing an GERD-HRQL score improved 50% or more. Statistically significant improvements also were observed in median heartburn and regurgitation symptom scores. At 12 months, the need for daily proton pump inhibitor (PPI) therapy was eliminated for 58% of the patients. At baseline, 18% of the subjects had been satisfied with their GERD symptom control while on antisecretory therapy. At 12 months, 75% of the patients were satisfied with their GERD symptom control after undergoing the Plicator procedure, and 86% would recommend the procedure to family or friends. There were no serious adverse events and no late onset of any adverse events. CONCLUSIONS: In this multicenter study, the Plicator procedure effectively improved GERD quality-of-life scores, reduced GERD symptoms and medication use, and yielded higher treatment satisfaction than with the use of chronic antisecretory therapy. These effects all were seen 12 months after plication, and no major adverse effects were observed.

Value of preoperative upper endoscopy in patients undergoing laparoscopic gastric bypass.

BACKGROUND: Preoperative evaluation of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) has included esophagogastroduodenoscopy (EGD) with little data to substantiate its use. METHODS: A retrospective analysis was conducted of patients from Feb 04 to Mar 05 who underwent preoperative EGD and subsequently LRYGBP. RESULTS: 169 patients underwent EGD prior to surgery. Their mean age was 41.1 years (range 14-66), mean BMI 49.7 (range 35-78), and 82% were females. There were no complications from EGD. Significant findings in patients at EGD included gastric ulceration in 3 (2%), duodenal ulcer in 1 (0.7%), Barrett's esophagus in 2 (1.3%), and a GI stromal tumor (GIST) in 1 (0.7%). EGD revealed hiatal hernias in 56 (35.2%), esophagitis in 28 (17%), Schatzki's ring in 5 (3%), gastritis in 43 (27%), gastric polyps in 8 (5%), and duodenitis in 9 (6%). 53 patients (33.3%) had a negative EGD. Ulcer and severe gastritis, esophagitis, and duodenitis diagnosed preoperatively were treated medically before surgery. 9 hiatal hernias were repaired intraoperatively. The patient with the GIST underwent laparoscopic near-total gastrectomy and gastric bypass, while 1 patient with an antral polyp underwent laparoscopic partial gastrectomy in addition to the LRYGBP. CONCLUSION: EGD is essential for diagnosis of GI diseases including tumors, ulcers, and hiatal hernias that alter the medical and surgical management of patients undergoing gastric bypass.