SAGES white paper on the current state of community practice surgeons: re-discovering the value of our community practice surgeons.

BACKGROUND: The Community Practice (CP) surgeon is the first point of access to surgical care globally and performs the majority of procedures in the USA. CP surgeons include those of various practice models, locations and communities, education and training, and much more. It is a diverse group that drives quality, access to care, research, and innovation. The SAGES CP Committee was formed to better define the role and highlight the contribution of the CP surgeon, as well as advocate for the position of CP surgeons in our society. METHODS: In 2018, a survey was distributed to the SAGES membership asking members to self-identify as either a Community Surgeon or Academic Surgeon. RESULTS: The majority (71%) of SAGES members surveyed self-identified as "Community Surgeons." This was in stark contrast to the distribution of Community versus Academic Surgeons in SAGES leadership (25% versus 75%, respectively). CONCLUSION: By better defining the characteristics and role of the CP, SAGES will be better informed on how to effectively engage with this large group within the society and increase its representation within the leadership. The CP Committee met on a biannual basis over a period of two years focusing on assessing their role in the SAGES organization. The committee members created the following initial goals: (1) define in a broad sense the characteristics of a CP Surgeon, (2) discuss and characterize the value of the CP surgeons, (3) highlight past and future areas of contributions of the group, and (4) delineate ways to engage and represent this subgroup. This manuscript is a culmination of the work of this committee while also serving as a way to support the initiatives and direction of SAGES leadership.

Highly efficient, in-vivo Fas-mediated apoptosis of B-cell lymphoma by hexameric CTLA4-FasL.

Non-Hodgkin lymphomas (NHLs) account for 4% of all malignancies. 5-year survival rate increased to 50% with new treatment modalities, however there is need for new effective treatment for the more aggressive, relapsing forms. Recently, CTLA4-FasL, that can bind to B7 and Fas receptor (Fas), was shown to induce robust apoptosis of cell lines originating from B cell lymphomas expressing both B7 and Fas, by activating pro-apoptotic signals in parallel to abrogating anti-apoptotic ones. The present study focuses on the unique properties of CTLA4-FasL as a potent apoptosis inducer of malignant cells in-vitro and in a xenograft model. CTLA4-FasL was found to naturally form a stable homo-hexamer. CTLA4-FasL induces robust apoptosis of a large variety of malignant cells while relatively sparing non-malignant ones, being more efficient when both receptors (B7 and Fas) are expressed on target cells. Even in non-B7 expressing cells, CTLA4-FasL exhibited better apoptotic activity than its parts, alone or in combination, however, only in B7 expressing cells apoptosis occurs at low concentrations and CTLA4-FasL induces activation of apoptotic signals and reduces anti-apoptotic ones. Importantly, CTLA4-FasL efficiently inhibited the growth of human B cell lineage tumors in a xenograft model, by provoking tumor cells' apoptosis. Thus, CTLA4-FasL, a natural homo-hexamer protein, induces robust apoptosis of malignant cells, in-vitro and in-vivo. In B-cell lymphoma, its potency stems from the combination of its synergistic effect of activating the caspases while abrogating the anti-apoptotic signaling, with its unique hexameric structure, making CTLA4-FasL a promising candidate for aggressive B cell lymphomas treatment.

The role of reverse transcriptase in intron gain and loss mechanisms.

Intron density is highly variable across eukaryotic species. It seems that different lineages have experienced considerably different levels of intron gain and loss events, but the reasons for this are not well known. A large number of mechanisms for intron loss and gain have been suggested, and most of them have at least some level of indirect support. We therefore figured out that the variability in intron density can be a reflection of the fact that different mechanisms are active in different lineages. Quite a number of these putative mechanisms, both for intron loss and for intron gain, postulate that the enzyme reverse transcriptase (RT) has a key role in the process. In this paper, we lay out three predictions whose approval or falsification gives indication for the involvement of RT in intron gain and loss processes. Testing these predictions requires data on the intron gain and loss rates of individual genes along different branches of the eukaryotic phylogenetic tree. So far, such rates could not be computed, and hence, these predictions could not be rigorously evaluated. Here, we use a maximum likelihood algorithm that we have devised in the past, Evolutionary Reconstruction by Expectation Maximization, which allows the estimation of such rates. Using this algorithm, we computed the intron loss and gain rates of more than 300 genes in each branch of the phylogenetic tree of 19 eukaryotic species. Based on that we found only little support for RT activity in intron gain. In contrast, we suggest that RT-mediated intron loss is a mechanism that is very efficient in removing introns, and thus, its levels of activity may be a major determinant of intron number. Moreover, we found that intron gain and loss rates are negatively correlated in intron-poor species but are positively correlated for intron-rich species. One explanation to this is that intron gain and loss mechanisms in intron-rich species (like metazoans) share a common mechanistic component, albeit not a RT.

Laparoscopic bariatric surgery in super-obese patients (BMI>50) is safe and effective: a review of 332 patients.

BACKGROUND: Bariatric surgery in super-obese patients (BMI >50 kg/m(2)) can be challenging because of difficulties in exposure of visceral fat, retracting the fatty liver, and strong torque applied to instruments, as well as existing co-morbidities. METHODS: A retrospective review of super-obese patients who underwent laparoscopic adjustable gastric banding (LAGB n=192), Roux-en-Y gastric bypass (RYGBP n=97), and biliopancreatic diversion with/without duodenal switch (BPD n= 43), was performed. 30 day peri-operative morbidity and mortality were evaluated to determine relative safety of the 3 operations. RESULTS: From October 2000 through June 2004, 331 super-obese patients underwent laparoscopic bariatric surgery, with mean BMI 55.3 kg/m(2). Patients were aged 42 years (13-72), and 75% were female. When categorized by operation (LAGB, RYGBP, BPD), the mean age, BMI and gender were comparable. 6 patients were converted to open (1.8%). LAGB had a 0.5%, RYGBP 2.1% and BPD 7.0% conversion rate (P=0.02, all groups). Median operative time was 60 min for LAGB, 130 min for RYGBP and 255 min for BPD (P<0.001, all groups). Median length of stay was 24 hours for LAGB, 72 hours for RYGBP, and 96 hours for BPD (P <0.001). Mean %EWL for the LAGB was 35.3+/-12.6, 45.8+/-19.4, and 49.5+/-18.6 with follow-up of 87%, 76% and 72% at 1, 2 and 3 years, respectively. Mean %EWL for the RYGBP was 57.7+/-15.4, 54.7+/-21.2, and 56.8+/-21.1 with follow-up of 76%, 33% and 54% at 1, 2 and 3 years, respectively. Mean %EWL for the BPD was 60.6+/-15.9, 69.4+/-13.0 and 77.4+/-11.9 with follow-up of 79%, 43% and 47% at 1, 2 and 3 years, respectively. The difference in %EWL was significant at all time intervals between the LAGB and BPD (P<0.004). However, there was no significant difference in %EWL between LAGB and RYGBP at 2 and 3 years. Overall perioperative morbidity occurred in 27 patients (8.1%). LAGB had 4.7% morbidity rate, RYGBP 11.3%, and BPD 16.3% (P=0.02, all groups). There were no deaths. CONCLUSION: Laparoscopic bariatric surgery is safe in super-obese patients. LAGB, the least invasive procedure, resulted in the lowest operative times, the lowest conversion rate, the shortest hospital stay and the lowest morbidity in this high-risk cohort of patients. Rates of all parameters studied increased with increasing procedural complexity. However, the difference in %EWL between RYGBP and LAGB at 2 and 3 years was not statistically significant.

Laparoscopic treatment of superior mesenteric artery syndrome.

BACKGROUND: Superior mesenteric artery syndrome is caused by compression of the third portion of the duodenum by the superior mesenteric artery. Many disease states predispose one to this condition. METHODS: We present a case report of a young female patient who presented with gastro-duodenal obstruction from superior mesenteric artery syndrome and subsequently underwent surgical treatment with minimally invasive techniques. Pathophysiology of SMA syndrome is reviewed. RESULTS: The cause of superior mesenteric artery syndrome is variable but always results in duodenal obstruction. Surgery is one treatment option that is effective and can be performed laparoscopically. CONCLUSION: Laparoscopic duodenojejunostomy is an acceptable method of treating superior mesenteric artery syndrome.

Impact of patient follow-up on weight loss after bariatric surgery.

BACKGROUND: Postoperative follow-up after bariatric surgery is important. Because of the need for adjustments, follow-up after gastric banding may have a greater impact on weight loss than after Roux-en-Y gastric bypass. We reviewed all patients at 1 year after these two operations. METHODS: During the first year after surgery, laparoscopic adjustable gastric banding (LAGB) patients were followed every 4 weeks and Roux-en-Y gastric bypass (RYGBP) patients were followed at 3 weeks postoperatively and then every 3 months. The number of follow-up visits for each patient was calculated, and 50% compliance for follow-up and weight loss was compared. RESULTS: Between October 2000 and September 2002, 216 LAGB and 139 RYGBP operations were performed. Of these patients, 186 LAGB patients and 115 RYGBP patients were available for 1-year follow-up. Age and BMI were similar for each group. Overall excess weight loss (EWL) after LAGB was 44.5%. 130 (70%) returned 6 or less times in the first year and achieved 42% EWL. 56 patients (30%) returned more than 6 times and had 50% EWL (P=0.005). Overall %EWL after RYGBP was 66.1%. 53 patients (46%) returned 3 or less times in the first year, achieving 66.1% EWL. 62 patients (54%) returned more than 3 times after surgery and achieved 67.6% EWL (P=NS). CONCLUSION: Patient follow-up plays a significant role in the amount of weight lost after LAGB, but not after RYGBP. Patient motivation and surgeon commitment for long-term follow-up is critical for successful weight loss after LAGB surgery.

Removal of peri-gastric fat prevents acute obstruction after Lap-Band surgery.

BACKGROUND: Acute postoperative gastroesophageal obstruction is a potential complication after laparoscopic adjustable gastric banding (LAGB). Utilizing the pars flaccida technique may increase the incidence due to the incorporation of perigastric fat, particularly in patients with greater visceral obesity. Removal of peri-gastric fat pads may be necessary to avoid postoperative obstruction. We present our experience of 267 LAGB operations using the LapBand System and the incidence of postoperative obstruction, before and after incorporating routine removal of peri-gastric fat pads. METHODS: A retrospective review of a prospective database of 267 consecutive Lap-Band placements between July 2001 and November 2002 was conducted. RESULTS: All operations were completed laparoscopically using the pars flaccida technique, and all patients underwent esophagogram the morning after surgery. From July 2001 to May 2002, 143 Lap-Band placements were performed, with 11 patients (8%) having abnormal postoperative esophagograms. There were 43 males/100 females with mean BMI 48.3 (range 35 to 78.9). Complete esophageal obstruction was seen in 5 of these patients, all of whom underwent laparoscopic revision. Significantly delayed emptying was seen in the 6 remaining patients, who were managed conservatively with intravenous fluids from 2-7 days. In these 11 patients, there were 6 males/5 females with mean BMI 47.1 (range 37.3-57.9). Subsequently, removal of peri-gastric fat pads was routinely performed during Lap-Band placement. From June 2002 to November 2002, there were 43 males/81 females with mean BMI 48 (range 35-79); these 124 Lap-Band placements were performed with no abnormal postoperative esophagograms. CONCLUSION: Routine removal of peri-gastric fat pads when using the pars flaccida technique for Lap Band surgery appears to prevent postoperative esophageal obstruction.