Nonaccidental Trauma Is an Independent Risk Factor for Mortality Among Injured Infants.

OBJECTIVES: The Centers for Disease Control disclosed over 600,000 cases of child abuse or neglect in 2016. Single-institution studies have shown that nonaccidental trauma (NAT) has higher complication rates than accidental trauma (AT). Nonaccidental trauma is disproportionately represented in infants. We hypothesized that NAT would increase the risk of mortality in infants. This study aims to provide a contemporary descriptive analysis for infant trauma patients and determine the association between NAT and mortality. METHODS: Infants (<1 year of age) within the Pediatric Trauma Quality Improvement Program database (2014-2016) were identified. Descriptive statistics (χ2 and t test) were used to compare NAT infants to AT infants. A multivariable logistic regression was used to determine the risk of mortality associated with select variables including NAT. RESULTS: From 14,965 infant traumas, most presented to a level I pediatric trauma center (53.5%) with a median injury severity score of 9. The most common mechanism was falls (48.6%), followed by NAT (14.5%). Overall mortality was 2.1%. Although most NAT infants were white (60.2%), black infants were overrepresented (23.6% vs 18.3%; P < 0.0001) compared with AT infants. The incidence of mortality was higher in NAT infants (41.6% vs 13.9%; P < 0.0001), and they were more likely to have traumatic brain injury (TBI) (63.1% vs 50.6%; P < 0.001). Nonaccidental trauma [odds ratio (OR), 2.48; P < 0.001], hypotension within 24 hours (OR, 8.93; P < 0.001), injury severity score (OR, 1.12; P < 0.001), and severe abbreviated injury scale-head (OR 1.62, P = 0.014) had the highest association with mortality. CONCLUSIONS: This study confirms the incidence of TBI and NAT in infants. Although providers should be vigilant for NAT, suspicion of NAT should prompt close surveillance, as there is a 2-fold increased risk of mortality independent of injury or TBI.

Perioperative blood transfusion is associated with an increased risk for post-surgical infection following pancreaticoduodenectomy.

BACKGROUND/PURPOSE: Perioperative blood transfusion is common after pancreaticoduodenectomy (PD) and may predispose patients to infectious complications. The purpose of this study is to examine the association between perioperative blood transfusion and the development of post-surgical infection after PD. METHODS: Patients who underwent PD from 2014 to 2015 were identified in the NSQIP pancreas-specific database. Logistic regression analysis was used to compute adjusted odds ratios (aOR) to identify an independent association between perioperative red blood cell transfusion (within 72 h of surgery) and the development of post-operative infection after 72 h. RESULTS: A total of 6869 patients underwent PD during this time period. Of these, 1372 (20.0%) patients received a perioperative blood transfusion. Patients receiving transfusion had a higher rate of post-operative infection (34.7% vs 26.5%, p < 0.001). After adjusting for significant covariates, perioperative transfusion was independently associated the subsequent development of any post-operative infection (aOR 1.41 [1.23-1.62], p < 0.001), including pneumonia (aOR 2.01 [1.48-2.74], p < 0.001), sepsis (aOR 1.62 [1.29-2.04], p < 0.001), and septic shock (aOR 1.92 [1.38-2.68], p < 0.001). CONCLUSION: There is a strong independent association between perioperative blood transfusion and the development of subsequent post-operative infection following PD.

Risk Factors for Post-Operative Sepsis and Septic Shock in Patients Undergoing Emergency Surgery.

Background: Sepsis after emergency surgery is associated with a higher mortality rate than elective surgery, and total hospital costs increase by 2.3 times. This study aimed to identify risk factors for post-operative sepsis or septic shock in patients undergoing emergency surgery. Methods: A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program (NSQIP) by identifying patients undergoing emergency surgery between 2012 and 2015 and comparing those who developed post-operative sepsis or septic shock (S/SS) with those who did not. Patients with pre-operative sepsis or septic shock were excluded. Multiple logistic regression was used to identify risk factors for the development of S/SS in patients undergoing non-elective surgery. Results: Of 122,281 patients who met the inclusion criteria, 2,399 (2%) developed S/SS. Risk factors for S/SS were American Society of Anesthesiologists Physical Status (ASA PS) class 2 or higher (odds ratio [OR] 2.57; 95% confidence interval [CI] 2.19-3.02; p < 0.0001), totally dependent (OR 2.00, 95% CI 1.38-2.83; p = 0.00021) or partially dependent (OR 1.62, 95% CI 1.35-2.00; p < 0.0001) functional status, and male gender (OR 1.31; 95% CI 1.18-1.45; p < 0.0001). Compared with colorectal procedures, patients undergoing pancreatic (OR 2.33, CI 1.40-3.87; p = 0.00108) and small intestine (OR 1.27; CI 1.12-1.44; p = 0.00015) surgery were more likely to develop S/SS. Patients undergoing biliary surgery (OR 0.38; CI 0.30-0.48; p < 0.0001) were less likely to develop S/SS. Conclusions: Risk factors for the development of sepsis or septic shock are ASA PS class 2 or higher, partially or totally dependent functional status, and male gender. Emergency pancreatic or small intestinal procedures may confer a higher risk. Greater vigilance and early post-operative screening may be of benefit in patients with these risk factors.

Quantitative magnetic resonance evaluation of the trigeminal nerve in familial dysautonomia.

PURPOSE: Familial dysautonomia (FD) is a rare autosomal recessive disease that affects the development of sensory and autonomic neurons, including those in the cranial nerves. We aimed to determine whether conventional brain magnetic resonance imaging (MRI) could detect morphologic changes in the trigeminal nerves of these patients. METHODS: Cross-sectional analysis of brain MRI of patients with genetically confirmed FD and age- and sex-matched controls. High-resolution 3D gradient-echo T1-weighted sequences were used to obtain measurements of the cisternal segment of the trigeminal nerves. Measurements were obtained using a two-reader consensus. RESULTS: Twenty pairs of trigeminal nerves were assessed in ten patients with FD and ten matched controls. The median (interquartile range) cross-sectional area of the trigeminal nerves in patients with FD was 3.5 (2.1) mm2, compared to 5.9 (2.0) mm2 in controls (P < 0.001). No association between trigeminal nerve area and age was found in patients or controls. CONCLUSIONS: Using conventional MRI, the caliber of the trigeminal nerves was significantly reduced bilaterally in patients with FD compared to controls, a finding that appears to be highly characteristic of this disorder. The lack of correlation between age and trigeminal nerve size supports arrested neuronal development rather than progressive atrophy.

Online Interactive Case-Based Instruction in Prostate Magnetic Resonance Imaging Interpretation Using Prostate Imaging and Reporting Data System Version 2: Effect for Novice Readers.

PURPOSE: To assess the effect on reader performance of an interactive case-based online tutorial for prostate magnetic resonance imaging (MRI) interpretation using Prostate Imaging and Reporting Data System (PI-RADS). METHODS: An educational website was developed incorporating scrollable multiparametric prostate MRI examinations with annotated solutions based on PI-RADS version 2. Three second-year radiology residents evaluated a separate set of 60 prostate MRI examinations both before and after review of the online case material, identifying and scoring dominant lesions. These 60 examinations included 30 benign cases and 30 cases with a dominant lesion demonstrating Gleason score ≥3 + 4 tumor on fusion-targeted biopsy. The readers' pooled performance was compared between the 2 sessions using logistic regression and Wilcoxon signed rank tests. RESULTS: All readers completed the online material within four-hours. Review of the online material significantly improved sensitivity (from 57.8%-73.3%, P = 0.003) and negative predictive value (from 69.2%-78.2%, P = 0.049), but not specificity (from 70.0%-67.8%, P = 0.692) or positive predictive value (from 59.6%-64.7%, P = 0.389). Reader confidence (1-10 scale; 10 = maximal confidence) also improved significantly (from 5.6 ± 2.7 to 6.3 ± 2.6, P = 0.026). However, accuracy of assigned PI-RADS scores did not improve significantly (from 45.5%-53.3%, P = 0.149). CONCLUSION: An online interactive case-based website in prostate MRI interpretation improved novice readers' sensitivity and negative predictive value for tumor detection, as well as readers' confidence. This online material may serve as a resource complementing existing traditional methods of instruction by providing a more flexible educational experience among a larger volume of learners. However, further more targeted educational initiatives regarding the proper application of PI-RADS remain warranted.

Perforated Peptic Ulcer Surgery: Decreased Length of Stay but No Difference in Mortality with Laparoscopic Repair.

BACKGROUND: Perforated peptic ulcer (PPU) surgery mortality ranges 1% to 24%. We hypothesized a decrease in length of stay (LOS) with laparoscopic surgical repair (LSR) compared with open surgical repair (OSR). METHODS: Patients undergoing PPU surgery 2005 to 2015 were identified in NSQIP. LSR was compared with OSR 2005 to 2015. LSR 2005 to 2010 was compared with 2011 to 2015. OSR 2005 to 2010 was compared with 2011 to 2015. The primary outcome was LOS. Secondary outcomes were mortality and morbidity. RESULTS: Between 2005 and 2015, LSR had a decreased LOS, was more likely to wean from the ventilator, but had no significant difference in mortality compared with OSR. There was no significant difference in mortality for LSR or OSR over time. CONCLUSIONS: When patients are appropriately selected, LSR for PPU is a viable alternative to OSR, decreasing LOS and pulmonary complications. This demonstrates significant benefit to patients and hospital throughput.

A Propensity Score Analysis of Clostridium difficile Infection among Adult Trauma Patients.

BACKGROUND: Clostridium difficile infection (CDI) is now the most common cause of health-care-associated infection and carries a mortality rate ranging from 5-30%. Previously, trauma patients in whom CDI developed were thought to represent a unique younger at-risk population. This study aimed to establish the incidence of CDI among adult trauma patients. We hypothesized that these patients would have increased risk of death, intensive care unit (ICU) length of stay (LOS), and hospital LOS compared with trauma patients without CDI. PATIENTS AND METHODS: A retrospective study of all adult trauma patients admitted for greater than 48 hours to a single Level I trauma center between 2014 and 2016 was conducted. Analysis was performed using 1-to-5 propensity score matching with the aim to analyze the relationship between CDI, death, and other outcome variables. RESULTS: Between 2014 and 2016, of 4893 trauma patients admitted for >48 hours, 27 (0.6%) patients received a diagnosis of CDI. These patients had a mean age of 55.6 years, mean injury severity score (ISS) of 22.4, and mortality rate of 9.1%. Of these patients, 22 were able to find appropriate propensity score matches. After adjusting for important covariables, there was no significant difference in death between CDI and non-CDI patients (odds ratio = 0.39, 95% confidence interval [CI]: 0.06-2.57, adjusted p = 0.66). In addition, there was no significant difference in ICU LOS between the two groups (relative mean [RM]: 1.55, 95% CI: 1.04-2.33, adjusted p = 0.0971). The CDI patients, however, did have a significantly longer hospital LOS, compared with non-CDI patients (RM = 1.39, 95% CI: 1.16-1.66, adjusted p = 0.0017). CONCLUSIONS: Among trauma patients admitted >48 hours CDI occurred at a rate of 0.6%, much lower than anticipated. Patients in whom CDI developed had a significantly longer hospital LOS however, had no significant difference in odds of mortality or ICU LOS compared to patients without CDI.

JOURNAL CLUB: Informal Consultations Between Radiologists and Referring Physicians, as Identified Through an Electronic Medical Record Search.

OBJECTIVE: The purpose of this study is to assess informal consultations between radiologists and referring physicians as identified through an electronic medical record (EMR) search. MATERIALS AND METHODS: The EMR was searched for physician notes containing either the term "radiologist" or "radiology" in combination with any of the following: "second opinion," "second-opinion," "2nd opinion," "2nd-opinion," "rereview," "re-review," "reread," "re-read," "overread," "over-read," "spoke with," "discussed with," or "reviewed with." A sample of 300 notes describing a consultation by a referring physician with a diagnostic radiologist was identified. RESULTS: Of the consultations, 73.3% were related to a specific previously interpreted imaging study, and 26.7% were related to other general management issues, including patient safety. Only 18.7% of the physicians' notes indicated the name of the consulted radiologist; a fraction of these consultations were with a radiologist other than the one who originally interpreted the study or with a radiologist at an outside institution. Of consultations with a local radiologist regarding a specific prior examination, 33.9% resulted in a new finding, a change in severity of a previously detected finding, or a change in management recommendation. Of consultations with a change from the initial report, 24.6% were documented by the radiologist via an addendum; 92.9% of these addenda agreed with the referring physicians' notes. CONCLUSION: Radiologists may be unaware of how their consultations are captured within physician notes that may be incomplete or misrepresent the communication. Radiology practices should consider developing policies requiring radiologists to document informal consultations potentially affecting patient management, while developing solutions to facilitate such documentation when it is not readily achieved through report addenda (e.g., through direct documentation by the radiologist in the EMR).

Assessing the Content of YouTube Videos in Educating Patients Regarding Common Imaging Examinations.

PURPOSE: To assess the content of currently available YouTube videos seeking to educate patients regarding commonly performed imaging examinations. METHODS: After initial testing of possible search terms, the first two pages of YouTube search results for "CT scan," "MRI," "ultrasound patient," "PET scan," and "mammogram" were reviewed to identify educational patient videos created by health organizations. Sixty-three included videos were viewed and assessed for a range of features. RESULTS: Average views per video were highest for MRI (293,362) and mammography (151,664). Twenty-seven percent of videos used a nontraditional format (eg, animation, song, humor). All videos (100.0%) depicted a patient undergoing the examination, 84.1% a technologist, and 20.6% a radiologist; 69.8% mentioned examination lengths, 65.1% potential pain/discomfort, 41.3% potential radiation, 36.5% a radiology report/results, 27.0% the radiologist's role in interpretation, and 13.3% laboratory work. For CT, 68.8% mentioned intravenous contrast and 37.5% mentioned contrast safety. For MRI, 93.8% mentioned claustrophobia, 87.5% noise, 75.0% need to sit still, 68.8% metal safety, 50.0% intravenous contrast, and 0.0% contrast safety. For ultrasound, 85.7% mentioned use of gel. For PET, 92.3% mentioned radiotracer injection, 61.5% fasting, and 46.2% diabetic precautions. For mammography, unrobing, avoiding deodorant, and possible additional images were all mentioned by 63.6%; dense breasts were mentioned by 0.0%. CONCLUSIONS: Educational patient videos on YouTube regarding common imaging examinations received high public interest and may provide a valuable patient resource. Videos most consistently provided information detailing the examination experience and less consistently provided safety information or described the presence and role of the radiologist.

Leptin stimulates hepatic growth hormone receptor and insulin-like growth factor gene expression in a teleost fish, the hybrid striped bass.

Leptin is an anorexigenic peptide hormone that circulates as an indicator of adiposity in mammals, and functions to maintain energy homeostasis by balancing feeding and energy expenditure. In fish, leptin tends to be predominantly expressed in the liver, another important energy storing tissue, rather than in fat depots as it is in mammals. The liver also produces the majority of circulating insulin-like growth factors (IGFs), which comprise the mitogenic component of the growth hormone (GH)-IGF endocrine growth axis. Based on similar regulatory patterns of leptin and IGFs that we have documented in previous studies on hybrid striped bass (HSB: Morone saxatilis×Morone chrysops), and considering the co-localization of these peptides in the liver, we hypothesized that leptin might regulate the endocrine growth axis in a manner that helps coordinate somatic growth with energy availability. Using a HSB hepatocyte culture system to simulate autocrine or paracrine exposure that might occur within the liver, this study examines the potential for leptin to modulate metabolism and growth through regulation of IGF gene expression directly, or indirectly through the regulation of GH receptors (GHR), which mediate GH-induced IGF expression. First, we verified that GH (50nM) has a classical stimulatory effect on IGF-1 and additionally show it stimulates IGF-2 transcription in hepatocytes. Leptin (5 and/or 50nM) directly stimulated in vitro GHR2 gene expression within 8h of exposure, and both GHR1 and GHR2 as well as IGF-1 and IGF-2 gene expression after 24h. Cells were then co-incubated with submaximal concentrations of leptin and GH (25nM each) to test if they had a synergistic effect on IGF gene expression, possibly through increased GH sensitivity following GHR upregulation by leptin. In combination, however, the treatments only had an additive effect on stimulating IGF-1 mRNA despite their capacity to increase GHR mRNA abundance. This suggests that leptin's stimulatory effect on GHRs may be limited to enhancing transcription or mRNA stability rather than inducing full translation of functional receptors, at least within a 24-h time frame. Finally, leptin was injected IP (100ng/g and 1µg/gBW) to test the in vivo regulation of hepatic IGF-1 and GHR1 gene expression. The 100ng/g BW leptin dose significantly upregulated in vivo IGF-1 mRNA levels relative to controls after 24h of fasting, but neither dosage was effective at regulating GHR1 gene expression. These studies suggest that stimulation of growth axis component transcripts by leptin may be an important mechanism for coordinating somatic growth with nutritional state in these and perhaps other fish or vertebrates, and represent the first evidence of leptin regulating GHRs in vertebrates.

The outcome of trauma patients with do-not-resuscitate orders.

BACKGROUND: Institutional variation in outcome of patients with do-not-resuscitate (DNR) orders has not been well described in the setting of trauma. The purpose of this study was to assess the impact of trauma center designation on outcome of patients with DNR orders. MATERIALS AND METHODS: A statewide trauma database (Pennsylvania Trauma Outcome Study) was used for the analysis. Characteristics of patients with DNR orders were compared between state-designated level 1 and 2 trauma centers. Inhospital mortality and major complication rates were compared using hierarchical logistic regression models that included a random effect for trauma centers. We adjusted for a number of potential confounders and allowed for nonlinearity in injury severity score and age in these models. RESULTS: A total of 106,291 patients (14 level 1 and 11 level 2 trauma centers) were identified in the Pennsylvania Trauma Outcome Study database between 2007 and 2011. We included 5953 patients with DNR orders (5.6%). Although more severely injured patients with comorbid disease were made DNR in level 1 trauma centers, trauma center designation level was not a significant factor for inhospital mortality of patients with DNR orders (odds ratio, 1.33; 95% confidence interval, 0.81-2.18; P = 0.26). Level 1 trauma centers were significantly associated with a higher rate of major complications (odds ratio, 1.75; 95% confidence interval, 1.11-2.75; P = 0.016). CONCLUSIONS: Inhospital mortality of patients with DNR orders was not significantly associated with trauma designation level after adjusting for case mix. More aggressive treatment or other unknown factors may have resulted in a significantly higher complication rate at level 1 trauma centers.

Diagnostic Accuracy of Cardiac Magnetic Resonance Imaging in the Evaluation of Newly Diagnosed Heart Failure With Reduced Left Ventricular Ejection Fraction.

The aim of this study was to determine the diagnostic value of cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE), cine imaging, and resting first-pass perfusion (FPP) in the evaluation for ischemic (IC) versus nonischemic (NIC) cardiomyopathy in new-onset heart failure with reduced (≤40%) left ventricular ejection fraction (HFrEF). A retrospective chart review analysis identified 83 patients from January 2009 to June 2012 referred for CMR imaging evaluation for new-onset HFrEF with coronary angiography performed within 6 months of CMR. The diagnosis of IC was established using Felker criteria on coronary angiography. CMR sequences were evaluated for the presence of patterns suggestive of severe underlying coronary artery disease as the cause of HFrEF (subendocardial and/or transmural LGE, regional wall motion abnormality on cine, regional hypoperfusion defect on resting FPP). Discriminative power was assessed using receiver operator characteristics curve analysis. Coronary angiography identified 36 patients (43%) with IC. Presence of subendocardial and/or transmural LGE alone demonstrated good discriminative power (C-statistic 0.85, 95% confidence interval 0.76 to 0.94) for the diagnosis of IC. The presence of an ischemic pattern on both LGE and cine sequences resulted in a specificity of 87% for the diagnosis of IC, whereas the absence of an ischemic pattern on both LGE and cine sequences resulted in a specificity of 94% for the diagnosis of NIC. Addition of resting FPP on a subset of patients did not improve diagnostic values. In conclusion, CMR has potential value in the diagnostic evaluation of IC versus NIC.

Propensity score matching: a conceptual review for radiology researchers.

The propensity score is defined as the probability of each individual study subject being assigned to a group of interest for comparison purposes. Propensity score adjustment is a method of ensuring an even distribution of confounders between groups, thereby increasing between group comparability. Propensity score analysis is therefore an increasingly applied statistical method in observational studies. The purpose of this article was to provide a step-by-step nonmathematical conceptual guide to propensity score analysis with particular emphasis on propensity score matching. A software program code used for propensity score matching was also presented.

Association of postoperative hyperglycemia with outcomes among patients with complex ventral hernia repair.

IMPORTANCE: Patients with medically complex conditions undergoing repair of large or recurrent hernia of the abdominal wall are at risk for early postoperative hyperglycemia, which may serve as an early warning for delays in recovery and for adverse outcomes. OBJECTIVE: To evaluate postoperative serum glucose level as a predictor of outcome after open ventral hernia repair in patients with major medical comorbidities. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective medical record review of 172 consecutive patients who underwent open ventral hernia repair at Penn State Milton S. Hershey Medical Center, an academic tertiary referral center, from May 1, 2011, through November 30, 2013. We initially identified patients by medical complexity and repair requiring a length of stay of longer than 1 day. MAIN OUTCOMES AND MEASURES: Postoperative recovery variables, including time to the first solid meal, length of stay, total costs of hospitalization, and surgical site occurrence. RESULTS: Postoperative serum glucose values were available for 136 patients (79.1%), with 130 (95.6%) obtained within 48 hours of surgery. Among these patients, Ventral Hernia Working Group grade distributions included 8 patients with grade 1, 79 with grade 2, 41 with grade 3, and 8 with grade 4. Fifty-four patients (39.7%) had a postoperative glucose level of at least 140 mg/dL, and 69 patients (50.7%) required insulin administration. Both outcomes were associated with delays in the interval to the first solid meal (glucose level, ≥140 vs <140 mg/dL: mean [SD] delay, 6.4 [5.3] vs 5.6 [8.2] days; P = .01; ≥2 insulin events vs <2: 6.5 [5.5] vs 5.4 [8.4] days; P = .02); increased length of stay (glucose level, ≥140 vs <140 mg/dL: mean [SD], 8.0 [6.0] vs 6.9 [8.2] days; P = .008; ≥2 insulin events vs <2: 8.3 [6.1] vs 6.5 [8.4] days; P < .001); increased costs of hospitalization (glucose level, ≥140 vs <140 mg/dL: mean [SD], $31 307 [$20 875] vs $22 508 [$22 531]; P < .001; ≥2 insulin events vs <2: $31 943 [$22 224] vs $20 651 [$20 917]; P < .001); and possibly increased likelihood of surgical site occurrence (glucose level, ≥140 vs <140 mg/dL: 37.5% [21 of 56 patients] vs 22.5% [18 of 80 patients]; P = .06; ≥2 insulin events vs <2: 36.4% [24 of 66 patients] vs 21.4% [15 of 70 patients]; P = .06). Not all patients with diabetes mellitus developed postoperative hyperglycemia or needed more intense insulin therapy; however, 46.4% of the patients who developed postoperative hyperglycemia were not previously known to have diabetes mellitus, although most had at least 1 clinical risk factor for a prediabetic condition. CONCLUSIONS AND RELEVANCE: Postoperative hyperglycemia was associated with outcomes in patients in this study who underwent complex ventral hernia repair and may serve as a suitable target for screening, benchmarking, and intervention in patient groups with major comorbidities.

Emphysematous gastritis and gastric emphysema: similar radiographic findings, distinct clinical entities.

INTRODUCTION: Despite similar appearances on imaging studies, emphysematous gastritis (EG) and gastric emphysema (GE) are rare clinical entities encountered in surgical practices. The purpose of this review is to clarify the presentation, natural history, and optimal treatment strategies for these two disorders. METHODS: We conducted a comprehensive literature review for reported adult cases of EG and GE in MEDLINE. Two cases from our institution were also included. Patient with demographics, diagnostic and therapeutic data, and outcomes were compared between patients with EG and GE. RESULTS: A total of 75 cases were included for our review. The finding of intramural air in the stomach was often associated with portal vein gas, pneumatosis intestinalis, or pneumoperitoneum in both groups. Surgical removal of the stomach was performed in 23.1% of EG patients, but only one patient in the GE group. In the EG group, overall mortality (55%) appeared to be driven by sepsis and its complications, whereas in the GE group, mortality (29%) was attributable to comorbid conditions and the underlying illness. CONCLUSIONS: Prompt surgical intervention is more commonly indicated for severe EG and is directed at removal of the septic organ, while the primary indication for surgical intervention in GE is the uncertainty of the diagnosis.

Gastric sleeve leak: a single institution's experience with early combined laparoendoscopic management.

BACKGROUND: Sleeve gastrectomy is an effective weight loss procedure that is technically less complex than Roux-en-Y gastric bypass. However, staple line leak (SLL) remains a significant complication of this procedure with reported incidence ranging from 1%-7%. Multiple treatment strategies for SLL are reported including surgical re-exploration, percutaneous drainage, and endoscopic stenting. Our objective was to review the results of our experience with combined laparoendoscopic procedures in managing SLL. METHODS: A retrospective review of patients with SLL after laparoscopic sleeve gastrectomy (LSG) between June 2008 and October 2013 was performed. Patient characteristics, operative details, and postoperative management strategies were reviewed. All patients were managed with a combination of early laparoscopic washout and endoscopic stenting. RESULTS: One hundred sixty-five patients underwent LSG with SLL identified in 4 patients (2.4%). One patient was transferred from an outside institution for SLL. Average time to SLL diagnosis was postoperative day 3 (range 1-7). After diagnosis patients underwent laparoscopic washout and initial endoscopic stenting. Three patients required additional endoscopic procedures to manage stent migration, and 2 required additional procedures for peri-stent leak. Complications were managed endoscopically with stent adjustment or replacement. Patients had indwelling stents for an average of 29 days (range 15-56). Mean hospital length of stay was 30 days (range 20-42). CONCLUSION: SLL after LSG can confer a high morbidity and mortality. Endoscopic management of SLL with stenting has been advocated because it successfully manages the leaks and avoids additional invasive procedures. Based on our experience, successful management of SLL can be achieved with an early combined laparoendoscopic approach.

A comparative study of three-year weight loss and outcomes after laparoscopic gastric bypass in patients with "yellow light" psychological clearance.

The relationship between psychological factors and bariatric surgical outcomes is unclear. While some psychological contraindications to bariatric surgery are described, there is no consensus on preoperative psychological evaluation or on factors that can predict bariatric outcomes. Our aim was to determine whether full or reserved psychological clearance predicts early weight loss or compliance with follow-up. We found no clinically significant differences in short-term weight loss outcomes or in attendance at scheduled follow-up visits between patients receiving full or "green light" clearance versus "yellow light" clearance, meaning clearance with recommendations for ongoing therapy. Further research may identify psychological predictors of success following bariatric surgery and help optimize preoperative evaluation practices.