Laparoscopic transgastric removal of eroded adjustable band: a novel approach.

Gastric erosion is a well-known complication of laparoscopic adjustable gastric band (LAGB) placement for morbid obesity. We describe a novel approach for the removal of an eroded band through a laparoscopic gastrotomy with subsequent intraluminal division and removal of the band. A 67-year-old woman with a body mass index of 35.5 kg/m2 was seen 1 year after LAGB placement performed outside the United States. She had developed dysphagia and regurgitation of undigested food a few months after the procedure. The LAGB had been adjusted twice by her primary surgeons and was completely deflated once her symptoms began. The patient failed to improve and was subsequently referred to our institution where an upper endoscopy revealed intragastric band erosion. The patient was taken to the operating room for LAGB removal; however, standard laparoscopic and endoscopic attempts at band retrieval were unsuccessful. We then attempted a novel laparoscopic technique. An anterior gastrotomy was created, distal to the area of erosion, to facilitate easy intraluminal band division and removal. The gastrotomy was repaired, and a leak test was performed. A postoperative Gastrografin upper gastrointestinal series showed no extravasation. The patient began a diet, was discharged, and was seen in follow-up with complete resolution of her symptoms. The results of this case have shown that laparoscopic transgastric removal of an eroded gastric band is safe and feasible when standard endoscopic and laparoscopic techniques fail.

Improved outcomes using a systematic and evidence-based approach to the laparoscopic Roux-en-Y gastric bypass in a single academic institution.

No standardized approach exists for laparoscopic Roux-en-Y gastric bypass (LRYGB). At a newly instituted bariatric surgery program, four experienced laparoscopic surgeons used the systematic and evidence-based approach consisting of multidisciplinary preoperative evaluation, screening, and education; standardized operative technique; inpatient clinical pathway; and close postoperative follow-up. The outcomes were subsequently analyzed to determine if this approach improved the morbidity and mortality. From January 2003 to June 2006, 835 consecutive LRYGBs were performed. The patient population was 85 per cent women with a mean body mass index (BMI) of 50.4 kg/m2 (range 33-96 kg/m2). The mean age was 44 (range 15-67). Sixty-two per cent of the patients had previous abdominal or pelvic operations. The conversion rate to open surgery was 0.2 per cent. The average length of hospital stay was 2.6 days (range 2-13 days). There were no anastomotic leaks or deaths. The 30-day readmission and re-operation rates were 3.2 per cent and 1.8 per cent, respectively. The incidence of anastomotic stricture, marginal ulcer, bleeding, pulmonary embolism, and internal hernia was 0.8 per cent, 3.5 per cent, 4.2 per cent, 0.1 per cent, and 0.4 per cent, respectively. A systematic and evidence-based approach to the LRYGB by experienced laparoscopic surgeons resulted in a lower incidence of complications when compared with the published results from other comparable institutions.

LPS inhibits fasted plasma ghrelin levels in rats: role of IL-1 and PGs and functional implications.

LPS injected intraperitoneally decreases fasted plasma levels of ghrelin at 3 h postinjection in rats. We characterized the inhibitory action of LPS on plasma ghrelin and whether exogenous ghrelin restores LPS-induced suppression of food intake and gastric emptying in fasted rats. Plasma ghrelin and insulin and blood glucose were measured after intraperitoneal injection of LPS, intravenous injection of IL-1beta and urocortin 1, and in response to LPS under conditions of blockade of IL-1 or CRF receptors by subcutaneous injection of IL-1 receptor antagonist (IL-1Ra) or astressin B, respectively, and prostaglandin (PG) synthesis by intraperitoneal indomethacin. Food intake and gastric emptying were measured after intravenous injection of ghrelin at 5 h postintraperitoneal LPS injection. LPS inhibited the elevated fasted plasma ghrelin levels by 47.6 +/- 4.9%, 58.9 +/- 3.3%, 74.4 +/- 2.7%, and 48.9 +/- 8.7% at 2, 3, 5, and 7 h postinjection, respectively, and values returned to preinjection levels at 24 h. Insulin levels were negatively correlated to those of ghrelin, whereas there was no significant correlation between glucose and ghrelin. IL-1Ra and indomethacin prevented the first 3-h decline in ghrelin levels induced by LPS, whereas astressin B did not. IL-1beta inhibited plasma ghrelin levels, whereas urocortin 1 had no influence. Ghrelin injected intravenously prevented an LPS-induced 87% reduction of gastric emptying and 61% reduction of food intake. These data showed that IL-1 and PG pathways are part of the early mechanisms by which LPS suppresses fasted plasma ghrelin and that exogenous ghrelin can normalize LPS-induced-altered digestive functions.

Surgical clips: a nidus for foreign body reaction after hepatic resection.

This case report describes a patient who underwent segment IV hepatic resection and 7 months later developed an abdominal wall abscess. This was a foreign body reaction to the surgical clips. The patient required an exploratory laparotomy with debridement and excision of the inflammatory mass in the anterior abdominal wall. Although occurrence is rare, foreign body reactions to surgical clips have been reported, especially as a complication of laparoscopic surgery.

Staphylococcal rib osteomyelitis in a pediatric patient.

Osteomyelitis in children commonly occurs in the long bones such as the femur, tibia, and humerus. It is rarely found in the ribs, occurring in less than 1% of children with osteomyelitis. Thirteen cases of rib osteomyelitis were reported in the literature, of which, 11 were caused by Staphylococcus aureus. Pediatric osteomyelitis often masquerades as skeletal neoplasia, as illustrated in the following case presentation. Here, the authors describe a case of pediatric staphylococcal rib osteomyelitis, review the published literature on similar cases, and describe its medical and surgical treatment.

Interval jejunoileal bypass reduces the morbidity and mortality of Roux-en-Y gastric bypass in the super-obese.

Among Roux-en-Y gastric bypass (RYGB) patients, large male patients carry the greatest risk for severe, life-threatening complications. The higher complication rate is partly related to large amounts of intra-abdominal fat that increases the technical difficulty of the RYGB. In order to minimize the risk for complications, we established a staged approach for weight loss surgery for high-risk, super-obese patients. Patients with intra-abdominal fat at exploration which precluded the performance of RYGB underwent jejunoileal bypass (JIB). Following an initial period of weight loss (6-24 months), they were converted to a RYGB during a second operation. Twenty-four patients underwent initial JIB that was associated with a major complication rate of 8.3 per cent (2/24) and no mortality. Eight patients lost 53.4 +/- 6.3 kg prior to their conversion to RYGB (mean, 14.1 months). There was one major complication (12%) and no deaths (0%). Following RYGB, an additional period of weight loss resulted in overall excess weight loss (EWL) totaling 62 per cent. A two-step procedure is a safe and effective approach for minimizing complications for high-risk patients undergoing RYGB. The initial JIB was associated with low morbidity and no mortality, and the follow-up RYGB procedure was a technically simple operation that could be performed with few complications.

Corticotropin-releasing factor receptor 1-deficient mice do not develop postoperative gastric ileus.

BACKGROUND & AIMS: Corticotropin-releasing factor (CRF) signaling pathways play a key role in the stress response through the activation of CRF(1) and CRF(2) receptors. We investigated the CRF receptor subtypes involved in gastric postoperative ileus. METHODS: Adult male mice (C57BL/6, CRF(1)-deficient, and wild-type), fasted for 16-18 hours, were anesthetized for 10 minutes and had a midline celiotomy and cecal exteriorization and palpation for 30 or 60 seconds or no surgery (sham). Phenol red was given by gavage 100 minutes after anesthesia; 20 minutes later, gastric emptying and blood glucose level were measured. RESULTS: In C57BL/6 mice, cecal palpation for 30 or 60 seconds significantly reduced gastric emptying to 30.3% +/- 1.4% and 5.8% +/- 3.4%, respectively, compared with 58.5% +/- 4.4% in sham. The CRF(1) antagonist CP-154,526 (20 mg/kg subcutaneously) completely prevented the 30-second cecal palpation-induced delayed gastric emptying (53.0% +/- 7.9% vs. 28.0% +/- 4.0% in vehicle + surgery), whereas the CRF(2) antagonist astressin(2)-B injected subcutaneously had no effect. In CRF(1)-deficient mice, cecal palpation for 30 seconds did not delay gastric emptying (80.3% +/- 4.5% compared with 84.7% +/- 6.3% in sham); in wild-type mice, gastric emptying was decreased to 17.8% +/- 16.1% (P < 0.05 vs. sham 72.0% +/- 12.4%). Surgery increased glucose levels by 46% compared with sham in wild-type mice, while glycemia was not altered in CRF(1)-deficient mice. Basal emptying was similar in wild-type and CRF(1)-deficient mice and not influenced by CRF antagonists in C57BL/6 mice. CONCLUSIONS: These data show that CRF(1) activation plays an important role in mediating the early phase of gastric ileus.

Bacterial lipopolysaccharide shifts fasted plasma ghrelin to postprandial levels in rats.

Lipopolysaccharide (LPS) injected intraperitoneally (i.p.) is known to decrease food intake. Ghrelin is a peptide hormone produced by the stomach with a potent orexigenic effect and plasma levels that are inversely correlated with the fed state. We examined changes in plasma ghrelin levels 3 h after LPS (100 microg/kg, i.p.) in fasted rats with or without a 1 h re-feeding period. LPS injection decreased the fasting levels of ghrelin by 51+/-5% compared with preinjection values while i.p. vehicle did not modify ghrelin levels in fasted rats. LPS at this dose reduced fasting-induced food intake by 60% compared with the i.p. vehicle group. Re-feeding decreased plasma ghrelin levels by 58+/-3% compared with pre-feeding fasting values in i.p. vehicle group. These data provide the first evidence that LPS shifts fasting ghrelin levels to those observed postprandially.