Intragastric balloon as an adjunct to lifestyle intervention: a randomized controlled trial.

BACKGROUND/OBJECTIVES: This trial evaluated the safety and effectiveness of the Orbera Intragastric Balloon as an adjunct to lifestyle intervention. SUBJECTS/METHODS: In this multicenter, randomized, open-label clinical trial, 255 adults with a body mass index of 30-40 kg m-2 were treated and outcomes were assessed up to 12 months. Participants were randomized to endoscopic placement of an intragastric balloon plus lifestyle or lifestyle intervention alone. Balloons were removed at 6 months and lifestyle intervention continued for both groups through 12 months. At 9 months, coprimary end points were two measures of weight loss. RESULTS: At 6 months, weight loss was -3.3% of total body weight (-3.2 kg) in the lifestyle arm vs -10.2% (-9.9 kg) in the balloon plus lifestyle arm (P<0.001); at 9 months (3 months postballoon removal), weight loss was -3.4% (-3.2 kg) vs -9.1% (-8.8 kg, P⩽0.001); and at 12 months, -3.1% (-2.9 kg) vs -7.6% (-7.4 kg, P⩽0.001). For the primary end points, at 9 months, mean percent loss of weight in excess of ideal body weight (s.d.) at 9 months was 26.5% (20.7) (P=0.32) and 9.7% (15.1) in the balloon and control groups, respectively. Also, 45.6% (36.7, 54.8) of the subjects randomized to the balloon achieved at least 15% loss of weight in excess of ideal body weight greater than the control group (P<0.001). The majority of balloon subjects experienced adverse events; 86.9% nausea, 75.6% vomiting, 57.5% abdominal pain and 18.8% had their device removed before 6 months because of an adverse event or subject request. Five subjects (3.1%) in the balloon group had a gastric abnormality at the time of device removal, and no ulcers were found. CONCLUSIONS AND RELEVANCE: Intragastric balloon achieved greater short-term weight loss at 3 and 6 months postballoon removal than lifestyle intervention alone. Adverse gastrointestinal events were common.

Preoperative lifestyle intervention in bariatric surgery: initial results from a randomized, controlled trial.

OBJECTIVE: To document preoperative outcomes of a behavioral lifestyle intervention delivered to patients prior to bariatric surgery in comparison to treatment as usual (insurance-mandated physician supervised diet). DESIGN AND METHODS: After completing a baseline assessment, candidates for surgery were randomized to a 6-month, evidence-informed, manualized lifestyle intervention (LIFESTYLE, n = 121) or to preoperative care as usual (USUAL CARE, n = 119). At 6 months, 187 participants remained candidates for bariatric surgery and were included in the analyses. RESULTS: LIFESTYLE participants lost significantly more weight than those receiving USUAL CARE [8.3 ± 7.8 kg vs. 3.3 ± 5.5 kg, F(1,183) = 23.6, P < 0.0001], with an effect size of 0.72. Additionally, logistic regression modeling indicated that LIFESTYLE patients were significantly more likely to lose at least 5% of initial body weight than those in USUAL CARE [OR (95% CI) = 2.94 (1.253, 6.903)], as were participants who were heavier [OR (95% CI) = 1.07 (1.001-1.14) for each unit increase in BMI] or with larger improvements in eating behaviors [OR (95% CI) = 1.1 (1.049, 1.145) for each unit increase on the Eating Behavior Inventory). CONCLUSIONS: A behavioral lifestyle intervention for severely overweight individuals leads to clinically significant weight loss prior to bariatric surgery. Post-surgery follow-up will allow us to examine the impact of the preoperative intervention on postoperative outcomes.

Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy.

BACKGROUND: Longstanding morbid obesity can be associated with severe cardiomyopathy. However, the safety and efficacy of bariatric surgery in patients with severe cardiomyopathy has not been studied, and the effect of surgical weight loss on postoperative cardiac function is also unknown. In addition, morbidly obese patients have significantly increased mortality associated with cardiac transplantation, often precluding them from becoming recipients. METHODS: A retrospective study of patients with a left ventricular ejection fraction < or =35% who underwent bariatric surgery (1998-2005) was performed. Short-term morbidity/mortality, length of stay, excess weight loss, pre- and postoperative left ventricular ejection fraction, and New York Heart Association (NYHA) functional class were assessed. RESULTS: A total of 14 patients (10 men and 4 women) with a mean preoperative body mass index of 50.8 +/- 2.04 kg/m(2) underwent bariatric surgery (10 underwent laparoscopic Roux-en-Y gastric bypass, 1 open Roux-en-Y gastric bypass, 2 sleeve gastrectomy, and 1 laparoscopic gastric banding). The complications were pulmonary edema in 1, hypotension in 1, and transient renal insufficiency in 2. The median length of stay was 3.0 days (range 2-9). The mean excess weight loss at 6 months was 50.4%, with a decrease in the mean body mass index from 50.8 +/- 2.04 kg/m(2) to 36.8 +/- 1.72 kg/m(2). The mean left ventricular ejection fraction at 6 months had significantly improved from 23% +/- 2% to 32% +/- 4% (P = .04), correlating with improved functional capacity, as measured by the NYHA classification. Preoperatively, 2 patients (14%) had an NYHA classification of IV, 6 (43%) a classification of III, and 6 (43%) a classification of II. At 6 months postoperatively, no patient had an NYHA classification of IV, 2 (14%) had a classification of III, and 12 (86%) an NYHA classification of II. Two patients had undergone cardiac transplant evaluations preoperatively and underwent successful transplantation after weight loss. CONCLUSION: The results of our study have shown that bariatric surgery for patients with cardiomyopathy is feasible and effective. Surgically induced weight loss results in both subjective and objective improvement in cardiac function. In addition, surgical weight loss can provide a bridge to transplantation in patients who were prohibited secondary to their morbid obesity.

Outcome of laparoscopic ventral hernia repair in morbidly obese patients with a body mass index exceeding 35 kg/m2.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) for morbidly obese patients with a body mass index (BMI) exceeding 35 kg/m(2) has not been well investigated. METHODS: Hernia recurrence was evaluated by surveillance computed tomography. A p value less than 0.05 was considered significant. RESULTS: Between 2003 and 2006, LVHR was attempted for 27 patients with a BMI exceeding 35 kg/m(2). There was one conversion to open surgery (3.7%). The 27 patients included 8 men (29.6%) and 19 women (70.4%) with a mean age of 48 years (range, 33-73 years). The mean BMI was 46.9 kg/m(2) (range, 35-70 kg/m(2)). Nine patients (33%) were superobese (BMI > 50 kg/m(2)), and five patients (22.7%) underwent emergency LVHR because of small bowel obstruction. Concomitant LVHR with laparoscopic gastric bypass (LGB) was performed for 13 patients (48%). Primary, incisional, or recurrent incisional ventral hernia was present in 7 (26%), 15 (55%), and 5 (19%) patients, respectively. A large hernia (>50 cm(2)) was found in 20 patients (74%). The mesh used was porcine submucosal small intestine extracellular matrix for 15 patients (57%), Gore-Tex for 9 patients (35%), and Composix for 2 patients (8%). The mean hernia size was 158 cm(2 )(range, 12-806 cm(2)), and the mean mesh size was 374 cm(2) (range, 117-2,400 cm(2)). The mean operative time was 190 min (range, 80-480 min), and the mean hospital length of stay (LOS) was 3.6 days (range, 1-11 days). Minor or major complications occurred in seven patients (25.9%), and five patients (18.5%) experienced recurrence during a mean follow-up period of 14.9 months (range, 3-32 months). Emergency setting, BMI, concomitant LGB, hernia type, hernia size, and mesh type had no statistically significant effect on operative time, LOS, morbidity, or recurrence rates. CONCLUSIONS: For morbidly obese patients, LVHR is safe and effective, but it is associated with higher likelihood of recurrence, and patients should be appropriately informed.

Driveway injuries in children: risk factors, morbidity, and mortality.

BACKGROUND/PURPOSE: Injuries that occur around the driveway are not typically regarded as reportable to the police and thus are often underrecognized. The aim of this study was to characterize the pattern and consequences of motor vehicle collisions that occur in the driveway. METHODS: Over the past 13 years, 64 patients admitted to the Children's Hospital of Pittsburgh sustained motor vehicle-related injuries in a driveway. These injuries resulted from a vehicle driven by an adult driver striking a child (group 1) or a child shifting an idle vehicle out of gear (group 2). We compared demographic variables and outcome measures between the 2 groups. RESULTS: There was no difference in gender, injury pattern, Injury Severity Score, length of stay, or operations performed between the groups. Patients in group 1 were younger, smaller, had a lower Glasgow Coma Scale, and had poorer outcomes. The majority of collisions (~65%) in group 1 resulted from a truck or sport-utility vehicle going in reverse. CONCLUSIONS: Younger children are more severely injured in driveway-related crashes, which are most likely to be caused by a truck or sport-utility vehicle going in reverse. These vehicles should be equipped with additional safety features such as extended mirrors to visualize small children.

Trauma center maturation: quantification of process and outcome.

BACKGROUND AND OBJECTIVE: The regional trauma system with the trauma center as its center is a model for health care networks. However, trauma center maturation has not been defined in the literature. The authors' hypothesis was that maturation of the trauma center would affect quantitatively both process and patient outcome. MATERIALS AND METHODS: A total of 15,303 trauma patients were admitted from 1987 to 1995. Annual admissions increased from 813 to 2669. Resources were generated as patient volume increased. Time to the operating room, length of stay, and complications were determined. TRISS methodology was used to calculate z scores and w values to compare actual with predicted mortality rates. RESULTS: Time to the operating room for laparotomy decreased from 62+/-73 to 35+/-47 minutes, from 32+/-32 to 20+/-17 minutes in hypotensive patients, and for craniotomy decreased from 88+/-54 to 67+/-49 minutes. The incidence of infectious, airway, neurologic, orthopedic, respiratory, gastrointestinal, and procedure-related complications declined significantly. Z scores and w values increased for penetrating and blunt injuries. Deaths for patients with ISS >15 declined significantly. Hospital length of stay decreased for all ranges of injury severity. CONCLUSIONS: As the trauma center matured, the process of delivering patient care became more efficient. The result was improved survival, fewer complications, and a shorter length of stay.

MIDCAB characteristics and results: the CardioThoracic Systems (CTS) registry.

OBJECTIVE: The CardioThoracic Systems (CTS) registry of minimally invasive direct coronary artery bypass (MIDCAB) was established to examine baseline characteristics of patients undergoing this surgical procedure, document details of the procedures including grafting techniques and post-operative complication rates, and assess post-operative graft patency. METHODS: A total of 508 consecutive patients who had MIDCAB using CTS instrumentation between April 1996 and March 1997 at 35 international centers were analyzed. RESULTS: The mean age of patients, 27% of whom were women, was 63 years. Eight percent had previous coronary artery bypass surgery. While nearly all patients had significant stenoses in the left anterior descending artery, 23% had disease in two vessels and 9% in three vessels. Almost all procedures used the left internal mammary artery, with 7% employing multiple or sequential grafts. The entire surgical procedure lasted on average 135 min (median 2 h), with a mean time of 14 min to perform anastomosis. Surgical approaches, including anastomosis technique and method used to maintain bloodless field, varied widely across clinical centers. In-hospital complication rates were relatively low, with 0.6% mortality (0% perioperative), 1.2% conversion to sternotomy with cardiopulmonary bypass, 1.4% conversion to sternotomy without bypass, and 5.5% redo or reintervention. In total, 92% of patients were free from all of these events at hospital discharge; women showed a strong trend toward increased risk for major in-hospital events compared with men. Rib fracture was the most common complication, reported in 12% of patients. Post-operative angiography, performed in 83 patients at an average 2.2 days post-procedure, found full patency in 78 (94%). CONCLUSIONS: The CTS registry data indicates that in the great majority of patients, MIDCAB using CTS instrumentation was performed safely and with acute success. Comparative studies, most importantly clinical trials, are needed to determine the types of patients who benefit most from this procedure, as well as its longer-term outcome.

Percutaneous endoscopic gastrostomy reduces total hospital costs in head-injured patients.

BACKGROUND: Gastrostomies provide reliable long-term enteral access in patients with traumatic brain injuries. The impact of technique of gastrostomy on total hospital cost is not known. METHODS: A retrospective analysis of patients who sustained head trauma and required gastrostomies for long-term enteral access between 1 July 1990 and 1 July 1996 was performed. RESULTS: The patients who received percutaneous endoscopic gastrostomies (PEG) were similar to patients who received Stamm gastrostomies (OPEN) with respect to age, injury severity score, mechanism of injury, associated injuries, complication rates, and deaths. Total hospital costs ($ x 10(3)) were lower for patients who had PEGs placed in the intensive care unit (78.2 +/- 37.4) or endoscopy suite (71.9 +/- 37.7) compared with PEGs placed in the operating room (122.4 +/- 75.7) or OPEN gastrostomies (119.8 +/- 65.1). CONCLUSIONS: In head-injured patients, PEGs are a reliable method of obtaining long-term enteral access with a complication rate equivalent to Stamm gastrostomies. If performed in either the intensive care unit or the endoscopy suite, PEGs are associated with significantly reduced total hospital costs.

Lung volume reduction or lung transplantation for end-stage pulmonary emphysema?

OBJECTIVE: As the waiting period for lung transplant (LT) candidates with end-stage pulmonary emphysema (COPD) continues to increase, there is a need for alternative treatments to reduce the morbidity and mortality associated with COPD. We hypothesized that lung reduction (LR) may avoid the need for subsequent LT in patients on the waiting list that are also candidates for LR. METHODS: From July 1994 to December 1995, 20 patients received LR as alternative to LT. The average age was 58 +/- 7 years; 11 were males. Eighteen patients had primary COPD and two had alpha-1 antitrypsin deficiency. Eighteen LRs were thoracoscopic (two bilateral and 16 unilateral) and two were done through a median sternotomy. RESULTS: At a follow-up of 32 +/- 4 months, 19 patients are alive (19/20 = 95%). Fifteen patients (15/20 = 75%) are currently off the LT list and doing well: FEV1 is 40 +/- 18% predicted at 2 years compared with 22.7 +/- 6% before LR (P < 0.001); FVC is 84 +/- 13% at 2 years compared with 55 +/- 7% (P < 0.001) and the RV is 145 +/- 59% compared with 270 +/- 58% (P < 0.001). One patient (5%) required extra-corporeal membrane oxygenation (ECMO) after LR to the contralateral side of the first procedure and subsequently died. Two patients (10%) are currently listed for LT because of persistent symptoms. One patient (5%) in whom deterioration was secondary to exposure to toxic fumes, underwent successful LT. One patient (5%) is doing well from the pulmonary standpoint but is being worked up for new severe coronary artery disease (CAD). The freedom from LT is 95% (19/20) and the freedom from repeat LR is 85% (17/20). CONCLUSIONS: LR has the potential to offer an effective palliative alternative to LT in 75% of selected patients up to 32 months of follow-up. Widespread use of bilateral LR is anticipated to further improve the results.

Blunt splenic injury in adults: clinical and CT criteria for management, with emphasis on active extravasation.

PURPOSE: To evaluate and determine the relevance of clinical and computed tomographic (CT) criteria, particularly extravasation, for prediction of clinical outcome in adults with splenic injuries. MATERIALS AND METHODS: Retrospective blinded review was performed of the records of 270 patients with splenic injury during a 5-year period. Of these, 120 died or underwent surgery without CT and 150 underwent dynamic bolus-enhanced CT. Fifty of the latter underwent immediate surgery and 100 initially were treated without surgery, according to CT and clinical criteria: morphologic grade of injury, amount of hemoperitoneum, active extravasation, and injury severity score (a clinical measure of multiorgan trauma). RESULTS: Of the clinical criteria, injury severity score had the best correlation with outcome. Of the CT criteria, active extravasation correlated best with the need for splenic surgery. Of 96 patients selected for nonsurgical treatment and who did not have active extravasation, 83 recovered without surgery or other intervention. Nonsurgical therapy failed in 15 of the 100 patients. The splenic salvage rate was 59.3% overall and was 92% among the 100 patients with initial nonsurgical management. CONCLUSION: Standard clinical criteria allow triage of patients into immediate surgery or initial nonsurgical groups. CT criteria, especially absence of active extravasation, can help predict successful nonsurgical management of splenic injuries.

Management of blunt splenic trauma: significant differences between adults and children.

BACKGROUND: Although highly successful in children, nonoperative management of blunt splenic injury in adults is less defined. The purpose of this study was to determine whether mechanism of injury, grade of splenic injury, associated injuries, and pattern of injury differ between adults and children (younger than 15 years of age). METHODS: Four hundred eleven patients (293 adults and 118 pediatric patients) with blunt splenic injury were admitted to an affiliated adult/pediatric trauma program from 1989 to 1994. Computed tomography (CT) scans were interpreted in a blinded fashion. Mechanism of injury was significantly different for adults versus children (p < 0.05): motor vehicle crash (66.9% versus 23.7%), motorcycle (8.8% versus 0.8%), sports (2.4% versus 16.9%), falls (8.8% versus 25.4%), pedestrian/automobile (4.4% versus 11.0%), bicycle (1.4% versus 9.3%), and other (7.3% versus 12.7%). RESULTS: Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality indicated that the adults were more severely injured than the children. Fifty-nine percent of the adults and 7% of the children required immediate laparotomy for splenic injury. Both CT grade and quantity of blood on CT predicted the need for exploration in adults but not in children. An injury severity score above 15 and high-energy mechanisms correlated with the need for operative intervention. CONCLUSIONS: Rather than children simply being physically different, they are injured differently than adults, hence the high rate of nonoperative management.

Effects of hemodilution on long-term survival in an uncontrolled hemorrhagic shock model in rats.

Prehospital guidelines for the treatment of penetrating trauma recommend rapid volume resuscitation to normal blood pressure. There is evidence, however, that fluid resuscitation to normal blood pressure in the setting of uncontrolled hemorrhagic shock (UHS) causes increased bleeding, hemodilution, and mortality. To test this hypothesis, we evaluated the effects of blood pressure and hemodilution on survival in a rat model of UHS. UHS was produced in rats by preliminary bleed of 3 mL/100 g followed by a 75% tail amputation. Experimental design consisted of three phases: a prehospital phase, with uncontrolled bleeding and resuscitation to either 40 or 80 mm Hg with lactated Ringer's solution (LR) or lactated Ringer's solution and whole blood (WB); followed by a hospital phase, with control of the bleeding and continued resuscitation to mean arterial pressure (MAP) > 80 mm Hg and hematocrit near 30%; followed by a 3-day observation phase. There were four treatment groups, n = 8 in each group: group I, MAP = 80 mm Hg with LR only; group II, MAP = 80 mm Hg with WB and LR; group III, MAP = 40 mm Hg with LR only; and group IV, MAP = 40 mm Hg with WB and LR. All group I rats died within 2.5 hours. There were no significant differences in survival among groups II, III, and IV. Base deficit, arterial pH, and lactate levels were significantly worse in the rats resuscitated to a MAP of 80 mm Hg with LR (group I). The effects of blood pressure alone, hemodilution alone, and their interaction were significantly related to base deficit and arterial pH. Hemodilution, but not blood pressure as an end point in resuscitation, was significantly related to lactate levels. The high mortality in this model of uncontrolled hemorrhage was attributable to the effects of blood pressure, hemodilution, and the interaction between the two variables, rather than simply continued blood loss from increased hydrostatic pressure.

Cardiac arrest before repair or extracorporeal membrane oxygenation cannulation does not increase the mortality rate associated with congenital diaphragmatic hernia.

Despite recent advances in the management of high-risk congenital diaphragmatic hernia (CDH), mortality remains high. Deaths occur later because infants with inadequate pulmonary parenchyma are treated aggressively but eventually succumb to respiratory failure. In an attempt to identify absolute predictors of mortality the authors examined retrospectively their experience with CDH to determine if cardiac arrest before repair or initiation of extracorporeal membrane oxygenation (ECMO) invariably increased mortality. The authors reviewed the charts of 119 infants who had high-risk CDH treated between 1981 and 1994. They were divided into two groups: those that suffered cardiopulmonary arrest (CA, n = 21) before CDH repair or ECMO cannulation; and those that did not (NCA, N = 98). The authors compared mortality rate, ventilatory parameters, duration of, and complications on ECMO, as well as length of hospitalization between groups. Twenty-one infants suffered CA before initiation of ECMO support or CDH repair. Three infants (14%) suffered CA before arrival at our institution; seven (33%) after, and 11 (53%) both before and after arrival. There was no difference between the CA and NCA groups in terms of birth weight, gestational age, race and gender mix, or pregnancy and delivery complications. Five-minute Apgar scores were significantly lower in the CA group compared with the NCA group (4.6 v 5.7, P = .04). The CA group also had significantly worse "best postductal" blood gas and ventilatory parameters. There was no significant difference in length of hospitalization, time from admission to ECMO cannulation or CDH repair, or incidence of complications while on ECMO between the two groups. CA cases were more likely to require ECMO support (76% v 48%, P = .02) and to stay on ECMO for a more prolonged period than NCA cases (5.8 v 3.8 days, P = NS). However, there was no significant difference in overall survival between CA and NCA cases (43% v 51%, P = NS). Cardiopulmonary arrest before repair of CDH or ECMO cannulation is not a univariate independent predictor of mortality and therefore should not preclude these high-risk infants from maximum intensive care therapy, including ECMO cannulation.

Resource utilization for minimally invasive direct and standard coronary artery bypass grafting.

BACKGROUND: Minimally invasive direct coronary artery bypass grafting (MIDCABG) has been recently reintroduced into the cardiac surgical armamentarium for selected patients with suitable coronary anatomy. We hypothesized that MIDCABG had the potential for similar immediate results with decreased perioperative morbidity and decreased resource utilization compared with standard coronary artery bypass grafting (CABG). METHODS: From January 1996 to August 1996, 17 MIDCABG patients were compared with 33 patients with left ventricular ejection fraction greater than 0.50 who underwent CABG with standard technique. No significant differences were observed between the two groups for preoperative variables that are known to affect cost and resource utilization. Length of stay in the hospital was 2.5 +/- 0.8 days for MIDCABG and 5.9 +/- 2 days for CABG (p < 0.0001); length of stay in the intensive care unit was 12.3 +/- 3.3 hours for MIDCABG compared to 32.3 +/- 12.6 hours for the CABG group (p < 0.0001). RESULTS: Forty-one percent of MIDCABG patients were extubated in the operating room and 59% were discharged home on the first or second postoperative day versus none in the CABG group (p < 0.0001). Significantly less morbidity was observed in the MIDCABG group compared with CABG. Total ratio of cost-to-charge was $12,885 +/- $1,511 for MIDCABG and $21,260 +/- $5,497 for CABG (p < 0.0001), with an average savings of $8,375. CONCLUSIONS: Minimally invasive CABG is associated with significant reduction of resource utilization and morbidity related to inital hospitalization compared with CABG.

An analysis of the operative experience of North American pediatric surgical training programs and residents.

There has been a rapid increase in the number of pediatric surgical training programs. To meet the goals of quality patient care and surgical education, training and practice activities must be objectively monitored. The aim of this study was to collect and analyze the experience of American and Canadian Pediatric Surgical training centers and residents. The authors collected the 1-year operative experience of 31 American and six Canadian training programs and the 2-year operative experience of the 25 most recently graduated residents. Categories analyzed included total cases, defined categories (neonatal, important, and tumor cases), routine cases, thoracic, cardiac, urologic reconstructive, head and neck, endoscopy, vascular, plastics and burn procedures. From these data six assumptions about the training in pediatric surgery were addressed. (1) The operative activity of the United States and Canadian training programs and residents are comparable. The results show that there are few major differences in operative experience. (2) There should be variability in operative experience between programs but little variability between residents. The North American operative experience for both residents and institutions are marked by high variability and leftward shift in the frequency distributions. (3) A resident's training should consist of a significant portion of "index cases" and fewer routine cases. The residents perform 28% of their total cases in the three defined categories (index cases) and 26% as routine cases. (4) Pediatric surgeons are the true general surgeons, performing operations in areas such as cardiac, reconstructive genitourinary, plastic, and burn surgery. Examination of the data shows that most programs and residents perform few cases in these four areas. (5) Certain procedures such as thoracic, genitourinary, vascular, head and neck, and endoscopy remain within the domain of pediatric surgery. The results show that this assumption is true for thoracic, vascular, head and neck, and endoscopy but not for genitourinary, and there is wide variability between institutions and between residents. (6) "Core" pediatric surgical conditions such as esophageal atresia, biliary atresia, and intersex are still available in significant numbers to train residents. The data show that a surprising number of programs and residents perform few or none of the core operations. This analysis is the first step toward monitoring of pediatric surgical resident education. A future study is underway to evaluate the current experience of practicing pediatric surgeons who have taken the recertification examination.

Inhibition of nitric oxide with aminoguanidine reduces bacterial translocation after endotoxin challenge in vivo.

BACKGROUND: Administration of lipopolysaccharide (LPS) has been shown to increase bacterial translocation (BT) in vivo and in vitro. In addition, LPS upregulates inducible nitric oxide synthase expression in the intestinal epithelium-a phenomenon that can either enhance microbial killing, or alternatively, promote BT by impairing the gut barrier. OBJECTIVE: To determine the effect, if any, of an inhibitor of nitric oxide synthase, namely, aminoguanidine (AG), on BT after LPS challenge. DESIGN: Sprague-Dawley rats were randomized to receive either AG or normal saline solution via subcutaneously placed osmotic pumps (Alzet), followed 18 hours later by LPS injection (5 mg/kg or 20 mg/kg intraperitoneally). Quantitative cultures of the cecum, mesenteric lymph nodes, liver, and spleen were obtained, and plasma nitrite and nitrate levels were measured at 24 hours. Transmembrane potential difference and mucosal permeability to fluorescein isothiocyanate-labeled dextran and fluorescein isothiocyanate-labeled Escherichia coli C25 were measured in the Using chamber. The intestinal membrane was examined by light, transmission electron, and confocal laser microscopy. RESULTS: Rats that were given high-dose LPS had elevated levels of nitrite and nitrate and a 100% incidence of BT. In contrast, AG infusion significantly reduced both BT (22%) and nitrite and nitrate levels. Animals that received LPS and normal saline solution had a significantly lower transmembrane potential difference than those that received LPS and AG. High-dose LPS resulted in sloughing of the apical enterocytes at the villus tips where bacterial entry seemed to occur, as seen with confocal laser microscopy. CONCLUSIONS: Inhibition of nitric oxide production with AG decreases BT after high-dose LPS challenge. The mechanism may involve increased cellular viability and decreased damage to the gut mucosal barrier in rats that receive AG.

Laparoscopic cholecystectomy in the transplant population.

BACKGROUND: The results of laparoscopic cholecystectomy in a group of transplant recipients were reviewed to determine the safety and efficacy of the procedure in the setting of immunosuppression. METHODS: All solid-organ-transplant recipients who underwent laparoscopic cholecystectomy over a 3-year period were reviewed. Indication for operation, conversion to open procedure, length of stay, and complications were characterized. These results were compared to the registry data of all laparoscopic cholecystectomies performed at the same institution. RESULTS: There were 26 transplant patients who underwent laparoscopic cholecystectomy including renal, heart, double lung, and heart-lung recipients. The mean age was 47 years. Symptomatic cholelithiasis was the most common indication in 73% of patients followed by acute cholecystitis in 11%. Seven patients (27%) underwent conversion to an open procedure. Three patients (11.5%) experienced a minor complication in hospital. Median length of stay was 2.5 days. One patient died during a subsequent unrelated operation. These results compared favorably to the registry experience at the same institution where the mean age was 49 years, 24% of cases were performed for acute cholecystitis, there was a 10% complication rate, median length of stay was 2 days, and 3 deaths occurred in hospital. The only statistically significant difference was a lower conversion rate (11% vs 27%) in the registry vs transplant group. CONCLUSIONS: This experience confirms that laparoscopic cholecystectomy is as safe in the transplant population as the general population. Despite a slightly higher conversion rate to an open procedure, the advantages of short hospital stay, low morbidity, and early return to preoperative routines remain equivalent.