The significance of the ileocecal valve in massive resection of the gut in puppies.

Clinical observations suggest that retention of the ileocecal valve is vital for survival in neonates who undergo resection of small bowel to the extent that less than 40 cm remain. Twenty-four puppies underwent 90% resection of small bowel and 12 of these also had a destructive procedure performed on the ileocecal valve. Survival and weight patterns were used to assess results when it was found both parameters supported the clinical observations. The practical application is that all attempts should be made to retain the ileocecal valve in situations in which only short lengths of small bowel remain.     

The ureteric orifice: the embryologic key to radiologic status of duplex kidneys.

In this study the ureteric orifice position of duplex ureters in the bladder or urethra of children was correlated with the kidney configuration as determined by x-ray examination and in some by surgical excision and biopsy.A previous study¹ of 51 necropsy speciments of duplex kidneys, ureters, and bladders of neonates, revealed a close correlation between ureteric oreteric orifice position and kidney morphology.This clinical study of children further confirms that the position and type of ureteral orifice act as guides to renal order and disorder in duplex kidneys. A radiographic classification of kidney configurrations was invoked to match and correlate form with orifice position. From this cystoradiographic study, it appears that renal abnormalities occur when ureteric buds arise from faulty locations in the Wolffian duct during embryogenesis.     

Duodenal switch: Fully stapled technique

BackgroundDuodenal switch and single anastomosis modifications continue to gain greater interest among bariatric surgeons. Limiting factors to adoption include concerns around the nutritional management, patient compliance and follow-up, and the technical challenge of the operation. The majority of techniques offered currently use a hand-sewn duodenoileostomy. This approach is limited by the steep learning curve as well as longer operating times.ObjectivesWe present a video demonstrating the fully stapled technique for duodenoileostomy and ileileostomy. We offer technical pearls around the technique, specifically focused on maintaining a widely patent anastomosis, open biliopancreatic limb, safe duodenal dissection, and correct loop orientation.MethodsLaparoscopic fully stapled duodenoileostomy for duodenal switch and single anastomosis modification.SettingCommunity hospital, single institution, 3 surgeons.ConclusionTriple staple offers a reproducible and safe technique for the duodenoileostomy and specifically for construction of a Roux or loop anastomosis in duodenal switch.     

Microvascular second toe transfer for digital reconstruction.

Reconstruction of a severely damaged hand, with multiple amputations of digits, presents a difficult reconstructive problem. The development of a safe method of transfer of the great toe for thumb reconstruction, using the dorsalis pedis artery and the saphenous vein, suggested the possibility of one-stage microvascular transfer of the second toe for reconstruction of fingers. In two patients a one-stage transfer of the second toe was done to replace an index finger and in another for restoration of part of the left ring finger. The transplants survived without anticoagulants and vessel complications were not encountered. Sensory return was adequate and a significant improvement in function was achieved.     

Serum gastrin levels in congenital hypertrophic pyloric stenosis.

The Etiology of congenital hypertrophic pyloric stenosis remains conjectural despite many and varied theories involving both genetic¹ and environmental² factors. Heinische³ was the first investigator to produce hypertrophic pyloric stenosis experimentally in rabbits by attaching glass beads or rubber bags filled with lead shot to the gastric fundus. Gastric peristalsis was generally decreased, except in the antrum, where it was enhanced. It was postulated that the hypertrophy was the result of increased antral motility. Dodge⁴ successfully induced hypertrophic pyloric stenosis in puppies by prolonged perinatal administration of pentagastrin. He postulated that, in the presence of the requisite genetic factors, perinatal stress acting via gastrin produced pyloric obstruction. The resulting distension of the gastric antrum stimulates further release of gastrin.Serum gastrin levels in infants with congenital hypertrophic pyloric stenosis have not been previously reported and form the basis of this preliminary communication.     

Research Pearls: How Do We Establish the Level of Evidence?

Evidence-based medicine (EBM) guidelines were first introduced in 1986 and were defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Level of evidence (LOE) stratifies publications from Level I to Level V and provides the foundation for EBM. Three questions should be asked when an LOE is assigned to a scientific article: (1) What is the research question? (2) What is the study type? and (3) What is the hierarchy of evidence? In cases in which LOE is not appropriate or relevant (basic science and laboratory-based investigations), a clinical relevance statement should be used. Unfortunately, study quality is not assessed by the assigned hierarchy level. LOE and EBM have increased the number of investigations published with better levels of evidence. As authors, reviewers, editors, and publishers, we desire a system that is consistent, effective, and reliable. Fortunately, the system has proven to have all of those attributes with good interobserver and intra-observer values. The increase in investigations with higher LOEs allows for more frequent use of EBM.     

Development of a bariatric surgery specific risk assessment tool for perioperative myocardial infarction

BackgroundPerioperative myocardial infarction (PMI) is a feared complication after surgery. Bariatric surgery, due to its intraabdominal nature, is traditionally considered an intermediate risk procedure. However, there are limited data on MI rates and its predictors in patients undergoing bariatric surgery.ObjectivesTo enumerate the prevalence of PMI after bariatric surgery and develop a risk assessment tool.SettingBariatric surgery centers, United States.MethodsPatients undergoing bariatric surgery were identified from the MBSAQIP participant use file (PUF) 2016. Preoperative characteristics, which correlated with PMI were identified by multivariable regression analysis. PUF 2015 was used to validate the scoring tool developed from PUF 2016.ResultsWe identified 172,017 patients from PUF 2016. Event rate for MI within 30 days of the operation was .03%; with a mortality rate of 17.3% in patients with a PMI. Four variables correlated with PMI on regression, including history of a previous MI (odds ratio [OR] = 8.57, confidence interval [CI] = 3.4–21.0), preoperative renal insufficiency (OR = 3.83, CI = 1.2–11.4), hyperlipidemia (OR = 2.60, CI = 1.3–5.1), and age >50 (OR = 2.15, CI = 1.1–4.2). Each predicting variable was assigned a score and event rate for MI was assessed with increasing risk score in PUF 2015; the rate increased from 9.5 per 100,000 operations with a score of 0 to 3.2 per 100 with a score of 5.ConclusionThe prevalence of MI after bariatric surgery is lower than other intraabdominal surgeries. However, mortality with PMI is high. This scoring tool can be used by bariatric surgeons to identify patients who will benefit from focused perioperative cardiac workup.     

Impact of rapid weight loss on risk reduction of developing arterial hypertension in severely obese patients undergoing bariatric surgery. A single-institution experience using the Framingham Hypertension Risk Score

BackgroundMorbid obesity is strongly associated with hypertension.ObjectiveThe objective of this study is to compare the risk of developing hypertension before and after bariatric surgery.SettingU.S. university hospital.MethodsWe retrospectively reviewed all patients who underwent bariatric surgery from 2010 to 2015 at our institution. Nonhypertensive white individuals without diabetes at baseline were included in our study. The Framingham Hypertension Risk Score was used to predict the near-term incidence of the disease. This calculator predicts 1-, 2-, and 4-year incidence of hypertension.ResultsA total of 475 patients met the criteria for the hypertension risk score calculation. Females composed 72% (n = 342) of our population with a mean age of 42.6 ± 11.6 years. Laparoscopic sleeve gastrectomy was the most prevalent procedure at 81.89% (n = 389). At 12- month follow-up, the 1-year absolute risk reduction (ARR) and the relative risk reduction (RRR) were 6.2% and 69.2% (P < .01), respectively. The 2-year ARR was 11.9%, with an RRR of 67.9% (P < .01). The 4-year risk was also calculated at 12-month follow-up, resulting in an ARR of 20.1%, and RRR of 63.7% (P < .01). Furthermore, stratifying by type of procedure, the results were comparable between sleeve gastrectomy and Roux-en-Y gastric bypass. Regarding blood pressure values at 12-month follow-up, the systolic blood pressure was reduced 11.4 mm Hg (P < .01) and the diastolic blood pressure was reduced 4.4 mm Hg (P = .07). The percentage of estimated body mass index loss at 12-month follow-up was 71.7%.ConclusionsSleeve gastrectomy and Roux-en-Y gastric bypass significantly diminish the risk of developing hypertension in morbidly obese patients. Prospective studies are needed to better comprehend these findings.     

Systematic review and meta-analysis of Roux-en-Y gastric bypass against laparoscopic sleeve gastrectomy for amelioration of NAFLD using four criteria

Nonalcoholic fatty liver disease (NAFLD) prevalence is rising worldwide, as a direct consequence of the obesity epidemic. Bariatric surgery provides proven NAFLD amelioration, although questions remain regarding whether Roux-en-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (LSG) is more effective. To answer this question, we conducted a systematic review and meta-analysis exclusively comparing RYGB and LSG for amelioration of NAFLD using 4 separate criteria: alanine transaminase, aspartate transaminase, NAFLD activity score, and NAFLD fibrosis score. Our search included 1290 initial studies, which were narrowed to 20 final studies in the meta-analysis. Overall, both RYGB and LSG significantly improved alanine transaminase, aspartate transaminase, NAFLD activity score, and NAFLD fibrosis score postoperatively. Direct comparisons of RYGB to LSG in any of the 4 criteria failed to demonstrate superiority. Our findings corroborate the current literature showing that bariatric surgery significantly improves biochemical and histologic parameters in patients with NAFLD. The novel individual comparisons of 4 criteria failed to show superiority between RYGB and LSG in ameliorating NAFLD. Despite several limitations, our study can assist clinicians by supporting the notion that RYGB and LSG may be equally efficacious in ameliorating NAFLD.     

Research Pearls: Expert Consensus Based Evidence Using the Delphi Method

The evolution of a systematic approach to assessing pertinent investigations is known as evidence-based medicine (EBM). EBM is defined as the conscientious and judicious use of current best evidence from clinical care research and integration of clinical expertise in the management of individual patients. There is no doubt that EBM is important but may not give clinically meaningful guidance on topics with clinical equipoise for individual patient care. When EBM has been insufficiently developed for a specific topic, a consensus opinion of experts can be valuable. In principle, there are 2 consensus methods for expert opinion available: the nominal group technique and the Delphi method. The nominal group technique is a structured face-to-face meeting facilitating discussion and allows participants to voice their opinions. The key characteristics of the Delphi method are the use of panel experts to obtain data, no face-to-face discussions, the use of sequential questionnaires, the systematic emergence of a concurrent opinion, use of frequency distributions to identify patterns, and the use of at least 2 rounds with feedback between rounds. We should not dismiss the collective experience of our leading experts, and expert consensus-based evidence should be explored as another tool to improve the quality of treatment for our patients.     

Banded versus nonbanded Roux-en-Y gastric bypass: a systematic review and meta-analysis of randomized controlled trials

BackgroundBariatric surgery is remarkably effective in achieving weight loss and improving obesity-related co-morbidities; however, efforts still continue to improve its long-term outcomes. Particularly, banded Roux-en-Y gastric bypass (RYGB) has been scrutinized in comparison to standard (nonbanded) RYGB in terms of benefits and postoperative complications.ObjectivesThis study aims to compare the safety and efficacy of banded versus nonbanded RYGB.SettingMeta-analysis of randomized controlled trials (RCTs).MethodsA meta-analysis of high-quality studies that compared banded and nonbanded RYGB was conducted through February 2019 by systematically searching multiple electronic databases. Published RCTs comparing these 2 procedures were included to pool the data on excess weight loss, food tolerability, and postoperative complications.ResultsThree RCTs were eligible to be included in this meta-analysis, comprising a total of 494 patients (247 in each group). Two of the RCTs provided 2-year postoperative data, and 1 study reported 5-year outcome. Age ranged from 21 to 50 years, and body mass index ranged from 42 to 65 kg/m². Percentage of excess weight loss was significantly greater with banded RYGB than with nonbanded RYGB (mean difference 5.63%; 95% CI 3.26–8.00; P < .05). Postoperative food intolerance, emesis, and dysphagia were more common after banded RYGB (odds ratio 3.76; 95% CI 2.27–6.24; P < .001). Nevertheless, major postoperative complications did not significantly differ between the 2 groups.ConclusionFindings of this meta-analysis of RCTs indicate that in a medium-term follow-up, excess weight loss with banded RYGB would be 5% greater than that with the nonbanded RYGB (about 1 point difference in body mass index) at the expense of more food intolerance and postoperative vomiting; however, the frequency of postoperative complications would not be significantly different.     

Lymphocyte response after surgery and blood transfusion

This study presents further evidence that there is a depression of cellular immune function after surgical trauma. Cellular immune function was measured by the degree of mitogenic transformation of peripheral blood lymphocytes. The significant reduction (P < 0.02) in lymphocyte transformation seen after surgery was partly reversed in those patients transfused with blood during operation. In a group of medical patients there was a significant increase above the normal level (P < 0.02) in lymphocyte transformation seen after surgery, and this was partly reversed in these patients transfused with blood during operation. In a group of medical patients there was a significant increase above the normal level (P < 0.02) in lymphocyte transformation after transfusion.