Age,microbiology and prognostic scores help to differentiate between secondary and tertiary peritonitis

Background and aims  Tertiary peritonitis is a severe persisting intra-abdominal infection and associated with high mortality. The aim was to find significant risk factors for mortality and tertiary peritonitis including the Mannheim Peritonitis Index (MPI), the Acute Physiology and Chronic Health Evaluation (APACHE) II score, and a sumscore of both. Materials and methods  In this retrospective single-center cohort study, 122 patients were treated at the Surgical Department of a University Hospital. Results  Sixty-nine patients (56.6%) developed tertiary peritonitis. Nineteen patients (27.5%), who suffered from tertiary peritonitis, died in contrast to eight patients (15.1%) with secondary peritonitis (P = 0.101). Patients with tertiary peritonitis had significantly higher APACHE II (P < 0.001), MPI (P = 0.035), and combined APACHE II and MPI scores (P < 0.001) than patients with secondary peritonitis. Age (P = 0.035), fungal infections (P = 0.025), and infections with more than one microbial organism (P = 0.047) were predictive for tertiary peritonitis. Combined APACHE II and MPI scores detected tertiary peritonitis better than the MPI (P = 0.014). Detection of mortality was comparable in all evaluated prognostic scores. Conclusion  Prognostic scores besides age and fungal infections are risk factors for mortality and help to differentiate between secondary and tertiary peritonitis. The combination of prognostic scores is comparable to the APACHE II and superior compared to the MPI in regard to detection of tertiary peritonitis. Presented in part to the 19th European Congress on Surgical Infections of the Surgical Infection Society-Europe (SIS-E), Athens, Greece, May 2006.     

Organ dysfunction and long term outcome in secondary peritonitis

Background and aims Secondary peritonitis is still associated with high mortality, especially when multiorgan dysfunction complicates the disease. Good prognostic tools to predict long term outcome in individual patients are lacking and therefore require further study. Patients and methods 163 consecutive patients with secondary peritonitis were included, except those with postoperative or traumatic peritonitis. In 58 patients treated in the intensive care unit (ICU), organ dysfunction was quantified using Sequential Organ Failure Assessment (SOFA) score in the first 4 days. Predictive factors for poor outcome were evaluated in all patients. Hospital and 1-year mortality was assessed. Results Hospital mortality was 19% and 1-year mortality 23%. Acute physiology and chronic health evaluation II (APACHE II), previous functional status, and sepsis category were predictive of fatal outcome in the total cohort (p = 0.034, p < 0.001, and p < 0.001). In patients treated in the ICU, advanced age and admission SOFA score were independent predictors of death (p = 0.014, p < 0.0001). The SOFA score showed the best discriminative ability for poor outcome (AuROC 0.78). Conclusion Degree of organ dysfunction measured using SOFA score was the best predictor of hospital mortality in patients suffering from secondary peritonitis. This study was supported by the Helsinki University Hospital HUS-EVO funding.     

Factors Related to Anastomotic Dehiscence and Mortality After Terminal Stomal Closure in the Management of Patients with Severe Secondary Peritonitis

Introduction  Management of severe secondary peritonitis (SSP) may require intestinal resections and bowel exteriorization due to an unacceptable high risk for anastomotic dehiscence (AD). Bowel exteriorization can be achieved through loop or terminal stomas. There are no studies addressing the fate of these latter. Our aim was to determine factors associated with AD and mortality in patients submitted to restoration of intestinal continuity after creation of terminal stomas as part of their operative management for SSP. Patients and Methods  We analyzed prospectively collected databases on all consecutive patients with SSP submitted to restoration of intestinal continuity after having had terminal ileostomies (TI) or terminal colostomies (TC) as part of their operative management during a 30-month period. Several patient and disease and operative variables were evaluated as factors related to AD and mortality in this group of patients. Univariate statistical comparisons were made using Student’s t test for continuous variables and chi-square test when categorical variables were compared. Multivariate analyses were also performed. Results  A total of 72 male patients and 36 female patients were included in the study; 54 had TI and 54 had TC. Median number of operations performed as part of their management for SSP (prior to stomal closure) was 2 (range, 1–15). A total of 76 (70%) had had diffuse peritonitis, and 39 (36%) required management with an open abdomen (26 of them with a skin-only closure technique). Median time interval between stomal creation and closure was 190 days (range, 14–2,192). Stapled and hand-sewn anastomoses were done in 24 and 84 patients, respectively. AD occurred in 11 patients (10%). Univariate analyses disclosed age ≥50 years (p < 0.05), high American Society of Anesthesiologists (ASA) score (≥3; p < 0.01), history of chronic renal failure (p < 0.04), history of diffuse peritonitis (p < 0.05), management with an open abdomen (p < 0.05), and lower preoperative hemoglobin values (p < 0.05) as risk factors for AD. Only age ≥50 years prevailed after multivariate analyses. A total of seven patients died (6%). Factors associated with mortality were age ≥65 years (p < 0.02), high ASA score (≥3; p < 0.01), preoperative use of total parenteral nutrition (p < 0.02), lower preoperative hemoglobin values (p < 0.05), time interval between stomal creation and closure <3 months (p < 0.01), AD (p < 0.02), and need for reoperation after stomal closure (p < 0.02). After multivariate analyses, time interval between stomal creation and closure <3 months and need for reoperation were the only ones that prevailed as independent risk factors for mortality (p < 0.05). Conclusions  Although several variables were related to AD and mortality, waiting at least >3 months before attempting restoration of intestinal continuity seems to be the best approach and a practical recommendation in this group of challenging patients.     

Global left-ventricular function by tissue Doppler imaging in pediatric dialysis patients

Cardiovascular abnormalities are observed in most children with end-stage renal disease (ESRD). The aim of this study was evaluation of left-ventricular (LV) myocardial performance using tissue-Doppler imaging (TDI) in patients with ESRD. Twenty-five patients with ESRD and 25 healthy gender- and age-matched control subjects were assessed with conventional M-mode echocardiography, pulsed-wave Doppler (PWD), and TDI. Myocardial Performance Index (MPI) and LV mass index (LVMI) were calculated. MPI and conventional echo-Doppler indices were compared in the ESRD and control groups. Significant differences were present in the mean systolic and diastolic blood pressure (BP) between children with ESRD and healthy children (p = 0.007 and p < 0.001, respectively). The mean LVMI was significantly greater in the patient group (p < 0.001). The tissue-Doppler MPI of patients was significantly higher than that in healthy children (p < 0.001). LVMI was significantly correlated with systolic and diastolic BP. MPI obtained by TDI was significantly correlated with LVMI. Our study confirms that LV dysfunction is present in patients with ESRD and hypertension is an important risk factor.     

Staged lavage versus single high-volume lavage in the treatment of feculent/purulent peritonitis: a matched pair analysis

Background  Spontaneous and iatrogenic secondary peritonitis remain to have a mortality of 10–30% and significant socioeconomic impact in survivors and especially non-survivors. Data on the most cost-effective treatment are lacking. We therefore studied outcome and resource utilization in a homogeneous cohort of patients with secondary fecal or purulent peritonitis undergoing surgery with source control and two different types of abdominal lavage. Methods  Thirty-one consecutive patients with secondary feculent or purulent peritonitis of the lower gastrointestinal tract underwent a single high-volume lavage. That cohort was matched with 31 patients with the same source, extent, and quality of peritonitis treated by source control and staged lavage (intermittent lavage). Results  Patients in both groups were comparable in gender distribution, age, comorbidity, source, extent, and severity of peritonitis with the history of intestinal perforation in the single high-volume lavage group being significantly higher than in the intermittent lavage group (2.0 ± 1.7 vs. 1.1 ± 0.8d; p = 0.008). Patients in the single high-volume lavage group had significantly less operations, thus requiring significantly less operation time (OR-time), intensive care unit (ICU)-requirement, ventilatory support, and inotropic support. Conclusion  Patients with secondary fecal or purulent peritonitis in at least two quadrants, undergoing a one step surgical repair including source control, primary anastomosis, and single high-volume lavage with more than 25 l have a comparable outcome to patients treated by staged lavage at significantly lower OR and ICU-utilization.     

Serum C-Reactive Protein and White Blood Cell Count in Morbidly Obese Surgical Patients

Background  Obesity has been widely recognized as a chronic inflammatory condition and associated with elevated inflammatory indicators including C-reactive protein (CRP) and white blood cell count (WBC). Recent studies have shown elevated CRP or WBC is a significant risk factor for cardiac events and stroke but the clinical significance of CRP and WBC has not been clearly studied in morbidly obese patients. This study is aimed at the clinical significance of WBC and CRP in morbidly obese patients and the change after bariatric surgery. Methods  The study was a prospectively controlled clinical study. From December 1, 2001 to January 31, 2006, of 640 (442 females and 198 males) consecutive morbid obese patients enrolled in a surgically supervised weight loss program with at least 1 year’s follow-up were examined. Results  Of the patients, 476 (74.4%) had elevated CRP and 100 (15.6%) had elevated WBC at preoperative study. CRP and WBC were significantly related and both increased with increasing body mass index (BMI). CRP is also increased with increasing waist, glucose level, hemoglobin, albumin, Ca, insulin, C-peptide, and metabolic syndrome while WBC is increased with metabolic syndrome but decreased with increasing age. Multivariate analysis confirmed fasting glucose level and hemoglobin are independent predictors of the elevation of CRP while age is the only independent predictor for elevated WBC. Both WBC and CRP levels decreased rapidly after obesity surgery. These improvements resulted in a 69.8% reduction of CRP and 26.4% reduction of WBC 1 year after surgery. Although individuals who underwent laparoscopic gastric bypass lost significantly more weight (36.8 ± 11.7 kg vs. 17.3 ± 10.8 kg; p = 0.000) and achieved a lower BMI (27.8 ± 4.6 vs. 35.0 ± 5.5; p = 0.000) than individuals who underwent laparoscopic gastric banding, there was no difference in the resolution of elevated CRP 1 year after surgery (95.9% vs. 84.5%; p = 0.169) and WBC (99.4% vs. 98.3%; p = 0.323). Conclusions  Both baseline WBC and CRP are elevated in morbid obese patients but CRP has a better clinical significance. Significant weight reduction 1 year after surgery markedly reduced CRP and WBC with a resolution rate of 93.9% and 98.2% separately. Obesity surgery performed by laparoscopic surgery is recommended for obese patients with elevated CRP or WBC.     

Radiofrequency Ablation vs. Resection for Hepatic Colorectal Metastasis: Therapeutically Equivalent?

Introduction  The role of ablation for hepatic colorectal metastases (HCM) continues to evolve as ablation technology changes and systemic chemotherapy improves. Our aim was to evaluate the therapeutic efficacy of radiofrequency ablation (RFA) of HCM compared to surgical resection. Methods  A retrospective review of our 1,105 patient prospective hepatic database from August 1995 to July 2007 identified 192 patients with only hepatic resection or only ablation for HCM. Results  Patients who underwent RFA were similar to resection patients based on a similar Fong score (1.8 vs. 2.1 p = 0.28), presence of extrahepatic disease (15% vs. 9% p = 0.19), mean number of hepatic lesions (2.8 vs. 2.1 p = 0.14), and prior chemotherapy (67% vs. 60% p = 0.33). Median time to recurrence was shorter with ablation than resection (12.2 vs. 31.1 months; p < 0.001). Recurrence at the ablation–resection site was more common with ablation than resection occurring 17% vs. 2% (p ≤ 0.001) of the time, respectively. Distant recurrence in the liver was also more common with ablation occurring in 33% of patients vs. 14% for resection (p = 0.002). Conclusions  Surgical resection is associated with a lower chance of recurrence and a longer disease-free interval than RFA and should remain the treatment of choice in resectable HCM.     

Perioperative Treatment with Infliximab in Patients with Crohn’s Disease and Ulcerative Colitis is Not Associated with an Increased Rate of Postoperative Complications

Purpose  The impact of infliximab (IFX) on postoperative complications in surgical patients with Crohn’s disease (CD) and ulcerative colitis (UC) is unclear. We examined a large patient cohort to clarify whether a relationship exists between IFX and postoperative complications. Methods  A total of 413 consecutive patients—188 (45.5%) with suspected CD, 156 (37.8%) with UC, and 69 (16.7%) with indeterminate colitis—underwent abdominal surgery at the Massachusetts General Hospital between January 1993 and June 2007. One hundred one (24.5%) had received preoperative IFX ≤ 12 weeks before surgery. These patients were compared to those who did not receive IFX with respect to demographics, comorbidities, presence of preoperative infections, steroid use, and nutritional status. We then compared the cumulative rate of complications for each group, which included deaths, anastomotic leak, infection, thrombotic complications, prolonged ileus/small bowel obstruction, cardiac, and hepatorenal complications. Potential risk factors for infectious complications including preexisting infection, pathological diagnosis, and steroid or IFX exposure were further evaluated using logistic regression analysis. Results  Patients were similar with respect to gender (IFX = 40.6% men vs. non-IFX = 51.9%, p = 0.06), age (36.1 years vs.37.8, p = 0.43), Charlson Comorbidity Index (5.3 vs. 5.7, p = 0.25), concomitant steroids (75.3% vs. 76.9%, p = 0.79), preoperative albumin level (3.3 vs. 3.2, p = 0.36), and rate of emergent surgery (3.0% vs. 3.5%, p = 1.00). IFX patients had higher rates of CD (56.4% vs. 41.9%, p = 0.02), concomitant azathioprine/6-mercaptopurine use (34.6% vs. 16.6%, p < 0.0001), and lower rates of intra-abdominal abscess (3.9% vs. 11%, p < 0.05). After surgery, the two groups had similar rates of death (2% vs. 0.3% p = 0.09), anastomotic leak (3.0% vs. 2.9%, p = 0.97), cumulative infections (5.97% vs. 10.1%, p = 1), thrombotic complications (3.6% vs. 3.0%, p = 0.06), prolonged ileus/small bowel obstructions (3.9 vs. 2.8, p = 0.59), cardiac complications (1% vs. 0.6%, p = 0.42), and hepatic or renal complications (1.0 vs. 0.6% p = 0.72). A logistic regression model was then created to assess the impact of IFX, as well as other potential risk factors, on the rates of cumulative postoperative infections. We found that steroids (odds ratio [OR] = 1.2, p = 0.74), IFX (OR 2.5, p = 0.14), preoperative diagnosis of CD (OR = 0.7, p = 0.63) or UC (OR = 0.6, p = 0.48), and preoperative infection (OR = 1.2, p = 0.76) did not affect rates of clinically important postoperative infections. Conclusions  Preoperative IFX was not associated with an increased rate of cumulative postoperative complications. Dr. Sands has received research grants and honoraria for lecturing and consulting from Centocor.     

Safety of Conservative Management of Bile Leakage after Hepatectomy with Biliary Reconstruction

Background  The risks associated with the conservative management of bile leakage after hepatectomy and associated cholangiojejunostomy are not well defined. Aim  The aim of this study was to evaluate incidence and severity of complications associated with bile leakages after liver resection with biliary reconstruction. Patients and methods  Clinical data from 1,034 consecutive patients who underwent liver resection were prospectively collected and reviewed. Bile leakage occurred in 25 out of 119 patients (21.0%) who underwent hepatectomy with biliary reconstruction (group 1) and in 42 out of 915 patients (4.6%) without biliary anastomosis (group 2; p < 0.001). Serum albumin and bilirubin levels were the only preoperative factors significantly different between the two groups. Lymphadenectomy was more frequently performed in patients of group 1 (88% vs 16.7, p < 0.001). Results  Mortality rates were similar in the two groups (8% in group 1 vs 2.3% in group 2, p = 0.28). One or more postoperative complications occurred in 68% in group 1 and in 40.4% in group 2 (p = 0.02). The incidence of sepsis (32% vs 7.1%, p = 0.01), intra-abdominal abscess (12% vs 0, p = 0.04), and abdominal bleeding (28% vs 0, p = 0.006) was significantly higher in group 1. Bile leaks spontaneously healed in 52% of patients in group 1 vs 76.2% in group 2 (p = 0.04). In order to identify independent predictive factors for abdominal bleeding, we compared clinical data of patients with abdominal bleeding (seven patients) and without abdominal bleeding (18 patients) after hepatectomy and biliary reconstruction. Stepwise logistic regression analysis identified the number of reconstructed bile ducts as an independent predictive factor of abdominal bleeding (p = 0.038). Conclusions  Conservative management of bile leakage after liver resection with biliary reconstruction is associated with higher rates of morbidity. The most severe complication is abdominal bleeding, which is related to the number of bile ducts requiring reconstruction.     

Laparoscopic Adjustable Silicone Gastric Banding vs Laparoscopic Vertical Banded Gastroplasty in Morbidly Obese Patients: Long-Term Results of a Prospective Randomized Controlled Clinical Trial

Background  Aim of the study is to present long-term results of a prospective randomized single-institution clinical trial comparing laparoscopic adjustable silicone gastric banding (LASGB) with laparoscopic vertical banded gastroplasty (LVBG) in morbid obesity. Methods  A total of 100 morbidly obese patients (body mass index 40 to 50 kg/m²) were randomized to LASGB (n = 49) or LVBG (n = 51) and followed up for a minimum of 7 years. Results  Mean operative time was 65.4 min in LASGBs and 94.2 min in LVBGs (p < 0.05); mean hospital stay was 3.7 and 6.6 days, respectively (p < 0.05). Late complication rates were 36.7% in LASGBs vs 15.7% in LVBGs at 3 years (p < 0.05), 46.9% vs 43.1% at 5 years (NS), and 55.1% vs 47.1% at 7 years (NS). Late reoperation rates were 28.6% in LASGBs and 2.0% in LVBGs at 3 years (p < 0.001), 38.8% and 2.0% at 5 years (p < 0.001), and 46.9% and 7.8% at 7 years (p < 0.001). Excess weight loss in LASGBs was 41.8% at 3 years, 33.2% at 5 years, and 29.9% at 7 years; excess weight loss in LVBGs was 60.9%, 57%, and 53.1%, respectively (p < 0.05). Conclusions  This study demonstrates that in a carefully selected group of patients, LVBG is significantly more effective than LASGB in terms of late complications, late reoperations, and long-term results on weight loss.     

Revisional vs. Primary Roux-en-Y Gastric Bypass—a Case-matched Analysis

With the increase in bariatric procedures performed, revisional surgery is now required more frequently. Roux-en-Y gastric bypass (RYGB) is considered to be the gold standard revision procedure. However, data comparing revisional vs. primary RYGB is scarce, and no study has compared non-resectional primary and revisional RYGB in a matched control setting. Analysis of 61 revisional RYGB that were matched one to one with 61 primary RYGB was done. Matching criteria were preoperative body mass index, age, gender, comorbidities and choice of technique (laparoscopic vs. open). After matching, the groups did not differ significantly. Previous bariatric procedures were 13 gastric bands, 36 vertical banded gastroplasties, 10 RYGB and two sleeve gastrectomies. The indication for revisional surgery was insufficient weight loss in 55 and reflux in 6. Intraoperative and surgical morbidity was not different, but medical morbidity was significantly higher in revisional procedures (9.8% vs. 0%, p = 0.031). Patients undergoing revisional RYGB lost less weight in the first two postoperative years compared with patients with primary RYGB (1 month, 14.9% vs. 29.7%, p = 0.004; 3 months, 27.4% vs. 51.9%, p = 0.002; 6 months, 39.4 vs. 70.4%, p < 0.001; 12 months, 58.5% vs. 85.9%, p < 0.001; 24 months, 60.7% vs. 90.0%, p = 0.003). Although revisional RYGB is safe and effective, excess weight loss after revisional RYGB is significantly less than following primary RYGB surgery. Weight loss plateaus after 12 months follow-up.     

Impact of clinical pathways in surgery

Background  One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities. Method  Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65). Results  Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from € 6,390 to € 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from € 1,810 to € 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07). Conclusions  This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.     

Failure of successful renal transplant to produce appropriate levels of 1,25-dihydroxyvitamin D

Introduction Bone metabolism disturbances following renal transplantation (RT) are complex and multifactorial in origin. Abnormalities in 1,25-dihydroxyvitamin D levels in RT patients under treatment at our Bone Center prompted this retrospective study. Methods Parameters of vitamin D metabolism were compared in RT patients and a cohort of patients with primary hyperparathyroidism (PHTP) who mimicked the hyperparathyroid state of the RT patients. Thirty-one RT recipients (from 300 reviewed) matched our inclusion criteria with a stable graft function for more than 1 year and a glomerular filtration rate (GFR) >50 mL/min per 1.73 m² (Group A); these were compared with 42 consecutive patients with PHTP who had been referred to the same Bone Center for treatment for over 1 month (Group B). Statistical analysis included the chi-square or Fisher’s exact tests for categorical data and the Wilcoxon rank sum test for quantitative measures. Results The mean (±SD) 1,25-dihydroxyvitamin D level was significantly lower (p < 0.001) in Group A patients (29.8 ± 16.2) than in Group B patients (70.2 ± 25.9) despite non-significant differences in the levels of parathyroid hormone (PTH) (mean: 184.0 vs.101.1;p < 0.29), phosphorus (mean: 3.2 vs. 3.1; p < 0.3) and 1,25-vitamin D (mean: 19.5 vs. 25.2; p < 0.06). Group A patients had lower levels (p < 0.05) of mean serum calcium and calculated GFR (9.3 mg/dL, 65.7 mL/min) than Group B patients (10.6 mg/dL, 97.6 mL/min). 1,25-Dihydroxyvitamin D significantly correlated with calcium (p < 0.001), 25-vitamin D (p < 0.005) and GFR (p < 0.001) in both groups, but there was a notable lack of association between 1,25-dihydroxyvitamin D and PTH (p < 0.64) or phosphorus (p < 0.26) in Group A patients. In this group, 1,25-dihydroxyvitamin D was not influenced by the type of immunosuppresion regimen (p < 0.06), use of biphosphonates (p < 0.73), presence of diabetes (p < 0.59), menopause in women (p < 0.08), season (p < 0.43) or race (p < 0.31). Our data indicate that 1,25-dihydroxyvitamin D metabolism remains disturbed for a considerable time after successful RT, with the result that the level of 1,25-dihydroxyvitamin D in RT patients is lower despite physiological signals that should stimulate its production. Our analysis of many clinical variables was unable to elucidate the underlying mechanism(s) for this disturbance. Conclusion Successful RT may not produce appropriate levels of 1,25-dihydroxyvitamin D commensurate to the elevated levels of PTH. This abnormality along with sustained hyperparathyroidism may contribute to bone loss following transplantation.     

The Lymph Node Ratio is the Strongest Prognostic Factor after Resection of Pancreatic Cancer

Introduction  Survival after surgery of pancreatic cancer is still poor, even after curative resection. Some prognostic factors like the status of the resection margin, lymph node (LN) status, or tumor grading have been identified. However, only few data have been published regarding the prognostic influence of the LN ratio (number of LN involved to number of examined LN). We, therefore, evaluated potential prognostic factors in 182 patients after resection of pancreatic cancer including assessment of LN ratio. Methods  Since 1994, 204 patients underwent pancreatic resection for ductal pancreatic adenocarcinoma. Survival was evaluated in 182 patients with complete follow-up evaluations. Of those 182 patients, 88% had cancer of the pancreatic head, 5% of the body, and 7% of the pancreatic tail. Patients underwent pancreatoduodenectomy (85%), distal resection (12%), or total pancreatectomy (3%). Survival was analyzed by the Kaplan–Meier and Cox methods. Results  In all 204 resected patients, operative mortality was 3.9% (n = 8). In the 182 patients with follow-up, 70% had free resection margins, 62% had G1- or G2-classified tumors, and 70% positive LN. Median tumor size was 30 (7–80) mm. The median number of examined LN was 16 and median number of involved LN 1 (range 0–22). Median LN ratio was 0.1 (0–0.79). Cumulative 5-year survival (5-year SV) in all patients was 15%. In univariate analysis, a LN ratio ≥ 0.2 (5-year SV 6% vs. 19% with LN ratio < 0.2; p = 0.003), LN ratio ≥ 0.3 (5-year SV 0% vs. 18% with LN ratio < 0.3; p < 0.001), a positive resection margin (p < 0.01) and poor differentiation (G3/G4; p < 0.03) were associated with poorer survival. In multivariate analysis, a LN ratio ≥ 0.2 (p < 0.02; relative risk RR 1.6), LN ratio ≥ 0.3 (p < 0.001; RR 2.2), positive margins (p < 0.02; RR 1.7), and poor differentiation (p < 0.03; RR 1.5) were independent factors predicting a poorer outcome. The conventional nodal status or the number of examined nodes (in all patients and in the subgroups of node positive or negative patients) had no significant influence on survival. Patients with one metastatic LN had the same outcome as patients with negative nodes, but prognosis decreased significantly in patients with two or more LN involved. Conclusions  Not the lymph node involvement per se but especially the LN ratio is an independent prognostic factor after resection of pancreatic cancers. In our series, the LN ratio was even the strongest predictor of survival. The routine estimation of the LN ratio may be helpful not only for the individual prediction of prognosis but also for the indication of adjuvant therapy and herein related outcome and therapy studies. Presented in part at the 49th Annual Meeting of the Society for Surgery of the Alimentary Tract, May 2008 in San Diego and at the Annual Meeting of the German Cancer Society, February 2008 in Berlin, Germany     

The Effect of Laparoscopic Adjustable Gastric Bands on Esophageal Motility and the Gastroesophageal Junction: Analysis Using High-Resolution Video Manometry

Background  Laparoscopic adjustable gastric bands (LAGB) are a safe and effective treatment for obesity. Conflicting data exist concerning their effect on the esophagus, gastroesophageal junction, and mechanism of action. These patients will increasingly require accurate assessment of their esophageal function. Methods  Twenty LAGB patients underwent high-resolution video manometry with the LAGB empty, 20% under, 20% over, and at their optimal volume. Twenty obese controls were also studied. Effects on esophageal motility, the lower esophageal sphincter (LES), and the gastroesophageal junction were measured. Transit during liquid and semisolid swallows was assessed. Results  The intraluminal pressure at the level of LAGB was a mean of 26.9 (19.8) mm Hg. This pressure varied depending on the volume within the LAGB and was separate to and distal to the lower esophageal sphincter LES. The LES was attenuated compared to controls (10 vs 18 mm Hg; p < 0.01) although relaxed normally. Esophageal motility was well preserved at optimal volume compared to 20% overfilled, with 77% normal swallows vs 51%, p = 0.008. Repetitive esophageal contractions were observed in 40% of swallows at optimal volume compared to 16% in controls, p = 0.024. In comparison to controls, the transit of liquid, 21 vs 8 s (p < 0.001), and semisolids, 50 vs 16 s (p < 0.001), was delayed. Conclusions  In LAGB patients, the LES is attenuated, although relaxes normally. Esophageal motility is preserved, although disrupted by overfilling the band. In the optimally adjusted LAGB, a delay in transit of liquids and semisolids through the esophagus and band is produced, along with an increase in repeated esophageal contractions. Paul Burton has received funding from the National Health and Medical Research Council (NHMRC) and the Royal Australasian College of Surgeons.     

Morbid Obesity and Inflammation: A Prospective Study After Adjustable Gastric Banding Surgery

Background  Inflammatory status underlying obesity seems to be implicated in several aspects of metabolic syndrome. Objective  This study aimed to investigate the association between weight loss achieved by laparoscopic gastric banding (LAGB) surgery, chronic inflammatory markers, and nutritional state. Methods  Thirty-two morbid obese females were enrolled in the study and evaluated at baseline, 1 and 18 months after LAGB surgery. Serum immunoglobulin G (IgG), IgA, IgM, C-reactive protein (CRP), haptoglobin, alpha-1 antitrypsin, total proteins, albumin, prealbumin, transferrin, ferritin, and transferrin soluble receptor were evaluated. In addition, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and fasting glucose were also evaluated. Results  In average, patients presented 18.7% and 63.2% excess body weight loss 1 and 18 months after LAGB, respectively (p < 0.01). CRP and total cholesterol mean levels were elevated (1.03 ± 1.11 mg dL⁻¹ and 2.02 ± 0.41 g L⁻¹) at the presurgery study. CRP mean levels were significantly reduced when compared to reference range (p < 0.01) 18 months after the LAGB surgery. Prealbumin as well as serum total protein mean levels decreased 1 month after surgery (p < 0.01) and values returned to normal at 18 months after surgery. Albumin mean levels showed an increase during the postsurgery evaluations. Serum IgA and IgM concentrations were significantly increased at 1 month after surgery compared to baseline (p < 0.01, both cases). Conclusions  Our results indicate that amelioration of inflammatory markers after LAGB does not seem to negatively impact nutritional status following weight reduction surgery. However, careful attention should be driven to serum IgA. Adequacy of nutritional intake and complete serial laboratory measurements should be always included in the required life-long follow-up of patients surgically treated for morbid obesity.     

Use of Endoluminal Antireflux Therapies for Obese Patients with GERD

Background  Obese patients with gastroesophageal reflux disease (GERD) refractory to medical therapy are a challenging patient population as obesity is a preoperative predictor of failure after antireflux surgery. We therefore sought to evaluate outcomes using one of two commercially available endoluminal therapies in this population. Methods  Consecutive obese patients (body mass index (BMI) > 30) with GERD (DeMeester >14.5) undergoing either Plicator (NDO) or Stretta (Curon) were identified in our single-institution prospective database. Outcomes assessed were: (1) failure rate (absolutely no symptomatic improvement after procedure and/or need for subsequent antireflux surgery), (2) postoperative vs. preoperative symptom (heartburn, chest pain, regurgitation, dysphagia, cough, hoarseness, and asthma) scores, and (3) proton-pump inhibitor (PPI) medication use. Results  Twenty-two patients each underwent an endoluminal therapy (ten Plicator patients and 12 Stretta patients) with mean follow-up of 1.5 years. There were no treatment-associated complications. Mean BMI was not different between Plicator and Stretta groups (39.6 vs. 38.6, respectively, p = 0.33). The failure rate for the entire cohort was 28% (10% Plicator vs. 42% Stretta, p = 0.11). The proportion of patients reporting moderate/severe symptoms postop was significantly less than preop: chest pain 9% vs. 13% (p = 0.04), cough 22% vs. 36% preop (p = 0.025), voice changes 9% vs. 36% preop (p = 0.012), and dysphagia 9% vs. 32% preop (p = 0.04). The proportion of patients on PPI medications postop was also less than preop (45% vs. 81%, p = 0.1) Conclusion  Endoluminal treatment can provide a safe means of improving GERD symptoms for some obese patients, though many will continue to require medication therapy also. Further work aimed at understanding optimal candidates for endoluminal therapy in this patient population is warranted.     

Vitamin D deficiency and parathyroid hormone levels following renal transplantation in children

The objectives were to determine the prevalence of vitamin D deficiency [25(OH)D < 10 ng/ml] in pediatric renal transplant (RTx) recipients, compared with controls and identify correlates of changes in 25(OH)D and intact parathyroid hormone (iPTH) levels following transplantation. Serum 25(OH)D, 1,25(OH)₂D, and iPTH were measured once in 275 healthy controls and at transplantation, and 3 and 12 months posttransplantation in 58 RTx recipients. Multivariate logistic regression models determined the odds ratio (OR) of vitamin D deficiency in RTx recipients vs. controls adjusted for age, sex, race, and season. Generalized estimating equations were used to assess changes following transplantation. At transplantation, 22% of nonblack and 27% of black RTx recipients were vitamin D deficient. The adjusted OR of vitamin D deficiency was greater in RTx recipients (p < 0.001) compared with controls; however, the transplant association was greater in nonblack vs. black individuals (interaction p = 0.02). Overall, 25(OH)D levels did not change significantly following transplantation. Younger age (p < 0.01), nonblack race (p < 0.001), visits in nonwinter months (p < 0.001), and supplementation with ≥400 IU/day ergo/cholecalciferol (p < 0.001) were associated with increases (or lesser declines) in 25(OH)D following transplantation. Increases in 25(OH)D levels (p < 0.001) and vitamin D supplementation (p < 0.01) were associated with greater reductions in iPTH levels following transplantation, independent of 1,25(OH)₂D levels.     

Evaluation of Gastric Bypass Patients 1 Year After Surgery: Changes in Quality of Life and Obesity-Related Conditions

Background  Obesity has recently been cited as the number one killer in the USA. This problem is both a national and regional epidemic. The health care costs of obesity and obesity-related illnesses are ever increasing, and gastric bypass surgery is becoming a popular treatment strategy. Recently, reports describe not only surgical outcomes, but also quality of life outcomes. The bigger issue of obesity-related illness resolution is still evolving. Our institution has performed well over 500 gastric bypasses since 2002. We evaluated over 100 patients prior to and 1 year after gastric bypass surgery. Methods  A prospective study was designed in order to systematically examine quality of life in gastric bypass patients and couple the results with both objective and subjective assessment of bariatric surgery outcomes. One hundred nineteen patients undergoing gastric bypass at our institution from January 2005 to December of 2005 were enrolled in the study. In addition to routine preprocedural and postprocedural follow-up, completion of quality of life forms and anthropometric measurements were performed. Using these data, we then correlated the change in quality of life scores with social factors, weight loss success, and status of obesity-related conditions. We also examined the impact of alcohol intake and other demographic factors on both quality of life and obesity related conditions. Results  A total of 119 patients were enrolled in the study during the calendar year 2005. Follow-up at approximately 1 year (average 12.86 months) postsurgery was obtained in 75 patients. A significant reduction in weight (144.4 ± 34.4 vs. 91.5 ± 28.8; p < 0.0001), body mass index (52.4 ± 12.2 vs. 32.3 ± 8.6; p < 0.0001), mean systolic blood pressure (140.4 ± 14.7 vs. 130.0 ± 21.7; p < 0.001), and lipids (194.3 ± 33.8 vs. 165.7 ± 32.1; p < 0.0001) was noted. Quality of life scores 1 year after gastric bypass surgery were also significantly improved (35.9 ± 19.5 vs. 82.2 ± 23.5; p < 0.0001). There was also a significant reduction in the reported usage of medications for obesity related conditions. Various measures of success (change in BMI, change in quality of life scores, and follow up health ranking) were compared across demographic and social factors and no significant associations were identified. Conclusions  Gastric bypass is associated with a reduction in weight, BMI, mean systolic blood pressure, cholesterol, and the usage of medications for obesity-related conditions. A significant improvement in quality of life was also noted 1 year after surgery.     

Assessment of long-term renal complications in extremely low birth weight children

We assessed the long-term renal complications in a regional cohort of extremely low birth weight (ELBW) children born in 2002–2004. The study group, comprising 78 children born as ELBW infants (88% of the available cohort), was evaluated with measurement of serum cystatin C, urinary albumin excretion, renal ultrasound, and 24-h ambulatory blood pressure measurements. The control group included 38 children born full-term selected from one general practice in the district. Study patients were evaluated at a mean age of 6.7 years, and had a median birthweight of 890 g (25th–75th percentile: 760–950 g) and a median gestational age of 27 weeks (25th–75th percentile: 26–29 weeks). Mean serum cystatin C levels were significantly higher (0.64 vs. 0.59 mg/l; p = 0.01) in the ELBW group. Hypertension was diagnosed in 8/78 ELBW and 2/38 of the control children (p = 0.5). Microalbuminuria (>20 mg/g of creatinine) was detected only in five ELBW children (p = 0.17). The mean renal volume was significantly lower in the ELBW group (absolute kidney volume 81 ml vs. 113 ml; p < 0.001, relative kidney volume 85 vs. 97%; p < 0.001). Abnormally small kidneys (<2/3 of predicted size) were detected in 19 ELBW and four control children (p = 0.08). Multivariate logistic regression revealed that the only independent risk factor for renal complications was weight gained during neonatal hospitalization (odds ratio: 0.67; 95% confidence interval: 0.39–0.94). Serum cystatin C and kidney volume are significantly lower in school-age ELBW children. It is important to include systematic renal evaluation in the follow-up programs of ELBW infants.