Transection of the deep metatarsal transverse ligament in Morton’s neuroma surgery does not increase risk of splayfoot development

Purpose

Although operative excision is regarded as the treatment of choice in Morton’s neuroma, it remains unclear whether transection of deep transverse metatarsal ligament (DTML) is a risk for metatarsal splaying and whether simultaneous surgery in adjacent intermetatarsal spaces is a risk for osteonecrosis of the adjacent metatarsals.

Methods

Fifty-seven feet in 47 patients had excision of a Morton’s neuroma, with a mean follow-up of 15.3 years. Feet were categorised depending upon whether the DTML was or was not divided. Pre-operative and post-operative intermetatarsal angles were measured on standardised weightbearing radiographs and inspected for evidence of osteonecrosis.

Results

Comparison of pre- and post-operative intermetatarsal angles in patients with surgery in the second web space showed no significant increase (transected p?=?0.659, preserved p?=?0.142). In regards to comparison of pre- and post-operative radiographic intermetatarsal angles in patients with surgery in the third web space, statistical analysis also did not show a significance increase (transected p?=?0.240, preserved p?=?0.078). Radiological assessment showed no signs of osteonecrosis of metatarsal heads, not even in cases of double-space surgery.

Conclusions

In conclusion, DTML transection does not increase the intermetatarsal angle or the risk of splayfoot development. Moreover, transection is recommended due to an enhanced overview during surgery and better clinical outcome. Our data could also prove that double-space surgery is not a risk for avascular osteonecrosis.

     

Trends in Early Morbidity and Mortality after Sleeve Gastrectomy in Patients over 60 Years

Background

The population are getting older and obesity is growing. Laparoscopic sleeve gastrectomy (LSG) is increasingly used worldwide but is still used with skepticism in the elderly. The purpose of our analysis is to judge the security of LSG in patients older than 60 years compared to patients younger than 60 years.

Methods

This retrospective review included data of all patients in Germany who underwent LSG between January 2005 and December 2016.The data were published online in the German Bariatric Surgery Registry. A total of 21,571 operations were gathered and divided into two groups: group I, patients <?60 years old; and group II, patients ≥?60 years old.

Results

The total number of patients and the mean body mass index of group I and group II was 19,786, 51.7?±?9.5 kg/m² and 1771, 49.2?±?8.1 kg/m², respectively. Regarding comorbidities, group II suffered statistically significantly more comorbidities than group I (p?<?0.001). The general postoperative complications were 4.9% in group I and 7.8% in group II (p?<?0.001). There was no significant difference in special postoperative complications (p?=?0.048) and a slightly higher intraoperative complication rate in group II (2.2% vs. 1.6%, p?=?0.048). Thirty-day mortality rate for group I versus II was 0.22% and 0.23% (p?=?0.977), respectively.

Conclusions

LSG is a low-risk operation and safe surgical method with acceptable, not elevated perioperative morbidity and mortality rates in patients ≥?60 years of age.

     

The significance of tubulointerstitial lesions in childhood Henoch–Schönlein nephritis

Background

Little information is currently available on the development of tubulointerstitial lesions in children with Henoch–Schönlein nephritis (HSN). To identify the impact of the development of tubulointerstitial changes in HSN, we retrospectively analyzed renal biopsies obtained from children with HSN.

Methods

Twenty-eight children with HSN from whom serial renal biopsies had been obtained before and after immunosuppressive therapy were enrolled in the study. The patients were divided into two groups according to the observed change in tubulointerstitial lesion development: group I (n?=?15), with stable or improved tubulointerstitial lesions, and group II (n?=?13), with worsened tubulointerstitial lesions. Group II patients had longer duration of proteinuria than group I patients (3.7?±?3.7 years vs. 1.7?±?1.7 years, p?=?0.052).

Results

The change in serum albumin level was negatively correlated with the change in tubulointerstitial scores before and after treatment (γ?=??0.444, p?=?0.018). Group II patients showed a significant decrease in immunoglobulin G (IgG) and IgA deposits after treatment (p?=?0.039 and 0.003, respectively), while group II patients did not (p?=?0.458 and 0.506, respectively).

Conclusions

Although the International Study of Kidney Disease in Children classification of HSN does not include tubulointerstitial lesions, they can progress during treatment and could have significant clinical implications in association with the duration of proteinuria.

     

Association of osteoporosis with genetic variants of circadian genes in Chinese geriatrics

Summary

This study was designed to investigate the association of circadian gene single nucleotide polymorphisms (SNPs) with the risk of osteoporosis. We found that the rs3781638 GG genotype was positively associated with osteoporosis prevalence in females, whereas the rs2292910 AC genotype was negatively associated with osteoporosis prevalence in a geriatric cohort.

Introduction

Studies have shown that disruption of endogenous circadian rhythms may increase the risk of developing type II diabetes and obesity, which are reportedly associated with osteoporosis (OP). Thus, abnormalities of circadian genes may indirectly induce OP. Here, we investigated the association of OP with 14 SNPs located in seven circadian genes.

Methods

The research subjects, geriatric residents of Shanghai Minhang, China, diagnosed with OP (N?=?171) or osteopenia (N?=?226) or without specific diseases (N?=?200), were genotyped for 14 genetic variants of circadian genes by competitive allele-specific polymerase chain reaction. The prevalence of polymorphisms among the subject groups and the association between the SNPs and osteoporosis were investigated.

Results

Among the 14 genotyped SNPs, we found an association between the CRY2 gene rs2292910 SNP and osteoporosis (r?=??0.082, p?=?0.045) in the geriatric cohort. We found a decreased risk between cryptochrome 2 rs2292910 and OP (A/C odds ratio?=?0.647, p?=?0.044) but an increased risk between MTNR1B rs3781638 and OP (G/G odds ratio?=?2.058, p?=?0.044).

Conclusion

For the first time, we show that Cry 2 rs2292910 and MTNR1B rs3781638 are associated with osteoporosis in a Chinese geriatric cohort. Therefore, targeting the abnormalities of the CRY2 and MTNR1B genes may be a potential strategy to treat and/or to prevent osteoporosis.

     

Hospital cost savings and other advantages of sutureless vs stented aortic valves for intermediate-risk elderly patients

Purpose

To evaluate and compare the clinical outcomes and hospital costs of using sutureless aortic valves vs conventional stented aortic valves.

Methods

Between 2007 and 2011, 52 elderly patients undergoing aortic valve replacement for aortic stenosis in our center had a sutureless valve inserted. From among 180 patients who had a stented valve inserted during the same period, 52 patients were matched to the sutureless group, based on age, gender, and operation type. We compared clinical outcomes and hospital costs between the two groups.

Results

The sutureless group had a higher Euroscore (logistic Euroscore I) risk (12.8 vs 9.7; p?=?0.02), with significantly shorter aortic cross-clamp (ACC) time (p?<?0.01), cardiopulmonary bypass (CPB) time (p?<?0.01), intensive care unit stay (p?<?0.01), intubation time (p?<?0.01), and overall hospital stay (p?=?0.05). The sutureless group also revealed a significant hospital cost saving of approximately 8200€ (p?=?0.01).

Conclusions

The clinical and hemodynamic outcomes of using the sutureless bioprosthesis were excellent. The reduced ACC and CPB times had a favorable effect on the duration of intubation and intensive care stay, resulting not only in faster recovery and discharge home, but also in a significant hospital cost reduction.

     

Esophageal Magnetic Sphincter Augmentation as a Novel Approach to Post-bariatric Surgery Gastroesophageal Reflux Disease

Background

We sought to evaluate the safety and effectiveness of magnetic sphincter augmentation (MSA) in patients with GERD after bariatric surgery.

Methods

Pre- and post-operative GERD quality of life (G-QOL) surveys were conducted. Standard indications (SI) group or the post-bariatric group (PB) created. Outcomes were compared between groups.

Results

Twenty-eight patients analyzed with no losses to follow-up. All patients had preoperative testing confirming normal motility and presence of GERD. No patients were lost to follow-up. The PB group (N?=?10) were mostly prior sleeve gastrectomies (N?=?8) with two previous gastric bypasses. PB patients required larger MSA device size (16 beads) compared to the SI group (14 beads, p?<?0.001). Outcomes were no different with percent improvement between pre- and post-operative G-QOL survey scores with 70% improvement for PB and 84% for SI (p?=?0.13). Medication cessation was possible in 90% for PB versus 94% for SI (p?=?0.99). Rates of post-operative dysphagia were similar between the two groups.

Conclusions

Although larger prospective randomized studies are needed, there is an exciting potential for the role of MSA, providing surgeons a new and much needed tool in their armamentarium against refractory or de novo GERD after bariatric procedures.

     

Postoperative atrial fibrillation is less frequent in pulmonary segmentectomy compared with lobectomy

Objective

The aim of this study was to elucidate the characteristics and predictors of postoperative atrial fibrillation (POAF) from the standpoint of surgical mode.

Methods

Retrospective analysis was carried out on 607 patients who underwent lobectomy or segmentectomy for clinical stage IA lung cancer. We investigated the clinical factors to determine the predictors of the development of POAF.

Results

Of the 607 patients, 443 underwent lobectomy, and 164 underwent segmentectomy. POAF developed in 37 patients. Of these, 34 (7.7%) were in the lobectomy group, and 3 (1.8%) in the segmentectomy group. In the univariate analysis for predictors of POAF, age (p?<?0.01), history of ischemic heart disease (p?=?0.03), FEV1.0% (p?<?0.01) and surgical mode (p?=?0.01) showed significant differences between the groups. The multivariate analysis revealed that increasing age (p?<?0.01, HR 1.059, CI 1.015–1.106), surgical mode (p?=?0.02, HR 5.734, CI 1.350–24.361) and FEV1.0%?<?70% (p?=?0.03, HR 2.182, CI 1.067–4.461) were independent predictors of POAF.

Conclusion

POAF was significantly less following segmentectomy compared with lobectomy.

     

Basal and stress-activated hypothalamic pituitary adrenal axis function in postmenopausal women with overactive bladder

Introduction and hypothesis

The aim of this study was to measure physiologic and psychologic stress reactivity in women with overactive bladder (OAB). There is growing evidence in preclinical models that central nervous system dysregulation, particularly in response to psychological stress, may contribute to lower urinary tract symptoms in women with OAB.

Methods

Postmenopausal women with OAB and healthy controls underwent Structured Clinical Interview for DSM-IV Axis I disorders (SCID) to identify those without identifiable psychiatric disease. Eligible participants underwent physiologic measures including basal (cortisol-awakening response; CAR) and stress-activated salivary cortisol levels, heart rate (HR), urinary metanephrines and neurotrophins, as well as validated symptom assessment for stress, anxiety, depression, and bladder dysfunction at baseline and during, and following an acute laboratory stressor, the Trier Social Stress Test (TSST).

Results

Baseline measures of cortisol reactivity measured by CAR showed blunted response among women with OAB (p?=?0.015), while cortisol response to the TSST was greater in the OAB group (p?=?0.019). Among OAB patients, bladder urgency as measured by visual analog scale (VAS) increased from pre- to post-TSST (p?=?0.04). There was a main effect of TSST on HR (p?<?0.001), but no group interaction.

Conclusions

Preliminary findings suggest that women with OAB have greater physiologic and psychologic stress reactivity than healthy controls. Importantly for women with OAB, acute stress appears to exacerbate bladder urgency. Evaluation of the markers of stress response may suggest targets for potential diagnostic and therapeutic interventions.

     

Reflux and Belching after Laparoscopic 270 degree Posterior Versus 180 degree Anterior Partial Fundoplication

Background

Laparoscopic 270 degree posterior, or Toupet (LTF), and 180 degree anterior partial fundoplication (LAF) ensure equal reflux control and reduce the risk of gas-related symptoms compared to 360 degree (Nissen) fundoplication. It is unclear which type of partial fundoplication is superior in preventing gas-related side-effects. The aim of this study was to determine differences in effect of LTF and LAF on reflux characteristics and belching patterns.

Methods

Upper gastrointestinal endoscopy, esophageal manometry, and 24-h combined pH-impedance monitoring were performed before and 6 months after fundoplication (n?=?10, LTF vs. n?=?10, LAF). Observed changes after surgery (?) were compared between the two procedures.

Results

Symptomatic reflux control as well as the reduction in the mean number of acid (? ??58.5 vs. ??66.5; P?= 0.912), liquid (? ??17.0 vs. ??43.5; P?=?0.247), and mixed liquid gas reflux episodes (? ??38.0 vs. ??40.0; P?=?0.579) were comparable following LTF and LAF. There were no differences in the mean number of weakly acidic reflux episodes after LTF and LAF (1.0 (0.8–4) vs. 1.0 (0–3), P?= 0.436). The reduction in proximal (P?=?1.000), mid-esophageal (P?=?0.063), and distal reflux episodes (P?=?0.315) was comparable. Both procedures equally reduced the number of gastric belches (P?=?0.278) and supragastric belches (P?=?0.123), with no significant reduction in the number of air swallows after either procedure (P?=?0.278).

Conclusion

LTF and LAF provide similar reflux control, with a comparable effect on acidic, liquid, and gas reflux. Both procedures equally reduced the number of belches and supragastric belches. This study provides the physiological evidence for the published randomized trials reporting similar symptomatic outcome after both types of partial fundoplication.

     

Cervical instability in cervical spondylosis patients

Background

Cervical spondylosis is one of the most common causes of cervical instability. Various methods are used for measuring cervical instability on X?ray films. The purpose of this study was to assess the application of the radiographic index method to analyze the radiographic features of cervical spondylosis instability.

Material and methods

Digitized dynamic radiographs of 121 subjects with cervical spondylosis were retrospectively retrieved. The cervical spondylosis patients were divided into two groups according to the symptoms: patients with positive neurological deficits with and without neck symptoms (group I, n?=?62) and patients with neck symptoms only (group II, n?=?59). A total of 62 healthy subjects were assigned to the control group (group III). The radiographic indices of cervical curvature, the full flexion to full extension ranges of motion (ROM) and horizontal displacement of the three groups were analyzed and compared with each other.

Results

On flexion-extension views there were significant differences (p?=?0.00000 [significance of cervical lordosis on flexion view between the three groups], p?=?0.00271 [significant difference of cervical lordosis between the three groups on extension view]) between the three groups concerning the cervical lordosis: group I had the least cervical curvature, followed by group II and group III. The full flexion to full extension ranges of motion for group I was significantly decreased (p?=?0.0039) when compared with group II and group III. The horizontal displacement at each segmental level (except C2/C3) was significantly higher in group I than that of the other two groups.

Conclusion

With the application of the radiographic index method, cervical spine lordosis, the full flexion to full extension ROM, horizontal displacement, and cervical instability can be accurately illustrated. Cervical spondylosis is an age-related, wear and tear change of the spine that occurs over time. The index of the horizontal displacement ≥0.3 is suggestive of cervical instability.

     

Eradication of Barrett Esophagus with Early Neoplasia by Radiofrequency Ablation,with or without Endoscopic Resection

Background

Radiofrequency ablation is safe and effective for complete eradication of nondysplastic Barrett esophagus (BE). The aim was to report the combined results of two published and two ongoing studies on radiofrequency ablation of BE with early neoplasia, as presented at SSAT presidential plenary session DDW 2008.

Methods

Enrolled patients had BE ≤12 cm with early neoplasia. Visible lesions were endoscopically resected. A balloon-based catheter was used for circumferential ablation and an endoscope-based catheter for focal ablation. Ablation was repeated every 2 months until the entire Barrett epithelium was endoscopically and histologically eradicated.

Results

Forty-four patients were included (35 men, median age 68 years, median BE 7 cm). Thirty-one patients first underwent endoscopic resection [early cancer (n?=?16), high-grade dysplasia (n?=?12), low-grade dysplasia (n?=?3)]. Worst histology remaining after resection was high-grade (n?=?32), low-grade (n?=?10), or no (n?=?2) dysplasia. After ablation, complete histological eradication of all dysplasia and intestinal metaplasia was achieved in 43 patients (98%). Complications following ablation were mucosal laceration at resection site (n?=?3) and transient dysphagia (n?=?4). After 21 months of follow-up (interquartile range 10–27), no dysplasia had recurred.

Conclusions

Radiofrequency ablation, with or without prior endoscopic resection for visible abnormalities, is effective and safe in eradicating BE and associated neoplasia.

     

Which factors should be considered in choosing pessary type and size for pelvic organ prolapse patients in a fitting trial?

Introduction and hypothesis

This study explored whether the optimal pessary type and size can be predicted using the specific pelvic organ prolapse quantification system (POP-Q) measurements in women with pelvic organ prolapse in a fitting trial.

Methods

We conducted a prospective study in women who had undergone pessary fitting. A total of 78 patients with stage II, III or IV symptomatic pelvic organ prolapse completed a detailed history. Data were analysed using nonparametric tests, continuity correction chi-squared tests and multivariate logistic regression.

Results

Differences in total vaginal length (TVL; p?<?0.01) and vaginal introitus width/TVL ratio (p?=?0.012) were observed between patients with and without a history of hysterectomy. Patients with a history of hysterectomy and patients with a larger vaginal introitus had more success with the Gellhorn pessary than with the ring pessary with support (p?=?0.005 and p?=?0.01, respectively). Factors determining the size of the ring pessary with support were the genital hiatus (GH) width (p?=?0.044), TVL (p?=?0.011), vaginal introitus width (p?<?0.001), and vaginal introitus width/TVL ratio (p?=?0.025). Factors determining the size of the Gellhorn pessary were the GH width (p?=?0.025), GH width/TVL ratio (p?=?0.013), vaginal introitus width (p?=?0.003), vaginal introitus width/TVL ratio (p?=?0.001), stage of apical prolapse (p?=?0.006) and stage of posterior prolapse (p?=?0.003).

Conclusions

Patients with a history of hysterectomy or with a larger vaginal introitus were more likely to achieve success with the Gellhorn pessary. The GH width and the vaginal introitus width influenced the size of both pessaries chosen. The TVL was predictive of the optimal size of the ring pessary with support but was not predictive of the optimal size of the Gellhorn pessary. Finally, the size of the Gellhorn pessary was associated with POP stage.

     

Long term outcomes in the use of ileal ureter for radiation-induced ureteral strictures

Purpose

Radiation-induced ureteral stricture disease poses significant surgical challenges. Ureteral substitution with ileum has long been a versatile option for reconstruction. We evaluated outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction due to radiation-induced ureteral stricture versus other causes.

Methods

Between July 1989 and June 2013, 155 patients underwent consecutive ileal ureter creation. The study cohort included 104 patients with complete data sets and at least 7 months of follow up. Records were retrospectively reviewed with regard to demographics, indications, complications, and renal deterioration.

Results

Surgical indications included radiation-induced stricture in 23 (22%) and non-radiation-induced stricture in 81 (78%). Comparing ileal ureter substitution due to radiation versus other stricture etiologies, no statistical significance was observed in regard to age (45.6 vs. 51.2, p?=?0.141), hospital length of stay in days (8.8 vs. 7.7, p?=?0.216), percent GFR loss (MDRD-4 vs. -5%, p?=?0.670 and CKD-EPI-7 vs. -6%, p?=?0.914), 30-day surgical complications (26.1 vs. 30.1%, p?=?0.658), metabolic acidosis (8.7 vs. 1.2%, p?=?0.059), and renal failure requiring dialysis (4.3 vs. 1.2%, p?=?0.337). Fistula formation (13.0 vs. 3.7%, p?=?0.095), partial small bowel obstructions (21.7 vs. 7.4%, p?=?0.063), and small bowel obstructions requiring reoperation (13.0 vs. 1.2%, p?=?0.033) approached or reached statistical significance. Using Kaplan–Meier methodology, there was no difference in time to worsening renal outcome between the radiation and non-radiation groups (p?>?0.05).

Conclusion

Ureteral substitution with ileum is an effective reconstructive option for radiation-induced ureteral strictures in carefully selected patients.

     

A Randomized,Double-Blind,Placebo-Controlled Trial of Intravenous Acetaminophen on Hospital Length of Stay in Obese Individuals Undergoing Sleeve Gastrectomy

Background

Retrospective studies indicate that acetaminophen iv administration reduces hospital length of stay (LoS) and opiate consumption in patients undergoing bariatric surgery.

Objective

This study sought to determine whether using acetaminophen iv in morbidly obese subjects undergoing sleeve gastrectomy decreased LoS and total hospital charges as compared to patients receiving saline placebo.

Setting

Single-center university hospital

Methods

Using a randomized, double-blind, placebo-controlled design, subjects were assigned to receive either acetaminophen iv (group A) or saline placebo iv (group P). Data were collected between Jan 1 and Dec 31, 2016. Group A received acetaminophen every 6 h for a total of four doses. The first dose was administered following the induction of general anesthesia; group P received saline iv on the same schedule. Anesthetic management and prophylactic antiemetic regimen were standardized in all subjects. Postoperative pain management consisted of hydromorphone via patient-controlled infusion pump. Primary outcomes include hospital LoS and associated hospital costs. Secondary outcomes include patient satisfaction and postoperative nausea and pain scores.

Results

Subject demographics (n?=?127) and intraoperative management were similar in the two groups. Across all subjects, median hospital LoS in group A (n?=?63) was 1.87 vs. 1.97 days in group P (n?=?64) (p?=?0.03, Wilcoxon rank-sum test). Postoperatively, daily quality-of-recovery (QoR-15) scores, narcotic consumption, and the use of rescue antiemetics were not significantly different between groups. Median hospital costs were as follows: group A, $12,885 vs. group P, $12,977 (n?=?64).

Conclusions

Acetaminophen iv may reduce hospital LoS in subjects undergoing sleeve gastrectomy.

     

Clinical and ultrasonographic evaluation of the pelvic floor in primiparous women: a cross-sectional study

Introduction and hypothesis

We used clinical examination and transperineal 3D/4D ultrasound (US) to evaluate pelvic floor muscles (PFM) after different delivery modes.

Methods

Women were surveyed using validated questionnaires. PFM were evaluated and classified according to the Modified Oxford Scale following 3D/4D transperineal US. For statistical analysis, Kruskal–Wallis, Mann–Whitney, chi-square, and Fisher exact tests were used.

Results

Fifty-three women were evaluated: 32 with previous vaginal delivery (VD) and 21 with cesarean section (CS) (8 nonelective and 13 elective). No significant difference among groups was observed regarding urinary incontinence (UI) after delivery (p?=?0.39), loss of muscle strength referred by the patient (p?=?0.48), or evaluated through digital examination (p?=?0.87). No patient with elective CS had avulsion, with difference between VD and elective CS (p?=?0.008). US evaluation identified no differences in bladder-neck elevation (p?=?0.69) or descent (p?=?0.65) , and no difference in genital hiatus size (p?=?0.35), levator ani thickness (p?=?0.35 –0.44), or presence of major or minor levator ani avulsion (p?=?0.10).

Conclusions

We evaluated primiparous women within 12 to 24 months of delivery and found that VD was associated with PFM avulsion. There was no difference among VD and nonelective or elective CS in symptomatology or other anatomic alterations evaluated through 3D/4D transperineal US.

     

Complications in hepatic arterial infusion chemotherapy: retrospective comparison of catheter tip placement in the right/left hepatic artery vs. the gastroduodenal artery

Purpose

To compare the complication rates associated with hepatic arterial infusion chemotherapy (HAIC) for unresectable hepatocellular carcinoma (HCC) using two different catheter tip locations, the right/left hepatic artery (group 1) and the gastroduodenal artery (group 2).

Methods

Between April 2001 and March 2015, 88 patients (group 1, n?=?36; group 2, n?=?52) with unresectable HCC, underwent HAIC via a transfemorally placed infusion catheter. The incidence of complications related to catheter placement (including hepatic arterial occlusion, catheter dislocation, non-target embolization and port-catheter system infection) as well as catheter patency and patient survival were evaluated.

Results

The technical success rate was 100%. The overall complication rate was 17% (15/88 patients). The specific complications were as follows: hepatic artery occlusion, n?=?1 (group 2, n?=?1), gastroduodenal ulcer, n?=?6 (group 1, n?=?2; group 2, n?=?4); catheter dislocation, n?=?1 (group 2, n?=?1); port-catheter system infection, n?=?3 (group 2, n?=?3); and bleeding at the puncture site, n?=?4 (group 1, n?=?1; group 2, n?=?3).

Conclusions

The complication rates in groups 1 and 2 did not differ to a statistically significant extent.

     

Early Weight Recidivism Following Laparoscopic Sleeve Gastrectomy: A Prospective Observational Study

Background

Although weight loss following laparoscopic sleeve gastrectomy (LSG) can be substantial, weight recidivism is still a major concern. The aim of our work is to study early weight recidivism following LSG and to evaluate the role of gastric computed tomography volumetry (GCTV) in the assessment of patients experiencing early weight regain.

Methods

One-hundred and one morbidly obese patients undergoing LSG were prospectively studied. Patients were followed up for 2 years. Those who presented with weight recidivism were counseled for dietary habits and assessed for the amount of weight regain. Patients who regained weight were scheduled for GCTV.

Results

Twelve patients were excluded from the study. Weight recidivism was reported in 9/89 patients (10.1 %) [weight loss failure (n?=?1), weight regain (n?=?8)] and was almost always first recognized 1½–2 years after LSG. The amount of weight regain showed negative correlations with preoperative body weight and body mass index (r?=??0.643, P?=?0.086 and r?=??0.690, P?=?0.058; respectively) and positive correlations with the distance between the pylorus and the beginning of the staple line (r?=?0.869, P?=?0.005), as well as with the residual gastric volume (RGV) on GCTV 2 years after LSG (r?=?0.786, P?=?0.021).

Conclusions

In the small group of patients who regained weight, a longer distance between the pylorus and the beginning of the staple line, as well as a higher RGV on GCTV 2 years after LSG, were both associated with increased weight regain. Gastric computed tomography volumetry with RGV measurement holds promise as a useful research tool after LSG.

     

Out-of-Pocket and Catastrophic Expenses Incurred by Seeking Pediatric and Adult Surgical Care at a Public,Tertiary Care Centre in Uganda

Background

Surgical care is critical to establish effective healthcare systems in low- and middle-income countries, yet the unmet need for surgical conditions is as high as 65% in Ugandan children. Financial burden and geographical distance are common barriers to help-seeking in adult populations and are unmeasured in the pediatric population. We thus measured out-of-pocket (OOP) expenses and distance traveled for pediatric surgical care in a tertiary hospital in Mbarara, Uganda, as compared to adult surgical and pediatric medical patients.

Methods

Patients admitted to pediatric surgical (n?=?20), pediatric medical (n?=?18) and adult surgical (n?=?18) wards were interviewed upon discharge over a period of 3 weeks. Patient and caregiver-reported expenses incurred for the present illness included prior/future care needed, and travel distance/cost. The prevalence of catastrophic expenses (≥10% of annual income) was calculated and spending patterns compared between wards.

Results

Thirty-five percent of pediatric medical patients, 45% of pediatric surgical patients and 55% of adult surgical patients incurred catastrophic expenses. Pediatric surgical patients paid more for their current treatment (p?<??0.01)—specifically medications (p?<??0.01) and tests (p?<??0.01)—than pediatric medical patients, and comparable costs to adults. Adult patients paid more for treatment prior to the hospital (p?=?0.04) and miscellaneous expenses (e.g., food while admitted) (p?=?0.02). Patients in all wards traveled comparable distances.

Conclusions

Seeking healthcare at a publicly funded hospital is financially catastrophic for almost half of patients. Out-of-stock supplies and broken equipment make surgical care particularly vulnerable to OOP expenses because analgesics, anaesthesia and preoperative imaging are prerequisites to care.

     

Choledochal Cyst Disease in a Western Center: A 30-Year Experience

Background

The aim of this study was to report a Western experience in the diagnosis and management of choledochal cyst disease.

Results

Sixty-seven patients were identified including 15 children and 52 adults; 76.1 % were females. The median age at diagnosis was 3 [inter-quartile range (IQR)?=?6.0–0.7]?years for children, and 46 [IQR?=?55.6–34.3]?years for adults. Forty-eight patients (72 %) were symptomatic. Types of choledochal cyst included: I (n?=?49, 73.1 %), II (n?=?1, 1.5 %), IV (n?=?9, 13.4 %), and V (n?=?8, 12 %). The median diameter of the type I choledochal cyst was 35 [IQR?=?47–25]?mm. All 48 patients underwent excision of cyst with Roux-en-Y hepaticojejunostomy, and eight underwent resection with hepaticoduodenostomy. Six patients underwent liver resection, and five patients underwent orthotopic liver transplantation. Malignancy was concomitant in five adult patients, being identified on preoperative imaging in three cases; and atypia was seen in three additional patients. Early morbidity included Clavien–Dindo classification grades III (n?=?7) and II (n?=?5), while long-term complications consisted of Clavien–Dindo grades V (n?=?5), IV (n?=?2), III (n?=?18), and II (n?=?1).

Conclusions

Presentation and management of choledochal cyst is varied. Malignant transformation is often detected incidentally, and so should be the driving source for resection when a choledochal cyst is diagnosed.

     

Bone mineral density,vitamin D status,and calcium intake in healthy female university students from different socioeconomic groups in Turkey

Summary

Peak bone mass is reached in late adolescence. Low peak bone mass is a well recognized risk factor for osteoporosis later in life. Our data do not support a link between vitamin D status, bone mineral density (BMD), and socioeconomic status (SES). However, there was a marked inadequacy of daily calcium intake and a high presence of osteopenia in females with low SES.

Purpose

Our aims were to (1) examine the effects of different SES on BMD, vitamin D status, and daily calcium intake and (2) investigate any association between vitamin D status and BMD in female university students.

Subjects and methods

A questionnaire was used to obtain information about SES, daily calcium intake, and physical activity in 138 healthy, female university students (age range 18–22 years). Subjects were stratified into lower, middle, and higher SES according to the educational and occupational levels of their parents. All serum samples were collected in spring for 25-hydroxyvitamin D concentration (25OHD). Lumbar spine and total body BMD was obtained by dual-energy X-ray absorptiometry (DXA) scan (Lunar DPX series). Osteopenia was defined as a BMD between ??1.0 and ??2.5 standard deviations (SDs) below the mean for healthy young adults on lumbar spine DXA.

Results

No significant difference was found between the three socioeconomic groups in terms of serum 25OHD concentration, BMD levels, or BMD Z scores (p?>?0.05). Both the daily intake of calcium was significantly lower (p?=?0.02), and the frequency of osteopenia was significantly higher in girls with low SES (p?=?0.02). There was no correlation between serum 25OHD concentration and calcium intake and BMD values and BMD Z scores (p?>?0.05). The most important factor affecting BMD was weight (β?=?0.38, p?<?0.001).

Conclusions

Low SES may be associated with sub-optimal bone health and predispose to osteopenia in later life, even in female university students.