Peritoneal inflammatory response of natural orifice translumenal endoscopic surgery (NOTES) versus laparoscopy with carbon dioxide and air pneumoperitoneum

Background

The immunologic and physiologic effects of natural orifice translumenal endoscopic surgery (NOTES) versus traditional surgical approaches are poorly understood. Previous investigations have shown that NOTES and laparoscopy share similar inflammatory cytokine profiles except for a possible late-phase tissue necrosis factor-α (TNF-α) depression with NOTES. The local peritoneal reaction and immunomodulatory influence of pneumoperitoneum agents in NOTES also are not known and may play an important role in altering the physiologic insult induced by NOTES.

Methods

In this study, 51 animals were divided into four study groups, which respectively underwent abdominal exploration via transgastric NOTES using room air (AIR) or carbon dioxide (CO₂) or via laparoscopy (LX) using AIR or CO₂ for pneumoperitoneum. Laparotomy and sham surgeries were additionally performed as control conditions. Measurements of TNF-α, interleukin-1β (IL-1β), and IL-6 were performed for peritoneal fluid collected after 0, 2, 4, and 6 h and on postoperative days (PODs) 1, 2, and 7.

Results

Of the 45 animals assessed, 6 were excluded because of technical operative complications. The findings showed that LX-CO₂ generated the most pronounced response with all three inflammatory markers. However, no significant differences were detected between LX-CO₂ and either NOTES group at these peak points. No differences were encountered between NOTES-CO₂ and NOTES-AIR. Subgroup comparisons showed significantly higher levels of TNF-α and IL-6 with NOTES-CO₂ than with LX-AIR on POD 1 (p = 0.022) and POD 2 (p = 0.002). The LX-CO₂ subgroup had significantly higher levels of TNF-α than the LX-AIR subgroup at 4 h (p = 0.013) and on POD 1 (p = 0.021). No late-phase TNF-α depression occurred in the NOTES animals.

Conclusion

The local inflammatory reaction to NOTES was similar to that with traditional laparoscopy, and the previously described late-phase systemic TNF-α depression in serum was not reproduced. At the peritoneal level, NOTES is no more physiologically stressful than laparoscopy. Furthermore, regardless of which gas was used, the role of the pneumoperitoneum agent did not affect the cytokine profile after NOTES, suggesting that air pneumoperitoneum is adequate for NOTES.     

Perioperative inflammatory response in natural orifice translumenal endoscopic surgery

Background

Natural orifice translumenal endoscopic surgery (NOTES) could offer multiple advantages compared with the laparoscopic approach. One such potential advantage, not yet proven, is the inferior inflammatory response, which translates into less significant operative stress. This study aimed to compare the immuno-inflammatory response between transgastric NOTES and laparoscopy for simple surgical procedures (oophorectomy) with reference to the cytokine levels.

Methods

For this study, 20 female pigs were randomly assigned to either NOTES or laparoscopic oophorectomy. Seven animals were used as a control group and received only general anesthesia, with no other procedure performed. Blood samples were obtained before surgery, 1 h after the start of the procedure, and at the end of the intervention. The serum levels of IL1β and IL6 were determined using a porcine enzyme-linked immunosorbent assay (ELISA) kit. The mean operative time, intraoperative incidents, and postoperative complications were recorded. On postoperative day 14, the animals were killed, and gastric leak tests were performed.

Results

Both the NOTES and laparoscopic procedures were successfully completed. No gastric leaks were observed during necropsy. The transgastric oophorectomy required a significantly longer time to perform than the laparoscopic surgery. Compared with the NOTES procedures, laparoscopic oophorectomy resulted in significantly higher levels of interleukin-1β (IL1β) (42.34 ± 5.26 ng/ml with NOTES vs 46.93 ± 4.79 ng/ml with laparoscopy; p = 0.028) and IL6 (66.95 ± 7.29 ng/ml with NOTES vs 71.75 ± 4.76 ng/ml with laparoscopy, p = 0.049) during the postoperative phase. No statistical difference was detected between the pre- and postoperative cytokine levels in the NOTES group.

Conclusion

The study findings suggest that pure transgastric endoscopic surgery is a safe approach resulting in less perioperative inflammatory response than laparoscopy in the early postoperative phase.     

Gastric Bypass and Sleeve Gastrectomy: the Same Impact on IL-6 and TNF-α. Prospective Clinical Trial

Background

Due to the association between the quantity of adipose tissue and concentrations of interleukin-6 (IL-6) and tumor necrosis factor (TNF-α), this work aimed to assess the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures on serum IL-6 and TNF-α concentrations.

Methods

This study evaluated serum IL-6 and TNF-α levels, as well as routine anthropometric and biochemical values, before and 1 year post-bariatric surgery. Fifty percent of patients (n?=?24) underwent RYGB, and 50 % (n?=?24) underwent SG. Prior to bariatric surgery, IL-6 and TNF-α mRNA expression levels in subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) were investigated in obese women.

Results

There was a significant reduction (p?<?0.05) in all anthropometric and routine biochemical measurements in patients in the RYGB and SG groups 1 year post-surgery. The serum concentrations of IL-6 and TNF-α were reduced following surgery in both groups (p?<?0.05). No differences in the relative expression levels of IL-6 and TNF-α were found between SAT and VAT prior to bariatric surgery.

Conclusions

RYGB and SG procedures demonstrated a similar impact on adipokine levels in women 1 year post-surgery. Both techniques may improve the course of chronic diseases and the state of inflammation associated with obesity.     

Stress response and well-being after open,laparoscopic, and NOTES transgastric uterine horn resection in a randomized porcine model

Background

NOTES is believed to induce less surgical trauma than open and laparoscopic surgery. The degree of surgical trauma can be assessed by measuring serum levels of acute-phase proteins such as CRP and TNF-α. We conducted a prospective randomized survival trial in which the inflammatory responses after laparoscopic, open, and NOTES transgastric uterine horn resection were compared. The aim of this study was to investigate whether NOTES procedures induce less inflammatory response.

Methods

Thirty pigs were randomized into three groups to undergo open, laparoscopic, or transgastric uterine horn resection. Weight, body temperature, and postoperative recovery were recorded and venous blood samples were taken for analysis of CRP and TNF-α at different time points. Analyses of CRP and TNF-α were performed using pig-specific ELISA assays.

Results

Procedure time was significantly longer for NOTES [median = 121 min (range = 94–155)] compared with that for open surgery [median = 22 min (14–27)] and laparoscopy [median = 37 min (20–45)] (p < 0.0001). There was a nonsignificant tendency for shorter recovery time for the NOTES animals. Twenty-seven animals survived for 4 weeks. One animal in each group was euthanized prior to 4 weeks. All animals gained weight during the 4-week period with no significant differences. Only animals in the NOTES group showed a significant weight gain during the first postoperative week (p = 0.007). On postoperative day (POD) 1, CRP was significantly lower in the NOTES group compared with the open and laparoscopic groups (mean = 0.72 ± 0.22, 0.98 ± 0.26, and 0.97 ± 0.20, respectively; p = 0.048). The CRP levels were normalized on day 14. Throughout the study there were no significant changes in TNF-α levels in the laparoscopic and NOTES groups. At POD 3 the open surgery group showed significantly higher TNF-α levels than the other groups (p = 0.036).

Conclusions

Despite the longer operating time, the transgastric NOTES approach seems to be less traumatic than open or laparoscopic uterine horn resection in this porcine model.     

A Prospective Randomized Study Comparing Patients with Morbid Obesity Submitted to Sleeve Gastrectomy With or Without Omentectomy

Background

Increased visceral adipose tissue is a risk factor for the metabolic complications associated with obesity and promotes a low-grade chronic inflammatory process. Resection of the great omentum in patients submitted to a bariatric procedure has been proposed for the amelioration of metabolic alterations and the maximization of weight loss. The aim of the present study was to investigate the impact of omentectomy performed in patients with morbid obesity undergoing sleeve gastrectomy (SG) on metabolic profile, adipokine secretion, inflammatory status, and weight loss.

Methods

Thirty-one obese patients were randomized into two groups: SG alone or with omentectomy. Adiponectin, omentin, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), high-sensitivity C-reactive protein (hs-CRP), blood lipids, fasting glucose, insulin, and insulin resistance were measured before surgery and at 7 days, and 1, 3 and 12 months after surgery.

Results

During the 1-year follow-up, body mass index (BMI) decreased markedly and comparably in both groups (p?<?0.001). Insulin, IL-6, and hs-CRP levels decreased significantly compared to baseline (p?<?0.05) in both groups with no significant difference between groups. Adiponectin and high-density lipoprotein cholesterol levels were significantly and similarly increased compared to baseline (p?<?0.001) in both groups. Omentin levels increased significantly (p?<?0.05) in the control group and decreased in the omentectomy group 1 year postoperatively. There was no significant change in TNF-α levels in either group.

Conclusions

The theoretical advantages of omentectomy in regard to weight loss and obesity-related abnormalities are not confirmed in this prospective study. Furthermore, omentectomy does not induce important changes in the inflammatory status in patients undergoing SG.     

Does penile tourniquet application alter bacterial adhesion to rat urethral cells: an in vitro study

Purpose

To investigate the effects of penile tourniquet (PT) application on bacterial adhesion to urothelium.

A prospective, randomized comparison of pain, inflammatory response, and short-term outcomes between single port and laparoscopic cholecystectomy

Background

The purpose of this study was to compare the postoperative inflammatory response and severity of pain between single-incision laparoscopic surgery (SILS) cholecystectomy and conventional laparoscopic cholecystectomy (LC).

Methods

Two groups of 20 patients were prospectively randomized to either conventional LC or SILS cholecystectomy. Serum interleukin-6 (IL-6) levels were assayed before surgery, at 4–6 h, and at 18–24 h after the procedure. Serum C-reactive protein (CRP) levels also were assayed at 18–24 h after surgery. Pain was measured at each of three time points after surgery using the visual analogue scale (VAS). The number of analgesia doses administered in the first 24 h after the procedure also was recorded and 30-day surgical outcomes were documented.

Results

The groups had equivalent body mass index (BMI), age, and comorbidity distribution. Peak IL-6 levels occurred 4–6 h after surgery, and the median level was 12.8 pg/ml in the LC and 8.9 pg/ml in the SILS group (p = 0.5). The median CRP level before discharge was 1.6 mg/dl in the LC and 1.9 mg/dl in the SILS group (p = 0.38). There was no difference in either analgesic use or pain intensity as measured by the VAS between the two groups (p = 0.72). The length of the surgical procedure was significantly longer in the SILS group (p < 0.001). No intraoperative complications occurred in either group.

Conclusions

Single-incision laparoscopic surgery does not significantly reduce systemic inflammatory response, postoperative pain, or analgesic use compared with LC.     

Gastric Histopathology in Laparoscopic Sleeve Gastrectomy: Pre- and Post-Operative Comparison

Background

Sleeve gastrectomy (SG) produces excellent results in weight reduction and resolution of comorbidities. The histology of the gastric mucosa can be affected by the surgical procedure, with alterations of inflammatory patterns. The objective of this study is to evaluate alterations of the inflammatory patterns of the gastric mucosa in SG and the results in weight loss and resolution of comorbidities.

Methods

Morbidly obese patients were selected to undergo SG. Endoscopies were performed pre-operatively and post-operatively after 6 months, with an incisura and 3 cm before the pylorus biopsies. Data on weight, height, and associated diseases were collected. The data were compared, and the biopsies evaluate the inflammatory patterns.

Results

There was a reduction of body weight with a pre-operative weight of 132.5?±?15.7 kg and a post-operative weight of 95.8 ±10.6 kg with a p?<?0.001. Also, the body mass index (BMI) was reduced significantly with a mean pre-operative of 42.6?±?10.6 kg/m² and a post-operative of 30.9?±?3.2 kg/m² with a p?<?0.001. The comorbidities were all resolved or improved. The pattern of gastric histology showed chronic gastritis with inflammatory activity associated with Helicobacter pylori in 33.3 % of the patients, along with foveolar hyperplasia at 58.3 %. The chronic gastritis with discrete inflammatory activity was reduced by 16.7 %, and the foveolar hyperplasia was reduced by 33.3 %.

Conclusion

The inflammatory alterations in the pre-operative period were mainly foveolar hyperplasia and chronic gastritis associated with H. pylori, and they were reduced in the post-operative period. A significant reduction of weight and BMI occurred, and a resolution of comorbidities was observed.     

Early and late postoperative inflammatory and collagen deposition responses in three different meshes: an experimental study in rats

Purpose

Although meshes reduce abdominal hernia recurrence, they increase the risk of inflammatory complications. This study aimed to compare the early and late postoperative inflammation and collagen deposition responses induced by three meshes.

Methods

Rats were allocated into three groups. In group I, a polypropylene (PP) mesh was implanted in the abdominal wall. In groups II and III, PP + polyglactin (PP + PG) and PP + titanium (PP + TI) meshes were employed, respectively. On the seventh (7th) postoperative day, collagen deposition and inflammation were evaluated, and immunohistochemistry was performed on abdominal wall biopsies. These data were compared with those obtained on the fortieth (40th) postoperative day in a previous study.

Results

The early inflammatory responses were the same in all groups. With time, it decreased in group I (p = 0.047) and increased in group II (p = 0.003). Group I exhibited early elevated VEGF (p < 0.001), COX2 (p < 0.001), and collagen (p = 0.023) levels, and group II exhibited the most severe inflammatory tissue response. On the 40th postoperative day, the VEGF (p < 0.001) and collagen (p < 0.005) were reduced as compared with the 7th postoperative day in all groups.

Conclusions

Belatedly, the inflammatory reaction decreased in PP mesh group and increased in PP + PG mesh group. The PP mesh induced early great elevations in VEGF, COX2 and collagen levels, whereas the PP + PG mesh caused severe tissue inflammation with small elevation in these levels. PP + TI mesh induced inflammatory response levels between the others. In conclusion, the inflammatory response depends on the mesh density and also the mesh material with clinical implications.     

Lower Glycemic Fluctuations Early After Bariatric Surgery Partially Explained by Caloric Restriction

Background

We assessed the acute impact of laparoscopic Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG) compared to caloric-matched control group without surgery on glucose excursion in obese patients with type 2 diabetes, and examined if this was mediated by changes in insulin resistance, early insulin response or glucagon-like peptide (GLP)-1 levels.

Methods

Six-day subcutaneous continuous glucose monitoring (CGM) recordings were obtained from patients beginning 3 days before GBP (n?=?11), SG (n?=?10) or fasting in control group (n?=?10). GLP-1, insulin and glucose were measured during 75 g oral glucose tolerance testing at the start and end of each CGM.

Results

Post-operative hyperglycaemia occurred after both surgeries in the first 6 h, with a more rapid decline in glycaemia after GBP (p?<?0.001). Beyond 24 h post-operatively, continuous overlapping of net glycaemia action reduced from baseline after GBP (median [interquartile range]) 1.6 [1.2–2.4] to 1.0 [0.7–1.3] and after SG 1.4 [0.9–1.8] to 0.7 [0.7–1.0]; p?<?0.05), similar to controls (2.2 [1.7–2.5] to 1.3 [0.8–2.8] p?<?0.05). Higher log GLP-1 increment post-oral glucose occurred after GBP (mean ± SE, 0.80?±?0.12 vs. 0.37?±?0.09, p?<?0.05), but not after SG or control intervention. Among subgroup with baseline hyperglycaemia, a reduction in HOMA-IR followed GBP. Reduction in time and level of peak glucose and 2-h glucose occurred after both surgeries but not in controls.

Conclusions

GBP and SG have a similar acute impact on reducing glycaemia to caloric restriction; however, with a superior impact on glucose tolerance.     

Reduced plasma ghrelin levels on day 1 after esophagectomy: a new predictor of prolonged systemic inflammatory response syndrome

Background and purpose

Ghrelin, a stomach-derived hormone, stimulates growth hormone secretion and appetite, and inhibits excessive inflammatory response. Plasma ghrelin might affect the inflammatory response to stressful surgical interventions. The aim of this study was to investigate the relationship between serial changes in plasma ghrelin concentrations and the postoperative clinical course after esophagectomy.

Methods

The prospective cohort study subjects were 20 patients with esophageal cancer, who underwent esophagectomy with gastric tube reconstruction. Blood samples were taken six times perioperatively during the course of esophagectomy.

Results

The plasma ghrelin level decreased to 33 % (range 15?C90 %) on postoperative day (POD) 1, relative to the preoperative level, then recovered to about 50 % by POD 3?C10. The duration of systemic inflammatory response syndrome (SIRS) was significantly longer in patients with a marked ghrelin reduction to <33 % on POD 1, than in those with less marked reduction of ??33 % (6.1 ± 1.3 vs. 2.1 ± 0.6 days, P = 0.019). On POD 1, the only inflammatory marker that correlated with the duration of SIRS was the % ghrelin, whereas C-reactive protein, leukocyte count, and IL-6 did not.

Conclusion

An early postoperative drop in plasma ghrelin correlated with prolonged SIRS after esophagectomy. Thus, the supplementation of low plasma ghrelin may help minimize excess inflammatory response in these patients.     

Comparative effects of gastric bypass and sleeve gastrectomy on plasma osteopontin concentrations in humans

Background

Bariatric surgery (BS) has proven to be an effective treatment for morbid obesity. Osteopontin (OPN) is a proinflammatory cytokine involved in the development of obesity. The aim of our study was to determine the effect of weight loss following BS on circulating levels of OPN in humans.

Methods

Body composition and circulating concentrations of OPN and markers of bone metabolism were determined in obese patients who underwent Roux-en-Y gastric bypass (RYGB; n = 40) or sleeve gastrectomy (SG; n = 11).

Results

Patients who underwent RYGB or SG showed decreased body weight (P < 0.001) and body fat percentage (P < 0.001) as well as lower insulin resistance. However, plasma OPN levels were significantly increased after RYGB (P < 0.001) but remained unchanged following SG (P = 0.152). Patients who underwent RYGB also showed significantly increased C-terminal telopeptide of type-I collagen (ICTP) (P < 0.01) and osteocalcin (P < 0.001) while bone mineral density tended to decrease (P = 0.086). Moreover, OPN concentrations were positively correlated with the bone resorption marker ICTP after surgery. On the other hand, patients who underwent SG showed significantly increased ICTP levels (P < 0.05), and the change in OPN was positively correlated with the change in ICTP and negatively with the change in vitamin D after surgery (P < 0.05).

Conclusions

RYGB increased circulating OPN levels, while they remained unaltered after SG. The increase in OPN levels after RYGB could be related to the increased bone resorption in relation to its well-known effects on bone of this malabsorptive procedure in comparison to the merely restrictive SG.     

Evaluation of the clinical and inflammatory responses in exclusively NOTES transvaginal cholecystectomy versus laparoscopic routes: an experimental study in swine

Background

The aim of this study was to evaluate the clinical and inflammatory responses to surgical trauma caused by the natural orifice transluminal endoscopic surgery (NOTES) transvaginal endoscopic procedure compared with those of the laparoscopic route.

Methods

Twenty-one female swine were divided into three groups of seven animals and subjected to cholecystectomy using laparoscopic, laparotomic, and exclusively NOTES transvaginal routes. A group of five animals served as a control. The animals were monitored during surgery to evaluate anesthetic/surgical time and the presence of complications, which were evaluated after surgery with respect to roaming time, feeding, and the presence of clinical occourrence Measurements of TNF-α, IL-1β, IL-6, CRP, IFN-γ were obtained before and after surgery, on the second and seventh postoperative days, and when the animals were killed and necropsied.

Results

All procedures were successfully completed as proposed in each group. Perioperative complications consisted of only gallbladder perforation and hepatic bleeding. The anesthetic/surgical time was longer in the NOTES vaginal group (p?<?0.001). The postanesthetic recovery time, roaming, nutrition, and clinical evolution were similar in all groups. IL-1β and IL-6 were undetectable in all groups. Levels of TNF-α, CRP, and IFN-γ were similar among the groups. However, the evolution of the inflammatory process, measured as the difference between the peak dose and the basal dose of IFN-γ, was lower in the NOTES group than in the laparotomy group. In the necropsy findings, only adhesions were found, with no difference among the groups.

Conclusions

The entirely NOTES transvaginal cholecystectomy was feasible and safe. The surgical time was greater for the NOTES vaginal route. The inflammatory response was similar among the groups based on the levels of CRP and IFN-γ. However, the evolution of the inflammatory process seems to have been shorter in the vaginal NOTES group than in the laparotomy group as demonstrated by the difference between the peak and basal doses of IFN-γ.     

Two-Year Results on Morbidity, Weight Loss and Quality of Life of Sleeve Gastrectomy as First Procedure, Sleeve Gastrectomy After Failure of Gastric Banding and Gastric Banding

Background

Sleeve gastrectomy (SG) is an alternative to gastric bypass and laparoscopic adjustable gastric banding (GB).

Methods

From January 2004 to January 2006, 111 patients with a follow-up longer than 24 months were prospectively followed. Three treatment groups were defined. Sleeve gastrectomy as first procedure (SGFP; n?=?50), sleeve gastrectomy after failure of GB (SG after GB; n?=?9) and GB (n?=?52). We compared morbidity, mortality, length of stay, number of procedures under general anaesthesia, excess weight loss (EWL) and quality of life.

Results

Mean initial body mass index (BMI) was 50.4 (SG), 50.8 (SG after GB) and 43.8 (GB; p?=?0.000001). Mean operating time was 97.1 min (SGFP), 122.2 min (SG after GB) and 69.8 min (GB; p?<?0.0001). The reoperation rate under general anaesthesia was 2% (SGFP), 11% (SG after GB) and 30.76% (GB; p?=?0.00001).The fistula rate was 2% (SGFP), 0% (SG after GB) and 0% (GB). BMI at 24 months was 33.8 (SGFP), 35.3 (SG after GB) and 33.2 (GB; NS). EWL at 24 months was 67.4 (SGFP), 60.3 (SG after GB) and 58.6 (GB; NS). In the SGFP group and in the SG after GB group, the mean quality-of-life score was 1.1. In the GB group, the mean score was 0.95 (NS).

Conclusions

Initial BMI was significantly higher in the SG group but was no longer significantly different from the BMI of the GB group at 12 and 24 months. Excess BMI loss was higher after SG than after GB. This reduction of BMI was considered to be a success for GB. Thus, results of SG should be considered as a success. Quality of life was not significantly different between the three groups. These results validated SG as first procedure or after failure of GB.     

Revisional surgery after failed adjustable gastric banding: institutional experience with 90 consecutive cases

Background

Revisional surgery may be required in a high percentage of patients (up to 30 %) after laparoscopic adjustable gastric banding (LAGB). We report our institutional experience with revisional surgery.

Methods

From January 1996 to November 2011, 90 patients underwent revisional surgery after failed LAGB. Both Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were proposed. In the presence of gastroesophageal reflux disease, esophageal dysmotility, hiatal hernia, or diabetes, RYGB was preferentially proposed.

Results

In two cases, revisional surgery was aborted due to local severe adhesions. Eighty-eight patients (74 females; mean age 42.79 ± 10.03 years; mean BMI 44.73 ± 6.19 kg/m²) successfully underwent revisional SG (n = 48) or RYGB (n = 40). One-stage surgery was performed in 29 cases. Follow-up rate was 78.2 % (n = 61) and 40.9 % (n = 36) at 12 and 24 months respectively. One major complication after SG (staple-line leakage) was observed. Overall postoperative excess weight loss (%EWL) was 31.24, 40.92, 52.41, and 51.68 % at 3, 6, 12, and 24 months of follow-up respectively. There was a statistically significant higher %EWL at 1 year in patients <50 years old (55.9 vs. 41.5 % in patients >50 years old; p = 0.01), of female gender (55.22 vs. 40.73 % in male; p = 0.04), and in patients in which the AGB was in place for <5 years (57.09 vs. 47.43 % if >5 years p = 0.02).

Conclusions

Revisional surgery is safe and effective. Patients <50 years, of female gender, and with the AGB in place for <5 years had better %EWL after revisional surgery.     

Pseudomyxoma Peritonei: Inflammatory Responses in the Peritoneal Microenvironment

Background

Pseudomyxoma peritonei (PMP), a peritoneal mucinous neoplasm of appendiceal origin, is associated with inflammation and fibrosis, which is central to its biology. The significance of the microenvironment in PMP has not been well characterized.

Methods

Immunoassays were used to measure cytokines and C-reactive protein (CRP). Forty-two cytokines were initially measured in 23 PMP ascites and 10 PMP peritoneal washings. On the basis of these results, matching serum and ascites samples were analyzed for ten relevant cytokines (n = 32) and CRP (n = 28). Immunohistochemistry was performed on formalin-fixed tissue sections. Statistical analysis was by Wilcoxon signed rank test, Mann–Whitney U-test, and bivariate analysis.

Results

Serum CRP was elevated in PMP and correlated to CRP level in ascites. Interleukin (IL)-6, IL-8 (CXCL8), interferon gamma-induced protein 10 (IP-10), (CXCL10), monocyte chemotactic protein (MCP)-1 (CCL2), and macrophage inflammatory protein (MIP)-1α (CCL3) levels were grossly elevated in ascites but did not correlate with serum levels. Cytokines normally associated with infection or tissue injury (e.g., IL-1, IL-2, interferon gamma) were not elevated. Immunohistochemistry localized IL-6 to stroma, IP-10, and MCP-1 to tumor cells and IL-8 to adipose tissue. There were complex interactions among cytokines. IL-6, in particular, had many significant correlations in ascites. Serum IL-8, MIP-1β, and CRP were higher in PMP compared to controls.

Conclusions

The pattern of cytokines in PMP is distinct from infection- or injury-associated inflammation. The results support peritoneal synthesis for cytokines. CRP, IL-8, and MIP-1β are potential serum markers for PMP. IL-6 appears to play a central role in PMP biology. This study provides new details about PMP tumor biology and identifies possible therapeutic targets.     

Needs analysis for developing a virtual-reality NOTES simulator

Introduction and study aim

Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical technique that requires a cautious adoption approach to ensure patient safety. High-fidelity virtual-reality-based simulators allow development of new surgical procedures and tools and train medical personnel without risk to human patients. As part of a project funded by the National Institutes of Health, we are developing the virtual transluminal endoscopic surgery trainer (VTEST?) for this purpose. The objective of this study is to conduct a structured needs analysis to identify the design parameters for such a virtual-reality-based simulator for NOTES.

Methods

A 30-point questionnaire was distributed at the 2011 National Orifice Surgery Consortium for Assessment and Research meeting to obtain responses from experts. Ordinal logistic regression and the Wilcoxon rank-sum test were used for analysis.

Results

A total of 22 NOTES experts participated in the study. Cholecystectomy (CE, 68 %) followed by appendectomy (AE, 63 %) (CE vs AE, p = 0.0521) was selected as the first choice for simulation. Flexible (FL, 47 %) and hybrid (HY, 47 %) approaches were equally favorable compared with rigid (RI, 6 %) with p < 0.001 for both FL versus RI and HY versus RI. The transvaginal approach was preferred 3 to 1 to the transgastric. Most participants preferred two-channel (2C) scopes (65 %) compared with single (1C) or three (3C) or more channels with p < 0.001 for both 2C versus 1C and 2C versus 3C. The importance of force feedback and the utility of a virtual NOTES simulator in training and testing new tools for NOTES were rated very high by the participants.

Conclusion

Our study reinforces the importance of developing a virtual NOTES simulator and clearly presents expert preferences. The results of this analysis will direct our initial development of the VTEST? platform.     

Evolution of Glycolipid Profile After Sleeve Gastrectomy vs. Roux-en-Y Gastric Bypass: Results of a Prospective Randomized Clinical Trial

Background

This study aims to report glycolipid changes after sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) in the setting of a prospective randomized clinical trial.

Methods

One hundred patients were randomly assigned to RYGB (n?=?45) and SG (n?=?55). Fasting glucose, insulin, glycated hemoglobin (HbA1c%), triglycerides, and serum cholesterol (total, HDL, and LDL) were evaluated at inclusion and after 1, 3, 6, and 12 months. The index for homeostasis model assessment of insulin resistance (HOMA-IR) and β cell function (HOMA-B) were assessed.

Results

Mean postoperative 1-, 3-, 6-, and 12-month excess weight loss was 25.39, 43.47, 63.75, and 80.38 % after RYGB and 25.25, 51.32, 64.67, and 82.97 % after SG, respectively. Mean fasting glucose and fasting serum insulin were similarly and statistically significantly reduced in both RYGB and SG. Mean HOMA-IR improved in both groups, particularly in case of high preoperative values, and mean HOMA-B improved at 1 year after RYGB. HbA1c% dropped from 5.66 % (SD?=?0.61) to 5.57 % (SD?=?0.32) after RYGB and from 5.64 % (SD?=?0.43) to 5.44 % (SD?=?0.43) after SG. Total cholesterol was significantly higher at 1 month (p?=?0.04), 3 months (p?=?0.03), and 1 year (p?=?0.005) after SG as compared to RYGB. LDL cholesterol decreased significantly after RYGB at 1 month (p?=?0.03), 3 months (p?=?0.0001), and 1 year (p?=?0.0004) as compared to SG. HDL cholesterol was increased at 1 year in the RYGB group but not in the SG group. Triglycerides decreased similarly in both groups.

Conclusions

Short-term glycemic control was comparable after SG and RYGB. An improved lipid profile was noted after RYGB in patients with abnormal preoperative values.     

Improvement in Cardiovascular Indices After Roux-en-Y Gastric Bypass or Sleeve Gastrectomy for Morbid Obesity

Background

Morbidly obese patients display cardiac abnormalities which are partially reversed after weight loss. The aim of the present study was to assess the potential difference in cardiovascular disease indices between patients who underwent either gastric bypass surgery or sleeve gastrectomy.

Methods

Thirty-seven morbidly obese patients who underwent either Roux-en-Y gastric bypass (RYGB) (n?=?14) or SG (n?=?23) were examined before, 3 and 6 months after surgery. Indices of cardiac autonomic nervous system activity were evaluated, namely baroreflex sensitivity (BRS) and heart rate variability (HRV). A complete echocardiographic study was performed in a subgroup of 17 patients (RYGB 8, SG 9) preoperatively and 6 months after surgery, evaluating epicardial fat thickness, aortic distensibility, left ventricular (LV) Tei index, left atrium diameter, ejection fraction, and LV mass.

Results

All subjects experienced significant (p?<?0.001) and similar weight loss independently of the type of operation. BRS and HRV indices improved significantly and to the same degree after surgery in both groups. In the echocardiographic study, all parameters improved significantly at 6 months in comparison with the baseline values. In addition, the RYGB group displayed significantly greater reduction in epicardial fat thickness (p?=?0.007) and also tended to have a better LV performance as expressed by the lower values of the Tei index (p?=?0.06) compared to the SG group 6 months after surgery.

Conclusions

Both RYGB and SG exert comparable effects on weight loss and improvement of cardiovascular parameters. RYGB displays a more beneficial influence on epicardial fat thickness and left ventricular performance than SG.     

Effect of transgastric peritoneal access on peritoneal innate cellular immunity: experimental study in swine

Background

One of the main concerns of natural orifice surgery is the local and systemic impact on physiology. Few studies have compared natural orifice transluminal endoscopic surgery (NOTES) with other surgical modalities. Most studies are based on systemic variables such as postoperative serum cytokines, with conflicting results. Surgical trauma induces an early inflammatory response, release of cytokines, and local leukocyte activation and oxidative burst. Major surgical trauma is related to impairment of phagocytic function and an increase in production of active oxygen species by phagocytes. The aim of this study was to evaluate the impact of transgastric peritoneoscopy on peritoneal innate immune response compared with laparoscopy and laparotomy in swine.

Methods

Thirty-four male Sus scrofa domesticus swine were assigned to four groups: transgastric peritoneoscopy (13), laparoscopy (7), laparotomy (7), and sham procedure (7). Twenty-four hours after the procedure, peritoneal fluid cells were harvested by peritoneal washing after necropsy. Flow cytometry analysis of labeled S. aureus and E. coli phagocytosis by peritoneal neutrophils and macrophages was blindly performed. Oxidative burst activity measured by H₂O₂ production under different challenges was also evaluated.

Results

Total operative time varied between all groups. The transgastric, laparoscopy, and laparotomy groups required 56, 17.2, and 40.3 min of mean operative time, respectively (p < 0.05). Even though the mean percentage and intensity of phagocytosis by peritoneal phagocytes were higher in the sham, transgastric, and laparoscopy groups, there was no significant difference between these groups and laparotomy. Macrophage production of H₂O₂ has been shown to be similar among the transgastric, laparoscopy, and sham groups, and smaller than that in laparotomy (p < 0.05), either under basal conditions, while performing E. coli phagocytosis, or challenged by the presence of E. coli membrane lipopolysaccharide.

Conclusion

Under the conditions of this study, transgastric peritoneoscopy has been shown to have minimal impact on peritoneal innate immune response.