ObjectiveThe aim of this study was to examine the relationship between changes in liver fat and changes in insulin sensitivity and β‐cell function 2 years after gastric banding surgery.MethodsData included 23 adults with the surgery who had prediabetes or type 2 diabetes for less than 1 year and BMI 30 to 40 kg/m2 at baseline. Body adiposity measures including liver fat content (LFC), insulin sensitivity (M/I), and β‐cell responses (acute, steady‐state, and arginine‐stimulated maximum C‐peptide) were assessed at baseline and 2 years after surgery. Regression models were used to assess associations adjusted for age and sex.ResultsTwo years after surgery, all measures of body adiposity, LFC, fasting and 2‐hour glucose, and hemoglobin A1c significantly decreased; M/I significantly increased; and β‐cell responses adjusted for M/I did not change significantly. Among adiposity measures, reduction in LFC had the strongest association with M/I increase (r = −0.61, P = 0.003). Among β‐cell measures, change in LFC was associated with change in acute C‐peptide response to arginine at maximal glycemic potentiation adjusted for M/I (r = 0.66, P = 0.007). Significant reductions in glycemic measures and increase in M/I were observed in individuals with LFC loss >2.5%.ConclusionsReduction in LFC after gastric banding surgery appears to be an important factor associated with long‐term improvements in insulin sensitivity and glycemic profiles in adults with obesity and prediabetes or early type 2 diabetes.

Robotic surgical technology has grown in popularity and applicability, since its conception with emerging uses in general surgery. The robot’s contribution of increased stability and dexterity may be beneficial in technically challenging surgeries, namely, inguinal hernia repair. The aim of this project is to contribute to the growing body of literature on robotic technology for inguinal hernia repair (RIHR) by sharing our experience with RIHR at a large, academic institution. We performed a retrospective chart review spanning from March 2015 to April 2018 on all patients who had undergone RIHR at our university hospital. Extracted data include preoperative demographics, operative features, and postoperative outcomes. Data were analyzed with particular focus on complications, including hernia recurrence. A total of 43 patients were included, 40 of which were male. Mean patient age was 56 (range 18–85 years) and mean patient BMI was 26.4 (range 17.5–42.3). Bilateral hernias were diagnosed in 13 patients. All of the patients received transabdominal approaches, and all but one received placement of synthetic polypropylene mesh. There was variety in mesh placement with 23 patients receiving suture fixation and 14 receiving tack fixation. Several patients received a combination of suture, tacks, and surgical glue. Mean patient in-room time was 4.0 h, mean operative time was 2.9 h, and mean robotic dock time was 2.0 h. Regarding intraoperative complications, there was one bladder injury, which was discovered intraoperatively and repaired primarily. Same-day discharges were achieved in 32 patients (74.4%) of patients. One patient was admitted overnight for management of urinary retention. Additional ten patients were admitted for observation. Post-operatively, none of the cases resulted in wound infections. Eleven patients developed seromas and one patient was diagnosed with a groin hematoma. Median follow-up was 37.5 days, and one recurrence was reported during this time. The recurrent hernia in this case was initially discovered during a separate case and was repaired with temporary mesh. The use of the robot is safe and effective and should be considered an acceptable approach to inguinal hernia repair. Future prospective studies will help define which patients will benefit most from this technology.

Lateral abdominal wall hernias are rare defects but, due to their location, repair is difficult, and recurrence is common. Few studies exist to support a standard protocol for repair of these lateral hernias. We hypothesized that anchoring our repair to fixed bony structures would reduce recurrence rates. A retrospective review of all patients who underwent lateral hernia repair at our institution was performed. Eight cases (seven flank and one thoracoabdominal) were reviewed. The median defect size was 105 cm2 (range 36–625 cm2). The median operative time was 185 min (range 133–282 min). There were no major complications. One patient who was repaired without mesh attachment to bony landmarks developed a recurrence at ten months and subsequently underwent reoperation. Patients with mesh secured to bony landmarks were recurrence free at a median follow-up of 171 days. Lateral hernias present a greater challenge due to their anatomic location. An open technique with mesh fixation to bony structures is a promising solution to this complex problem.

BackgroundVideoesophagram (VEG) and esophageal manometry (EM) are components of the preoperative evaluation for foregut surgery. EM is able to identify motility disorders and diminished contractility that may alter surgical planning. However, there are no clearly defined criteria to guide this. Reliable manometry is not always easily obtained, and therefore its necessity in routine preoperative evaluation is unclear. We hypothesized that if a patient has normal videoesophagram, manometry does not reveal clinically significant esophageal dysfunction.MethodsWe reviewed patients who underwent protocolized videoesophagram and manometry at our institution. Measures of esophageal motility including the mean distal contractile integral (DCI), mean wave amplitude (MWA), and percent of peristaltic swallows (PPS) were analyzed. The Chicago Classification was used for diagnostic criteria of motility disorders. Normal VEG was defined as stasis of liquid barium on less than three of five swallows.ResultsThere were 418 patients included. 231 patients (55%) had a normal VEG, and 187 patients (45%) had an abnormal VEG. In the normal VEG group, only 2/231 (0.9%) patients had both abnormal DCI and PPS, 1/231 (0.4%) patients had both abnormal DCI and MWA and no patients had both abnormal MWA and PPS. There were no patients with achalasia or absent contractility and 1 patient with ineffective esophageal motility (IEM) in the normal VEG group. This was significantly different from the abnormal VEG group which included 4 patients with achalasia, 1 with absent contractility and 22 with IEM (p<0.0001). The negative predictive value of VEG was 99.6% and the sensitivity was 96.4%.ConclusionsA normal videoesophagram reliably excluded the presence of clinically significant esophageal dysmotility that would alter surgical planning. Routine manometry is not warranted in patients with normal videoesophagram, and should be reserved for patients with abnormal VEG.

Weight loss induced by gastric banding improves insulin sensitivity and reduces secretory demand on β-cells in the Restoring Insulin Secretion (RISE) Consortium BetaFat Study. Here we examined the role of liver fat in this process. Total % body fat (%BF) was measured by DXA; visceral fat volume (VFV) and hepatic fat fraction (HFF) by MRI; and insulin sensitivity (steady-state glucose infusion rate/insulin [M/I]) and β-cell function (acute, steady state [SSCP] and arginine-stimulated maximum ([ACPRmax]) C-peptide concentrations by hyperglycemic clamp. Associations were assessed using linear regression models adjusted for age and sex. Baseline included 73 adults with moderate obesity and impaired glucose tolerance or early type 2 diabetes (81% female; mean±SD age of 49±10 years., BMI 35±3 kg/m2, %BF 44±6%, VFV 3.3±1.4 L and HFF 12±8%). At baseline, BMI and HFF were significantly associated with M/I (r=-0.27 and -0.33 respectively; p≤0.02) and SSCP (r=0.26 for each; p=0.02). Adjustment for M/I eliminated the significance of the associations with SSCP (r≤0.11 for each; p>0.3). %BF and VFV were not significantly associated with M/I or β-cell measures. During follow-up, 23 subjects from the gastric banding group repeated baseline tests at 2-years after surgery. BMI, %BF, VFV and HFF decreased by 3.7±2.9 kg/m2, 3.2±3.6%, 0.6±0.7 L, and 5.0±7.2% respectively during the 2-years follow-up (all p≤0.0003). Change in BMI was significantly associated with change in M/I (r=-0.42, p=0.049) but not with changes in β-cell measures. Change in HFF was significantly associated with changes in M/I (r=-0.59, p=0.003) and ACPRmax (r=0.55, p=0.007); adjustment for change in M/I reduced the association of HFF with ACPRmax to r=0.39 (p=0.06). Changes in %BF and VFV were not significantly associated with changes in M/I or β-cell measures. Thus, changes in hepatic fat may contribute to improved insulin sensitivity and reduced secretory demand on β-cells following gastric banding. Disclosure A. Xiang: None. J. Wu: None. T. Chow: None. M.P. Martinez: None. D.H. Hwang: None. E. Trigo: None. N. Katkhouda: Consultant; Self; Bard davol, Baxter, Medtronic, Storz. E. Beale: None. K.S. Nayak: None. T.A. Buchanan: Research Support; Self; Allergan, Apollo EndoSurgery. Funding National Institutes of Health; National Institute of Diabetes and Digestive and Kidney Diseases

OBJECTIVE Type 2 diabetes (T2D) results from progressive loss of β-cell function. The BetaFat study compared gastric banding and metformin for their impact on β-cell function in adults with moderate obesity and impaired glucose tolerance (IGT) or recently diagnosed, mild T2D. RESEARCH DESIGN AND METHODS Eighty-eight people aged 21–65 years, BMI 30–40 kg/m2, with IGT or diabetes known for <1 year, were randomized to gastric banding or metformin for 2 years. Hyperglycemic clamps (11.1 mmol/L) followed by arginine injection at maximally potentiating glycemia (>25 mmol/L) were performed at baseline, 12 months, and 24 months to measure steady-state C-peptide (SSCP) and acute C-peptide response to arginine at maximum glycemic potentiation (ACPRmax) and insulin sensitivity (M/I). RESULTS At 24 months, the band group lost 10.7 kg; the metformin group lost 1.7 kg (P < 0.01). Insulin sensitivity increased 45% in the band group and 25% in the metformin group (P = 0.30 between groups). SSCP adjusted for insulin sensitivity fell slightly but not significantly in each group (P = 0.34 between groups). ACPRmax adjusted for insulin sensitivity fell significantly in the metformin group (P = 0.002) but not in the band group (P = 0.25 between groups). HbA1c fell at 12 and 24 months in the band group (P < 0.004) but only at 12 months (P < 0.01) in the metformin group (P > 0.14 between groups). Normoglycemia was present in 22% and 15% of band and metformin groups, respectively, at 24 months (P = 0.66 between groups). CONCLUSIONS Gastric banding and metformin had similar effects to preserve β-cell function and stabilize or improve glycemia over a 2-year period in moderately obese adults with IGT or recently diagnosed, mild T2D.

not comparing the disposable and reusables at the same level of protection, or they have exceeded the rated pressure for strikethrough for the reusables. The failure of 26 of 27 new reusable gowns (and zero for new disposables) should have been an immediate red flag to the fact that something was incorrect. For reusables and disposables that are designated level 3, the liquid performance is required to be the same, similarly as that for levels 2 and 4. For orthopedic implant surgery, the generally recommended gown is a level 4, and if these were not used, full strike-through protection is not unexpected. At level 4, the results would have been substantially different and no strike-through expected. In addition, the health care scientific community has agreed for the last decade that the only full consensus standard microbial challenge test methods are ASTM F1671 or AATCC 42-2000 series. The authors did not follow these. Then to put subsequent major weight on this strike-through comparison and to abandon reusables for disposables has at the least provided no incremental improvement. The conclusions and actions are just not supported by the data.

Magnetic sphincter augmentation (MSA) has demonstrated long-term safety and efficacy in the treatment of patients with gastroesophageal reflux (GERD), but its efficacy in patients with large hiatal hernias has yet to be proven. The aim of our study was to assess outcomes of MSA in patients with hiatal hernias ≥3 cm.

Protracted dysphagia and bloating are potential troublesome side effects following Nissen fundoplication. The aim of this study was to evaluate the effects of conversion from Nissen to Toupet on dysphagia and bloating.

Laparoscopic repair of large paraesophageal hernias has been challenging due to high recurrence rates with primary repair and complications associated with the use of nonabsorbable mesh to reinforce the hiatus. The aim of our study was to evaluate the recurrence rate over time and mesh-related complications using an absorbable polyglactin mesh secured with Bioglue to reinforce the hiatus after laparoscopic repair of large paraesophageal hernias. There were 190 patients who met inclusion criteria from June 2006 to June 2014. Follow-up was routinely performed at 1-year intervals, including endoscopy and/or video esophagram, and the gastroesophageal reflux disease health-related quality of life questionnaire. Mean follow-up was 21 months (3–88). There were no incidences of mesh erosion. Recurrence was detected in 17 patients (15.3%), with a median time to recurrence of 23 months (8–67). Recurrence rate was estimated with the Kaplan-Meier method to be 2.9 ± 1.6 per cent, 11.6 ± 3.7 per cent, 22.4 ± 5.6 per cent, 25.1 ± 6.0 per cent, and 29.5 ± 7.9 per cent at 12, 24, 36, 48, and 60 months, respectively. The mean gastroesophageal reflux disease health-related quality of life was 2 in patients both with and without recurrence. Laparoscopic intrathoracic stomach repair using absorbable polyglactin mesh and Bioglue for crural reinforcement is effective, safe, and durable. The rate of recurrence plateaus over time with the majority of recurrences being small to moderate asymptomatic hernias.

BACKGROUND AND OBJECTIVESGastric cancer in young patients is rare. We analyzed the clinicopathological features and prognosis of early‐onset gastric carcinoma.METHODSWe retrospectively reviewed patients with gastric adenocarcinoma aged ≤45 years and >45 years at our institution over a 17‐year period. Clinicopathological features were compared and survival analysis was performed using Kaplan‐Meier curves.RESULTSA total of 121 patients with gastric carcinoma aged ≤45 years were identified. The young group (YG) had a higher incidence of stage III/IV disease (86.8% vs. 57.9%, P < 0.001), poorly‐differentiated carcinoma (95.9% vs. 74.4%, P < 0.001), and signet‐cell type tumor (88.4% vs. 32.2%, P < 0.001) relative to the older group (OG). The majority of tumors were in the middle third of the stomach in both groups (P = 0.108). Three‐year survival in the YG was 87.1%, 32.2%, and 6.9% in stage I/II, III, and IV disease, respectively. Surgical intervention in young patients with advanced carcinoma was not associated with improved survival. Although median survival was shorter in the YG compared to the OG (11.7 vs. 41.0 months, P < 0.001), stage‐specific survival was similar.CONCLUSIONEarly‐onset gastric cancer demonstrates advanced stage of disease, and a high incidence of poorly‐differentiated and signet‐cell type carcinoma. Overall survival is poor with no added benefit to surgical intervention in advanced disease.

Laparoscopic sleeve gastrectomy (LSG) has emerged as an effective weight-loss procedure for morbid obesity that is also effective for treating comorbidities such as diabetes. However, it has been associated with the development of GERD postoperatively. The pathophysiology of post-LSG GERD is unknown, and current studies have shown conflicting results. The aim of our study is to shed light on this issue by investigating the effect of LSG on the lower esophageal sphincter (LES) function and the relationship of LES function to GERD symptoms.

Magnetic sphincter augmentation (MSA) is approved for uncomplicated GERD. Multiple studies have shown MSA to compare favorably to laparoscopic Nissen fundoplication (LNF) in terms of symptom control with results out to 5 years. The MSA device itself, however, is an added cost to an anti-reflux surgery, and direct cost comparison studies have not been done between MSA and LNF. The aim of the study was to compare charges, complications, and outcome of MSA versus LNF at 1 year.

Background: Among the extra-esophageal manifestations of GERD, dental erosion is currently considered one of the most frequent.These dental erosions have a characteristic localization and may sometimes be the first symptom of the GERD.Wireless nasopharyngeal pH metry (ResTech pH probe) is a minimally invasive device for detection of oropharyngeal acid reflux.Aim: To ascertain whether adult patients with dental erosions (DE) have a higher incidence of reflux into the nasopharynx compared with controls using the ResTech phH probe.Materials and methods: A cross-sectional study was conducted among patients whom attend to the dental service at the Health Services Research Center in our institution.Dental erosion was classified by means of severity and anatomic location, according to the Eccles and Jenkins dental (0=no erosion present [control group];grade 1=loss of surface detail, with change confined to the enamel; grade 2=exposure of dentin affecting less than one third of the crown; and 3=exposure of dentin affecting one third or more of the crown).In all subjects eating habits and dental medical history (CPO index) was obtained and GERD symptoms were assessed using the GERD-Q questionnaire and the ISR index.In all subjects a Restech Dx-pH was performed and separate pH thresholds of <5.5, 5.0, 4.5 and 4.0 were defined for reflux episodes.Number and duration of events and percent time in reflux were calculated Results: Thirty-eight patients were studied, 26 subjects with DE and 12 healthy controls (HC).There was no difference in age, gender and dental medical history (CPO index) among groups (p>0.05).DE subjects had a higher prevalence of positive GERD-Q questionnaires (92% vs 42%, p=0.002) and also higher scores (45 vs 6, p=0.01).DE subjects had more number of reflux episodes at pH 5.0 and 4.5 compared to HC (p<0.05, Figure ) .A positive correlation was found between the # of reflux episodes (pH 5.0 and 4.5) with the GERD-Q score (p=0.50 and 0.57).Conclusion: A relationship between DE and GERD was established by precise and accurate measurement of pH changes in the oral cavity using ResTech pH metry.This method could be an ideal tool for evaluation of GRED as cause of DE.

INTRODUCTION:The role of percutaneous cholecystostomy (PC) or laparoscopic cholecystectomy (LC) in the management of patients with acute cholecystitis presenting beyond 72 hours from the onset of symptoms is unclear and undefined. The aim of this study was to examine and compare the outcomes of PC or LC in the management of these patients, who failed 24 hours of initial nonoperative management.PATIENTS AND METHODS:A retrospective chart review between January 1999 and October 2010 revealed 261 patients with acute calculus cholecystitis beyond 72 hours from onset of symptoms who failed initial nonoperative management. Twenty-three of 261 (8.8%) underwent PC and were compared with a similar 1:1 matched cohort of LC, matched using sex, age, race, BMI, diabetes, and sepsis to minimize the influence of treatment selection bias.RESULTS:There was no significant difference between PC versus LC regarding morbidity [4/23 (17%) vs. 2/23 (9%), P=0.665] and mortality [3/23 (13%) vs. 0/23 (0%), P=0.233]. The length of hospital stay was significantly longer in the PC group (15.9±12.6 vs. 7.6±4.9 d, P=0.005).CONCLUSION:In this matched cohort analysis, PC failed to show a significant reduction in morbidity compared with LC and was associated with a significantly longer hospital stay.

Magnetic sphincter augmentation (MSA) of the gastroesophageal junction with the LINX Reflux Management System is an alternative to fundoplication for gastroesophageal reflux disease (GERD) that was approved by the U.S. Food and Drug Administration (FDA) in March 2012. This is a prospective observational study of all patients who underwent placement of the LINX at two institutions from April 2012 to December 2013 to evaluate our clinical experience with the LINX device after FDA approval. There were no intraoperative complications and only four mild post-operative morbidities: three urinary retentions and one readmission for dehydration. The mean operative time was 60 minutes (range, 31 to 159 minutes) and mean length of stay was 11 hours (range, 5 to 35 hours). GERD health-related quality-of-life scores were available for 83 per cent of patients with a median follow-up of five months (range, 3 to 14 months) and a median score of four (range, 0 to 26). A total of 76.9 per cent of patients were no longer taking proton pump inhibitors. The most common postoperative complaint was dysphagia, which resolved in 79.1 per cent of patients with a median time to resolution of eight weeks. There were eight patients with persistent dysphagia that required balloon dilation with improvement in symptoms. MSA with LINX is a safe and effective alternative to fundoplication for treatment of GERD. The most common postoperative complaint is mild to moderate dysphagia, which usually resolves within 12 weeks.

Background The current standard of treatment for most ventral hernias is a mesh-based repair. Little is known about the safety and efficacy of biologic versus nonbiologic grafts. A meta-analysis was performed to examine two primary outcomes: recurrence and wound complication rates. Methods Electronic databases and reference lists of relevant articles were systematically searched for all clinical trials and cohort studies published between January 1990 and January 2012. A total of eight retrospective studies, with 1,229 patients, were included in the final analysis. Results Biologic grafts had significantly fewer infectious wound complications ( p < 0.00001). However, the recurrence rates of biologic and nonbiologic mesh were not different. In subgroup analysis, there was no difference in recurrence rates and wound complications between human-derived and porcine-derived biologic grafts. Conclusions Use of biologic mesh for ventral hernia repair results in less infectious wound complications but similar recurrence rates compared to nonbiologic mesh. This supports the application of biologic mesh for ventral hernia repair in high-risk patients or patients with a previous history of wound infection only when the significant additional cost of these materials can be justified and synthetic mesh is considered inappropriate.

Single-incision laparoscopic surgery has been proposed as a minimally invasive technique with the advantages of fewer scars and reduced pain. The aim of this study was to perform a systematic review and meta-analysis of prospective randomized clinical trials of single-access laparoscopic cholecystectomy (SALC) versus classic laparoscopic cholecystectomy (CLC).All randomized controlled trials were identified through electronic searches (MEDLINE, PubMed, SAGES, and Cochrane Central Register of Controlled Trials) up to October 2011. Methodologically appropriate clinical trials identified in the search process were included in a meta-analysis to provide a pooled estimate of effect.Nine true randomized controlled trials were included in the analysis and reported a total of 695 patients, divided into the SALC group of 362 patients and the CLC group of 333 patients. Median operating time was longer with 57 minutes in SALC versus 45 minutes in CLC (P=0.00001). There was no significant difference in length of stay (SALC 1.36 d vs. CLC 1.15 d, P=0.18). Conversion to laparotomy in either group was similar; however, in 18 of 66 SALC patients an additional instrument was used, compared with 1 of 67 CLC patients (P=0.0003). Complications were not significant different [16% in SALC vs. 12% in the CLC group (P=0.74)]. Median postoperative pain with the visual analog scale score was 3.8 points in SALC versus 3.15 points in the CLC group (P=0.48). Cosmetic satisfaction was significantly more satisfying with 9 points favoring SALC versus 0 points favoring CLC (P=0.0005) in contrast to the quality-of-life questionnaire where there was no significant difference in patient overall satisfaction between SALC and CLC groups (P=0.0515).SALC required longer operative times than CLC without significant benefits in patient overall satisfaction, postoperative pain, and hospital stay. Only satisfaction with the cosmetic result showed a significantly higher preference towards SALC.