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Preoperative antipseudomonal coverage reduces postoperative abscess formation in perforated appendicitis: A 10-year experience
ALIMENTARY TRACT III 37.3 ⫾ 5.4 uA/cm2 (n ⫽ 8; p⬍0.05). This effect was inhibited by the NKCC channel inhibitor bumetanide (dIsc ⫽ 10.41 ⫾ 1.4 uA/cm2; n ⫽ 5; p⬍0.05) and is thus indicative of chloride secretion.
The use of FIBROSpect II score avoids liver biopsy in gastric bypass patients with NASH Gustavo Eugenio Guajardo MD, Hilmy Ashraf MD, MBA, FACS, Maria Martinez MD UTHSCSA, San Antonio, TX
CONCLUSIONS: This study demonstrates a previously unrecognized effect of PGF2-alpha at a tissue level. Direct activation of cAMP by PGF2-alpha represents one mechanism by which prostaglandins modulate colonic function. This has implications for the regulation of ion transport, mitogenesis, and apoptosis.
INTRODUCTION: The inability to predict liver fibrosis in bariatric patients has prompted the use of liver biopsy as the “gold standard” for diagnosis of fatty liver disease. The use of liver biopsy has complications and may be expensive. The FIBROSpect II score measures serum hyaluronic acid, alpha-2-macroglogulin, and tissue inhibitor of metalloproteinases 1 and has been used to predict liver fibrosis in patients with hepatitis C but has never been tested in morbidly obese patients. Our study was designed to analyze the utility of the FIBROSpect II score to predict liver fibrosis in patients undergoing gastric bypass.
Bariatric surgery improves male endocrine function Gavitt Alida Woodard BS, Gaurav Banka BS, John Magana Morton MD, MPH, FACS Stanford University, Stanford, CA INTRODUCTION: Morbid obesity is the leading public health epidemic of the industrialized world with bariatric surgery as the only effective and enduring treatment. Little is known about the effects of bariatric surgery on male endocrine function, while it has been demonstrated that obese men have low testosterone levels and worse prostate cancer outcomes. We hypothesized that bariatric surgery may affect testosterone and prostate-specific antigen (PSA).
METHODS: We studied 170 wedge liver biopsies taken during Roux-en-Y gastric bypass surgery in morbidly obese patients (mean BMI, 46). All patients underwent biochemical (FIBROSpect II, CBC, SMA 12, lipid profile, and vitamin D, A, and E levels) and clinical examination. RESULTS: Of 170 patients, 12 (7%) had significant fibrosis (from grade II to cirrhosis). A FIBROSpect II score of more than 20 was used as a positive test. A FIBROSpect score of more than 20 had a sensitivity of 100% and a specificity of 44% in predicting liver fibrosis and a negative predictive value of 100%. Of 170 patients, 70 had a FIBROSpect score of less than 20 and all had negative biopsies for significant liver fibrosis.
METHODS: Between 2007 and 2009, 58 consecutive male bariatric patients (45 gastric bypass, 7 gastric banding, 5 sleeve gastrectomy) were recruited to participate in a case-crossover trial. BMI, percent excess weight loss (%EWL), testosterone (ng/dL), and PSA (ng/mL) levels were recorded preoperatively and at 3, 6, and 12 months postoperatively. Analysis was performed with paired 2-sample t tests and Pearson correlations with p⬍0.05 significance.
CONCLUSIONS: Significant liver fibrosis in morbidly obese patients has a prevalence of 7%. The use of noninvasive testing like FIBROSpect II can avoid liver biopsy in at least 40% of patients undergoing bariatric surgery.
RESULTS: Mean BMI declined from 49 preoperatively to 40 (41% EWL), 36 (60%), and 32 (79%) at 3, 6, and 12 months, respectively. Matched testosterone levels rose from 270 preoperatively to 365 (45% increase), 412 (62%), and 539 (98%) at 3, 6, and 12 months. Matched PSA levels increased from 0.81 preoperatively to 1.23, 0.84, and 0.95 at 3, 6, and 12 months. All increases in testosterone and PSA were significant and were significantly correlated with weight loss.
Prostaglandin F2-alpha modulates fluid secretion in human colon Danielle Collins MB, BCh, BAO, Aisling M Hogan MRCSI, Alan W Baird PhD, Des C Winter MD, FRCSI St Vincent’s University Hospital, Dublin, Ireland
CONCLUSIONS: With patients acting as their own controls, this study demonstrates that bariatric surgery improves male endocrine function by normalizing testosterone. Furthermore, it demonstrates that PSA levels rise with weight loss indicating that PSA levels may be artificially low in obese men due to hemodilution.
INTRODUCTION: Prostanoids mediate varied functions in human colon ranging from growth regulation to inflammation. PGF2alpha, one of the primary prostanoids, is implicated in the pathogenesis of inflammatory bowel disease and colorectal cancer, yet its effects on colonic epithelial function are unknown. The aim of this study was to investigate the direct actions of PGF2-alpha on human colonic mucosa in vitro.
Preoperative antipseudomonal coverage reduces postoperative abscess formation in perforated appendicitis: A 10-year experience
METHODS: Mucosal epithelium from colectomy specimens was mounted in Ussing chambers. Ion transport was quantified as changes in short circuit current (Isc) in microamperes per cm2. Cellular cAMP levels were measured by radioimmunoassay. Institutional ethical approval was granted for this study.
Robert A Brenes MD, Shohan Shetty MD, Jose M Pimiento MD, Tung Ho, Peter Ferrante, J Alexander Palesty MD, FACS Saint Mary’s Hospital, Waterbury, CT INTRODUCTION: Patients with perforated appendicitis can develop an abscess and should receive appropriate intravenous antibiotic coverage. The goal of the study is to determine the role of Pseudomonas aeruginosa in abscess formation and if prophylactic antipseudomonal coverage is necessary in this patient population.
RESULTS: PGF2-alpha increased cellular cAMP (32.7 ⫾ 3.4 pM/ mg; P⬍0.05). In addition, PGF2-alpha produced a concentrationdependent increase in Isc with an EC50 of 130 nmol/L; mean dIsc ⫽
© 2009 by the American College of Surgeons Published by Elsevier Inc.
ISSN 1072-7515/09/$34.00
S21
S22
Surgical Forum Abstracts
METHODS: A retrospective chart review was conducted between January 1998 and December 2007. Collected data included demographics, intraoperative cultures, abscess formation, preoperative white blood cell count, preoperative and postoperative antibiotics, and presenting temperature. RESULTS: A total of 220 charts were reviewed for perforated appendicitis. 156 patients (71%) had intraoperative cultures of which 16 patients (10%) had intraoperative cultures with P aeruginosa, and 140 patients had intraoperative cultures with nonpseudomonal organisms. Postoperative abscess formation in the pseudomonal group was 31% versus 6% in the nonpseudomonal group (p⫽0.001). Fourteen patients (6%) had a postoperative abscess. In the pseudomonal group, 82% of patients (9/11) receiving preoperative antipseudomonal coverage did not develop a postoperative abscess, while 40% of patients (2/5) not receiving preoperative antipseudomonal coverage developed a postoperative abscess. The hospital stay for patients with a postoperative abscess was 10.1 days and was 6.1 days for patients with no postoperative abscess (p⫽ ⬍0.0001). CONCLUSIONS: Pseudomonas is prevalent in perforated appendicitis and is associated with an increased risk of postoperative abscess formation. Preoperative antipseudomonal coverage decreases postoperative abscess formation in this group. By preventing postoperative abscesses, the duration of hospital stay can be decreased by almost half, which can potentially reduce hospital cost; therefore, preoperative antipseudomonal coverage is recommended for patients with suspected perforated appendicitis.
Differential regulation of MMPs in ligaments at the gastroesophageal junction Lora Melman MD, Phillip Chisholm BS, John A Curci MD, Batool Arif BS, Eric Jenkins MD, Corey R Deeken PhD, Margaret Frisella RN, Kathleen Miller BS, L Michael Brunt MD, Brent D Matthews MD, FACS Washington University, St. Louis, MO INTRODUCTION: The gastroesophageal junction maintains position via the gastrohepatic ligament (GHL), gastrophrenic ligament (GPL), and the phrenoesophageal ligament (PEL). Failure of these ligamentous structures leads to hiatal hernia formation. Zincdependent matrix metalloproteinases (MMPs) are responsible for collagen remodeling and have been implicated in the development of abdominal wall hernias. The purpose of this study is to investigate the potential role of MMPs in hiatal hernia formation. METHODS: Under an institutional review board–approved protocol, biopsies of GHL, GPL, and PEL were obtained from 6 patients in each of 3 groups: patients undergoing laparoscopic anterior esophageal myotomy for achalasia (control), type I/hiatal hernia, and type III/paraesophageal hernia. Total protein extracts from the tissues were analyzed for elastases MMP-2, MMP-9, and MMP-12 and collagenases MMP-1, MMP-3, MMP-8, and MMP-13 using a multiplex profiling kit (R&D Systems, Minneapolis, MN). Data are given as mean ⫾ SEM. A 1 -way ANOVA and Tukey posttest were
J Am Coll Surg
utilized to determine whether significant differences (p⬍0.05) were observed. RESULTS: MMP-2 (p⬍0.001) and MMP-8 (p⬍0.01) were significantly elevated in type III tissues compared with type I and control for both GHL and GPL. Only MMP-2 (p⬍0.001) was significantly elevated in type III tissues compared with type I and control for PEL. MMP-1, MMP-3, MMP-12, and MMP-13 were not detectable.
CONCLUSIONS: MMP-2 and MMP-8 are significantly upregulated in the GHL and GPL in patients with type III hiatal hernia, suggesting that paraesophageal hernias may be a result of disordered collagen metabolism at the diaphragmatic hiatus.
Sex hormone levels in men undergoing bariatric surgery Juan Javier Omana MD, Ronald Tamler MD, Erica Strohmayer MD, Daniel Herron MD, Subhash Kini MD Mount Sinai School of Medicine, New York, NY INTRODUCTION: High aromatase activity in obese men results in a lower androgen-estrogen ratio, leading to sexual dysfunction and increased cardiovascular risk. Previous studies have found increased testosterone levels and improved metabolic parameters in men losing weight by dieting. METHODS: We observed a group of 10 men undergoing weight loss surgery in a prospective observational study. Clinical data and laboratory tests were collected over the course of 12 months. Patients completed a Sexual Health Inventory for Men (SHIM) questionnaire to monitor their sexual function. A t test was used to determine the statistical difference between results before and 1 year after surgery. RESULTS: Mean age was 48 years. Mean BMI decreased from 48.3 to 33.4 (P ⫽ .0006). Total testosterone almost doubled within 1 year after surgery. As expected, the men undergoing surgery lost weight; the percentage of excess weight loss was 61.48% (confidence interval [CI], 47.3875-75.5725) and had a decrease in fasting insulin and triglyceride levels. Most interesting was that total testosterone levels almost doubled, which was also mirrored in improved SHIM scores. Refer to the following table.
The use of FIBROSpect II score avoids liver biopsy in gastric bypass patients with NASH Gustavo Eugenio Guajardo MD, Hilmy Ashraf MD, MBA, FACS, Maria Martinez MD UTHSCSA, San Antonio, TX
CONCLUSIONS: This study demonstrates a previously unrecognized effect of PGF2-alpha at a tissue level. Direct activation of cAMP by PGF2-alpha represents one mechanism by which prostaglandins modulate colonic function. This has implications for the regulation of ion transport, mitogenesis, and apoptosis.
INTRODUCTION: The inability to predict liver fibrosis in bariatric patients has prompted the use of liver biopsy as the “gold standard” for diagnosis of fatty liver disease. The use of liver biopsy has complications and may be expensive. The FIBROSpect II score measures serum hyaluronic acid, alpha-2-macroglogulin, and tissue inhibitor of metalloproteinases 1 and has been used to predict liver fibrosis in patients with hepatitis C but has never been tested in morbidly obese patients. Our study was designed to analyze the utility of the FIBROSpect II score to predict liver fibrosis in patients undergoing gastric bypass.
Bariatric surgery improves male endocrine function Gavitt Alida Woodard BS, Gaurav Banka BS, John Magana Morton MD, MPH, FACS Stanford University, Stanford, CA INTRODUCTION: Morbid obesity is the leading public health epidemic of the industrialized world with bariatric surgery as the only effective and enduring treatment. Little is known about the effects of bariatric surgery on male endocrine function, while it has been demonstrated that obese men have low testosterone levels and worse prostate cancer outcomes. We hypothesized that bariatric surgery may affect testosterone and prostate-specific antigen (PSA).
METHODS: We studied 170 wedge liver biopsies taken during Roux-en-Y gastric bypass surgery in morbidly obese patients (mean BMI, 46). All patients underwent biochemical (FIBROSpect II, CBC, SMA 12, lipid profile, and vitamin D, A, and E levels) and clinical examination. RESULTS: Of 170 patients, 12 (7%) had significant fibrosis (from grade II to cirrhosis). A FIBROSpect II score of more than 20 was used as a positive test. A FIBROSpect score of more than 20 had a sensitivity of 100% and a specificity of 44% in predicting liver fibrosis and a negative predictive value of 100%. Of 170 patients, 70 had a FIBROSpect score of less than 20 and all had negative biopsies for significant liver fibrosis.
METHODS: Between 2007 and 2009, 58 consecutive male bariatric patients (45 gastric bypass, 7 gastric banding, 5 sleeve gastrectomy) were recruited to participate in a case-crossover trial. BMI, percent excess weight loss (%EWL), testosterone (ng/dL), and PSA (ng/mL) levels were recorded preoperatively and at 3, 6, and 12 months postoperatively. Analysis was performed with paired 2-sample t tests and Pearson correlations with p⬍0.05 significance.
CONCLUSIONS: Significant liver fibrosis in morbidly obese patients has a prevalence of 7%. The use of noninvasive testing like FIBROSpect II can avoid liver biopsy in at least 40% of patients undergoing bariatric surgery.
RESULTS: Mean BMI declined from 49 preoperatively to 40 (41% EWL), 36 (60%), and 32 (79%) at 3, 6, and 12 months, respectively. Matched testosterone levels rose from 270 preoperatively to 365 (45% increase), 412 (62%), and 539 (98%) at 3, 6, and 12 months. Matched PSA levels increased from 0.81 preoperatively to 1.23, 0.84, and 0.95 at 3, 6, and 12 months. All increases in testosterone and PSA were significant and were significantly correlated with weight loss.
Prostaglandin F2-alpha modulates fluid secretion in human colon Danielle Collins MB, BCh, BAO, Aisling M Hogan MRCSI, Alan W Baird PhD, Des C Winter MD, FRCSI St Vincent’s University Hospital, Dublin, Ireland
CONCLUSIONS: With patients acting as their own controls, this study demonstrates that bariatric surgery improves male endocrine function by normalizing testosterone. Furthermore, it demonstrates that PSA levels rise with weight loss indicating that PSA levels may be artificially low in obese men due to hemodilution.
INTRODUCTION: Prostanoids mediate varied functions in human colon ranging from growth regulation to inflammation. PGF2alpha, one of the primary prostanoids, is implicated in the pathogenesis of inflammatory bowel disease and colorectal cancer, yet its effects on colonic epithelial function are unknown. The aim of this study was to investigate the direct actions of PGF2-alpha on human colonic mucosa in vitro.
Preoperative antipseudomonal coverage reduces postoperative abscess formation in perforated appendicitis: A 10-year experience
METHODS: Mucosal epithelium from colectomy specimens was mounted in Ussing chambers. Ion transport was quantified as changes in short circuit current (Isc) in microamperes per cm2. Cellular cAMP levels were measured by radioimmunoassay. Institutional ethical approval was granted for this study.
Robert A Brenes MD, Shohan Shetty MD, Jose M Pimiento MD, Tung Ho, Peter Ferrante, J Alexander Palesty MD, FACS Saint Mary’s Hospital, Waterbury, CT INTRODUCTION: Patients with perforated appendicitis can develop an abscess and should receive appropriate intravenous antibiotic coverage. The goal of the study is to determine the role of Pseudomonas aeruginosa in abscess formation and if prophylactic antipseudomonal coverage is necessary in this patient population.
RESULTS: PGF2-alpha increased cellular cAMP (32.7 ⫾ 3.4 pM/ mg; P⬍0.05). In addition, PGF2-alpha produced a concentrationdependent increase in Isc with an EC50 of 130 nmol/L; mean dIsc ⫽
© 2009 by the American College of Surgeons Published by Elsevier Inc.
ISSN 1072-7515/09/$34.00
S21
S22
Surgical Forum Abstracts
METHODS: A retrospective chart review was conducted between January 1998 and December 2007. Collected data included demographics, intraoperative cultures, abscess formation, preoperative white blood cell count, preoperative and postoperative antibiotics, and presenting temperature. RESULTS: A total of 220 charts were reviewed for perforated appendicitis. 156 patients (71%) had intraoperative cultures of which 16 patients (10%) had intraoperative cultures with P aeruginosa, and 140 patients had intraoperative cultures with nonpseudomonal organisms. Postoperative abscess formation in the pseudomonal group was 31% versus 6% in the nonpseudomonal group (p⫽0.001). Fourteen patients (6%) had a postoperative abscess. In the pseudomonal group, 82% of patients (9/11) receiving preoperative antipseudomonal coverage did not develop a postoperative abscess, while 40% of patients (2/5) not receiving preoperative antipseudomonal coverage developed a postoperative abscess. The hospital stay for patients with a postoperative abscess was 10.1 days and was 6.1 days for patients with no postoperative abscess (p⫽ ⬍0.0001). CONCLUSIONS: Pseudomonas is prevalent in perforated appendicitis and is associated with an increased risk of postoperative abscess formation. Preoperative antipseudomonal coverage decreases postoperative abscess formation in this group. By preventing postoperative abscesses, the duration of hospital stay can be decreased by almost half, which can potentially reduce hospital cost; therefore, preoperative antipseudomonal coverage is recommended for patients with suspected perforated appendicitis.
Differential regulation of MMPs in ligaments at the gastroesophageal junction Lora Melman MD, Phillip Chisholm BS, John A Curci MD, Batool Arif BS, Eric Jenkins MD, Corey R Deeken PhD, Margaret Frisella RN, Kathleen Miller BS, L Michael Brunt MD, Brent D Matthews MD, FACS Washington University, St. Louis, MO INTRODUCTION: The gastroesophageal junction maintains position via the gastrohepatic ligament (GHL), gastrophrenic ligament (GPL), and the phrenoesophageal ligament (PEL). Failure of these ligamentous structures leads to hiatal hernia formation. Zincdependent matrix metalloproteinases (MMPs) are responsible for collagen remodeling and have been implicated in the development of abdominal wall hernias. The purpose of this study is to investigate the potential role of MMPs in hiatal hernia formation. METHODS: Under an institutional review board–approved protocol, biopsies of GHL, GPL, and PEL were obtained from 6 patients in each of 3 groups: patients undergoing laparoscopic anterior esophageal myotomy for achalasia (control), type I/hiatal hernia, and type III/paraesophageal hernia. Total protein extracts from the tissues were analyzed for elastases MMP-2, MMP-9, and MMP-12 and collagenases MMP-1, MMP-3, MMP-8, and MMP-13 using a multiplex profiling kit (R&D Systems, Minneapolis, MN). Data are given as mean ⫾ SEM. A 1 -way ANOVA and Tukey posttest were
J Am Coll Surg
utilized to determine whether significant differences (p⬍0.05) were observed. RESULTS: MMP-2 (p⬍0.001) and MMP-8 (p⬍0.01) were significantly elevated in type III tissues compared with type I and control for both GHL and GPL. Only MMP-2 (p⬍0.001) was significantly elevated in type III tissues compared with type I and control for PEL. MMP-1, MMP-3, MMP-12, and MMP-13 were not detectable.
CONCLUSIONS: MMP-2 and MMP-8 are significantly upregulated in the GHL and GPL in patients with type III hiatal hernia, suggesting that paraesophageal hernias may be a result of disordered collagen metabolism at the diaphragmatic hiatus.
Sex hormone levels in men undergoing bariatric surgery Juan Javier Omana MD, Ronald Tamler MD, Erica Strohmayer MD, Daniel Herron MD, Subhash Kini MD Mount Sinai School of Medicine, New York, NY INTRODUCTION: High aromatase activity in obese men results in a lower androgen-estrogen ratio, leading to sexual dysfunction and increased cardiovascular risk. Previous studies have found increased testosterone levels and improved metabolic parameters in men losing weight by dieting. METHODS: We observed a group of 10 men undergoing weight loss surgery in a prospective observational study. Clinical data and laboratory tests were collected over the course of 12 months. Patients completed a Sexual Health Inventory for Men (SHIM) questionnaire to monitor their sexual function. A t test was used to determine the statistical difference between results before and 1 year after surgery. RESULTS: Mean age was 48 years. Mean BMI decreased from 48.3 to 33.4 (P ⫽ .0006). Total testosterone almost doubled within 1 year after surgery. As expected, the men undergoing surgery lost weight; the percentage of excess weight loss was 61.48% (confidence interval [CI], 47.3875-75.5725) and had a decrease in fasting insulin and triglyceride levels. Most interesting was that total testosterone levels almost doubled, which was also mirrored in improved SHIM scores. Refer to the following table.