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PROBLEM - Premature birth complicates 10%-12% of deliveries. Infection and inflammation are the most common etiologies and are associated with increased offspring morbidity and mortality. We hypothesize that lipopolysaccharide (LPS)-induced maternal inflammation causes direct placenta injury and subsequent injury to the fetal intestine.
METHOD OF STUDY - Pregnant C57Bl6 mice were injected intraperitoneally on day 15.5 with 100 μg/kg LPS or saline. Maternal serum, amniotic fluid, placental samples, and ileal samples of offspring were obtained assessed for inflammation and/or injury. Maternal placental ultrasounds were performed. Placental DNA was isolated for microbiome analysis.
RESULTS - Maternal injection with LPS caused elevated IL-1β, IL-10, IL-6, KC-GRO, and TNF. Placental tissue showed increased IL-1β, IL-6, and KC-GRO and decreased IL-10, but no changes were observed in amniotic fluid. Placental histology demonstrated LPS-induced increases in mineralization and necrosis, but no difference in placental blood flow. Most placentas had no detectable microbiome. Exposure to maternal LPS induced significant injury to the ilea of the offspring.
CONCLUSION - Lipopolysaccharide causes a maternal inflammatory response that is mirrored in the placenta. Placental histology demonstrates structural changes; however, placental blood flow is preserved. LPS also induces an indirect intestinal injury in the offspring that lasts beyond the neonatal period.
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Importance - Low health literacy is known to adversely affect health outcomes in patients with chronic medical conditions. To our knowledge, the association of health literacy with postoperative outcomes has not been studied in-depth in a surgical patient population.
Objective - To evaluate the association of health literacy with postoperative outcomes in patients undergoing major abdominal surgery.
Design, Setting, and Participants - From November 2010 to December 2013, 1239 patients who were undergoing elective gastric, colorectal, hepatic, and pancreatic resections for both benign and malignant disease at a single academic institution were retrospectively reviewed. Patient demographics, education, insurance status, procedure type, American Society of Anesthesiologists status, Charlson comorbidity index, and postoperative outcomes, including length of stay, emergency department visits, and hospital readmissions, were reviewed from electronic medical records. Health literacy levels were assessed using the Brief Health Literacy Screen, a validated tool that was administered by nursing staff members on hospital admission. Multivariate analysis was used to determine the association of health literacy levels on postoperative outcomes, controlling for patient demographics and clinical characteristics.
Main Outcomes and Measures - The association of health literacy with postoperative 30-day emergency department visits, 90-day hospital readmissions, and index hospitalization length of stay.
Results - Of the 1239 patients who participated in this study, 624 (50.4%) were women, 1083 (87.4%) where white, 96 (7.7%) were black, and 60 (4.8%) were of other race/ethnicity. The mean (SD) Brief Health Literacy Screen score was 12.9 (SD, 2.75; range, 3-15) and the median educational attainment was 13.0 years. Patients with lower health literacy levels had a longer length of stay in unadjusted (95% CI, 0.95-0.99; P = .004) and adjusted (95% CI, 0.03-0.26; P = .02) analyses. However, lower health literacy was not significantly associated with increased rates of 30-day emergency department visits or 90-day hospital readmissions.
Conclusions and Relevance - Lower health literacy levels are independently associated with longer index hospitalization lengths of stay for patients who are undergoing major abdominal surgery. The role of health literacy needs to be further evaluated within surgical practices to improve health care outcomes and use.
BACKGROUND - Magnetic compression anastomosis (magnamosis) uses a pair of self-centering magnetic Harrison Rings to create an intestinal anastomosis without sutures or staples. We report the first-in-human case series using this unique device.
STUDY DESIGN - We conducted a prospective, single-center, first-in-human pilot trial to evaluate the feasibility and safety of creating an intestinal anastomosis using the Magnamosis device. Adult patients requiring any intestinal anastomosis to restore bowel continuity were eligible for inclusion. For each procedure, 1 Harrison Ring was placed in the lumen of each intestinal segment. The rings were brought together and mated, and left to form a side to side, functional end to end anastomosis. Device movement was monitored with serial x-rays until it was passed in the stool. Patients were monitored for adverse effects with routine clinic appointments, as well as questionnaires.
RESULTS - Five patients have undergone small bowel anastomosis with the Magnamosis device. All 5 patients had severe systemic disease and underwent complex open urinary reconstruction procedures, with the device used to restore small bowel continuity after isolation of an ileal segment. All devices passed without obstruction or pain. No patients have had any complications related to their anastomosis, including anastomotic leaks, bleeding, or stricture at median follow-up of 13 months.
CONCLUSIONS - In this initial case series from the first-in-human trial of the Magnamosis device, the device was successfully placed and effectively formed a side to side, functional end to end small bowel anastomosis in all 5 patients. No patients have had any anastomotic complications at intermediate follow-up.
Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
PURPOSE - Meckel diverticula containing gastric heterotopia predispose to local hyperacidity, mucosal ulceration, and gastrointestinal bleeding in children. Eradication of acid-producing oxyntic cells is performed by either of two surgical methods: segmental enterectomy including the diverticulum or diverticulectomy only.
METHODS - Retrospective review of all children having surgical resection of a Meckel diverticulum at a tertiary-referral children's hospital from 2002 to 2016 was performed. Demographic data, surgical method, pathological specimens, and outcomes were evaluated.
RESULTS - 102 children underwent surgical resection of a Meckel diverticulum during the study period. 27 (26.5%) children presented with bleeding, of which 16 (59%) had diverticulectomy only, and 11 (41%) had segmental ileal resection. All Meckel diverticula in children presenting with bleeding contained gastric heterotopia, and resection margins were free of gastric mucosa. Histologically, 19 specimens showed microscopic features of ulceration, on average 2.95mm (SD 4.49) from the nearest gastric mucosa (range: 0-16mm). Mean length of hospitalization after ileal resection was 4.0days (SD 1.2) compared to 1.6days (SD 0.9) for diverticulectomy only (p<0.001), with no re-bleeding occurrences.
CONCLUSION - In the operative management of children having a bleeding Meckel diverticulum, diverticulectomy-only completely eradicates gastric heterotopia without increased risk of continued bleeding or complications and significantly shortens hospitalization.
LEVEL OF EVIDENCE - Treatment Study: Level III.
Copyright © 2017 Elsevier Inc. All rights reserved.
INTRODUCTION - Sacral neuromodulation (SNM) remains one of the few effective treatments for refractory bladder and bowel dysfunction. However, SNM is associated with frequent need for surgical intervention, in many cases because of a failed battery. A rechargeable SNM system, with a manufacturer-reported battery life of 15 years or more, has entered post-market clinical testing in Europe but has not yet been approved for clinical testing in the United States. Areas covered: We review existing neuromodulation technologies for the treatment of lower urinary tract and bowel dysfunction and explore the limitations of available technology. In addition, we discuss implantation technique and device specifications and programming of the rechargeable SNM system in detail. Lastly, we present existing evidence for the use of SNM in bladder and bowel dysfunction and evaluate the anticipated trajectory of neuromodulation technologies over the next five years. Expert commentary: A rechargeable system for SNM is a welcome technological advance. However surgical revision not related to battery changes is not uncommon. Therefore, while a rechargeable system would be expected to reduce costs, it will not eliminate the ongoing maintenance associated with neuromodulation. No matter the apparent benefits, all new technologies require extensive post-market monitoring to ensure safety and efficacy.
BACKGROUND - Anastomotic leak is one of the most feared complications of gastrointestinal surgery. Surgeons routinely perform a diverting loop ileostomy (DLI) to protect high-risk colo-rectal anastomoses.
STUDY DESIGN - The NSQIP database was queried from 2012 to 2013 for patients undergoing open ileo-colic resection with and without a DLI. The primary outcome was the development of any anastomotic leak-including those managed operatively and non-operatively. Secondary outcomes included overall complication rate, return to the OR, readmission, and 30-day mortality.
RESULTS - Four thousand one hundred fifty-nine patients underwent open ileo-colic resection during the study period. One hundred eighty-six (4.5 %) underwent a DLI. Factors associated with the addition of a DLI included emergency surgery, pre-operative sepsis, and IBD. There were 197 anastomotic leaks (4.7 %) with 100 patients requiring reoperation (2.4 %). DLI was associated with a decrease in anastomotic leaks requiring reoperation (DLI vs no DLI: 0 (0 %) vs 100 (2.5 %); p = 0.02) and with increased readmission (OR 1.93; 95 % CI 1.30-2.85; p = 0.001).
CONCLUSION - DLI is rarely used for open ileo-colic resection. There were no serious leaks requiring reoperation in the DLI group. A DLI was associated with an almost two-fold increase in the odds of readmission. Surgeons must weigh the reduction in serious leak rate with postoperative morbidity when considering a DLI for open ileo-colic resection.
BACKGROUND - Colonic obstruction is a surgical emergency, and delay in decompression results in added morbidity and mortality. Advances have led to less invasive procedures such as stenting as a bridge for definitive surgery. The aim of this article was to perform a systematic review regarding colon obstruction (malignant or benign) and to provide recommendations following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework.
METHODS - A systematic literature review was conducted using the PubMed, EMBASE, and the Cochrane Library databases of published studies. The search was last performed on January 2, 2015. Two independent reviewers extracted the desired variables from the studies. For our meta-analysis, we used Review Manager X.6 (RevMan). Recommendations are provided using GRADE methodology. A single POPULATION, Intervention, Comparator, Outcome (PICO) question with two outcomes was addressed as follows:
POPULATION - in adult patients with a colonic obstruction (malignant or benign).
INTERVENTION - should surgery be performed.Comparator: versus endoscopic stenting.
OUTCOMES - decreased mortality and decreased emergency, nonplanned procedures?
RESULTS - The search yielded 210 results. Screening of the titles excluded 102 articles, leaving 108 for review. After abstract review, 71 additional articles were excluded because of failure to address the PICO questions of this guideline. Thirty-seven articles were reviewed in their entirety, of those six randomized control trials that evaluated the use of stents versus emergency surgery in colonic obstruction caused by malignant disease were included in the final qualitative review.
CONCLUSION - We conditionally recommend endoscopic, colonic stenting (if available) as initial therapy for colonic obstruction. In our review, stent use was associated with decreased mortality and rates for emergency, nonplanned procedures to include reoperations. This conditional recommendation is limited to those with malignancy because of the lack of literature supporting this practice in benign colonic disease.
BACKGROUND - Gastric contractions are coordinated by slow waves, generated by interstitial cells of Cajal (ICC). Gastric surgery affects slow wave conduction, potentially contributing to postoperative gastric dysfunction. However, the impact of gastric cuts on slow waves has not been comprehensively evaluated. This study aimed to define consequences of surgical excisions on gastric slow waves by applying high-resolution (HR) electrical mapping and in silico modeling.
METHODS - Patients undergoing gastric stimulator implantation (n = 10) underwent full-thickness stapled excisions (25 × 15 mm, distal corpus) for histological evaluation, enabling HR mapping (256 electrodes; 36 cm(2) ) over and adjacent to excisions. A biophysically based in silico model of bidirectionally coupled ICC networks was developed and applied to investigate the underlying conduction mechanisms and importance of excision orientation.
KEY RESULTS - Normal gastric slow waves propagated aborally (3.0 ± 0.2 cpm). Excisions induced complete conduction block and wavelets that rotated around blocks, then propagated rapidly circumferentially distal to the blocks (8.5 ± 1.2 vs normal 3.6 ± 0.4 mm/s; p < 0.01). This 'conduction anisotropy' homeostatically restored antegrade propagating gastric wavefronts distal to excisions. Excisions were associated with complex dysrhythmias in five patients: retrograde propagation (3/10), ectopics (3/10), functional blocks (2/10), and collisions (1/10). Simulations demonstrated conduction anisotropy emerged from bidirectional coupling within ICC layers and showed transverse incision length and orientation correlated with the degree of conduction distortion.
CONCLUSIONS & INFERENCES - Orienting incisions in the longitudinal gastric axis causes least disruption to electrical conduction and motility. However, if transverse incisions are made, a homeostatic mechanism of gastric conduction anisotropy compensates by restoring aborally propagating wavefronts. Complex dysrhythmias accompanying excisions could modify postoperative recovery in susceptible patients.
© 2015 John Wiley & Sons Ltd.
Achalasia is an esophageal motility disorder that is commonly misdiagnosed initially as gastroesophageal reflux disease. Patients with achalasia often complain of dysphagia with solids and liquids but may focus on regurgitation as the primary symptom, leading to initial misdiagnosis. Diagnostic tests for achalasia include esophageal motility testing, esophagogastroduodenoscopy and barium swallow. These tests play a complimentary role in establishing the diagnosis of suspected achalasia. High-resolution manometry has now identified three subtypes of achalasia, with therapeutic implications. Pneumatic dilation and surgical myotomy are the only definitive treatment options for patients with achalasia who can undergo surgery. Botulinum toxin injection into the lower esophageal sphincter should be reserved for those who cannot undergo definitive therapy. Close follow-up is paramount because many patients will have a recurrence of symptoms and require repeat treatment.
OBJECTIVE - To describe the presence of laryngeal eosinophils and associated symptomatology in patients with aerodigestive dysfunction.
STUDY DESIGN - Case series with chart review.
SETTING - Single tertiary pediatric referral center.
SUBJECTS - Eighty-one consecutive pediatric patients referred to a multidisciplinary aerodigestive clinic with upper airway concerns.
METHODS - Microlaryngoscopy and posterior arytenoid biopsy, flexible bronchoscopy, esophagogastroduodenoscopy and esophageal biopsy, and impedance probe testing were performed as indicated by clinical symptoms. Positive versus negative posterior arytenoid biopsy for eosinophils and the presence or absence of concomitant histopathological laryngitis and/or esophagitis were measured.
RESULTS - Nine of 81 (11%) patients had positive laryngeal biopsy for eosinophils (range, 1-29 eosinophils/high-powered field [HPF]). Three of these 9 patients also had concurrent biopsy-proven eosinophilic esophagitis, while 8 of 81 total patients had biopsy-proven eosinophilic esophagitis. The frequency of biopsy-proven eosinophilic esophagitis was higher in patients with posterior arytenoid eosinophils versus patients without laryngeal eosinophils (33% versus 6.9%, P = .0408).
CONCLUSIONS - Eosinophilic inflammation in the larynx has not been described in children with complex aerodigestive complaints. Posterior arytenoid eosinophils may serve as a marker of chronic laryngeal inflammation in children with aerodigestive dysfunction, although their exact role in this inflammation remains unclear. In our population, >15 eosinophils/HPF within posterior arytenoid biopsies was associated with concomitant eosinophilic esophagitis.
© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.