Faculty Bibliography

INTRODUCTION/BACKGROUND:Acetaminophen (APAP) toxicity is the main cause of acute liver failure in the United States. A prior series (1992-1995) identified 71 hospitalized adults with APAP toxicity through the International Statistical Classification of Disease and Related Health Problems, 9th revision (ICD-9) code at Parkland Hospital, Dallas, TX. METHODS:We used a laboratory database search of serum APAP levels from 2011 to 2015 to identify patients with APAP toxicity in the same hospital. RESULTS:We identified 140 patients hospitalized for APAP toxicity from 27,143 APAP levels obtained; 35 required Intensive Care Unit (ICU) admission, and there were no deaths. APAP toxicity/100,000 admissions was similar between eras. DISCUSSION/CONCLUSIONS:APAP toxicity continues unabated after 20 years but with improved overall outcomes.

BACKGROUND: Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG. METHODS: A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls. RESULTS: Of 1762 LSG operations, 20 (1.1 %) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean = 1.3 days, range (1, 2)], while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89 %). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95 % CI (4.04, 68.10), p < 0.0001], SIRS criteria [OR 7.0, 95 % CI (1.47, 33.26), p = 0.014], and pain score >/=9 [OR 19.1, 95 % CI (1.38, 263.87), p = 0.028]. CONCLUSIONS: Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2-3 weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.

INTRODUCTION: Weight loss after laparoscopic adjustable gastric banding (LAGB) can be influenced by a variety of factors. The objective of this study is to investigate whether the maximum amount of previous weight loss with diet and exercise, prior to evaluation for bariatric surgery, is predictive of postoperative weight loss success among primary LAGB patients. METHODS: A retrospective cohort study was designed from a prospectively collected database at a single institution. Inclusion criteria consisted of age >/=18 years, initial body mass index (BMI) >/=35 kg/m2, intake information on the maximum weight loss at any time prior to referral to our bariatric practice, and at least 2 years of postoperative follow-up. Patients with prior bariatric surgery were excluded. Outcomes included mean % excess weight loss (EWL), percent that achieved weight loss success (%EWL >/= 40), and percent with suboptimal weight loss (%EWL < 20) at 2 years post-LAGB. RESULTS: In the study, 462 primary LAGB patients were included. Mean previous weight loss was 29.7 lb (SD 27.6, range 0-175). These patients were divided into four previous weight loss groups (0, 1-20, 21-50, >50 lb) for analysis. In adjusted multivariate analyses, patients with >50 lb of maximum previous weight loss had a significantly higher mean %EWL, (p < 0.0001) and %BMIL (p < 0.0001), were more likely to reach weight loss success (>/=40 % EWL, p = 0.047), and were less likely to experience suboptimal weight loss (<20 % EWL, p = 0.027) at 2 years postoperatively. CONCLUSION: Previous weight loss appears to be a significant predictor of weight loss after LAGB. With multiple options for weight loss surgery, this study helps elucidate which patients may be more likely to achieve greater weight loss with the LAGB, allowing clinicians to appropriately counsel patients preoperatively.

BACKGROUND: Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy. METHODS: A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 2014 were included. The performance of intraoperative leak testing and the type of test (air or methylene blue) were based on surgeon preference. Data obtained included BMI, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses. RESULTS: A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8 %), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7 %) cases, while 221 (14.3 %) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1 %) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1 %, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1-67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative. CONCLUSION: Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.