Objective The aim of the Acromegaly Consensus Group was to revise and update the consensus on diagnosis and treatment of acromegaly comorbidities last published in 2013. Participants The Consensus Group, convened by 11 Steering Committee members, consisted of 45 experts in the medical and surgical management of acromegaly. The authors received no corporate funding or remuneration. Evidence This evidence-based consensus was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence following critical discussion of the current literature on the diagnosis and treatment of acromegaly comorbidities. Consensus Process Acromegaly Consensus Group participants conducted comprehensive literature searches for English-language papers on selected topics, reviewed brief presentations on each topic, and discussed current practice and recommendations in breakout groups. Consensus recommendations were developed based on all presentations and discussions. Members of the Scientific Committee graded the quality of the supporting evidence and the consensus recommendations using the GRADE system. Conclusions Evidence-based approach consensus recommendations address important clinical issues regarding multidisciplinary management of acromegaly-related cardiovascular, endocrine, metabolic, and oncologic comorbidities, sleep apnea, and bone and joint disorders and their sequelae, as well as their effects on quality of life and mortality.

Prophylactic cefazolin, given as a single 2 g (IV bolus 3-5 min before skin incision) was more than adequate in providing protective cefazolin levels for the duration of bariatric surgery. Cefazolin 2 g (IV dose bolus given just before skin incision) achieves protective adipose tissue levels (> MIC of MSSA) for the duration (usually < 4 h) of bariatric surgical procedures. In this study, cefazolin 2 g (IV bolus) provided protective adipose tissue levels for 4.8 h. Since cefazolin is a water soluble antibiotic (V = 0.2 L/Kg), penetration into adipose tissue is not V not dose-dependent. Extremely high-dosed cefazolin, i.e., 3 or 4 g is excessive and unnecessary for bariatric surgery prophylaxis. A single cefazolin 2 g preoperative dose also eliminates the need for intraoperative redosing at 4 h.

ABSTRACT. We present an 80-year-old man with multiple medical problems, and acute abdominal pain with feculent emesis. An unenhanced CT examination of the abdomen and pelvis demonstrated jejunal diverticulitis and findings of high-grade small bowel obstruction caused by a large enterolith. Enterolith ileus has rarely been reported in the radiology literature. This phenomenon has occasionally been reported in the surgical and gastroenterology literature. We highlight the CT findings associated with enterolith ileus in the setting of jejunal diverticulitis, to alert radiologists to this unusual diagnosis. Case reportWe present an 80-year-old man with a medical history of hypertension, diabetes, left below-the-knee amputation for arterial disease, coronary arterial stent placement, myocardial infarction, Parkinson's dementia and splenectomy. The patient presented with a 1 day history of sharp, non-radiating left lower quadrant abdominal pain and feculent emesis. The patient was afebrile on presentation. Laboratory values were notable for a leukocytosis of 27 000 and acute renal failure.An unenhanced CT examination of the abdomen and pelvis was performed to evaluate the patient's abdominal pain. The study demonstrated a large-mouth jejunal diverticulum measuring 4.1 cm by 3.9 cm (Figure 1a,b,d,e). There was inflammation and oedema of the mesentery. The findings were diagnostic of jejunal diverticulitis. A second, although not inflamed, jejunal diverticulum was noted proximally (Figure 1c). Additionally, there was a 2.9 cm by 2.1 cm lamellated and partially-calcified enterolith (Figure 2a-d). The enterolith was not located within the above-mentioned inflamed jejunal diverticulum; however, it was noted more distally within the mid-small bowel lumen causing a high-grade small bowel obstruction with a transition point at the enterolith. Collapsed small bowel loops were noted distally. CT examination from 7 years earlier showed the jejunal diverticula in retrospect although they were smaller and did not contain any enteroliths (not shown). The CT findings were then prospectively reviewed with the attending surgeon.A nasogastric tube was then placed, and approximately 1.5 l of feculent material was removed. The patient underwent laparoscopic abdominal surgery which was subsequently converted to an exploratory laparotomy after finding adherent loops of small bowel, scarring and adhesions secondary to the patient's remote splenectomy. After running the small bowel proximal to the transition point of obstruction, an enterolith was palpated and was milked intraluminally to a proximal loop of jejunum, which was also noted to have a gross perforation at the inflamed jejunal diverticular site. A 38 cm segment of small bowel was resected. Pathological evaluation of the resected small bowel demonstrated chronic diverticular disease, an ulcerated/perforated diverticulum, mesenteric microabscesses and a 3 cm enterolith. The patient was post-operatively managed in the surgical intensive care unit secondary to intra-operative hypoten...

Many patients with hiatal hernias (HH) are asymptomatic; however, symptoms may include heartburn, regurgitation, dysphagia, nausea, or vague epigastric pain depending on the hernia type and severity. the ideal technique and timing of repair remains controversial. this report describes short-term outcomes and readmissions of patients undergoing HH repair at our institution. All patients who underwent HH repair from January 2012 through April 2017 were reviewed. Patients undergoing concomitant bariatric surgery were excluded. 239 patients were identified and 128 were included. Eighty-eight were female (69%) and 40 were male (31%) with a mean age of 59 years (range 20-91 years) and a mean BMI of 29.2 kg/m 2 (17-42). Worsening GERD was the most common presenting symptom in 79 (61.7%) patients. Eighty-four laparoscopic cases (65.6%) and 44 robotic assisted (34.4%) procedures were performed. Mesh was used in 59 operations (3 polytetrafluoroethylene; 56 biologic). All hiatal hernia types (I-IV) were collected. Majority were initial operations (89%). Techniques included: Toupet fundoplication in 68 cases (63.0%), Nissen fundoplication in 36 (33.3%), Dor fundoplication in 4 (3.7%), concomitant Collis gastroplasty in 4 (3.1%), and primary suture repair in 20 (15.6%). Outcomes between robotic and laparoscopic procedures were compared. Length of stay was reported as median and interquartile range for laparoscopic and robotic: 1.0 day (1.0-3.0) and 2.0 days (1.0-2.5); p = 0.483. Thirty-day readmission occurred in 9 patients, 7 (8.3%) laparoscopic and 2 (4.6%) robotic; p = 0.718. Two 30-day reoperations occurred, both laparoscopic; p = 0.545. Total of 16 complications occurred; 18.6% had a complication with the use of mesh compared to 8.7% without the use of mesh, p = 0.063. there were no conversion to open modality and no mortalities were reported. Hiatal hernia repair can be performed safely with a low incidence of complications.

Background and Objectives:Paraesophageal hiatal hernia repair can be performed with or without mesh reinforcement. The use, technique, and mesh type remain controversial because of mixed reports on mesh-related complications. Short-term outcomes have become important in all forms of surgery.Methods:From January 2012 through April 2017, all patients who underwent isolated hiatal hernia repair in our center were reviewed. Concomitant bariatric surgery cases were excluded. Repairs reinforced by porcine urinary bladder matrix (UBM) graft were compared to non-UBM repairs. Statistical comparison was based on a Wilcoxon 2-sample test or Fisher's exact test.Results:We reviewed 239 charts; 110 bariatric cases and 8 cases with non-UBM reinforcement were excluded. We identified 121 patients: 56 UBM-reinforced (46.3%) versus 65 non-UBM (53.7%). Sixteen (28.6%) UBM cases were male versus 23 (35.4%) non-UBM cases. The UBM patients were significantly older (63.9 versus 54.3; P = .001). There was no difference in mean BMI (29.6 vs 28.5; P = .28). Cases were performed laparoscopically (60.7% vs 67.7%; P = .45) or robotically (39.3% vs 32.3%; P = .45), with no conversions to open. The UBM group had a longer mean operative time (183 minutes vs 139 minutes; P = .001).There was no difference in median length of stay (2 days vs 2 days; P = .09) or 30-day readmission rate (7.1% vs 7.5%; P =.99). Postoperative complications were graded according to the Clavien-Dindo classification, and there was no difference (19.6% vs 9.2%; P = .12).Conclusions:Hiatal hernia repair with UBM reinforcement can be performed safely with no increase in postoperative complications.

Thirty years ago, a hypothesis stating that preoperative shrinkage of growth hormone (GH) producing macroadenomas with somatostatin receptor ligands (SRLs) may improve surgical outcome was put forward. Since then, multiple retrospective, non-randomized studies as well as four contemporary prospective, randomized studies have been performed to evaluate the validity of that hypothesis and are critically reviewed in this manuscript. With the exception of an occasional retrospective study the great preponderance of evidence could not confirm this hypothesis. Similarly, while all prospective studies suggested better surgical outcome for SRL-pretreated tumors 3 months post surgery, the differences in outcomes between pretreated and untreated control patients disappeared after 6–12 months. Thus, preoperative treatment of macrosomatotropinomas with SRLs should not be relied upon as a means to achieve complete tumor removal and cannot be recommended.

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