Weight loss following gastric bypass results in profound improvement in OSA. The severity of apnea cannot be reliably predicted by preoperative BMI and ESS; therefore, patients with symptoms of OSA should undergo polysomnography.

Operative treatment of clinically severe obesity reduces obesity-related expenditures and utilization of healthcare resources. The cost of undertaking RYGBP at the VA is offset by reduction of health-care costs within the first year after surgery. These data support allocation of resources to support existing bariatric surgery programs throughout the VA system.

Medical students' knowledge about obesity is significantly improved by rotation on a bariatric surgery program and not during rotations on other clinical disciplines. Medical school curricula should be changed to reflect the growing epidemic of obesity and enhance students' knowledge about obesity as a disease.

✓Nelson syndrome (NS) is a rare clinical manifestation of an enlarging pituitary adenoma that can occur following bilateral adrenal gland removal performed for the treatment of Cushing disease. It is characterized by excess adreno-corticotropin secretion and hyperpigmentation of the skin and mucus membranes. The authors present a comprehensive review of the pathophysiology, diagnosis, and management of NS. Corticotroph adenomas in NS remain challenging tumors that can lead to significant rates of morbidity and mortality. A better understanding of the natural history of NS, advances in neurophysiology and neuroimaging, and growing experience with surgical intervention and radiation have expanded the repertoire of treatments. Currently available treatments include surgical, radiation, and medical therapy. Although the primary treatment for each tumor type may vary, it is important to consider all of the available options and select tthe one that is most appropriate for the individual case, particularly in cases of lesions resistant to intervention.

Laparoscopic esophageal diverticulectomy, Heller myotomy, and partial fundoplication with intraoperative endoscopy safely reduce dysphagia associated with achalasia and esophageal diverticula while limiting symptoms of gastroesophageal reflux.

Alzheimer's disease (AD) is the most common form of dementia among the aging population and is characterized pathologically by the progressive intracerebral accumulation of ␤-amyloid (A␤) peptides and neurofibrillary tangles. The level of proangiogenic growth factors and inflammatory mediators with proangiogenic activity is known to be elevated in AD brains which has led to the supposition that the cerebrovasculature of AD patients is in a proangiogenic state. However, angiogenesis depends on the balance between proangiogenic and antiangiogenic factors and the brains of AD patients also show an accumulation of endostatin and A␤ peptides which have been shown to be antiangiogenic. To determine whether angiogenesis is compromised in the brains of two transgenic mouse models of AD overproducing A␤ peptides (Tg APPsw and Tg PS1/APPsw mice), we assessed the growth and vascularization of orthotopically implanted murine gliomas since they require a high degree of angiogenesis to sustain their growth. Our data reveal that intracranial tumor growth and angiogenesis is significantly reduced in Tg APPsw and Tg PS1/APPsw mice compared with their wild-type littermates. In addition, we show that A␤ inhibits the angiogenesis stimulated by glioma cells when cocultured with human brain microvascular cells on a Matrigel layer. Altogether our data suggest that the brain of transgenic mouse models of AD does not constitute a favorable environment to support neoangiogenesis and may explain why vascular insults synergistically precipitate the cognitive presentation of AD.

ELSON syndrome is a rare clinical manifestation of an enlarging pituitary adenoma that can occur following bilateral adrenalectomy performed in the treatment of CD. It is characterized by skin and mucus membrane hyperpigmentation and excess ACTH secretion. Diagnostic criteria for NS have been quite variable. Some authors 77 have defined NS as high levels of ACTH associated with skin hyperpigmentation after bilateral adrenalectomy regardless of pituitary enlargement, 80 whereas others consider the presence of an expanding pituitary adenoma causing visual field disturbance as a requirement for diagnosis. 114 With modern day imaging, and for the purposes of this review, corticotroph tumor progression and high ACTH have been proposed as a basis for the diagnosis of NS. 4 Historical Perspective The first suggestion that the adrenal gland was essential for life came from Brown-Séquard, who showed in the 1850s that bilateral adrenalectomy in animals caused death within a few days. 66 Harvey Cushing 13 was the first to link adrenal hypersecretion of cortisol to the presence of a pituitary tumor. The concept of the hypothalamic-pituitary-adrenal axis evolved further with the demonstration of the existence of ACTH-releasing factor in 1955 by Saffran and Schally. 98 The first case report of the characteristic triad of NS was published by Don Nelson in 1958. 78 He described a 33-year-old woman who developed marked skin hyperpigmentation, high plasma ACTH levels, and imaging evidence of a pituitary tumor (enlarged sella on skull radiographs) 3 years after bilateral adrenalectomy for CD. In 1960, Nelson and colleagues 79 formally described the syndrome of pituitary hypersecretion of ACTH and pituitary tumor enlargement, which has since become the eponymous syndrome. Corticotropin-releasing hormone was finally isolated and sequenced by Vale and coworkers in 1981, 113 and with the availability of radioimmunoassay, the elevation of plasma ACTH levels after bilateral adrenalectomy became diagnostic for NS. Historically, patients with CD were treated with bilateral

There is consensus that laparoscopic bariatric surgery should be undertaken only by surgeons with strong interest in bariatric surgery. Laparoscopic bariatric surgeons should incorporate lessons learned from open surgery. Both laparoscopic and open bariatric surgeons should seek added expertise via courses and preceptorships. The skepticism of surgeons with 'open' practices could be addressed by clinical trials. The ASBS should maintain its leadership position and foster emerging technologies.