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During fiscal crisis there was a period of shortage of staplers in our hospital, which drove us to manual suturing of bronchi and pulmonary vessels during major lung resections. We present our experience during that period in comparison to a subsequent period when staplers became available again. A total of 256 lobectomies and 78 pneumonectomies using manual suturing (group A) were performed between September 2009 and September 2010, and were compared regarding surgical outcome with 248 lobectomies and 60 pneumonectomies using staplers (group B), performed between September 2011 and September 2012. Although we did not observe statistically significant differences but only a trend toward shorter operative time, for both lobectomies (P ¼ 0.21) and pneumonectomies (P ¼ 0.31) we actually noted savings of 41 and 47 minutes, respectively, in operative time using staplers (group B), in comparison with manual suturing (group A). We also observed a trend toward lower morbidity rates in group B patients who underwent lobectomy (10.48%) and pneumonectomy (20%) versus group A patients who underwent lobectomy (15.62%) and pneumonectomy (30.76%); we did not observe any substantial differences in the other surgical outcome variables, in patients' demographic, comorbidities, or in anatomic allocation of surgical procedures performed. The use of staplers offers safety with secure bronchial or vascular sealing, as well as reduction of operative time. Their unavailability at an interval during fiscal crisis, although it did not affect surgical outcome, revealed their usefulness and value.

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INTRODUCTION:In patients with inflammatory bowel diseases (IBDs), high visceral adipose tissue (VAT) burden is associated with a lower response to infliximab, potentially through alterations in volume distribution and/or clearance. Differences in VAT may also explain the heterogeneity in target trough levels of infliximab associated with favorable outcomes. The aim of this study was to assess whether VAT burden may be associated with infliximab cutoffs associated with efficacy in patients with IBD.METHODS:We conducted a prospective cross-sectional study of patients with IBD receiving maintenance infliximab therapy. We measured baseline body composition parameters (Lunar iDXA), disease activity, trough levels of infliximab, and biomarkers. The primary outcome was steroid-free deep remission. The secondary outcome was endoscopic remission within 8 weeks of infliximab level measurement.RESULTS:Overall, 142 patients were enrolled. The optimal trough levels of infliximab cutoffs associated with steroid-free deep remission and endoscopic remission were 3.9 mcg/mL (Youden Index [J]: 0.52) for patients in the lowest 2 VAT % quartiles (<1.2%) while optimal infliximab level cutoffs associated with steroid-free deep remission for those patients in the highest 2 VAT % quartiles was 15.3 mcg/mL (J: 0.63). In a multivariable analysis, only VAT % and infliximab level remained independently associated with steroid-free deep remission (odds ratio per % of VAT: 0.3 [95% confidence interval: 0.17–0.64], P < 0.001 and odds ratio per μg/mL: 1.11 [95% confidence interval: 1.05–1.19], P < 0.001).DISCUSSION:The results may suggest that patients with higher visceral adipose tissue burden may benefit from achieving higher infliximab levels to achieve remission.