Hypermetabolic lesion in the prevascular mediastinum - always a thymoma/lymphoma?

Cholesterol granuloma is a foreign-body giant cell reaction that can occur in response to the presence of cholesterol crystals. They are usually found in the middle ear, paranasal sinuses or mastoid process due to chronic inflammation. Presentation in the prevascular mediastinum is a rare finding. We describe a case of a cholesterol granuloma located in the prevascular mediastinum in a symptomatic 57-year-old male patient.

A one-step conversion from gastric banding to laparoscopic Roux-en-Y gastric bypass is as safe as a two-step conversion: A comparative analysis of 885 patients.

AIMS: To achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (LAGB) can be converted to a laparoscopic Roux-en-Y gastric bypass (RYGB). There is limited data on the feasibility and safety of routinely performing a single-step conversion. We assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. METHODS: Between October 2004 and December 2015, a total of 885 patients who underwent LAGB removal with RYGB were identified from a prospectively collected database. In all cases, a single-stage conversion procedure was planned. The feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. RESULTS: A single-step approach was successfully achieved in 738 (83.4%) of the 885 patients. During the study period, there was a significant increase in performing the conversion from LAGB to RYGB single-staged. No mortality or anastomotic leakage was observed in both groups. Only 45 patients (5.1%) had a 30-d complication: most commonly hemorrhage (N = 20/45), with no significant difference between the groups. CONCLUSION: Converting a LAGB to RYGB can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. With increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. Only a migrated band remains a formal contraindication for a one-step approach.

Laparoscopic Roux-en-Y gastric bypass in the elderly: feasibility, short-term safety, and impact on comorbidity and weight in 250 cases.

INTRODUCTION: In the elderly obese population, frequently suffering from multiple comorbidities, laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered a high-risk procedure. The aim of this study was to evaluate short-term safety (30-day hospital morbidity and mortality) of this procedure and its impact on weight and associated comorbidities in the medium term (type-two diabetes, hypertension, sleep apnea, hypercholesterolemia, and joint pain). METHODS: This study represents a retrospective analysis of all our Belgian patients older than 60 years of age who underwent a LRYGB between October 2004 and October 2012. Patient files were reviewed and patients were contacted by formal consultation or by phone for an update of their clinical status. Demographics, operative details, postoperative course, and the evolution of weight and associated comorbidities were registered. RESULTS: A total of 280 patients were included. A complete follow-up was available for 250 patients (89 %), of whom 161 were female and 89 male. Mean age, BMI, and hospital stay were 64.1 years (60-78 years), 41.9 kg/m(2) (27.4-68 kg/m(2)), and 4.3 days (2-19 days), respectively. There was no in-hospital mortality, 27 (10.8 %) patients suffered from early postoperative complications and 5 (2 %) patients needed to be readmitted. After a mean follow-up of 31.5 months, the mean excess weight loss was 59.3 % (range 21.9-120.1 %). Resolution or improvement of diabetes, hypertension, sleep apnea, hypercholesterolemia, and joint pain was seen in 94.6, 77.6, 88.0, 77.1 and 57.6 % respectively. CONCLUSION: LRYGB has an acceptable complication rate in the elderly. Since all obesity-related comorbidities improved during follow-up, there is a plea not to exclude this subgroup of patients from the well-known benefits of gastric bypass surgery.

Rectal Biopsy for Hirschsprung's Disease: A Multicentre Study Involving Biopsy Technique, Pathology and Complications.

BACKGROUND: The heterogeneity of rectal biopsy techniques has encouraged us to search for a surgical and pathological standardisation of this diagnostic technique to exclude Hirschsprung's disease. The different amounts of information on the anatomopathology report prompted us to compile a template for the anatomopathology report for diagnostic rectal biopsies for surgical colleagues and pathologists working on Hirschsprung's disease. METHODS: We gathered the anonymous biopsy information and its pathology information from five hospitals for all patients in which rectal biopsies were taken to diagnose Hirschsprung's disease over two years (2020-2021). RESULTS: Of the 82 biopsies, 20 suction (24.4%), 31 punch (37.8%) and 31 open biopsies (37.8%) were taken. Of all biopsies, 69 were conclusive (84.2%), 13 were not (15.8%). In the suction biopsy group, 60% were conclusive and 40% were not; for punch biopsy, the values were 87% and 13%, respectively and for open biopsy, 97% and 3%. Inconclusive results were due to insufficient submucosa in 6/8 suction biopsies, 4/4 punch biopsies and 0/1 open biopsies. An insufficient amount of submucosa was the reason for an inconclusive result in 6/20 cases (30%) after suction biopsy, 4/31 (12.9%) cases after punch biopsy and 0 cases (0%) after open biopsy. We had one case with major postoperative bleeding post suction biopsy; there were no further adverse effects after biopsy. CONCLUSIONS: Diagnostic rectal biopsies in children are safe. Non-surgical biopsies are more likely to give inconclusive results due to smaller amounts of submucosa present in the specimen. Open biopsies are especially useful when previous non-surgical biopsies are inconclusive. An experienced pathologist is a key factor for the result. The anatomopathology report should specify the different layers present in the specimen, the presence of ganglion cells and hypertrophic nerve fibres, their description and a conclusion.

Post-bariatric Abdominoplasty: Identification of Risk Factors for Complications.

PURPOSE: The aim was to evaluate the complication rate after abdominoplasty procedures performed in a high volume post-bariatric center and to identify predictors of complications. MATERIAL AND METHODS: A retrospective analysis was performed and included all abdominoplasty procedures performed between January 2011 and December 2019. Complications classified according to the Clavien-Dindo classification were documented and potential risk factors were statistically evaluated. RESULTS: A total of 898 patients were included. Overall complication rate was 29.8%. Type I complications (minor wound problems) occurred in 15.8% (n = 140). Type II complications requiring medical intervention occurred in 10% (n = 90). Five patients had deep venous thrombosis or pulmonary embolism; others received antibiotic treatment for wound infections. In total 42 type III complications occurred in 36 patients, with re-intervention for wound problems (n = 16), seroma (n = 16), umbilical necrosis (n = 4), and bleeding (n = 6). The weight of tissue resected (p < 0.001), the interval between bariatric and body contouring surgery (p < 0.05), preoperative BMI (p < 0.05), male gender (p < 0.05), diabetes mellitus type 2 (p = 0.05), and smoking (p < 0.05) were important predictors for developing complications. CONCLUSION: In this large retrospective post-bariatric abdominoplasty series, the overall complication rate is low compared to other published series as a consequence of our completely standardized approach and technique. Our analysis shows a significant linear correlation between the amount of skin tissue resected and postoperative complications. Moreover, the longer the interval between bariatric surgery and abdominoplasty, the higher the complication rate. High preoperative BMI, diabetes mellitus type 2, smoking, and male gender were identified as independent significant risk factors for complications.

Impact of the patient's body position on the intraabdominal workspace during laparoscopic surgery.

BACKGROUND: The effects of the patient's body position on the intraabdominal workspace in laparoscopic surgery were analyzed. METHODS: The inflated volume of carbon dioxide was measured after insufflation to a preset pressure of 15 mmHg for 20 patients with a body mass index (BMI) greater than 35 kg/m(2). The patients were anesthetized with full muscle relaxation. The five positions were (1) table horizontal with the legs flat (supine position), (2) table in 20 degrees reverse Trendelenburg with the legs flat, (3) table in 20 degrees reverse Trendelenburg with the legs flexed 45 degrees upward at the hips (beach chair position), (4) table horizontal with the legs flexed 45 degrees upward at the hips, and (5) table in 20 degrees Trendelenburg with the legs flat. The positions were performed in a random order, and the first position was repeated after the last measurement. Repeated measure analysis of variance was used to compare inflated volumes among the five positions. RESULTS: A significant difference in inflated volume was found between the five body positions (P = 0.042). Compared with the mean inflated volume for the supine position (3.22 +/- 0.78 l), the mean inflated volume increased by 900 ml for the Trendelenburg position or when the legs were flexed at the hips, and decreased by 230 ml for the reverse Trendelenburg position. CONCLUSIONS: The Trendelenburg position for lower abdominal surgery and reverse Trendelenburg with flexing of the legs at the hips for upper abdominal surgery effectively improved the workspace in obese patients, even with full muscle relaxation.

Laparoscopic adjustable banded roux-en-y gastric bypass as a primary procedure for the super-super-obese (body mass index > 60 kg/m²).

BACKGROUND: Currently, there is no consensus opinion regarding the optimal procedure of choice in super-super-morbid obesity (Body mass index, BMI > 60 kg/m²). Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients. Also, percent EWL is significantly less after 1-year in the super-super-obese group as compared with the less obese group and many patients are still technically considered to be obese (lowest post-surgical BMI > 35) following RYGB surgery in this group. The addition of adjustable gastric band (AGB) to RYGB has been reported as a revisional procedure but this combined bariatric procedure has not been explored as a primary operation. METHODS: In a primary laparoscopic RYGB, an AGB is drawn around the gastric pouch through a small opening between the blood vessels on the lesser curve and the gastric pouch. The band is then fixed by suturing the gastric remnant to the gastric pouch both above and below the band to prevent slippage. RESULTS: Between November 2009 and March 2010, 6 consecutive super-super-obese patients underwent a primary laparoscopic adjustable banded Roux-en-Y gastric bypass procedure at our institution. One male patient (21 years, BMI 70 kg/m²) developed a pneumonia postoperatively. No other postoperative complications were observed. CONCLUSION: To the best of our knowledge, this is the first series of patients that underwent a laparoscopic adjustable banded RYGB as a primary operation for the super-super obese in the indexed literature. With the combined procedure, a sequential action mechanism for weight loss is to be expected. The restrictive, malabsorptive and hormonal working mechanism of the RYGB will induce weight loss from the start reaching a stabilised plateau of weight after 12 - 18 months. At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss. Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time.

Textiloma-Induced 1,25-Dihydroxyvitamin D-Mediated Hypercalcemia: A Case Report and Literature Study.

Foreign body causing 1,25-dihydroxyvitamin D [1,25(OH)2D]-induced hypercalcemia is an uncommon yet clinically significant cause of hypercalcemia. We report an unusual case of hypercalcemia due to a textiloma (a surgical gauze inadvertently left in place during surgery). A PubMed search for (HYPERCALCEMIA) and (FOREIGN BODY) was performed. A foreign body (surgical gauze) left over after removal of a kidney transplant caused 1,25(OH)2D-induced hypercalcemia. The diagnosis was complicated by end-stage renal disease, low PTH, and high 1,25(OH)2D.

Short- and long-term outcomes of vertical banded gastroplasty converted to Roux-en-Y gastric bypass.

BACKGROUND: Vertical banded gastroplasty (VBG) often necessitates revisional surgery for weight regain or symptoms related to gastric outlet obstruction. Roux-en-Y gastric bypass (RYGB) is considered as the revisional procedure of choice. However, revisional bariatric surgery is associated with relatively higher rates of complications. The aim of the current study is to analyse our single-centre experience with patients requiring revisional RYGB following primary VBG. METHODS: Retrospective review of the prospectively collected database identified 153 patients who underwent RYGB as a revisional procedure after VBG from Feb 2004-Feb 2011. Early and late complications, weight data and resolution of symptoms related to gastric outlet obstruction were analysed. RESULTS: One hundred twenty-three females and 30 males underwent revisional RYGB post VBG. Mean age was 44.4 (15-74) years with a mean pre-operative body mass index (BMI) of 34.2 (23.5-65.5) kg/m(2). Mean hospital stay was 4.3 days. Early complication rate was 3.9 % with a 30-day re-operation rate of 1.3 %. Mortality and leak rate were zero. After a mean follow-up of 48 months, the mean BMI decreased significantly to 28.8 kg/m(2) and a complete resolution of the obstructive symptoms was achieved in nearly all patients. Late complications developed in 11 (7.7 %) of the patients of which seven (4.9 %) required surgery. CONCLUSIONS: Revisional RYGB following VBG is technically challenging but safe with low rates of morbidity and mortality, comparable to primary RYGB. It produces a significant reduction in body weight and in symptoms resolution. We recommend RYGB as the procedure of choice in patients requiring revisional surgery following VBG.

Smaller staple height for circular stapled gastrojejunostomy in laparoscopic gastric bypass: early results in 1,074 morbidly obese patients.

BACKGROUND: Anastomotic leaks, stenosis, and bleeding from the gastrojejunal anastomosis (GJA) after gastric bypass may carry high morbidity and mortality. To date, the standard operation with the circular stapler (CS) used the 25 mm with a staple height of 4.8 mm. We present herein our experience with the 3.5-mm staple height. METHODS: A total of 1,074 morbidly obese patients who underwent fully stapled laparoscopic Roux-en-Y Gastric Bypass over a period of 18 months were included in the study. Mean body mass index was 41.9 (range 28.6-70.7). Mean age was 40.9 years (range 15-74 years). Mean operating time was 73 min (range 43-210 min) and the mean length of stay was 4.2 days (range 1-25 days). The 30-day complication rate associated with GJA was prospectively analyzed. RESULTS: Twenty patients (1.86%) developed postoperative bleeding. Four developed GJA bleeding (0.37%). One leak was recorded from the vertical staple line of the gastric pouch, but no leaks from the GJA were seen. Conversion to open approach was required in two patients (0.18%). Reoperation and readmission rates were 1.7% and 1.8%, respectively. Perioperative complications were observed in 34 patients (3.1%). One case of clinical GJA stenosis was detected in a mean follow-up of 10.5 months (range 5-20 months). There was no mortality in our series. CONCLUSION: Compared to our previous experience with 4.8 mm CS, creating the GJA using a smaller staple height significantly reduced the bleeding rate and seems to be a safe technique that potentially reduces other complications related to the GJA as reported in the literature.

Laparoscopic adjustable banded sleeve gastrectomy as a primary procedure for the super-super obese (body mass index > 60 kg/m2).

Isolated laparoscopic sleeve gastrectomy is increasingly being used for the treatment of morbid obesity. However, doubts still persist regarding long-term weight loss, and the 5-year results are awaited. Whether the aetiology of failed excess weight loss is the result of an inadequate sleeve or attributable to dilatation of the sleeve is not clear. In an effort to prevent gastric dilatation and increase gastric restriction to promote further weight loss in the long term, we performed a combined procedure of laparoscopic adjustable gastric banding with sleeve gastrectomy. The patient was a 39-year-old woman with a life-long history of obesity and a body mass index of 79.8 kg/m(2). The surgical technique of the laparoscopic adjustable gastric banded sleeve gastrectomy is described. There were no immediate complications, and the patient was discharged home on the third postoperative day. She is doing extremely well on clinic follow-up at 6 weeks. To the best of our knowledge, laparoscopic adjustable gastric banded sleeve gastrectomy, as a primary operation, has not been described in the literature. It is hoped that this combined procedure will be most useful in the super-super obese (body mass index > 60) patients. More patients with a long-term follow-up are necessary to provide definitive conclusions regarding long-term benefits and complications of this combined bariatric procedure.

Standardization of the fully stapled laparoscopic Roux-en-Y gastric bypass for obesity reduces early immediate postoperative morbidity and mortality: a single center study on 2606 patients.

BACKGROUND: Various techniques of laparoscopic Roux-en-Y gastric bypass have been described. We completely standardized this procedure to minimize its sometimes substantial morbidity and mortality. This study describes our experience with the standardized fully stapled laparoscopic Roux-en-Y gastric bypass (FS-LRYGB) and its influence on the 30-day morbidity and mortality. METHODS: We retrospectively analyzed 2,645 patients who underwent FS-LRYGB from May 2004 to August 2008. Operative time, hospital stay and readmission, re-operation, and 30-day morbidity/mortality rates were then calculated. The 30-day follow-up data were complete for 2,606 patients (98.5%). RESULTS: There were 539 male and 2,067 female patients. Mean age was 39.2 years (range 14-73), mean BMI 41.44 kg/m(2) (range, 23-75.5). The mean hospital stay was 3.35 days (range 2-71). Mean total operative time was 63 min (range 35-150). One patient died of pneumonia within 30 days of surgery (0.04%). One hundred and fifty one (5.8%) patients had postoperative complications as follows: gastrointestinal hemorrhage (n = 89, 3.42%), intestinal obstruction (n = 9, 0.35%), anastomotic leak (n = 5, 0.19%) and others (n = 47, 1.80%). In 66 patients, the bleeding resolved without any surgical re-intervention. One hemorrhage resulted in hypovolemic shock with subsequent renal and hepatic failure. CONCLUSION: The systematic approach and the full standardization of the FS-LRYGB procedure contribute highly to the very low mortality and the low morbidity rates in our institution. Gastrointestinal bleeding appears to be the commonest complication, but is self-limiting in the majority of cases. Our approach also significantly reduces operative time and turns the technically demanding laparoscopic Roux-en-Y gastric bypass procedure into an easy reproducible operation, effective for training.