Laparoscopic Sleeve Gastrectomy plus Duodenojejunal Bypass: Learning Curve Analysis and Technical Feasibility of Duodenojejunostomy Using Linear Stapler.

INTRODUCTION: Laparoscopic sleeve gastrectomy plus duodenojejunal bypass (LSG-DJB) has emerged as an alternative bypass surgery. Despite its potential benefits, the technical challenges of the procedure have limited its adoption. This study aims to present the learning curve for LSG-DJB and explore potentially beneficial technical modifications for the standardization of the procedure. METHODS: The study retrospectively analyzed 100 patients who underwent LSG-DJB as a primary procedure from July 2014 through September 2021. Baseline characteristics, weight loss outcomes, remission of metabolic diseases, and perioperative complications were assessed. The operative time was analyzed across both time trends and anastomosis type subgroups. RESULTS: At 1-year follow-up after LSG-DJB, the mean %total weight loss and the mean BMI loss were 25.38 ± 8.58% and 9.38 ± 4.25 kg/m2, respectively. Remission rates for type 2 diabetes, hypertension, and dyslipidemia were 72.0% (67/93), 84.1% (37/44), and 70.3% (52/74), respectively. In the analysis of operative time, the learning curve exhibited a plateau after 25 cases. The mean operative time was 136.00 ± 21.64 min in the stapled anastomosis group, and 150.62 ± 25.42 min in the hand-sewn anastomosis group. CONCLUSION: The learning curve for LSG-DJB plateaued after 25 cases. In the LSG-DJB procedure, stapled duodenojejunal anastomosis is feasible and achieves similar outcomes to the hand-sewn method.

Increasing Accessibility to Metabolic Bariatric Surgery: A Qualitative Study Based on In-Depth Interviews of Korean Adult Patients With Severe Obesity.

Purpose: After the initiation of national health insurance coverage in 2019, the number of metabolic bariatric surgeries (MBSs) in Korea has been increasing. Despite evidence regarding its efficacy, many candidates are hesitant regarding surgery for the treatment of severe obesity. This study interviewed patients who received MBS to further understand potential barriers and increase the accessibility of MBS. Materials and Methods: Eight interviewees who received MBS after 2019 participated. The interviews began in mid-July 2022 over approximately a month. Each one-on-one interview lasted a few hours and was done in person. The interviews were transcribed, and the results were analyzed based on grounded theory. Results: This study focused on the quality of life before and after MBS. On a scale of 1 to 10, all patients had a high degree of satisfaction in quality of life after surgery (average score: 8.9, sleeve gastrectomy: 8.8, and bypass surgery: 9). Scores did not differ depending on procedure type, but factors that caused satisfaction and dissatisfaction were distributed differently between the 2 procedures. Conclusion: Quality of life is significantly improved for patients undergoing MBS despite discomfort after surgery. Further promotion of the understanding of obesity as a chronic progressive disease is needed for both surgical candidates and the public to increase acceptance of MBS.

Sequence analysis of the first B5 subgenogroup strain of enterovirus 71 isolated in Korea.

Enterovirus A71 (EV71), the main etiological agent of handfoot- mouth disease (HFMD), circulates in many areas of the world and has caused large epidemics since 1997, especially in the Asia-Pacific region. In this study, we determined the full-genome sequence of CMC718, a newly isolated EV71 strain in Korea. The CMC718 genome was 7,415 nucleotides in length and was confirmed by whole-genome phylogenetic analysis to belong to the B5 genotype. In particular, CMC718 demonstrated maximum identity with strain M988 of the B5 genotype and numerous amino acid variants were detected in the 3D domain of the viral protein P3, which is consistent with the mutation pattern of a B5 strain isolated in 2012-2013. Comparison of the CMC718 sequence with other EV71 reference strains confirmed the relationship and genetic variation of CMC718. Our study was a full-genome sequence analysis of the first EV71 strain of the B5 genotype isolated in South Korea. This information will be a valuable reference for the development of methods for the detection of recombinant viruses, the tracking of infections, and the diagnosis of EV71.

Resident Learning Curve for Laparoscopic Appendectomy According to Seniority.

PURPOSE: To delineate the learning curve (LC) for laparoscopic appendectomy (LA) performed by residents according to seniority in training. METHODS: Between October 2015 and November 2016, 150 patients underwent LA by three residents (in their first, second, and third year of training) under supervision. The patients were non-randomly assigned to each resident. The data were reviewed and analyzed retrospectively from prospectively collected database. The perioperative outcomes were compared between the three residents including operation time, complication, conversion, and so on. The LCs were evaluated by the moving average method and cumulative sum control chart (CUSUM) for operation time and surgical completion. RESULTS: Baseline characteristics and perioperative outcomes were similar except for age and location of the appendix among the three groups. Operation time was not different among the three residents (43.9, 45.3, and 48.4 min for A, B, and C, respectively). The moving average method for operation time showed a decreasing tendency for all residents. CUSUM for operation time showed that the peak points occurred at the 24th, 18th, and 31st cases for resident A, B, and C, respectively. In terms of surgical failure, residents A, B, and C reached steady states after the 35th, 11th, and 16th cases, respectively. Perforation of the appendix base was the only risk factor for surgical failure. CONCLUSION: The LC for LA by residents was 11-35 cases according to multidimensional statistical analyses. The accumulation of surgical experience of residents might affect the LC, especially for surgical completion rather than for operation time.

Postoperative Outcomes of Stoma Takedown: Results of Long-term Follow-up.

PURPOSE: Stoma takedown is a frequently performed procedure with considerable postoperative morbidities. Various skin closure techniques have been introduced to reduce surgical site infections. The aim of this study was to assess postoperative outcomes after stoma takedown during a long-term follow-up period. METHODS: Between October 2006 and December 2015, 84 consecutive patients underwent a colostomy or ileostomy takedown at our institution. Baseline characteristics and perioperative outcomes were analyzed through retrospective reviews of medical records. RESULTS: The proportion of male patients was 60.7%, and the mean age of the patients was 59.0 years. The overall complication rate was 28.6%, with the most common complication being prolonged ileus, followed by incisional hernia, anastomotic leakage, surgical site infection, anastomotic stenosis, and entero-cutaneous fistula. The mean follow-up period was 64.3 months. The univariate analysis revealed no risk factors related to overall complications or prolonged ileus. CONCLUSION: The postoperative clinical course and long-term outcomes following stoma takedown were acceptable. Stoma takedown is a procedure that can be performed safely.

Anatomic and clinical risk factors for pulmonary embolism in patients with deep venous thrombosis of the lower extremity.

PURPOSE: Iliac vein compression is a known culprit of deep vein thrombosis (DVT). In contrast, the compression may prevent the pulmonary embolism (PE). The aim of this study was to evaluate the anatomic and clinical risk factors of PE in patients with lower extremity DVT. METHODS: PE was evaluated using chest computed tomography in patients with lower extremity DVT. The patients were classified into group I (DVT without PE) and group II (DVT with PE) and analyzed to clarify the anatomic and clinical risk factors associated with PE in patients with DVT. As the anatomic factor, the shortest length between the common iliac artery (CIA) and spinal body (SB) was measured. Statistical analyses utilized the multivariable logistic regression model, and receiver operating characteristic (ROC) curve analysis. RESULTS: We examined 114 patients (age; 62.7 ± 16.9 years, 41.7% men) with DVT with/without PE. The prevalence of concurrent DVT with PE was 52.6%. Blood tests showed no difference between the 2 groups. Of all the assessed patients' characteristics, only infection was significantly and independently associated with PE (P = 0.04). The shortest length between CIA and SB was 6.7 ± 3.5 mm in group I and 11.3 ± 3.7 mm in group II (P < 0.001). ROC curve analysis showed that 7.6 mm was the cut-off value for the anatomic risk of PE. CONCLUSION: Infection was significantly associated with concurrent DVT and PE. The shortest length between CIA and SB (<7.6 mm) may prevent PE in patients with DVT.