Management of Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity.

PURPOSES: Management of staple-line leaks following laparoscopic sleeve gastrectomy (LSG) is challenging and controversial. Guidelines for leak treatment are not standardized and often involve multidisciplinary management by surgical, medical and radiological methods. Herein we present our experience and proposed strategy for handling leaks after LSG. PATIENTS AND METHODS: Retrospective data regarding LSG performed from April 2012 to October 2017 at the Surgical Oncology Division, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital "G. Martino", University of Messina, Italy, were reviewed. The management approaches and the surgical, endoscopic, and percutaneous procedures used were examined. Outcomes measured included the prevalence of gastric leaks, radiological features, related morbidities and mortalities, hospital stay and management. RESULTS: LSG was performed in 310 patients. Eight patients were managed for gastric leak within the 5-year period: 5 (1.6% overall prevalence) from our division, 3 referred from another hospital. All cases were successfully treated conservatively with combined CT/US-guided drainage using a locking pigtail catheter and endoscopic gastric stent positioning. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (Hanarostent® 24 cm; M.I. Tech, Seoul, Korea) in addition to pigtail drains (Drainage Catheter Locking Pigtail 8F/21cm; Tru-Set® Ure-Sil, Skokie, IL, USA). Complete closure of the leak was achieved in all patients. The mean time from presentation to healing was 74 days ± 37.76 (SD). None of the patients underwent remedial surgery. CONCLUSION: This study presents our management strategy for leak resolution in LSG patients. Based on our results, we strongly recommend the conservative and combined management of gastric leaks following LSG by endoscopic stenting and percutaneous drainage.

Fever of unknown origin due to intrahepatic wooden toothpick.

Ingestion of foreign bodies is a common clinical problem, but intrahepatic migration is an exceptional occurrence. Clinical history is not helpful. Abdominal ultrasonography and CT are fundamental to exclude surgical causes of fever of unknown origin. Laparoscopic segmental liver resection is recommendable to avoid generalized peritonitis.

Three-Dimensional Versus Two-Dimensional Laparoscopic Right Hemicolectomy.

BACKGROUND AND AIMS: To address the issue whether three dimensional (3D) offers real operative time advantages to the surgical procedure (primary endpoint) and significant reduction of surgeon's physical strain (secondary endpoint), we have retrospectively analyzed two consecutive series of laparoscopic right hemicolectomy (LRH) performed by a single experienced laparoscopic colorectal surgeon with two different imaging systems (two dimensional [2D] and 3D). PATIENTS AND METHODS: Since January 2014, 25 consecutive patients with right colon cancer underwent 3D LRH and other 25 consecutive ones received a 2D LRH by a single experienced surgeon. After the insertion of the access ports, the surgical procedure has been divided in component tasks and the execution times were compared. Upon completion of each procedure, the consultant surgeon was asked to complete a nonvalidated subjective questionnaire to evaluate quality of depth perception and surgical strain. RESULTS: The execution times for the entire procedure and the single tasks were not significantly different between the 2D and 3D groups, except for the second task "side-to-side ileotransverse anastomosis" (P < .05). The surgeon experienced better depth perception with the 3D system and subjectively reported less strain using the 3D vision system rather than the 2D system, particularly during longer procedures. CONCLUSIONS: Three-dimensional imaging seems not to influence the performance time of laparoscopic right colon cancer surgery when the surgeon is experienced in 2D laparoscopy, although the 3D system seems to offer better depth perception and to subjectively determine less physical strain compared to 2D vision. Further comparative studies are necessary to address the issue whether novice surgeons could benefit from a reduced learning curve using 3D vision and to verify with greater numbers if 3D, even with a similar operative time, can reduce perioperative complications.

A clinical and nutritional comparison of biliopancreatic diversion performed with different common and alimentary channel lengths.

BACKGROUND: This retrospective study compares the clinical and nutritional outcomes of 100 morbidly obese patients who underwent biliopancreatic diversion (BPD) with common (CC) and alimentary channel (AC) length, respectively, 50/250 and 80/200 cm. METHODS: One hundred patients who received BPD from October 2006 to November 2011 were identified from a database of bariatric procedures performed at the University Hospital of Messina, and the outcomes in terms of weight loss and morbidity were compared. Forty morbidly obese patients underwent BPD with CC 80 cm and AC 200 cm (group 1) and 60 morbidly obese patients underwent BPD with CC 50 cm and AC 250 cm (group 2). RESULTS: A gradual weight loss was observed in both groups during the first 3 years after the operation without any significant difference between the two groups. Two cases of protein malnutrition occurred in the group 2 (3 %) due to poor patient compliance in terms of adequate dietary protein intake. Sideropenic anemia was found in 42 % of obese patients in group 2 versus 22.5 % in group 1 at third-year follow-up despite adequate supplementation (p = 0.047). Diarrhea occurred more frequently with a shorter CC. Lipophilic vitamin deficiencies occurred more frequently with a shorter CC despite adequate oral supplementation. CONCLUSIONS: In the medium term, our series showed that shorter CC was associated with no weight loss advantage but with higher morbidity rate, especially in young and fertile women. We recommend a longer CC (80 cm) to be performed especially in this sub-population of obese patients.

Single-incision versus three-port conventional laparoscopic right hemicolectomy: is there any real need to go single?

BACKGROUND: Preliminary results showed some benefits of single-incision laparoscopic surgery (SILS) over conventional laparoscopic colectomy, including better cosmesis, less postoperative pain, and faster recovery, but these results need further confirmation. In addition, the literature still lacks comparative studies between the two approaches to prove the above-mentioned advantages of SILS over conventional laparoscopy and, most importantly, its equivalent effectiveness in terms of initial oncological results. PATIENTS AND METHODS: Two consecutive series of 10 patients undergoing three-port conventional laparoscopic right hemicolectomy (3PCL-RH) and single-incision laparoscopic right hemicolectomy, respectively, were compared in their short-term surgical and oncological outcomes. RESULTS: Analysis of perioperative and postoperative outcomes revealed no significant differences between the two groups. In the SILS group an anastomotic leakage occurred, which was conservatively treated by continuous drainage, total parental nutrition, and antibiotic therapy. The analysis of oncological outcomes showed no differences in terms of length of distal tumor-free margin and harvest of lymph nodes. CONCLUSIONS: Despite its feasibility for right hemicolectomy and its equivalent short-term surgical and oncological outcome compared with conventional laparoscopy, SILS demonstrated no significant advantages in terms of surgical incision length and postoperative course compared with 3PCL-RH. We acknowledge that the small sample size and the nonrandomized design are a limit of the study. Thus, prospective randomized controlled trials are recommended to prove the superiority of single-incision laparoscopic right hemicolectomy.

Postoperative outcomes and quality of life in patients with cystic fibrosis undergoing laparoscopic cholecystectomy: a retrospective study.

BACKGROUND: Approximately 28% of the patients with cystic fibrosis are affected by cholelythiasis. More than 40% of them have a symptomatic disease, which would mandate cholecystectomy. AIM: The aim of this study was to review surgical and respiratory outcomes and quality of life scores of cystic fibrosis patients undergoing laparoscopic cholecystectomy for symptomatic cholelythiasis to verify the hypothesis that cholecystectomy is a low-risk operation by laparoscopy, not affecting unfavorably respiratory function and quality of life. PATIENTS AND METHODS: Study group was consisted of 9 patients with a mean age of 24.8±8.1 years (range, 15 to 38 y), 2 male and 7 female patients, with cystic fibrosis and symptomatic cholelithiasis. Three patients also presented common bile duct stones. All the patients underwent perioperative Positive End-Expiratory Pressure mask sessions and aggressive antibiotic regimens. At the middle of the antibiotics regimen period, a standard laparoscopic cholecystectomy was performed. In the 3 cases with common duct lithiasis, the so-called "rendezvous" technique was carried out. Preoperatively, intraoperatively, and postoperatively, respiratory function was strictly monitored by the evaluation of SO2 and of the forced expiratory volume in 1 second (FEV1). Preoperatively and 6 months after laparoscopic cholecystectomy the Gastro Intestinal Quality of Life Index was evaluated on all patients. RESULTS: All the operations were completed laparoscopically. No mortality was observed. The intraoperative mean SO2 was 89.0%±5.6% (range, 80% to 95%), versus 82.8%±8.5% (range, 66% to 91%) at the extubation (P=0.006). Intraoperative respiratory functions were stable in 6 patients. In 3 patients, a severe bronchospasm occurred determining marked desaturation. Preoperative mean FEV1 was 70.5%±7.0% (range, 55% to 75%) versus 61.8%±13.2% (range, 39% to 80%) 48 hours after the operation (P=0.132). The 3 patients, who experienced intraoperatively severe bronchospasm, reported a 48 hours postoperative FEV1 under 60%. All the patients showed disappearance of postprandial colicky pain and vomiting. Preoperative mean total Gastro Intestinal Quality of Life Index score was 105.2±13.6 versus 117.8±10 at 6-month follow-up (P=0.015). CONCLUSIONS: On the basis of a proper surgical timing and adequate preoperative physiokinesis therapy, laparoscopic cholecystectomy is a safe and indicated procedure in patients with cystic fibrosis and symptomatic cholelithiasis and it is able to significantly improve the quality of life. Quality of life of these patients it not worsened while symptoms and risks of biliary gallstones are removed.

Early experience with laparoscopic major liver resections: a case-comparison study.

Laparoscopic major liver resections are regarded as demanding operations whose convenience is still under evaluation. The aim of the present study was to report our early experience and to describe surgical technique of laparoscopic major liver resections. Study group consisted of 6 female patients with benign disease and a mean age of 40.5 years, who underwent right hepatectomy in 4 cases and left hepatectomy in 2 cases. No mortality was observed. Morbidity consists in 1 biliary fistula that requires rehospitalization and a new laparoscopic operation. The mean operative time was of 201.7 minutes, with a mean hospital stay of 5.5 days. The authors conclude that laparoscopic major liver resections could be performed, at least for benign disease and by surgeons experienced in laparoscopy, with good results. Nevertheless, further studies are required before to draw definitive conclusions, especially for neoplastic patients who represent the most relevant group.

LigaSure vs clamp-and-tie technique to achieve hemostasis in total thyroidectomy for benign multinodular goiter: a prospective randomized study.

HYPOTHESIS: Occurrence of adverse effects and advantages of the LigaSure diathermy system (or LigaSure vessel sealing system) in total thyroidectomy have not been tested in prospective randomized studies comparing its use with that of the time-saving clamp-and-tie technique to ligate and divide thyroid vessels. The effectiveness of LigaSure in achieving vessel division and hemostasis remains dependent on vessel diameter, and the risk of damage to adjacent structures cannot be completely excluded. We tested the hypothesis that use of LigaSure compared with the clamp-and-tie technique can significantly and conveniently reduce operative time without increasing postoperative complications in patients undergoing total thyroidectomy for benign multinodular goiter. DESIGN: Prospective randomized study. SETTING: Regional hospital. PATIENTS: Two hundred consecutive patients with benign multinodular goiter undergoing total thyroidectomy performed by 1 of 3 surgeons. INTERVENTIONS: According to a randomized sequence, total thyroidectomy was performed in 100 patients using LigaSure and in 100 patients using the clamp-and-tie technique. MAIN OUTCOME MEASURES: End points of the study included the comparative evaluation of postoperative complications, need for parathyroid gland autotransplantation, operative time, and time to hospital discharge. Preoperative, postoperative (24 hours), and 6-week follow-up serum Ca(++) levels are also reported and compared. RESULTS: The postoperative complication rate was 35% overall, including all transient postoperative disturbances. The incidence of cervical hematomas was 2%, but 3 patients (1.5%), 1 in the LigaSure group and 2 in the clamp-and-tie group, required repeat operations because of respiratory tract obstruction. The incidence of permanent complications was 2.5% overall, including 3 patients (1.5%) with permanent hypocalcemia and 2 patients (1%) with permanent recurrent nerve lesions. No statistical difference in the incidence of complications was found between the 2 study groups. Similarly, no difference was found in mean hospitalization time and need for parathyroid gland autotransplantation. Preoperative, postoperative, and 6-week follow-up mean serum Ca(++) levels were not statistically different in the 2 study groups and in the subset of patients undergoing parathyroid gland autotransplantation. Mean operative time was significantly shorter in the LigaSure group, although the mean difference between the 2 study groups was minimal (7.4 minutes). Concomitantly, there was an additional cost of 45euro (US $57.40) per operation using LigaSure. CONCLUSION: The use of LigaSure is equally as safe and effective at vessel division and homeostasis as the clamp-and-tie technique, with a statistically significant (although minimal) decrease in mean operative time. Because of this minimal decrease in operative time, use of LigaSure would allow more patients to undergo total thyroidectomy each year, which would eventually help to offset its higher cost.

Quality of life and predictors of long-term outcome in patients undergoing open Nissen fundoplication for chronic gastroesophageal reflux.

BACKGROUND: Long-term outcome of antireflux operations as well as pre- and postoperative parameters able to predict their clinical results are still controversial. The aim of the present study was to evaluate long-term quality of life of patients undergoing open fundoplication for chronic GERD and to investigate pre- and early postoperative functional parameters possibly related to persistence or recurrence of symptoms. METHODS: A cohort of 25 patients who underwent open Nissen fundoplications was reviewed for an evaluation of long-term residual symptoms and quality of life at an average follow-up of more than 10 years. Clinical evaluation was performed by using a symptom-specific score (DeMeester's score), 3 health-related quality of life scores, a GERD-specific (GERD-HRQL score) score, and 2 generic scores (SF-36) evaluating physical and psychological well-being. Subjective satisfaction grade of the patients was also investigated. In addition, a univariate analysis is provided, according to the long-term presence or absence of residual symptoms (120.6-month follow-up), taking into account pre- and postoperative (6-month follow-up) data of endoscopy, 24-hour pH monitoring, stationary manometry, and gastric-emptying test. RESULTS: Persistence or recurrence of GERD-specific symptoms (heartburn and regurgitation) were reported by 8 patients (32%); 2 patients (8%) were reoperated on for persistent dysphagia, whereas 17 patients (68%) were asymptomatic. GERD-HRQL and SF-36 scores displayed significant postoperative improvement, which continued in long-term follow-up. Twenty patients (80%) had repeat fundoplication. Among tested parameters, only postoperative mean supine esophageal clearance and gastric emptying half-time, although on average improved significantly after the antireflux procedure, differed significantly in long-term asymptomatic and symptomatic subgroups. In long-term asymptomatic patients, postoperative (6 month) mean supine esophageal clearance was 0.8 +/- 0.3 minutes (P = .011) and 2.4 +/- 0.2 minutes in symptomatic patients. Postoperative (6 month) mean gastric emptying half-time of long-term asymptomatic patients was 93.3 +/- 8.9 minutes, whereas in symptomatic patients it was 127.5 +/- 14.3 minutes (P = .047). CONCLUSIONS: Patients undergoing Nissen fundoplication had a satisfactory long-term quality of life. Clinical results did not deteriorate over time and showed to be related to postoperative esophageal clearance and gastric emptying, which could be regarded as early postoperative predictors of long-term clinical outcome.

Laparoscopic palliative gastrojejunostomy for advanced recurrent gastric cancer after Billroth I resection.

Palliative surgery for advanced gastric cancer has equivocal results. Laparoscopy is likely to provide some advantage compared to open procedures. We present a case of laparoscopic gastrojejunostomy for advanced gastric cancer, which recurred after Billroth I resection. Reproducing the results of the early experiences so far reported in the literature, laparoscopy provided us with the accurate staging of the disease along with the opportunity, at the same time, to perform a palliative procedure, avoiding laparotomy. Operative results were good, vomiting was relieved, and the patient was able to cope with his disease until death eventually occurred after 6 months.

Prospective evaluation of ultrasonography plus MIBI scintigraphy in selecting patients with primary hyperparathyroidism for unilateral neck exploration under local anaesthesia.

BACKGROUND: Unilateral neck exploration (UNE) is currently replacing conventional bilateral neck exploration with cervicotomy for the surgical treatment of primary hyperparathyroidism (PHPT). However, many concerns still exist about the indications and the effectiveness of this minimally invasive approach. METHODS: Prospective evaluation of operative results in consecutive patients having indications for UNE on the basis of strict selection criteria consisting of ultrasound-MIBI agreement in adenoma localization, absence of thyroid disease, and psychological suitability for undergoing a procedure under local anesthesia. No intraoperative confirmation study was adopted. RESULTS: Among 149 consecutive PHPT patients, 45 (30.2%) had indications for UNE. No operative morbidity or mortality was observed. Mean operative time for the UNE procedure was 42 minutes (range 25 to 57). Conversion to general anesthesia was chosen for 5 patients (11.1%), whereas conversion to bilateral neck exploration was chosen for 3 patients (6.6%). For the UNE procedure, the success rate was as high as 91.7%. When the only factor indicated UNE, ultrasound-MIBI localization agreement had low sensibility (44.1%) and specificity (55.6%) but a high positive predictive value (91.1%). CONCLUSIONS: We concluded that UNE performed under local anesthesia, without intraoperative confirmation studies, could be considered a safe and effective approach to treating patients with PHPT, but we regret the low rate of patients selected for this procedure because of the low sensitivity of the imaging-inclusion criterion.

A primary pancreatic carcinoid tumour with unusual clinical complaints: A case report.

BACKGROUND: Unless metastatic or compressing the pancreatic duct, carcinoid of the pancreas are asymptomatic showing normal levels of serotonine and its metabolites in plasma and urine, thus resulting in delayed diagnosis and a consequent poor prognosis. However, if resection is timely accomplished, no local recurrence might be encountered and a normal survival might be expected in the absence of metastatic disease. CASE PRESENTATION: The reported case of pancreatic carcinoid tumour in a 62-year-old woman reporting only atypical symptoms consisting of intermittent epigastric pain and nausea. Urinary 5-hydroxyindolacetic acid levels were within normal limits and only a slight elevation of serum serotonine level was detected on admission. After tumour localisation with endoscopic ultrasonography, left splenopancreasectomy with splenic, celiac and hepatic lymphadenectomy was carried out. CONCLUSION: The role of endoscopic ultrasonography in early detection and precise localisation of pancreatic carcinoids, as well as the role of somatostatin-receptor scintigraphy with 111Indium labelled pentreotide in excluding distant metastases, are confirmed. The radical resection with lymphadenectomy is recommended in order to have a precise histological examination and detect occult lymph node metastases.