The current role of robotics in bariatric surgery.

Significant improvements have been made in bariatric surgery for the past two decades. Thus, early and late complication rates decreased significantly. Thanks to its promising results, robotic surgery is finding increasing use in the field of surgery and the bariatric surgery is one of these areas. Following the first robotic bariatric surgery in 1997, it continues to be performed at increasing rates thanks to the advantages it brings. Robotic surgery offers new opportunities to improve bariatric surgery, thanks to remote control mechanical arms. The three-dimensional (3D) view, together with the precision of movements and the freedom of arms offer new insights into the more difficult surgeries. Hospitals should prepare a good business plan to financially activate robotic surgery, thus, more robotic procedures can be achieved. Among the expressed concerns for the Da Vinci Systems are issues such as the costs, operational times, and lack of tactile feedback. Annual maintenance fees and instrument costs are undoubtedly higher than laparoscopic surgery methods. Robotic surgery is now integrated into obesity surgery, such as sleeve gastrectomy, Roux-en-Y gastric bypass, one anastomosis gastric bypass, biliopancreatic diversion and single anastomosis duodenal switch. It allows for more efficient and ideal anastomosis and exposure in challenging fields. Robotic bariatric surgery is a safe procedure with a short learning curve, outcomes comparable to laparoscopy and other benefits of robotic technology.

Emergency Department visits after bariatric surgery.

BACKGROUND: Although bariatric surgery (BS) has an excellent safety profile, postoperative complications have undoubtedly increased due to the rise in the amount of operations performed annually. In parallel, the number of visits to the Emergency Department (ED) after surgery is increasing. The aim of this study was to describe the frequency, and the risk factors associated with postoperative ED visits after BS. METHODS: This study included patients who had undergone different types of BS procedures between June 2016 and December 2019. Patients' prior surgery types, ED visiting timings, main complaints, symptoms and the diagnoses they received, readmissions, and the interventions they had were noted and compared. RESULTS: A total of 408 patients operated on using either the robotic or laparoscopic method due to morbid obesity, including 91 (22.3%) SG, 231 (56.6%) OAGB, 62 (15.2%) SADS-p, and 24 (5.8%) RS, were included into the study. During follow-up, fifty-three of the 408 patients applied to the Emergency Department 62 times with different complaints. ED admission rates in the OAGB group were significantly higher (P=0.04). While the most common complaint seen in the patients admitted to the ED after BS was localized abdominal pain with 25.8%, the most common diagnosis of the patients was cholelithiasis with a rate of 16.1%. CONCLUSIONS: ED visits after BS usually continue intensively during the first year. Most of these applications can be prevented with regular outpatient follow-ups. Some of these require life-saving surgery in emergency conditions and do not allow the patient to be transferred to a bariatric center.

The Effect of Bariatric Surgery on Exocrine Pancreatic Function.

INTRODUCTION: After bariatric surgery (BS), patients might suffer from nutrient maldigestion, malabsorption, and vitamin deficiencies. In this study, our aim was to assess pancreatic functions after BS using fecal elastase-1 assay (FE-1). MATERIAL AND METHODS: Sixty patients (21M) undergoing BS and 20 (6M) healthy controls were included into the study. Stool samples were collected 1 year after surgery. Ten patients from one anastomosis gastric bypass (OAGB) and single anastomosis duodenal switch (SADS) groups with the lowest value of FE-1 and GIQLI scores were given pancreatic enzyme replacement therapy (PERT). After PERT, FE-1, excess weight loss (EWL), BMI, GIQLI scores, and vitamin D levels were measured. RESULTS: Vitamin D levels were detected as 19.04 (9-46.5) pg/ml, 15.1 (8.4-23.6) pg/ml, 17.8 (5-30) pg/ml, and 21.79 (11-40.3) pg/ml after sleeve gastrectomy (SG), OAGB, SADS, and control groups, respectively (p = 0.04). GIQLI scores in the first year were found to have increased in all patients (p = 0.02). FE-1 levels were found as 642.35 (566.3-711.4) µg/g, 378.52 (183.5-561.1) µg/g, 458.88 (252.5-593, 5) µg/g, and 518.2 (351.6-691) µg/g for the SG, OAGB, SADS, and control groups, respectively. There was a strong inverse correlation between EWL and FE-1 levels at the end of the first year (Spearman's rho = - 0.688, p = 0.003). After having performed PERT for patients with the lowest FE-1 levels, the levels increased to 683.39 (615.5-720) µg/g in the OAGB and 691.5 (643.1-720) µg/g in the SADS groups (p = 0.011). CONCLUSION: FE-1 measurements demonstrated that many patients suffer from malabsorption after OAGB or SADS, whereas functions remain normal after SG. PERT corrects pancreatic functions without affecting weight loss and also contributes to the normal serum level of vitamin D.

Bilateral Inguinal Hernia Repair: Robotic TAPP Versus Laparoscopic TEP.

BACKGROUND: As the advantages of minimally invasive techniques in general surgery have been shown, we prefer laparoscopic total extraperitoneal (LTEP) inguinal hernia repair or robotic transabdominal preperitoneal (RTAPP) inguinal hernia repair in patients diagnosed especially with a bilateral inguinal hernia in our practice. The present study aims to evaluate the early/midterm outcomes and complications in patients who underwent LTEP and RTAPP because of bilateral inguinal hernia. MATERIALS AND METHODS: In total, 189 patients underwent inguinal hernia repair between June 2016 and June 2019 in our department. Data of 49 (2F) patients (33 LTEP/16 RTAPP) who had undergone bilateral inguinal hernia repair were evaluated retrospectively. Univariate analysis was performed to identify the relations between the techniques (LTEP vs. RTAPP), outcomes, and complications. RESULTS: Patient demographics and comorbidities were similar in both groups. There was no difference between the groups in terms of American Society of Anesthesiologists (ASA) scores (P=0.09). Operative time was longer in the RTAPP group (P=0.001). Length of hospital stay was similar in both groups (P=0.11). No recurrence was observed in both groups. Mean pain scores were significantly less for the RTAPP group (P=0.05). When general complications were compared, it was found that the RTAPP group had a statistically significant lower complication rate (P=0.02). Mean follow-up was longer in the LTEP group (P=0.04). Total hospital costs for RTAPP and LTEP were 3968$ and 2506$, respectively. CONCLUSIONS: We conclude that RTAPP seems to have better results in terms of general complications and postoperative pain score when compared with LTAPP. Robotic surgery might be safely recommended for bilateral inguinal hernia repair.

Obesity and appendicitis: Laparoscopy versus open technique.

OBJECTIVES: The clinical results of obese patients who have undergone open or laparoscopic appendectomy, whether one technique is superior to the other is still not clearly known.In our study, we compared the clinical results of obese patients operated with laparoscopic or open technique for acute appendicitis. MATERIAL AND METHODS: We performed retrospective analyses of patients operated for acute appendicitis between the dates of July 2016 and July 2019 at Istinye University Faculty of Medicine Bahcesehir Liv Training and Research Hospital and Liv Hospital Ankara. Of the 241 patients whose height and weight information was accessible, 57 had a body mass index of 30 kg/m2 or higher. Eighteen of these patients underwent open surgery while the other 39 underwent laparoscopic surgery. The primary result criterion was complication ratio. Secondary criteria were operation time and length of hospital stay. RESULTS: Upon comparison of laparoscopic and open techniques in terms of intraoperative-postoperative complications (p= 0.01), operation time (p= 0.02) statistically significant differences were found between the groups. However the mean length of hospital stay (p= 0.181) was similar in both groups. CONCLUSION: In obese appendicitis patients, the laparoscopic technique proved to be superior to the open technique in criteria such as perioperative-postoperative complications, operation time, and etc. Length of hospital stay was determined to be similar between the groups.

Changes in HOMA-IR index levels after bariatric surgery: Comparison of Single Anastomosis Duodenal Switch-proximal approach (SADS-p) and One Anastomosis Gastric Bypass-Mini Gastric Bypass (OAGB-MGB).

BACKGROUND: Bariatric surgery plays a major role in ameliorating metabolic abnormalities of type 2 diabetes (T2DM). The aim of this study was to evaluate the early effects of "Single Anastomosis Duodenal Switch-proximal approach" (SADS-p) and "One Anastomosis Gastric Bypass-Mini Gastric Bypass (OAGB-MGB) on the "homeostasis model assessment of insulin resistance" (HOMA-IR) index levels in morbidly obese patients with T2DM. METHODS: In this retrospective 3-year trial, outcomes of SADS-p and OAGB-MGB patients were compared considering the changes in HOMA-IR index levels. All bariatric procedures were performed by a single primary surgeon recognized as a surgeon of excellence by IFSO-EC with the assistance of one or two additional attending surgeons. SADS-p was performed on 60(10 males) patients, and 200(27 males) patients underwent OAGB-MGB. Forty-six patients (78%) in the SADS-p group and 125 (63%) in the OAGB-MGB group had T2DM. Patients were evaluated before surgery and 1,3,9,12 months after surgery. RESULTS: In both groups, the HOMA-IR index levels decreased significantly after surgery (p < 0.05), and both procedures markedly improved glycemic control. In the SADS-p group the HOMA-IR index levels significantly decreased from 6.2 to 1.4 after the 12th month of surgery (p < 0.05), in OAGB-MGB group HOMA-IR index levels significantly decreased from 5,9 to 1.7 after the 12th month of surgery (p < 0.05). CONCLUSION: Both procedures are promising operations which offer excellent control on weight, HOMA-IR index and diabetes.

Fasciocutaneous Elliptical Rotation Flap for Pilonidal Sinus Disease and Its Outcomes.

OBJECTIVES: Sacrococcygeal pilonidal sinus is a common disease especially in the Caucasians of the Middle East. It has been reported in the incidence of 12-26 in a 100.000 population. Previously thought to be due to etiological reasons of congenital origin, it is now widely accepted as an acquired disease. The optimal treatment for pilonidal sinus disease still has no consensus. The elliptical rotation flap was first described by Nessar in the surgery of pilonidal sinus and reported successful results, but it has weak points. The purpose of this study was to share the findings of the fasciocutaneous elliptic rotation flap technique retrospectively. MATERIAL AND METHODS: One hundred and eighty-six patients (149 were males and 37 were females) operated for pilonidal disease with fasciocutaneous elliptic rotation flap between 2013 and 2018 were included into this study. Data of the patients including operation time, wound issues (infection, seroma, wound separation), time required to return to daily activities, complete healing time and recurrence rates were recorded retrospectively. RESULTS: The patients' complete healing time was 13 ± 3 days and mean follow-up was 19 (6-37) months. Mean operative time was 43 ± 13 minutes. Mean time of drain removal was 2.20 ± 1.18 days. There were no flap necrosis or ischemia. Postoperative infection developed in two patients (1%). Seroma developed in 7 (3.8%) patients. Partial wound dehiscence occurred in 5 (3.2%) patients. None of the cases developed hematoma or complete dehiscence. No recurrence was observed in postoperative follow-ups. CONCLUSION: Fasciocutaneous elliptical rotation flap is a method that has follow-up results similar to both the elliptical rotation flap technique and its modification and can be safely preferred in the treatment of pilonidal sinus with its other advantages.

Analysis of factors associated with mortality in major burn patients.

OBJECTIVES: Major burn injury is a type of trauma with high morbidity and mortality rates at all age groups. There is no consensus on the provided guidelines regarding the prediction of severity of the victims. Not being accessible to sophisticated clinical and blood monitoring in developing countries, it remains a challenge for them. The aim of the present study was to analyze the factors that have an effect on mortality and serve as a guide for burn treatment. Factors affecting mortality in major burn patients treated in a burn treatment center of a third step hospital with over 30% of burns of the total body surface area were evaluated, and parameters indicating severity were specifically determined. MATERIAL AND METHODS: Medical records and follow-up notes of patients hospitalized in Ankara Numune Education and Research Hospital Burn Center between 2008 and 2014 were evaluated retrospectively. Data on age, gender, comorbidities, burn percentage, locality, type of burn, process of the burn (suicide or accident), presence of inhalation injury, results of blood hemogram and biochemical tests, length of hospitalization, type of surgical procedures performed, presence of multitrauma, and ventilatory support requirement were analyzed to determine the factors affecting mortality. White blood cell count, hemoglobin count, platelet count, and lactate dehydrogenase level were examined at admission, at the middle of the clinical course, and at the end of treatment (at both exitus date or discharge date). RESULTS: A total of 224 patients were hospitalized with burns ≥ 30% total body surface area. Of the 224 patients, 81.7% were males, and 18.4% were females. In the mortality group, 41.3% were males, and 58.5% were females. Gender (female, p <0.041), age (p <0.001), age group (0-14/15-59/> 60 years, p <0.001), total body surface area (p <0.001), type of burn (flame, p <0.002), presence of inhalation injury (p <0.001), process of the burn (p <0.002), time spent between the event and admission to the hospital (p <0.001), length of hospitalization (p <0.001), presence of comorbidity (p <0.038), diabetes mellitus (p <0.05), ventilation support (p <0.001), lactate dehydrogenase values (lactate dehydrogenaseadmission, p <0.001; lactate dehydrogenasemiddle, p <0.015; lactate dehydrogenaselast, p <0.001), white blood cell count (p <0.001), and platelet count (p <0.043) were found to be significant for univariate analyses. These parameters were further evaluated using multivariate analyses. Lactate dehydrogenaselast level (p <0.001), age (p <0.001), length of hospitalization (negative odds ratio), p <0.001), presence of inhalation injury (p <0.029), total body surface area burned (p <0.029), and leukocytosis (p <0.006) were found to be significantly associated with mortality; however, leukocytosis and length of hospitalization did not pose risk for mortality with regard to odds ratios. CONCLUSION: Early recognition of the factors affecting morbidity and mortality in patients and taking preventive measures, in addition to earlier detection and prevention of complications in long-time intensive care unit patients, could reduce complication and mortality rates in major burn trauma patients. Parameters for the indication of severity and mortality are important; however, lactate dehydrogenase is an easily studied parameter and is found to have a predictive value on prognosis.

Analysis of factors associated with mortality in major burn patients.

OBJECTIVE: Major burn injury is a type of trauma that still has high morbidity and mortality rates at all age groups. There is no consensus on the provided guidelines regarding the prediction of the severity of the victims. It is sometimes not easy to have sophisticated clinical and blood monitoring for developing countries. It is still a challenge for them. The aim of the present study was to analyze the factors that have an effect on mortality and serve as a guide for burn treatment. Factors affecting mortality in major burn patients with over 30% of burns of the total body surface area who were treated in a burn treatment center of a third step hospital were evaluated, and parameters indicating severity were specifically determined. MATERIAL AND METHODS: Medical records and follow-up notes of patients hospitalized in in Ankara Numune Education and Research Hospital Burn Center between 2008 and 2014 were evaluated retrospectively. Data on age, gender, comorbidities, burn percentage, locality, type of burn, process of the burn (suicide or accident), presence of inhalation injury, results of blood hemogram and biochemical tests, length of hospitalization, type of surgical procedures performed, presence of multitrauma, and ventilatory support requirement were analyzed to determine the factors affecting mortality. White blood cell count, hemoglobin count, platelet count, and lactate dehydrogenase level were examined at admission, at the middle of the clinical course, and at the end of treatment (at both exitus date or discharge date). RESULTS: A total of 224 patients were hospitalized with burns ≥30% total body surface area. Of the 224 patients, 81.7% were males, and 18.4% were females. In the mortality group, 41.3% were males, and 58.5% were females. Gender (female, p<0.041), age (p<0.001), age group (0-14/15-59/>60 years, p<0.001), total body surface area (p<0.001), type of burn (flame, p<0.002), presence of inhalation injury (p<0.001), process of the burn (p<0.002), time spent between the event and admission to the hospital (p<0.001), length of hospitalization (p<0.001), presence of comorbidity (p<0.038), diabetes mellitus (p<0.05), ventilation support (p<0.001), lactate dehydrogenase values (lactate dehydrogenaseadmission, p<0.001; lactate dehydrogenasemiddle, p<0.015; lactate dehydrogenaselast, p<0.001), white blood cell count (p<0.001), and platelet count (p<0.043) were found to be significant for univariate analyses. These parameters were further evaluated using multivariate analyses. lactate dehydrogenaselast level (p<0.001), age (p<0.001), length of hospitalization (negative odds ratio), p<0.001), presence of inhalation injury (p<0.029), total body surface area burned (p<0.029), and leukocytosis (p<0.006) were found to be significantly associated with mortality; however, leukocytosis and length of hospitalization did not pose risk for mortality with regard to odds ratios. CONCLUSION: Early realization of the factors affecting morbidity and mortality in patients and taking preventive measures, in addition to earlier detection and prevention of complications in long-time intensive care unit patients, could reduce complication and mortality rates in major burn trauma patients. Parameters for the indication of severity and mortality are important; however, lactate dehydrogenase is an easily studied parameter and is found to have a predictive value on prognosis.

Clinical infection in burn patients and its consequences.

BACKGROUND: Burn injuries facilitate invasive infections and sepsis not only by destroying the continuity of the protective skin barrier but also through systemic effects. The burn wound, blood, and urine samples are frequently cultured to determine the pathogen agent. The aim of this study was to analyze pathogen growth in patients' cultures confirmed as "infection positive" by the hospital Infection Control Committee and to assess the clinical implications of these growths. METHODS: Hospitalized patients included in the study were those with a total burned body surface area of >10% and "presence of infection" confirmed by the Infection Control Committee. The patients were evaluated with respect to age, gender, burn etiology, the total body surface area burned (TBSA), the presence of inhalation injury, sepsis, positive cultures, the microorganisms cultured in wound-blood-urine samples, and septic focus. RESULTS: Of the total 36 (10.3%) "infection-positive" patients, 26 (72.2%) were male; the mean age of patients was 44±21 years. The mean burned TBSA of the whole group was 45.58%±23.1%. Acinetobacter baumannii was the most isolated organism in the wound cultures. In patients with confirmed infection, there was a correlation between the pathogen isolated in urine cultures and mortality rates (p=0.023). Sepsis was diagnosed in 23 (63.9%) patients, of whom 21 had inhalation injuries. There was a significant correlation between inhalation injury and sepsis (p=0.015), and both the presence of sepsis or inhalation injury increased mortality (p=0.027 and p=0.009, respectively). CONCLUSION: According to the study data, the TBSA burned demonstrated a greater significance for mortality, although the presence of sepsis and/or urinary tract infection should also be noted as a cause of mortality in burned patients.

The effects of obstructive jaundice on the brain: An experimental study.

BACKGROUND/OBJECTIVE: The study aims to evaluate the alterations in the brain due to oxidative stress and lipid peroxidation resulting from obstructive jaundice. METHODS: Forty-one Wistar albino rats were used in this study. Simple laparotomy was performed in the sham group (n = 5). In the remaining 36 rats, the common bile duct (CBD) was found and ligated. They were divided into six groups. Group I, Group II, and Group III were sacrificed at the 3(rd), 7(th), and 14(th) day of ligation, respectively. In Group Id, Group IId, and Group IIId ligated bile ducts were decompressed at the 3(rd), 7(th), and 14(th) day, respectively. One week after decompression these rats were also sacrificed and samples were taken. RESULTS: After the CBD ligation, serum levels of bilirubin and malondialdehyde were found to be increased progressively in parallel to the ligation time of the CBD. After decompression these values decreased. In electron microscopy evaluation, the damage was found to be irreversible depending on the length of the obstruction period. In Group II, the damage was mostly reversible after the internal drainage period of 7 days. However in Group III, the tissue damage was found to be irreversible despite the decreased values of oxidative stress and bilirubin. CONCLUSION: Ultrastructural changes in brain tissue including damage in the glial cells and neurons, were found to be irreversible if the CBD ligation period was >7 days and did not regress even after decompression. It is unreliable to trace these changes using blood levels of bilirubin and free radicals. Therefore, timing is extremely critical for medical therapies and drainage.