Novel Trocar-Free Elastic Liver Retractor in Bariatric Surgery Patients: Comparison of a Standard Laparoscopic Retraction With the First Series Using the LiVac Sling System.

During upper gastrointestinal surgery, retraction of the liver plays an essential role in the visualization and creation of an optimal surgical field. Liver retraction may be problematic, particularly in obese patients. The use of conventional liver retractors requires additional skin incision and has the potential to cause pain as well as liver injuries. The present study is the first to evaluate the performance and safety of the LiVac Sling (Livac Pty Ltd, Melbourne, Australia) trocar-free retractor system in bariatric surgery patients. In this retrospective study, data from laparoscopic primary or revisional bariatric surgeries that were performed with the LiVac Sling system and a standard retractor between May 2017 and December 2017 were collected. Demographic data, body mass index, type of surgery, number and indication of LiVac Sling system used, surgery time, and complications were analyzed. In total, 51 procedures were included. Twenty Sling devices have been used in 17 patients (13 female; 75%). The distribution of baseline characteristics was similar between the standard retractor group and LiVac Sling retractor group. In the LiVac Sling group, the number of trocars used was significantly reduced over the study period. Within 30 days postoperatively, no complications could be identified, and no device-related adverse events were reported. In this bariatric population, the use of the LiVac Sling for liver retraction was safe. No device-related adverse events were registered, and compared with standard retraction, the number of trocars used could be reduced by one.

Local recurrence in the neck and survival after thyroidectomy for metastatic renal cell carcinoma.

BACKGROUND: Most investigations of thyroidectomy for metastatic renal cell carcinoma (RCC) are case studies or small series. This study was conducted to determine the contribution of clinical and histopathologic variables to local recurrence in the neck and overall survival after thyroidectomy for RCC metastases. METHODS: The medical records of 140 patients with thyroidectomy for metastatic RCC performed between 1979 and 2012 at 25 institutions in Germany and Austria were analyzed. RESULTS: The median interval between nephrectomy and thyroidectomy was 120 months. Concurrence of thyroid and pancreatic metastases was present in 23 % of the patients and concurrence of thyroid and adrenal metastases in 13 % of the patients. Clinical outcome data were available for 130 patients with a median follow-up period of 34 months. The 5-year overall survival rate was 46 %, and 28 % of patients developed a local neck recurrence at a median of 12 months after thyroidectomy. Multivariate analysis showed that invasion of adjacent cervical structures (hazard ratio [HR] 3.2; p = 0.001), patient age exceeding 70 years (HR 2.5; p = 0.004), and current or past evidence of metastases to nonendocrine organs (HR 2.4; p = 0.003) were independent determinants of inferior overall survival. Conversely, invasion of adjacent cervical structures (HR 12.1; p < 0.0001) and year of thyroidectomy (HR 5.7 before 2000; p < 0.0001) were shown to be independently associated with local recurrence in the neck by multivariate analysis. CONCLUSIONS: Although significant improvement of local disease control in patients with thyroid metastases of RCC has been achieved during the last decade, overall outcome continues to be poor for patients with locally invasive thyroid metastases.

Evolution of nerve injury with unexpected EMG signal recovery in thyroid surgery using continuous intraoperative neuromonitoring.

BACKGROUND: Intermittent intraoperative neuromonitoring cannot prevent preparative surgical damage or predict imminent recurrent laryngeal nerve (RLN) damage with subsequent development of loss of electromyogram (EMG) signal during thyroid surgery. In case the nerve is stressed, i.e., from traction near the ligament of Berry, the nerve injury is only detected after it has occurred, not allowing the surgeon to correct the mechanical maneuver and salvage nerve function intraoperatively. METHODS: The unusual clinical scenario of sacrifice of a tumor-infiltrated RLN was used to study real-time evolution of RLN injury caused by mechanical distention. The ipsilateral vagus nerve (VN) was continuously stimulated with a new stimulation probe, and changes in EMG response were correlated with the varying levels of stretch and traction. RESULTS: Mechanical traction induced an intermittent depression of EMG amplitudes as a sign of impaired propagation of axon potentials or synaptic transmission. Prolonged mechanical stress caused a long-lasting depression of EMG response. When the mechanical distention was relieved, neurotransmission was gradually restored, with reappearance of singular muscle depolarization of full magnitude interspersed between the barely detectable deflections in the EMG recording. These responses of full amplitude appeared with increasing frequency, until the regular continuous EMG pattern was completely restored. CONCLUSIONS: Only continuous VN stimulation serves to detect early changes in EMG response that indicate imminent danger to RLN functional integrity and alerts the surgeon to immediately correctable surgical actions, thus possibly preventing nerve damage or transforming damage into a reversible event.

Hyperkalemia Following Parathyroidectomy in Patients with Renal Hyperparathyroidism-New Thresholds for Urgent Perioperative Dialysis.

Parathyroidectomy (PTX) is a mainstay of treating secondary hyperparathyroidism (SHPT) in patients with kidney failure in order to reduce the incidence of cardiovascular events (CVE), increase overall survival and improve quality of life. Perioperative hyperkalemia may lead to devastating cardiac complications. Distinct preoperative thresholds for serum potassium levels (SPL) were defined, but neither their usefulness nor consecutive risks are understood. This study compared the results and efficacy of different clinical procedures in preventing or treating perioperative hyperkalemia, including postoperative urgent hemodialysis (UHD). Methods: Patients from Charité-Universitätsmedizin Berlin and Rheinland Klinikum Lukaskrankenhaus, Neuss, undergoing PTX due to SHPT between 2008 and 2018 were analyzed retrospectively with regard to demographic parameters, surgery specific conditions and perioperative laboratory results. Comparisons of patient values from both centers with focus on perioperative hyperkalemia and the need for UHD were performed. Results: A total of 251 patients undergoing PTX for SHPT were included (Neuss: n = 121 (48%); Berlin: n = 130 (52%)). Perioperative hyperkalemia (SPL ≥ 5.5 mmol/L) was noted in 134 patients (53%). UHD on the day of surgery was performed especially in patients with intraoperative hyperkalemia, in females (n = 40 (16%) vs. n = 27 (11%); p = 0.023), in obese patients (n = 27 (40%) vs. n = 50 (28%), p = 0.040) and more often in patients treated in Neuss (n = 42 (35%) vs. 25 (19%); p = 0.006). For patients treated in Neuss, the intraoperative hyperkalemia cut-off level above 5.75 mmol/L was the most predictive factor for UHD (n = 30 (71%) vs. n = 8 (10%); p < 0.001). Concerning secondary effects of hyperkalemia or UHD, no patient died within the postoperative period, and only three patients suffered from acute CVE, with SPL > 5.5 mmol/L measured in only one patient. Conclusion: Perioperative values could not predict postoperative hyperkalemia with the need for UHD. Previously defined cut-off levels for SPL should be reconsidered, especially for patients undergoing PTX. Early postoperative dialysis in patients with postoperative hyperkalemia can be performed with a low risk for complications and may be indicated for all patients with increased perioperative SPL.

Is There a Gender Difference in Clinical Presentation of Renal Hyperparathyroidism and Outcome after Parathyroidectomy?

INTRODUCTION: Gender has been proven to influence the pathophysiology and treatment of numerous diseases, including kidney diseases and hormonal dysfunction like hyperparathyroidism. Thus, higher parathormone levels have been demonstrated in women with end-stage kidney disease, when compared to men. OBJECTIVES: We questioned whether female gender is associated with an increased risk for parathyroid nodular hyperplasia and necessary parathyroidectomy in dialysis patients and assessed demographics as well as outcome data for women and men undergoing parathyroidectomy for renal hyperparathyroidism. PATIENTS AND METHODS: One hundred and thirty patients (men = 75, female = 55) with end-stage renal disease on chronic dialysis and advanced secondary hyperparathyroidism who underwent parathyroidectomy between 2008 and 2014 at our center were analyzed retrospectively. Perioperative characteristics and short-term outcome were evaluated with respect to biological gender. RESULTS: No differences could be demonstrated for patient demography, comorbidities and the perioperative course between males and females. Only preoperative calcium levels were lower in female than in male patients (2.3 ± 0.19 vs. 2.3 ± 0.26, p = 0.04). There were more women, however, with cerebrovascular complications during follow-up (p = 0.04). There was no postoperative mortality, and all complications and comorbidities with exception of cerebrovascular diseases were equally distributed between female and male patients. CONCLUSION: Overall, we could not demonstrate many significant differences between male and female patients with end-stage renal diseases, chronic dialysis and operated secondary hyperparathyroidism. Only preoperative electrolyte levels were higher in male than in female patients, and cerebrovascular complications developed more often in females than in males during long-term follow-up.

Influence of Gender on Therapy and Outcome of Neuroendocrine Tumors of Gastroenteropancreatic Origin: A Single-Center Analysis.

INTRODUCTION: Gender-specific treatment is gaining growing attention in various fields of medicine. In gastrointestinal cancer, influence of sex on outcome has been discussed, while this has not been the case in neuroendocrine tumors. Overall, the incidence of neuroendocrine neoplasms is rising, especially for appendiceal neuroendocrine neoplasms in women. Also, women seem to have a slight advantage in response to therapy, especially for liver metastases. OBJECTIVES: This single-center analysis aimed to investigate gender-specific differences in our cohort related to distribution, therapy, and outcome. METHODS: Patients from the NET registry as well as the clinic database were evaluated retrospectively concerning overall survival and response to therapy with respect to gender. A subgroup analysis was carried out for patients with low grading and response to chemotherapy, as well as for patients with good and moderate grading receiving peptide receptor radionuclide therapy and for a group of patients with liver surgery. RESULTS: No specific differences could be detected for overall survival or response to therapy between male and female patients. Mean survival was estimated with 242.2 months (±10.39 SD) altogether and 221.7 months (± 13.02 SD) for male patients and 253.5 months (±15.24 SD) for female patients from the NET registry from initial diagnosis. There was no significant difference between female and male patients (p = 0.136). For patients receiving chemotherapy, overall survival from initial diagnosis was calculated with 26 months (±2.59) and did not show any significant differences between female and male patients 24.8 months (±2.81 SD) vs. 27.8 months (±3.86 SD, p = 0.87). Patients undergoing peptide receptor radionuclide therapy showed a median progression-free survival of 26.9 months (±2.82 SD), with 16.9 (±5.595 SD) and 26.9 months (±3.019 SD) for male and female patients, respectively (p = 0.2). In the group of patients with liver surgery, female patients reached an estimated overall survival of 64.7 months (±4.16 SD), male patients 65.1 months (±2.79 SD, p = 0.562). CONCLUSION: Our cohort did not reveal significant differences in outcome and response to therapy with regards to gender.

The "Hug" Technique-Roux-en-Y Gastric Bypass with Preservation of the Posterior Wrap in Patients with Previous Nissen Fundoplication: a Simple Solution for a Complex Problem.

BACKGROUND: Laparoscopic conversion of Nissen Fundoplication to Roux-en-Y gastric bypass (RYGB) is a complex procedure due to increased operative time, morbidity, and length of hospital stay (LOS). In this study, a new simplified technique avoiding the total dismantling of the previous Nissen repair to construct the gastric pouch, the so-called hug technique is presented for the conversion of Nissen fundoplication to RYGB. METHODS: The present study is a prospective single-center clinical series reporting on the feasibility and safety of the "hug" technique for the creation of laparoscopic RYGB. The major innovation of this approach is the fact that the posterior part of the fundoplication wrap is left in place without further dissection or manipulation. The anterior part is stapled and remains attached to the excluded stomach. Prospective data on intraoperative and postoperative morbidity and bariatric outcomes were collected. RESULTS: A total of 44 consecutive patients with a mean body mass index (BMI) of 43.7 kg/m2 (SD = 4.0, range = 35.6-52.0) underwent the "hug" procedure between 2004 and 2015. Mean operative time was 72 min (58-105 min). Morbidity was 4.5%, with no mortality. For patients with follow-up at 3 years, the percentage of total body weight loss (%TBWL) was 32.5%; the excess weight loss (EWL) was 64.2%. CONCLUSION: In contrast to current other techniques of bariatric surgery for patients having previously undergone a Nissen fundoplication, the "hug" procedure to create an RYGB is safe and simple to perform. This technique avoids the deconstruction of the previous repair and is still maintaining anti-reflux anatomy. Nevertheless, there is a need for further studies to evaluate the long-term outcomes of the procedure.

Influence of Parathyroidectomy on Kidney Graft Function in Secondary and Tertiary Hyperparathyroidism.

BACKGROUND: Timing of parathyroidectomy (PTX) remains controversial in candidates for kidney transplant with concomitant renal hyperparathyroidism (HPT). The aim of this retrospective study was to identify the influence of early vs late posttransplant PTX compared to pretransplant PTX on renal graft function and morbidity. METHODS: This single-center cohort study includes 57 patients with renal HPT and kidney transplantation treated between 2007 and 2017. Ninety-six patients had surgery for renal HPT between 2007 and 2017 as a consecutive sample. Group 1 (n = 30; tertiary HPT), group 2 (n = 66; secondary HPT). Of group 1, 4 patients were excluded for PTX before and after kidney transplantation. In group 2, 20 patients were excluded since they had not undergone kidney transplantation during follow-up. Twelve patients were excluded because of short follow-up (kidney transplantation in 2018), and 3 patients were excluded because of transplant failure within 90 days. Twenty-six patients underwent posttransplant PTX (10 patients within 12 months after transplant), and 31 patients had undergone PTX prior to kidney transplantation. Graft function, serum calcium concentrations, parathyroid hormone (PTH) levels, postoperative morbidity, and 90-day mortality were recorded. RESULTS: Median age was 53.1 years in group 1 and 49.1 years in group 2. Most patients were male (53.8% in group 1; 54.8% in group 2). Median preoperative PTH levels were significantly different with 331.6 pg/mL in group 1 and 667.5 pg/mL in group 2 (P = .003). Creatinine levels changed little from 1.4 mg/dL (range, 0.8-2.5) to 1.7 mg/dL (range, 0.7-7.3) in group 1, and no difference was seen between early or late PTX after transplantation. In group 2, creatinine levels were 8.5 mg/dL (range, 4.6-11.7) before PTX and 8.7 mg/dL (range, 5.1-11.9) after PTX. We saw no correlation between postoperative PTH and kidney function. Thirty-five patients with postoperative PTH < 15 pg/mL displayed a mean postoperative creatinine of 5.5 mg/dL (range, 4.3-6.8), similar to other patients. Both the 30-day and 90-day mortality rates were zero. CONCLUSIONS: PTX had no negative effect on graft function, whether performed before or after (early or late) kidney transplantation. Surgical cure of renal HPT should be performed as soon as possible to prevent secondary complications and can also be safely carried out early after transplantation.

ROUTINE USE OF V-LOCK® SUTURE FOR BARIATRIC ANASTOMOSIS IS SAFE: COMPARATIVE RESULTS FROM CONSECUTIVE CASE SERIES.

BACKGROUND: In high-income countries, morbid obesity is a growing health problem that has already reached epidemic proportions. When performing a laparoscopic gastric bypass several operative methods exist. AIM: To describe the institutional experience using a knotless unidirectional barbed suture (V-Loc 180/Covidien, Mansfield, MA) to create a hand-sewn gastrojejunostomy (GJ) and jejunojejunostomy (JJ) during bariatric surgery. METHODS: Evaluation of a case series of 87 morbidly obese patients who underwent laparoscopic gastric bypass with a hand-sewn gastrojejunostomy (GJA) and jejunojejunostomy (JJA) between 01/2015 and 06/2017. The patients were divided into two groups: in group I, GJA und JJA sutures were performed using the knotless unidirectional barbed suture; in group II, GJA and JJA were sutured with resorbable multifilament thread (Vicryl® 3/0 Ethicon, Livingstone, UK). The recorded data on gender, age, BMI, ASA score, operative time, postoperative morbidity, length of hospital stay, and reoperation, were analyzed and compared. RESULTS: All procedures were completed laparoscopically with no mortality. The mean operative time was 123.23 (±30.631) in group I and 127.57 (±42.772) in group II (p<0.05). The postoperative complications did not differ significantly between the two groups. Early complications were observed for two patients (0.9%) in the barbed suture group and for one patient (0.42%) in the multifilament suture group (p<0.05). In group I two patients (0.9%) required reoperation: on the basis of jejunojejunal stenosis in one patient, and local abscess near the gastrojejunostomy, without a leakage, in the other. In group II one patient (0.42%) required reoperation due to stenosis of the GJA. The duration of hospital admission was similar for both groups: 3.36 (±0.743) days in group I vs. 3.38 (±1.058) days in group II (p<0.05). CONCLUSION: The novel anastomotic technique is a safe and effective method and can be applied to gastrojejunal anastomosis and jejunojejunal anastomosis in laparoscopic gastric bypass.

Intragastric single-port surgery (IGS) accesses the gastric remnant and allows ERCP for common bile duct stones after RYGB: a simple solution for a difficult problem.

BACKGROUND: Patients who have undergone a Roux-en-Ygastric bypass (RYGB) and suffer from choledocholithiasis postoperatively pose a medical dilemma. Treatment of the cholestasis can be complicated because of the altered anatomy in these patients. The gastric remnant and duodenum are isolated from the pancreaticobiliary limb, making endoscopic retrograde pancreatography (ERCP) challenging and often impossible. OBJECTIVE: To describe a method for safe introduction of the endoscope into the gastric remnant through intragastric single-port surgery (IGS), thus allowing for simultaneous cholecystectomy. SETTING: Pilot clinical study. METHODS: The present study is a nonrandomized clinical series describing our preliminary results using a transgastric inserted single-port device for ERCP after RYGB. The series includes 8 patients who underwent IGS ERCP after RYGB. RESULTS: The technique was successfully applied for intraoperative ERCP through a transgastric inserted single-port device (Gelpoint Mini, Applied Medical, Rancho Santa Margarita, CA). Papilotomy was easily achieved without complications. Average operative time was 144.75 minutes. The patients recovered without complications and could be discharged after a mean of 4.38 days. CONCLUSIONS: The novel IGS technique is safe and effective and can be applied to perform ERCP in patients with RYGB anatomy. Transgastric single port ERCP was simple to perform, achieved excellent results, and allowed for endoscopic treatment and cholecystectomy to be performed in a single procedure. The technique can be indicated in patients with complicated gallstone obstruction under altered anatomy after RYGB.

How many parathyroid glands can be identified during thyroidectomy?: Evidence-based data for medical experts.

BACKGROUND: The purpose of this study is to provide guidance for medical experts regarding malpractice claims on permanent hypoparathyroidism by analyzing the number of parathyroid glands (PGs) identified during thyroidectomy and the clinical outcome. METHODS: Parathyroid findings were documented in a standardized protocol for 357 patients undergoing thyroidectomy and treated by a single specialized surgeon. The resected thyroid was routinely dissected for accidentally removed PGs with consecutive autotransplantation and the pathological report also described unintentionally resected PGs. Follow-up was performed for 6 months. RESULTS: The mean number of identified PGs was 2.28. No PGs were found in 20 (5.6%), one in 56 (15.7%), two in 126 (35.3%), three in 114 (31.9%), and four in 41 (11.5%) cases. One patient (0.28%) had manifest permanent hypoparathyroidism, while ten patients (2.8%) had latent permanent hypoparathyroidism (hypocalcemia and normoparathyroidism). The risk factors identified for postoperative hypoparathyroidism were an increasing number of visualized PGs, autotransplantation, central neck dissection, and PGs in the histopathological work-up. For permanent hypoparathyroidism, PGs in the histology examination and neck dissection were significant, but the number of identified PGs was not. CONCLUSION: Even an experienced surgeon is not always able to find all four PGs during thyroidectomy and occasionally identifies none. Rather than focusing on identifying a minimum number of PGs, it is more important not to miss them in risky positions. A documented awareness of PGs, i. e., knowledge of variable parathyroid positions and their saving, is a prerequisite for surgical quality and to protect surgeons from claims.

Increase of papillary thyroid microcarcinoma and a plea for restrictive treatment: A retrospective study of 1,391 prospective documented patients.

BACKGROUND: The incidence of papillary thyroid microcarcinomas (PMCs) has increased sharply and therefore the lack of consensus for treatment has become a clinical dilemma. Our aim was to evaluate a less-radical approach. METHODS: This study includes 1,391 patients with PMC treated at a single surgical referral center in the endemic goiter area in Austria. Data, including long-term follow-up examinations with a median follow-up time of 7 years, were collected from the institutional surgery database. RESULTS: Of the 1,391 patients, 947 (68.1%) had a near-total or total thyroidectomy; 1,090 patients (78.3%) had no lymphadenectomy, and 1,136 patients (81.7%) did not receive radioiodine treatment. Twenty-one patients (1.5%) underwent reoperation, 5 because of lymph node recurrence (0.4%), 16 with clinically benign recurrence, including 4 cases of another PMC. There were no recurrences in the thyroid bed and no disease-related deaths. Risk factors for lymph node recurrences were nonincidental finding, nodal metastases at presentation, young age, aggregate tumor size, and subcapsular tumor localization. Multifocality, sex, maximum tumor size, and the extent of surgery were not relevant factors. CONCLUSION: Nodal recurrence is rare and reoperation cured all patients. Micrometastases are not of clinical relevance. The postoperative findings of most PMCs suggest that, even if multifocal, a limited approach without completion thyroidectomy, lymphadenectomy and radioiodine treatment is sufficient. In case of pre- or intraoperative clinically suspected nodal metastases or postoperatively diagnosed risk factors we propose the standard radical procedure. Routine preoperative cervical lymph node sonography is advisable before any thyroid surgery.

Perioperative kinetics of parathyroid hormone in unilateral, primary thyroid surgery.

Dysfunction of the parathyroid glands is an important cause of complications after thyroid surgery. Intraoperative monitoring of the function of the parathyroid glands can be performed using parathyroid hormone (PTH) kinetics. Unilateral thyroid surgery is associated with a decreased risk for postoperative hypocalcemia (POH) and permanent hypoparathyroidism (PEH). We focused on unilateral thyroid surgery by monitoring the functionality of the parathyroid glands and comparing the perioperative PTH kinetics of patients with and without POH. In a prospective study, 143 patients scheduled for unilateral thyroid surgery underwent monitoring of perioperative changes in serum PTH and serum calcium levels, and of clinical symptoms of hypocalcemia. The rates of POH and PEH were 18.2 and 0%, respectively. In patients without POH, PTH significantly increased from the time of skin incision to the end of the operation and after the operation (20.1 pg/ml, IQR 15.5-26.8 vs. 21.4 pg/ml, IQR 16.4-29.5; p=0.005), which was not the case in patients who developed POH. In a multivariate analysis of predictive factors for POH, two parameters became significant, namely female gender (odds ratio 6.87, 95% confidence interval 0.92-51.01) and lower initial serum calcium levels (odds ratio 3.54*e(-8), 95% confidence interval 3.63*e(-12); 0.00). The rate of POH was unexpectedly high. Rather than intraoperative PTH declines, an unstable balance of factors that influence calcium metabolism likely is the major contributor to POH after unilateral thyroid surgery. There was no case of PEH after unilateral, primary thyroid surgery, which underlines the need for an individualized approach to the extent of resection.

Routine use of v-lock® suture for bariatric anastomosis is safe: comparative results from consecutive case series / Uso rotineiro da sutura v-lock® para anastomoses em obesidade é seguro: resultados de estudo clínico comparativo

ABSTRACT Background: In high-income countries, morbid obesity is a growing health problem that has already reached epidemic proportions. When performing a laparoscopic gastric bypass several operative methods exist. Aim: To describe the institutional experience using a knotless unidirectional barbed suture (V-Loc 180/Covidien, Mansfield, MA) to create a hand-sewn gastrojejunostomy (GJ) and jejunojejunostomy (JJ) during bariatric surgery. Methods: Evaluation of a case series of 87 morbidly obese patients who underwent laparoscopic gastric bypass with a hand-sewn gastrojejunostomy (GJA) and jejunojejunostomy (JJA) between 01/2015 and 06/2017. The patients were divided into two groups: in group I, GJA und JJA sutures were performed using the knotless unidirectional barbed suture; in group II, GJA and JJA were sutured with resorbable multifilament thread (Vicryl® 3/0 Ethicon, Livingstone, UK). The recorded data on gender, age, BMI, ASA score, operative time, postoperative morbidity, length of hospital stay, and reoperation, were analyzed and compared. Results: All procedures were completed laparoscopically with no mortality. The mean operative time was 123.23 (±30.631) in group I and 127.57 (±42.772) in group II (p<0.05). The postoperative complications did not differ significantly between the two groups. Early complications were observed for two patients (0.9%) in the barbed suture group and for one patient (0.42%) in the multifilament suture group (p<0.05). In group I two patients (0.9%) required reoperation: on the basis of jejunojejunal stenosis in one patient, and local abscess near the gastrojejunostomy, without a leakage, in the other. In group II one patient (0.42%) required reoperation due to stenosis of the GJA. The duration of hospital admission was similar for both groups: 3.36 (±0.743) days in group I vs. 3.38 (±1.058) days in group II (p<0.05). Conclusion: The novel anastomotic technique is a safe and effective method and can be applied to gastrojejunal anastomosis and jejunojejunal anastomosis in laparoscopic gastric bypass.

RESUMO Racional : Em países de alta renda, a obesidade mórbida é um problema crescente de saúde que já atingiu proporções epidêmicas. Ao realizar um bypass gástrico laparoscópico, existem vários métodos operatórios. Objetivo: Descrever a experiência institucional utilizando uma sutura farpada unidirecional sem nós (V-Loc 180/Covidien, Mansfield, MA) para criar gastrojejunostomia (JJ) e jejunojejunostomia (JJ) costuradas à mão durante a cirurgia bariátrica. Métodos: Avaliação de uma série de casos com 87 pacientes obesos mórbidos submetidos ao bypass gástrico por videolaparoscopia com gastrojejunostomia (JJA) e jejunojejunostomia (JJA) suturados à mão entre 01/2015 e 06/2017. Os pacientes foram divididos em dois grupos; no grupo I, GJA e JJA as suturas foram realizadas com a sutura farpada unidirecional sem nós e, no grupo II, com sutura multifilamentar reabsorvível (Vicryl® 3/0 Ethicon, Livingstone, UK). Foram analisados ​​e comparados os dados registrados sobre gênero, idade, IMC, escore ASA, tempo operatório, morbidade pós-operatória, tempo de internação hospitalar e reoperação. Resultados: Todos os procedimentos foram concluídos por laparoscopia sem mortalidade. O tempo cirúrgico médio foi 123,23 (±30,631) no grupo I e 127,57 (±42,772) no grupo II (p<0,05). As complicações pós-operatórias não diferiram significativamente entre os dois grupos. Complicações precoces foram observadas em dois pacientes (0,9%) no grupo de sutura farpada e um (0,42%) no de sutura multifilamentar (p<0,05). No grupo I, dois pacientes (0,9%) necessitaram de reoperação; um devido à estenose jejunojejunal e abscesso local próximo à gastrojejunostomia, sem vazamento, no outro. No grupo II, um paciente (0,42%) necessitou de reoperação por estenose da GJA. O tempo de internação hospitalar foi semelhante nos dois grupos: 3,36 (±0,743) dias no grupo I vs. 3,38 (±1,058) dias no grupo II (p<0,05). Conclusão: A nova técnica de anastomose é método seguro e eficaz e pode ser aplicado nas anastomoses gastrojejunal e jejunojejunal no bypass gástrico laparoscópico.

A prospective study on surgical-site infections in thyroid operation.

BACKGROUND: To evaluate the incidence and the microbe spectrum of surgical-site infections (SSIs) in patients undergoing elective thyroid operation and to develop a risk factor-based predictive model. METHODS: This prospective study included 6,778 consecutive patients who underwent thyroid operation at a single institution between 2007 and 2012. SSI was defined according to the Centers for Disease Control and Prevention. Regression models were fitted to evaluate risk factors for SSI. A predictive nomogram was constructed from relevant variables in the multivariable analysis. Discrimination and calibration of the nomogram were assessed. RESULTS: The cumulative incidence of SSI after 30 days was 0.49%. The median time from operation to SSI was 7 days (interquartile range, 4-10.5 days). SSI was classified as superficial incisional in 30 cases (93.8%), deep incisional in 1 case (3.1%), and organ/space in 1 case (3.1%). Staphylococcus aureus was the most common isolate. In multivariable analysis, duration of operation (P = .004) and American Society of Anesthesiologists' score (P = .031) were identified as independent risk factors for SSI. These variables formed the basis of a nomogram, which was validated internally by bootstrapping and reached a predictive accuracy of 70.1%. The calibration curve showed a good agreement between predicted probability and actual observation. CONCLUSION: The cumulative incidence of SSI in thyroid operation is <0.5%. American Society of Anesthesiologists' score and the duration of operation are independent risk factors for SSI. Antibiotic prophylaxis may be considered for selected patients based on the individual risk profile.

Can a surgeon predict the risk of postoperative hypoparathyroidism during thyroid surgery? A prospective study on self-assessment by experts.

BACKGROUND: Thyroid surgery can cause postoperative hypocalcemia (POH) and permanent hypoparathyroidism (PEH). Surgeons implicitly assess the risk and adapt their surgical strategy accordingly. METHODS: The outcome of this intraoperative decision-making process (the surgeons' ability to predict the risk of POH and PEH on a numerical rating scale and their actual incidence) was studied prospectively in 2,558 consecutive thyroid operations. RESULTS: POH and PEH occurred in 723 and 64 patients, respectively. In multivariate analysis, the surgeons' risk assessment score was an independent predictive factor for both complications (P < .05). Surgeons' differed significantly (P = .015) in their rates of POH but not of PEH (P = .062). Six and 3 (of 9) surgeons correctly predicted an increased risk of PEH and POH (adjusted odds ratios 1.67 to 2.21 and 1.47 to 12.73), respectively. CONCLUSION: The risk for hypoparathyroidism can be estimated, but surgeons differ substantially in this ability and in the extent to which this implicit knowledge is translated into lower complication rates.