Joint-preserving surgery for idiopathic bilateral osteonecrosis of the distal tibia: A case report.

Introduction: Osteonecrosis (ON) is a serious pathological condition that can affect weight-bearing areas of the lower limbs, including the distal tibia. Although trauma is a common cause of ON, the condition has multiple possible etiologies. ON has been associated with a range of factors, including trauma, medication use, alcoholism, and vascular disease. Interruption of blood flow to a particular bone region is the first step in the pathophysiology of ON. Conservative management is typically indicated in the early stages of ON, but joint-preserving procedures may be necessary in cases where conservative treatment fails. Case Report: This article presents a case of bilateral ON of the distal tibia in a 38-year-old female patient without a history of trauma or identifiable risk factors. The patient was initially managed conservatively but ultimately underwent joint-preserving surgery due to treatment failure. Conclusion: Joint-preserving procedures should be considered in cases of early-stage distal tibia ON that do not respond to conservative management to prevent joint collapse. This case highlights the importance of considering ON as a possible diagnosis even in the absence of identifiable risk factors or trauma.

Expanding horizons of reconstructive microsurgery in Lebanon: Reconstruction of complex traumatic wounds with anterolateral thigh perforator flaps in paediatrics patients less than 10 years of age.

Paediatric complex wounds pose a challenge to the reconstructive surgeon due to the intricacy of reconstructive options required. Developments in microsurgery and microsurgical technique have brought free tissue transfer ever closer to the comfort zone of the reconstructive surgeon for reconstruction of paediatric traumatic complex wounds. We present our experience of microsurgical reconstruction in Lebanon for complex traumatic wounds in paediatric patients under the age of 10 years using the free anterolateral thigh (ALT) flap. The ALT flap has proven its value as a safe, adaptable, and aesthetically acceptable reconstructive option in paediatric complex trauma.

The association between long-distance migration and PTSD prevalence in Syrian refugees.

BACKGROUND: Refugees are forced migrants but there is a large variation in the distance that refugees cover and there is a paucity in the evidence of how this may affect refugees' health and health care needs. OBJECTIVE: We investigated the association between long-distance migration and post-traumatic stress disorder (PTSD), a serious psychiatric disorder associated with deteriorating mental and somatic health. METHODS: Included from 2016-2019 were adult Syrian refugees in Lebanon and Denmark that arrived up to 12 months prior to inclusion. PTSD was assessed using the Harvard Trauma Questionnaire and the estimate of association was obtained by multiply imputing missing data and adjusting for confounding by propensity score-weighting with covariates age, sex, socioeconomic status, trauma experience and general mental well-being, reporting the bootstrap 95-percentile confidence interval (95% CI). Additionally, a number of sensitivity analyses were performed. RESULTS: Included were 599 participants in Lebanon (mean age 35 years old, 73% being female) and 133 participants in Denmark (mean age 30 years old, 47% being female). After multiply imputing missing data and propensity score-weighted adjustment for confounding, migration to Denmark instead of Lebanon was associated with an increase in PTSD prevalence of 9 percentage point (95% CI [-1; 19] percentage point). CONCLUSIONS: Long-distance migration may be associated with an increase in PTSD prevalence in refugees. The migration could be an important factor to consider when assessing refugees' and asylum seekers' health. Practitioners should consider "long-distance migration" in refugee health screenings and in particular when assessing the risk of post-traumatic stress disorder. Future research should be designed to ultimately lead to studies of relevant interventions to lower the risk of post-traumatic stress disorder in refugees.

Abdominal apoplexy: A rare case of spontaneous middle colic artery rupture with transverse colectomy.

INTRODUCTION AND IMPORTANCE: Idiopathic spontaneous intraperitoneal hemorrhage (ISIH) is a rare but potentially fatal entity. The majority of the reported cases of ISIH due to middle colic artery rupture are associated with pseudoaneurysm. Our case is unique in that no pathology could be identified. To our knowledge, this is the third case report in the literature of a spontaneous middle colic artery rupture with no underlying pathology. CASE PRESENTATION: In our report, we present the case of a 27-years old male presenting with a hemoperitoneum due to ruptured middle colic artery with no evidence of pseudoaneurysm or any other pathology. The patient's hemodynamic status deteriorated abruptly requiring a damage control exploratory laparotomy for evacuation of the hemoperitoneum, ligation of the middle colic artery and transverse colectomy. The post-operative course was uneventful afterwards and the patient was discharged a week after presentation with full recovery. DISCUSSION: Patients with ISIH might exhibit the "double rupture" phenomenon, compromising their hemodynamic stability and necessitating urgent surgical interventions. CTA can be of paramount importance to guide such interventions if the patient's clinical status permits. Angiographic embolization is an acceptable alternative approach in specific situations. CONCLUSION: ISIH should be on the differential diagnosis of any young patient presenting to the ED with an acute abdomen, regardless of the identifiable risk factors.

Comparison of the urgent referral for suspected breast cancer process with patient age and a predictive multivariable model.

BACKGROUND: The urgent 2-week wait referral for suspected breast cancer system (U2WW) in the UK prioritizes primary care referrals to one-stop breast clinics as 'urgent' or 'choose and book' (C&B). The aim of this study was to evaluate the accuracy of U2WW in discriminating cancer versus no cancer, and to consider alternative criteria. METHODS: Clinical features elicited in primary care and demographics of consecutive female patients in a specialist breast clinic were collated at the time of consultation from May 2008 to July 2017. U2WW was compared with patient age alone and a multivariable model in terms of accuracy and net cost for eight underlying cost-benefit assumptions. RESULTS: There were 7915 eligible referrals: 4877 urgent (61.6 per cent) and 3038 C&B (38.4 per cent) referrals. Breast cancer was diagnosed in 546 patients (6.9 per cent): 491 (10.1 per cent) in urgent and 55 (1.8 per cent) in C&B referrals (P < 0.001). The multivariable model summated the significant variables: age (odds ratio (OR) 1.07, 95 per cent c.i. 1.07 to 1.08), tumour (OR 4.85, 3.62 to 6.52), observed change (OR 1.73, 1.34 to 2.23), pain (OR 0.46, 0.35 to 0.61) and gravidity (OR 0.72, 0.54 to 0.95). The area under the curve was 0.651 for U2WW, 0.784 for age alone, and 0.824 for the multivariable model (P <0.001 for all comparisons). Considering the cost assumptions, age alone and the multivariable model were either more accurate than U2WW, or as accurate but less costly. CONCLUSION: The U2WW is surpassed by patient age as a single referral criterion. A multivariable model based on demographics and simple clinical features outperformed both. The continued use of the U2WW needs to be reconsidered.

Asylum seekers' and Refugees' Changing Health (ARCH) study protocol: an observational study in Lebanon and Denmark to assess health implications of long-distance migration on communicable and non-communicable diseases and mental health.

INTRODUCTION: By end of 2018, the European Union countries hosted approximately 2.5 million refugees and Lebanon alone hosted more than 1 million. The majority of refugees worldwide came from Syria. The prevailing study design in published studies on asylum seekers' and refugees' health leaves a number of fundamental research questions unanswerable. In the Asylum seekers' and Refugees' Changing Health (ARCH) study, we examine the health of a homogeneous group of refugees and asylum seekers in two very different host countries with very different migration histories. We aim to study the health impact of the migration process, living conditions, access to healthcare, gene-environment interactions and the health transition. METHODS AND ANALYSIS: ARCH is an international multisite study of the health of adult (>18 years old) Syrian refugees and asylum seekers in Lebanon and Denmark. Using a standardised framework, we collect information on mental and physical health using validated scales and biological samples. We aim to include 220 participants in Danish asylum centres and 1100 participants in Lebanese refugee camps and settlements. We will use propensity score weights to control for confounding and multiple imputation to handle missing data. ETHICS AND DISSEMINATION: Ethical approval has been obtained in Lebanon and Denmark. In the short term, we will present the cross-sectional association between long-distance migration and the results of the throat and wound swab, blood and faeces samples and mental health screenings. In the longer term, we are planning to follow the refugees in Denmark with collection of dried blood spots, mental health screenings and semistructured qualitative interviews on the participant's health and access to healthcare in the time lived in Denmark. Here, we present an overview of the background for the ARCH study as well as a thorough description of the methodology.

The Effect of Intraoperative Dexmedetomidine Versus Morphine on Postoperative Morphine Requirements After Laparoscopic Bariatric Surgery.

BACKGROUND: Dexmedetomidine is an α2 receptor agonist with sedative and analgesic properties. During bariatric surgery, its use may reduce postoperative opioid requirements, reduce their side effects, and improve quality of recovery. The aim of this prospective randomized controlled trial was to compare the effect of dexmedetomidine bolus and infusion versus morphine bolus given prior to the end of laparoscopic bariatric surgery. METHODS: Sixty morbidly obese patients (BMI > 40 kg m-2) aged 18 to 60 years, undergoing laparoscopic sleeve gastrectomy, received morphine sulfate (bolus 0.08 mg kg-1 followed by a saline infusion) (group M, n = 30) or dexmedetomidine (loading dose of 1 µg kg-1 followed by 0.5 µg kg-1 h-1) (group D, n = 30) 30 min before the end of surgery. Data collected included morphine consumption in the post-anesthesia care unit (PACU) (primary outcome) and at 24 h, pain intensity, nausea, heart rate, blood pressure, vomiting, sedation, and quality of recovery. RESULTS: There was no significant difference in morphine consumption in the PACU (group D 12.2 ± 5.44 mg, group M 13.28 ± 6.64 mg, P = 0.54) or at 24 h (group D 40.67 ± 24.78 mg, group M 43.28 ± 27.79 mg, P = 0.75); when accounting for intraoperative morphine given group M had significantly higher morphine consumption when compared to group D (23.48 ± 6.22 mg vs. 12.22 ± 5.54 mg, respectively, P < 0.01). Group D patients had more cardiovascular stability. CONCLUSIONS: Dexmedetomidine given prior to end of laparoscopic sleeve gastrectomy provides the same level of postoperative analgesia as morphine with better hemodynamic profile.

Does intraoperative endoscopy decrease complications after bariatric surgery? Analysis of American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Intraoperative endoscopy (IOE) has been proposed to decrease serious complications following bariatric surgeries such as leaks, bleeding, and stenosis. Such complications can lead to sepsis and eventually can be fatal. We aim to compare major postoperative complications in patients with and without IOE. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program database years 2011 till 2016 were used to identify laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) patients. We compared outcomes of IOE and non-IOE using bivariate and multivariate analysis. Thirty-day outcomes included sepsis, organ space infection, unplanned reoperations, unplanned readmissions, prolonged hospital stay, bleeding, and mortality. RESULTS: Out of 62,805 cases of LSG and 50,047 cases of LRYGB, 17.9%, and 19.7% had IOE, respectively. Endoscopy-assisted LSG was associated with a decrease in sepsis [0.37% vs. 0.21%, adjusted odds ratio (AOR) = 0.55 (0.36, 0.84)], unplanned reoperation [0.58% vs. 0.38%, AOR = 0.61 (0.44, 0.85)], prolonged hospital stay [14.9% vs. 14.0%, AOR = 0.87 (0.82, 0.92)], and composite complications [1.43% vs. 1.17%, AOR = 0.78 (0.65, 0.94)]. Outcomes after LRYGB were similar in both groups, except for decreased prolonged hospital stay with IOE [22.4% vs. 20.6%, AOR = 0.89 (0.84, 0.94)]. CONCLUSIONS: IOE is generally underutilized in baraitric procedures. IOE is associated with decreased risk of postoperative complications particularly sepsis, unplanned reoperations, prolonged hospital stay, and composite complications after LSG; and hospital stay after LRYGB. Large multicenter prospective studies are needed to explore the benefits of IOE in bariatric surgery, particularly the intermediate or long-term benefits.

Increased adverse outcomes after laparoscopic sleeve gastrectomy in older super-obese patients: analysis of American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has become the most popular bariatric operation over the last decade. Extreme obesity and increasing age have been generally associated with higher risks of complications after bariatric surgery. The postoperative risk for complications after SG has not been previously presented according to simultaneous grouping of body mass index (BMI) and age. OBJECTIVE: We aim to explore the association of age and BMI in determining the postoperative risk of SG from a national perspective. SETTING: The American College of Surgeons National Surgical Quality Improvement Program database. METHODS: We analyzed patient characteristics and operative outcomes of the 2010 to 2013 SG cohort available in the American College of Surgeons National Surgical Quality Improvement Program (N = 21,131). Patients were grouped based on age and BMI: young-obese (N = 10,291; <50 yr, BMI <0 kg/m2; reference group), young-super-obese (N = 3594; <50 yr and BMI ≥50 kg/m2), older-obese (N = 5636; ≥50 yr, BMI <0 kg/m2), and older-super-obese (N = 1610; ≥50 yr, BMI ≥50 kg/m2). Composite morbidity and/or mortality (M&M) was used as the primary outcome and risk-adjusted odds ratios (AOR[M&M]) were derived by logistic regression. M&M was a composite of surgical site, renal, neurologic, cardiac, thromboembolic, respiratory, septic and bleeding complications, unplanned readmissions, prolonged stay, and death. RESULTS: Overall operative mortality was low (.1%) but significantly worse in older-super-obese patients (.37%; P = .005). M&M rates were lowest in young-obese (5.8%), similarly worse in young-super-obese (7.0%) and older-obese (7.0%), and highest for older-super-obese (10.1%; P < .001). After comprehensive covariate risk adjustment, the composite M&M outcome after SG was significantly increased (42%) only in older-super-obese patients (AOR = 1.42 [1.16-1.73]), while older age alone (AOR = 1.09 [.94-1.25]) and super obesity alone (AOR = 1.09 [.93-1.28]) did not. CONCLUSIONS: Analysis of the American College of Surgeons National Surgical Quality Improvement Program showed that super obesity is associated with increased complications in older patients undergoing SG. Older-super-obese patients should be appropriately counseled about increased SG perioperative risks within the context of expected long-term benefits.

Correction to: Comparison of Early Morbidity and Mortality Between Sleeve Gastrectomy and Gastric Bypass in High-Risk Patients for Liver Disease: Analysis of American College of Surgeons National Surgical Quality Improvement Program.

The authors regret that some of the article text, which was in the original manuscript and was intended for and addressed to the reviewers during the review process of this article, was mistakenly overlooked during the proofs stage and remains in the published article.

Comparison of Early Morbidity and Mortality Between Sleeve Gastrectomy and Gastric Bypass in High-Risk Patients for Liver Disease: Analysis of American College of Surgeons National Surgical Quality Improvement Program.

INTRODUCTION: Chronic liver disease is prevalent in obese patients presenting for bariatric surgery and is associated with increased postoperative morbidity and mortality (M&M). There are no comparative studies on the safety of different types of bariatric operations in this subset of patients. OBJECTIVE: The aim of this study is to compare the 30-day postoperative M&M between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-Y-gastric bypass (LRYGB) in the subset of patients with a model of end-stage liver disease (MELD) score ≥ 8. METHODS: Data for LSG and LRYGB were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from years 2012 and 2013. MELD score was calculated using serum creatinine, bilirubin, INR, and sodium. Postoperative M&M were assessed in patients with a score ≥ 8 and compared for the type of operation. This was followed by analysis for MELD subcategories. Multiple logistic regression was performed to adjust for confounders. RESULTS: Out of 34,169, 9.8% of cases had MELD ≥ 8 and were included. Primary endpoint, 30-day M&M, was significantly lower post-LSG (9.5%) compared to LRYGB (14.7%); [AOR = 0.66(0.53, 0.83)]. Superficial wound infection, prolonged hospital stay, and unplanned readmission were more common in LRYGB. M&M post-LRYGB (30.6%) was significantly higher than LSG (15.7%) among MELD15-19 subgroup analysis. CONCLUSION: LRYGB is associated with a higher postoperative risk than LSG in patients with MELD ≥ 8. The difference in postoperative complications between procedures was magnified with higher MELD. This suggests that LSG might be a safer option in morbidly obese patients with higher MELD scores, especially above 15.

Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy with Concomitant Hiatal Hernia Repair: an Unresolved Question.

PURPOSE: The effectiveness of the concomitant repair of hiatal hernia (HHR) during laparoscopic sleeve gastrectomy (LSG) in reducing gastroesophageal reflux disease (GERD) symptoms is still unclear. The aim of this study is to assess the effect of concomitant HHR on postoperative GERD symptoms in our patient population. MATERIALS AND METHODS: A retrospective review of patients who underwent LSG with or without HHR between 2011and 2014 was performed. Pre- and postoperative GERD symptoms were assessed at different time intervals until a maximum of 2 years after the surgery. RESULTS: The study included 165 patients; 76 (46%) underwent LSG with concomitant HHR (group A) while the rest underwent only LSG (group B). Baseline GERD complaints were more prevalent in group A (61.8 vs 41.6%, p = 0.04), in which 44 patients (57.9%) had evidence of hiatal hernia on preoperative EGD. In the remaining 32 patients, it was diagnosed intraoperatively. GERD symptoms did not significantly differ between the two groups after years 1 and 2. GERD remission was observed in 21.3% of the 76 patients who underwent concomitant HHR (group A) and in 29.7% of those who did not (group B) while new-onset GERD symptoms were reported in 12 patients (41.4%) in group A and in 24 patients (46.2%) in group B. CONCLUSIONS: Routine HHR at the time of LSG does not show an improvement in GERD symptoms. More prospective studies are needed to clarify the role of the routine dissection, identification, and repair of concomitant hiatal hernia during LSG.

Long-Term Outcomes of Roux-en-Y Gastric Bypass Conversion of Failed Laparoscopic Gastric Band.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) carries a high rate of failure and reoperation. Laparoscopic conversion of failed LAGB to Roux-en-Y gastric bypass (RYGB) has been shown to be safe and feasible, but long-term follow-up data is still limited. OBJECTIVES: The aim of this study is to evaluate the safety and effectiveness of RYGB after failed LAGB in our patient population. SETTING: The setting was the University Hospital, Beirut, Lebanon. METHODS: Using a prospectively collected database, we retrospectively reviewed data of patients who underwent LAGB revision to RYGB at our institution between 2006 and 2014. RESULTS: A total of 58 patients underwent RYGB after failed LAGB in our institution between 2006 and 2014. Of those, 20 patients (34.5%) had concomitant band removal while the rest underwent a two-stage RYGB after a mean of 30 months after band removal. A follow-up was achieved in 84.5, 82, 83, 95, and 76% of patients at 1, 2, 3, 4, and 5 years after RYGB. Percentage of excess weight loss (%EWL) was 62.8, 68.1, 64.2, 63.8, and 61.3% at 1, 2, 3, 4, and 5 years, respectively, while percentage of total weight loss (%TWL) was 28.4, 30.7, 29.4, 28.9, and 28.6% at the corresponding time periods. The most common short-term complications were abscesses/leaks (5.2%) while the most common long-term complications were symptomatic gallstones necessitating laparoscopic cholecystectomy (5.2%), incisional hernias (5.2%), and small-bowel obstruction (3.4%). No surgery-related mortality was recorded. CONCLUSIONS: RYGB is a safe procedure with favorable weight loss outcomes at 5 years and can be considered a good rescue procedure after failed LAGB.

Concomitant Removal of Gastric Band and Gastric Bypass: Analysis of Outcomes and Complications from the ACS-NSQIP Database.

BACKGROUND: Conversion of laparoscopic adjustable gastric banding (LGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) is an established procedure. However, multiple reports have indicated higher morbidity and mortality rates associated with this operation, especially when performed as a single-staged procedure. PURPOSE: We sought to compare mortality and morbidity of LRYGB vs. LRYGB with concomitant gastric band removal (LRYGB/LGBR). METHODS: Data from the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database was obtained for the time period of 2008 to 2014 using CPT codes for LRYGB and LGBR. Sepsis was the primary outcome measure with overall morbidity as a secondary outcome. Bivariate and multivariate analyses were carried out using SAS (Statistical Analysis System). RESULTS: During the study period, 64,866 patients had primary LRYGB and 1212 had LRYGB/LGBR. On bivariate analyses, mean operative time was lower for patients undergoing LRYGB rather than LRYGB/LGBR (132.88 ± 56.29 vs. 177.72 ± 70.21 min, p < 0.001). There was no statistically significant difference in the rate of postoperative mortality (0.16 vs. 0.08 %, p > 0.999), sepsis (0.78 vs. 0.74 %, p = 0.87), or other postoperative outcomes such as return to the operating room, wound infection, and venous thromboembolism. The odds ratio (OR) for sepsis remained not significant (OR = 0.74; 95 % confidence interval (CI) = (0.38-1.45)) after multivariate analysis. CONCLUSION: LRYGBP/LGBR is not associated with a higher morbidity and mortality compared to LRYGB alone. The data implies that a one-step revisional procedure is appropriate when converting a failed gastric band to LRYGB.

Prevalence of Depression in Medical Students at the Lebanese University and Exploring its Correlation With Facebook Relevance: A Questionnaire Study.

BACKGROUND: The prevalence of major depression is particularly high in medical students, affecting around one-third of this population. Moreover, online social media, in particular Facebook, is becoming an intrinsic part in the life of a growing proportion of individuals worldwide. OBJECTIVE: Our primary objective is to identify the prevalence of depression in medical students at the Lebanese University Faculty of Medicine, a unique state university in Lebanon, its correlation with the utilization of the interactive features of Facebook, and the way students may resort to these features. METHODS: Students of the Lebanese University Faculty of Medicine were assessed for (1) depression and (2) Facebook activity. To screen for major depression, we used the Patient Health Questionnaire-9 (PHQ-9) scale. To test for Facebook activity, we developed the Facebook Resorting Questionnaire (FbRQ), which measures the degree to which students resort to Facebook. RESULTS: A total of 365 out of 480 students (76.0%) participated in the survey. A total of 25 students were excluded, hence 340 students were included in the final analysis. Current depression was reported in 117 students out of 340 (34.4%) and t tests showed female predominance. Moreover, PHQ-9 score multiple regression analysis showed that feeling depressed is explained 63.5% of the time by specific independent variables studied from the PHQ-9 and the FbRQ. Depression varied significantly among the different academic years (P<.001) and it peaked in the third-year students. One-way analysis of variance (ANOVA) showed that depression and resorting to Facebook had a positive and significant relationship (P=.003) and the different FbRQ categories had significant differences in resorting-to-Facebook power. The like, add friend, and check-in features students used when resorting to Facebook were significantly associated with depression. CONCLUSIONS: This study showed that depression was highly prevalent among students of the Faculty of Medicine at the Lebanese University. Moreover, Facebook may be a promising, helpful, psychological tool for optimizing the management of depression. Our study brought to bear further questions that now prompt further observation and scrutiny to know more about the high rates of depression in this student population, more so in the part of the world studied, and to the growing role of social media.

Management of gallbladder disease after sleeve gastrectomy in a selected Lebanese population.

BACKGROUND: Patients with morbid obesity are at a higher risk of developing gallstones after bariatric surgery. Studies on the incidence of symptomatic gallstones necessitating cholecystectomy after laparoscopic sleeve gastrectomy (LSG) are limited in the Middle East. OBJECTIVES: This study aims to assess the incidence of cholecystectomy after LSG during a 1-year follow-up and to evaluate potential risk factors and potential prophylactic measures. SETTING: Two university hospitals in Lebanon. METHODS: A prospectively maintained bariatric database of 361 patients who underwent primary LSG between January 2009 and December 2012 at the American University of Beirut Medical Center and Makassed General Hospital was reviewed. Data included demographics, preoperative weight, weight at 6 and 12 months postoperatively, and incidence of postoperative symptomatic cholelithiasis. RESULTS: A total of 319 patients (88.4%) were followed up at 1 year. Twenty-four (7.5%) had symptomatic gallstones and underwent cholecystectomy after LSG. Mean postoperative time for the development of symptomatic gallstones was 426 days (range, 91-1234 days). Patients who developed symptomatic gallstones were significantly younger (29.8 versus 34.8, P = 0.008) but comparable to patients who did not undergo cholecystectomy in terms of other baseline characteristics and weight loss results at 1 year. Out of the obesity-related co-morbidities, hypertension was the only co-morbidity associated with post-LSG cholecystectomy (OR = 3.35, P = 0.036) after multivariate adjustment. CONCLUSION: The incidence of symptomatic gallstones requiring cholecystectomy after LSG in our study cohort was higher than that of the general population (7.5%). This incidence does not warrant prophylactic cholecystectomy or routine pre- or postoperative ultrasounds.

Prevalence of depression in Syrian refugees and the influence of religiosity.

BACKGROUND: Many surveys have underlined the high levels of distress Syrian refugees have endured since the conflict aroused in their country, yet few have used reliable diagnostic tools for the clinical assessment of resulting mental disorders. The aim of our study is to assess for the onset of new depressive disorders following the Syrian war, and to investigate the correlation of religiosity with depression. METHODS: Single individual interviews were used, in a sample of 310 Syrian forced migrants, retrospectively assessing for depressive disorders with onset at different timelines of the conflict outbreak. Religiosity was assessed in a cross-sectional design using a reliable, recently developed and tested tool. Bivariate analysis and logistic regression analysis were used with a level of significance at 0.05. RESULTS: The prevalence of current depression was 43.9% (95% Confidence Interval (CI): 38.5-49.4%) with no difference across all socio-demographic factors, including gender. The overall mean for religiosity for the current sample was moderate (mean=9.76; standard deviation SD=2.34). No substantial correlation was found with religiosity. The prevalence rate for pre-war depression was 6.5% (95% CI: 4.2-9.8%) following the global pattern of socio-demographic epidemiological characteristics. Prevalence for past depression was 27.1% (95% CI: 22.5-32.3%); for current dysthymia: 4.5% (95% CI: 2.7-7.4%); for prewar and past dysthymia: 1% (95% CI: 0.3-2.8%), all with no significant differences detected across all demographic variables. CONCLUSION: In this retrospective study on a sample of Syrian refugees who fled their country after the war, we found a substantial emergence of depressive disorders with no meaningful correlation with the level of religiosity.

Concomitant removal of gastric band and sleeve gastrectomy: analysis of outcomes and complications from the ACS-NSQIP database.

BACKGROUND: Conversion of adjustable gastric band to laparoscopic sleeve gastrectomy (LSG) is feasible, but multiple reports have indicated higher morbidity and staple line leak rates when this is performed as a single-stage procedure. The objective of this study is to compare the safety profile and outcomes of LSG with concomitant gastric band removal (LSG/GBR) versus LSG using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP). METHODS: Using the ACS-NSQIP database (2010-2012), LSG cases were identified using Current Procedural Terminology (CPT) code 43775 and concomitant LSG/LGBR using CPT code 43775+(43772 or 43774). Baseline patient characteristics and perioperative variables including postoperative mortality and morbidity rates were retrieved. The primary endpoint was sepsis within 30 days. Bivariate and multivariate analyses were carried out. RESULTS: During the study period, 11,189 (96.9%) patients had LSG and 357 (3.1%) had LSG/GBR for a total of 11,546 patients. On bivariate analyses, the rate of sepsis was higher after LSG/GBR (1.68% versus .58%; P = .022), and the mean operative time was longer (124.6±52.3 versus 98.6±49.0 min; P<.001). There was no statistically significant difference in the rate of postoperative mortality (.28% versus .08 %; P = .27) or that of other outcomes such as return to the operating room, wound infection, or venous thromboembolism. After multivariate analysis, the odds of developing postoperative sepsis remained significantly higher for patients undergoing LSG/GBR compared with LSG alone (odds ratio [OR] 3.32; confidence interval [CI] 1.41-7.84; P = .006). CONCLUSION: LSG/GBR can be performed with low morbidity and mortality. However, this procedure carries a higher rate of postoperative sepsis.