Protective effects of statins on the incidence of NAFLD-related decompensated cirrhosis in T2DM.

BACKGROUND AND AIMS: Non-alcoholic fatty liver disease (NAFLD) is a hepatic manifestation of metabolic syndrome and poses a significant threat to patients with type 2 diabetes mellitus (T2DM) and metabolic dysregulation. Statins exert anti-inflammatory, antioxidative and antithrombotic effects that target mechanisms underlying NAFLD. However, the protective effects of the different doses, intensities and types of statins on the incidence of NAFLD-related decompensated liver cirrhosis (DLC) in patients with T2DM remain unclear. METHODS: This study used the data of patients with T2DM who were non-HBV and non-HCV carriers from a national population database to examine the protective effects of statin use on DLC incidence through propensity score matching. The incidence rate (IR) and incidence rate ratios (IRRs) of DLC in patients with T2DM with or without statin use were calculated. RESULTS: A higher cumulative dose and specific types of statins, namely rosuvastatin, pravastatin, atorvastatin, simvastatin and fluvastatin, reduced the risk of DLC in patients with T2DM. Statin use was associated with a significant reduction in the risk of DLC (HR: .65, 95% CI: .61-.70). The optimal daily intensity of statin use with the lowest risk of DLC was .88 defined daily dose (DDD). CONCLUSIONS: The results revealed the protective effects of specific types of statins on DLC risk in patients with T2DM and indicated a dose-response relationship. Additional studies are warranted to understand the specific mechanisms of action of different types of statins and their effect on DLC risk in patients with T2DM.

Reappraisal learning curve of laparoscopic Roux-en Y gastric bypass: retrospective results of one hundred and eight cases from a low-volume unit.

BACKGROUND: This study aimed to reevaluate the learning curve of laparoscopic Roux-en Y gastric bypass (LRYGB) in the modern era while considering a single surgeon's experience. METHODS: From the beginning of our LRYGB practice, all patients who met the regional criteria and underwent primary LRYGB were retrospectively enrolled. Patients with a body mass index (BMI) > 50 kg/m2 were excluded. Those who underwent surgery in 2016-17, 2018 and 2019 by a single surgeon with 10 + years of laparoscopic experience were assigned to groups A, B and C, respectively. The patient demographics and 30-day outcome data, including the operation time, length of stay (LOS), emergency room visits, readmission, and reoperation, were compared among the groups. RESULTS: One hundred and eight patients met the inclusion criteria; 36, 38, and 34 patients were assigned to groups A, B and C, respectively. There were no differences in age, sex distribution or common comorbidities among the groups; however, B had a lower BMI (35.1 kg/m2 vs. 37.0 kg/m2) and a higher rate of hypertension (44.7% vs. 22.2%) than group A. The operation time was markedly reduced (96.1 min and 114.9 min, p < 0.001), and the LOS was shortened (2.2 days and 2.9 days, p < 0.001) in group B compared to group A and remained stationary in group C, with no further reduction in 30-day complications. CONCLUSION: The learning process of LRYGB can be shortened to approximately 30 cases if conducted selectively by experienced laparoscopic surgeons. Further follow-up is required to verify the long-term safety and applicability in other patient subgroups.

The learning curve of one anastomosis gastric bypass and its impact as a preceding procedure to Roux-en Y gastric bypass: initial experience of one hundred and five consecutive cases.

BACKGROUND: The aim of this study was to assess the learning curve of one anastomosis gastric bypass (OAGB-MGB) at the start of a low volume bariatric unit and analyze its impact as a preceding procedure to Roux-en Y gastric bypass (RYGB). METHODS: From January 2014 to December 2017, all patients who underwent bariatric surgeries in our teaching hospital that were performed by the same surgeon were enrolled. The first 47 patients who underwent OAGB-MGB were assigned to group A. RYGB has been offered as a treatment option since July 2016; thereafter, 26 patients who underwent OAGB-MGB and 32 patients who underwent RYGB at the same time interval were assigned to group B and group C, respectively. Baseline characteristics, perioperative outcomes and percentage of total weight loss (%TWL) up to 12 months postoperatively were collected and analyzed between groups. RESULTS: Compared to the patients in group C, those in groups A and B were older (39.4 yrs. and 42.2 yrs., respectively, vs. 34.2 yrs.; p = 0.021) and predominantly male (48.9 and 73.1%, respectively vs. 40.6%; p = 0.04), and they had a higher body mass index (41.8 kg/m2 and 43.3 kg/m2, respectively vs. 37.7 kg/m2; p = 0.002) and a higher incidence of hypertension (44.7 and 61.5%, respectively vs. 21.9%; p = 0.008). In addition, the operation time was significantly reduced (118.2 min and 115.8 min, respectively vs. 153.1 min; p <  0.001), and the length of stay was shortened (3.0 days and 2.9 days, respectively vs. 3.4 days; p = 0.002) in groups B and C compared to group A. No mortality, conversion or leakage was reported throughout the study period. The 30-day complication rate was decreased in group C compared to groups A and B (0% vs. 6.4 and 7.7%, respectively; p = 0.307). The %TWL at the 12-month follow-up was 36.3, 30.9 and 28.3% for groups A, B and C, respectively (p <  0.001). CONCLUSION: Our study verified the early emergence of a learning curve effect for OAGB-MGB, and the proficiency acquired can be transferred to subsequent practice for RYGB in terms of acceptable operation time and length of stay without an increase in complications.

Trends in diagnostic approaches for pediatric appendicitis: nationwide population-based study.

BACKGROUND: To define the benefits of different methods for diagnosis of pediatric appendicitis in Taiwan, a nationwide cohort study was used for analysis. METHODS: We identified 44,529 patients under 18 years old who had been hospitalized with a diagnosis of acute appendicitis between 2003 and 2012. We analyzed the percentages of cases in which ultrasound (US) and/or computed tomography (CT) were performed and non-perforated and perforated appendicitis were diagnosed for each year. Multivariate logistic regression analyses were performed to evaluate risk factors for perforated appendicitis. RESULTS: There were more cases of non-perforated appendicitis (N = 32,491) than perforated appendicitis (N = 12,038). The rate of non-perforated cases decreased from 0.068% in 2003 to 0.049% in 2012; perforated cases remained relatively stable at 0.024%~0.023% from 2003 to 2012. The percentage of CT evaluation increased from 3% in 2003 to 20% in 2012; the rates of US or both US and CT evaluations were similar annually. The percentage of neither CT nor US evaluation gradually decreased from 97% in 2003, to 79% in 2012. The odds ratios of a perforated appendix for those patients diagnosed by US, CT, or both US and CT were 1.227 (95% confidence interval (CI) 0.91, 1.65; p = 0.173), 2.744 (95% CI 2.55, 2.95; p < 0.001), and 5.062 (95% CI = 3.14, 8.17; p < 0.001), respectively, compared to patients who did not receive US or CT. The odd ratios of a perforated appendix for those patients 7-12 and ≤6 years old were 1.756 (95% CI 1.67, 1.84; p < 0.001) and 3.094 (95% CI 2.87, 3.34; p < 0.001), respectively, compared to those 13-18 years old. CONCLUSIONS: Our study demonstrated that using CT scan as a diagnostic tool for acute appendicitis increased annually; most patients especially those ≤6 years old who received CT evaluation had a greater risk of having perforated appendicitis. We recommend a prompt appendectomy in those pediatric patients with typical clinical symptoms and physical findings for non-complicated appendicitis to avoid the risk of appendiceal perforation.

Therapeutic effectiveness of percutaneous drainage and factors for performing an interval appendectomy in pediatric appendiceal abscess.

BACKGROUND: In this study, we studied the therapeutic effectiveness of percutaneous drainage with antibiotics and the need for an interval appendectomy for treating appendiceal abscess in children with a research-oriented dataset released by the Bureau of National Health Insurance in Taiwan through the Collaboration Center for Health Information Application (CCHIA). METHODS: We identified 1225 patients under 18 years of age who had non-surgical treatment for an appendiceal abscess between 2007 and 2012 in a Taiwan CCHIA dataset. The treatment included percutaneous drainage with antibiotics or antibiotics alone. We also analyzed data of patient's baseline characteristics, outcomes of percutaneous drainage, and indicating factors for performing an interval appendectomy. RESULTS: Totally, 6190 children had an appendiceal abscess, an 1225 patients received non-operative treatment. Of 1225 patients, 150 patients received treatment with percutaneous drainage and antibiotics, 78 had recurrent appendicitis, 185 went on to receive an interval appendectomy, and 10 had postoperative complications after the interval appendectomy. We found that patients treated with percutaneous drainage and antibiotics had a significantly lower rate of recurrent appendicitis (p < 0.05), a significantly smaller chance of receiving an interval appendectomy (p < 0.05), and significantly fewer postoperative complications after the interval appendectomy (p < 0.05) than those without percutaneous drainage treatment. Older children (13 ~ 18 years) patients were found to have a significantly smaller need to receive an interval appendectomy than those who were ≤ 6 years of age (odd ratio (OR) = 2.071, 95 % confidence interval (CI) = 1.34-3.19, p < 0.01), and those who were 7 ~ 12 years old (OR = 1.662, 95 % CI = 1.15-2.41, p < 0.01). In addition, those treated with percutaneous drainage were significantly less indicated to receive an interval appendectomy later (OR = 2.249, 95 % CI = 1.19 ~ 4.26, p < 0.05). In addition, those with recurrent appendicitis had a significantly increased incidence of receiving an interval appendectomy later (OR = 3.231, 95 % CI = 1.95 ~ 5.35, p < 0.001). CONCLUSIONS: In this study, we used nationwide data to demonstrate therapeutic effectiveness of percutaneous drainage and antibiotics was more beneficial than only antibiotics in treating patients with an appendiceal abscess. We also found three factors that were significantly associated with receiving an interval appendectomy: recurrent appendicitis, being aged ≤ 13 years, and treatment with antibiotics only.

Laparoscopic appendectomy versus open appendectomy in pregnancy: a population-based analysis of maternal outcome.

BACKGROUND: Laparoscopic appendectomy (LA) is the standard treatment of acute appendicitis for the general population; however, there is still some doubt regarding its safety for pregnant patients. Therefore, the purpose of this study is to investigate and compare the maternal outcome of pregnant patients with acute appendicitis following either an open appendectomy (OA) or LA from a population-based database. METHODS: This study is based on the National Health Insurance Research Database. Patients with both ICD-9-CM codes for appendicitis (540.9, 540.0, and 540.1) and pregnancy (V22) in the same admission were considered to have acute appendicitis during pregnancy. These patients were divided into three groups according to the type of treatment: LA, OA, and non-operative treatment. Outcome measures that were compared between the groups included maternal complications such as preterm labor, abortion, and the need of cesarean section. Besides, the differences of medical expenditure and length of hospital stay between the groups were also analyzed. RESULTS: From 2005 to 2010, a total of 859 pregnant women who had acute appendicitis were identified. They had increased risks for preterm labor, abortion, and increased requirement of cesarean section compared to the control group (i.e., those without acute appendicitis). Among the three groups, the non-operated group has the highest risk of preterm labor. Patients who underwent LA did not have any increased risk of maternal complications compared to the OA group. Furthermore, LA patients had shorter hospital stay than OA. CONCLUSION: Compared to non-operative treatment, appendectomy is the preferred treatment for pregnant patients who have acute appendicitis. LA can be performed safely in pregnant patients without bringing additional maternal complications compared to OA.

Use of extracorporeal membrane oxygenation in severe traumatic lung injury with respiratory failure.

OBJECTIVES: The use of extracorporeal membrane oxygenation (ECMO) in managing acute respiratory distress syndrome had been accepted. Severe lung injury with respiratory failure is often encountered in trauma patients. We report our experience with the use of ECMO in severe traumatic lung injury. METHODS: Patients with severe traumatic lung injury that met the following criteria were candidates for ECMO: (1) severe hypoxemia, Pao2/fraction of inspired oxygen (1.0) less than 60, and positive end-expiratory pressure greater than 10 cm H2O in spite of vigorous ventilation strategy; (2) irreversible CO2 retention with unstable hemodynamics; and (3) an initial arterial Pao2/fraction of inspired oxygen (1.0) less than 60, where the pulmonary condition and hemodynamics rapidly deteriorated despite vigorous mechanical ventilation strategy. RESULTS: Over 60 months, a total of 19 patients with severe traumatic lung injury who received ECMO management were retrospectively reviewed. The median age was 38 years (25-58 years), the median injury severity score was 29 (25-34), the median admission Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 25 (21-36), and the median blood transfusion volume was 5500 mL (3500-13 000). There were 9 venovenous and 10 venoarterial types. The survival rate was 68.4% (13/19). The survivors were younger (30 vs 53 years; 21-39 vs 48-63). There were 6 mortalities (3 pneumonia, 2 coagulopathy, and 1 cardiac rupture with cardiac tamponade). There were 5 of 19 patients with pre-ECMO traumatic brain hemorrhage (3 survived and 2 mortalities). A total of 16 patients received heparinization with 5 mortalities. CONCLUSIONS: The use of ECMO may offer an additional treatment modality in severe traumatic lung injury with respiratory failure that is unresponsive to optimal conventional ventilator support. Timely ECMO intervention is of value.

Sutureless onlay omental patch for the laparoscopic repair of perforated peptic ulcers.

BACKGROUND: Because the feasibility and safety of laparoscopic approaches for the treatment of perforated peptic ulcer (PPU) have been fully recognized, laparoscopic repair of PPU (LPPU) has become a widely accepted procedure. Following closure of a PPU, the rationale to add an omental patch is based on the assumptions that a patch may decrease the possibility of leakage and make the closure more secure. However, one of the often mentioned disadvantages of LPPU is that it requires a significantly longer operating time. The purpose of the present study was to evaluate the efficacy of LPPU with a sutureless onlay omental patch. METHODS: Over 60 months, 43 patients underwent LPPU with sutureless onlay omental patch, and another 64 patients underwent LPPU with sutured omental patch. Patient demographics, operation parameters, and surgical outcomes were analyzed retrospectively. RESULTS: All patients in both groups survived to the end of the study. There were no leaks in either group. The operating time and length of stay in the sutureless onlay omental patch group were significantly shorter than in the sutured omental patch group. CONCLUSIONS: A sutureless onlay omental patch is as safe and effective as a sutured omental patch for the laparoscopic repair of PPU.

Successful Implementation of Enhanced Recovery After Surgery in a Single-Surgeon Bariatric Practice.

The feasibility and safety of unselectively applying an enhanced recovery after surgery (ERAS) protocol in a low-volume bariatric unit were determined. Retrospectively, review patients undergoing bariatric surgeries between 2015 and 2018 were included, and those receiving non-primary procedures or with BMI <32.5 kg/m2 were excluded. Demographics and 30-day outcomes were collected and compared between the ERAS (2017-2018) and control (2015-2016) groups. 62 (40.8%) were treated before and 90 (59.2%) were treated after ERAS. No differences in baseline demographics, except ERAS group had more Roux-en-Y gastric bypass procedures (58.9% vs. 12.9%). A markedly reduced operation time (101 min vs. 147 min) and shortened length of stay (2.6 days vs. 3.3 days) were observed with no increment of ER visits, readmissions (1.1% vs. 4.8%), or total complications between the groups (5.5% vs. 9.7%). Unselective ERAS implementation in low-volume units is feasible and safe, with significantly reduced operation times and shortened LOS without increased complications.

Effectiveness of a preoperative orlistat-based weight management plan and its impact on the results of one-anastomosis gastric bypass: A retrospective study.

INTRODUCTION: The aim was to first investigate the efficacy of a preoperative weight management program centered on orlistat, which is mechanistically similar to gastrointestinal bypass procedures in that it restricts dietary fat absorption, and then assess its impact on the results of one-anastomosis gastric bypass (OAGB). MATERIALS AND METHODS: We retrospectively reviewed the clinical data of consecutive patients aged 20-65 years with a body mass index (BMI) ≥ 42.5 kg/m2 who underwent primary OAGB from 2014 to 2020. Eligible patients who adhered to a 10-14 day orlistat regimen as part of a 4-6-week diet/lifestyle modification plan preceding surgery were stratified into weight reduction (Group 1) and weight gain (Group 2) groups post treatment. The correlation between pre- and postoperative weight loss and perioperative outcomes was assessed. RESULTS: Of 62 eligible patients, 55 met the inclusion criteria and complied with treatment; 35 (64%) patients in Group 1 lost a median of 2.0 kg, and Group 2 had a median weight gain of 2.9 kg. Group 1 had a significantly higher initial BMI (48.9 kg/m2 vs. 44.6 kg/m2; p = 0.003), more females (54% vs. 25%) and a shorter operation time than Group 2 (107 min vs. 140 min; p = 0.109). There was no difference in the incidence of 30-day complications. Weight loss did not differ between the groups at 24 months. CONCLUSION: Effective weight control through an orlistat-containing regimen benefitted two-thirds of patients who underwent OAGB; however, further weight loss was not observed at 2 years post-surgery.

A Shared Decision-making Process may Affect Bariatric Procedure Selection and Alter Surgical Outcomes: a Single-unit Retrospective Study.

PURPOSE: A shared decision-making (SDM) process centered on the patient perspective may increase understanding and treatment satisfaction. This study aimed to investigate whether SDM would increase the acceptance of bariatric/metabolic surgeries, change treatment decisions, and affect 1-year results. MATERIALS AND METHODS: This retrospective analysis enrolled 315 consecutive patients with a body mass index between 32.5 and 50 kg/m2 and aged 20-65 years who underwent consultation for a primary bariatric/metabolic procedure within 2 years before (pre-SDM) or after (post-SDM) SDM program implementation to assist in the decision to undergo Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery. Consent rate, procedure choice, weight loss, comorbidity remission, etc., were compared between periods and procedures. Statistical tests were two-sided, with p < 0.05 considered significant. RESULTS: More eligible patients underwent metabolic/bariatric procedures post-SDM than pre-SDM (115/159 [72%] vs. 106/156 [68%]; p = 0.395), and a stronger preference for RYGB post-SDM was observed (71% vs. 62%; p = 0.153). Significantly more patients with diabetes (28 [34.1%] vs. 5 [15.2%]; p = 0.041) chose RYGB over SG post-SDM. Patients who underwent RYGB had a higher diabetes remission rate both pre-SDM (70.0% vs. 58.3%; p = 0.571) and post-SDM (76.2% vs. 66.7%; p = 0.712) than those who underwent SG. While 1-year weight loss was similar between procedures, adherence to nutritional supplementation did not appear to be broadly enhanced post-SDM. CONCLUSION: SDM influenced procedure selection toward RYGB, which was more popular than SG among patients with diabetes. Higher diabetes remission was achieved with RYGB, although the results of other effects deserve further study.

Suggested Flowchart Through Integrated C-Reactive Protein and White Blood Cell Count Analysis for Screening for Early Complications After Gastric Bypass: a Single-Center Retrospective Study.

INTRODUCTION: Early leakage detection following bariatric procedures is crucial, but a standardized evaluation method is lacking. The aim was to validate the potential benefits of postoperative day 1 (POD1) C-reactive protein (CRP) levels and white blood cell (WBC) counts in distinguishing at-risk patients following Roux-en-Y gastric bypass (RYGB) while considering the impact of obesity-related chronic inflammation. METHODS: Retrospective analysis of 261 consecutive patients aged 18-65 years with a body mass index (BMI) of 32.5-50 kg/m2 who underwent primary RYGB between 2017 and 2022. Sequential changes in CRP levels and WBC counts measured 48 h preoperatively and on POD1 morning were collected and compared between patients with/without complications and in patients without complications stratified by preoperative CRP levels. RESULTS: Female patients and those with a higher BMI tended to have higher baseline CRP levels, which were positively related to postoperative CRP. Patients experiencing complications had higher WBC counts and a higher prevalence of WBC counts >14,000/µl (77.8% vs. 25.4%; p<0.001) than those without complications. Baseline CRP ≥ 0.3 mg/dl, a longer operative time, and blood loss >10 ml were significantly more common with WBC counts above 14,000/µl; a reasonable range of change in WBC count (∆WBC) derived from its positive correlation to postoperative WBC count (r=0.6695) may serve as a useful complementary indicator. CONCLUSION: An individualized CRP threshold setting and integrated interpretation of the WBC count can be more appropriate than using static criteria for differentiating at-risk patients after RYGB. Further studies are needed to validate these findings and determine their generalizability.

Can early laparoscopic cholecystectomy be the optimal management of cholecystitis with gallbladder perforation? A single institute experience of 74 cases.

BACKGROUND: Gallbladder perforation is a rare but serious complication of cholecystitis. It was usually managed by percutaneous gallbladder drainage (PTGBD) followed by elective cholecystectomy. However, evidences are emerging that early laparoscopic cholecystectomy (LC) is still feasible under these conditions. We hypothesized that early LC may have comparable surgical results as to those of PTGBD + elective LC. MATERIAL AND METHODS: From January 2005 to October 2011, patients admitted to China Medical University Hospital with a diagnosis of perforated cholecystitis were retrospectively reviewed. The diagnosis of gallbladder perforation was made by image and/or intraoperative findings. Those patients who had unstable hemodynamics that were not fitted for general anesthesia or those who had concomitant major operations were excluded. Patients were divided into three groups: early open cholecystectomy (group 1), early LC (group 2), and PTGBD followed by elective LC (group 3). The demographic features, surgical results, and patient outcome were analyzed and compared between groups. RESULTS: A total of 74 patients were included. All patients had similar demographic features except that patients in group 2 were younger (62 vs. 72 and 73.5 years) compared with group 1 and group 3 (p = 0.016). There were no differences in terms of operative time, blood loss, conversion, and complication rate between three groups. The length of hospital stay (LOS) was significant shorter in group 2 patients compared with that of groups 1 and 3. CONCLUSIONS: Although PTGBD followed by elective LC was still the mainstay for the treatment of gallbladder perforation, early LC had comparable surgical outcomes as that of PTGBD + LC but with a significantly shorter LOS. Early LC should be considered the optimal treatment for gallbladder perforation, and PTGBD + LC can be preserved for those who carried a high risk of operation.

Trauma during pregnancy: a population-based analysis of maternal outcome.

BACKGROUND: Serious injury during pregnancy is known to cause adverse maternal outcomes. However, the significance of minor injuries in adverse maternal outcomes requires clarification because most injuries sustained during pregnancy are minor ones. METHODS: Two population-based databases (inpatient and ambulatory care) were used to identify pregnant women who had severe (required hospitalization) or minor injuries (required ambulatory care only) prenatally. ICD-9-CM coding was used to categorize the types of prenatal injury and complications during delivery. The patient demographics, types and timing of the injuries, and their association with adverse maternal outcomes were compared among the uninjured, those with minor injury, and those with severe injury. Odds ratios were calculated to estimate the risks of having adverse outcomes in injured pregnant women compared with those who are uninjured. RESULTS: The severely injured women tended to be younger (<20 years old), lived in less urbanized regions, and had lower income levels than those who were uninjured or had minor injury. Motor vehicle crash was the most common mechanism of injury. While minor injuries were associated with preterm labor [odds ratio (OR)=1.25], a severe injury was strongly associated with increased risks of preterm labor, placental abruption, uterine rupture, and maternal death, especially during the third trimester (OR=2.71, 6.12, 7.79, and 20.15, respectively). Injuries away from the trunk could also lead to adverse maternal outcomes. CONCLUSIONS: Trauma during pregnancy, whether minor or severe, is associated with unfavorable maternal outcomes. Injuries considered minor for the general population are not minor for pregnant women. Therefore, these patients should be monitored carefully.

Laparoscopic common bile duct exploration in patients with complicated cholecystitis: a safety and feasibility study.

BACKGROUND: Laparoscopic cholecystectomy (LC) with common bile duct exploration (LCBDE) is nowadays a preferred one-stage treatment. However, the influence of complicated cholecystitis (CC) on LCBDE has rarely been addressed. In the present study we aimed to verify whether severe gallbladder inflammation would adversely affect the outcome of LCBDE. MATERIAL AND METHODS: From 2008 to 2011, all patients undergoing LC and LCBDE at China Medical University Hospital were included. Patients were divided into two groups based on the severity of cholecystitis. Those with unstable hemodynamics and co-morbidities who were deemed unfit for general anesthesia were excluded. Patient demographics, surgical results, and outcome were compared between the groups. RESULTS: During the study period, 117 patients diagnosed with cholecystitis were found to have common bile duct (CBD) stones and underwent LC + LCBDE. Of these 117 patients, 87 had uncomplicated cholecystitis (UC) and the remaining 30 patients had CC. There was no demographic difference between the groups, but for patients with CC there were marginally longer operative times (190 vs. 223 min, p = 0.141), more blood loss (10 vs. 150 ml, p < 0.05), and longer postoperative hospital stays (6 vs. 7 days, p < 0.05). The risk of developing major intraoperative complications was not greater for those with CC. Conversion to open cholecystectomy was necessary in a total of 12 cases (10 %) with an overall 1 % mortality rate. CONCLUSIONS: Complicated cholecystitis was not a contraindication for LCBDE. Complete stone clearance can be achieved in a substantial number of cases with an acceptable complication rate. Further prospective randomized studies are required to validate its long-term safety.

Factors that Hinder 24-Hour Discharge After Laparoscopic Roux-en-Y Gastric Bypass: a Retrospective Analysis at a Low-Volume Center.

PURPOSE: This study aimed to identify factors that hinder 24-h patient discharge after laparoscopic Roux-en-Y gastric bypass (LRYGB) in a low-volume practice. MATERIAL AND METHODS: Consecutive patients who fulfilled regional criteria and underwent primary LRYGB from 2018 to 2020 were retrospectively analyzed. Patients were discharged on the morning of the first postoperative day (POD1) after meeting the predefined criteria. The assessed outcome measures (POD1 vital signs, laboratory findings, pain scores and nausea/vomiting) and 30-day postoperative complications were compared between the early (stay ≤ 24 h) and delayed (>24 h) groups. RESULTS: For 107 patients who fulfilled the inclusion criteria, 48 (44.9%) were discharged within 24 h. There were no differences in the baseline demographics, except that the early group was more likely to have a previous abdominal operation (35.4% vs. 16.9%). Both groups had similar operation durations (89 min vs. 92 min), but the early group had a markedly shortened length of stay (23 (24-22) h vs. 27 (47-26) h). The POD1 parameters were the same between the groups, except that the delay group had a significantly higher visual analog scale score, with fewer patient scores of 0. Patients who were younger and female were more likely to need additional IV analgesics. No POD1 antiemesis was required throughout the study. There was no increase in the 30-day complications. CONCLUSION: Patient discharge at 24 h post-LRYGB is feasible and safe in a low-volume practice. A more comprehensive pain relief strategy may be required before generalizing this approach.

Laparoscopic simple closure alone is adequate for low risk patients with perforated peptic ulcer.

BACKGROUND: Helicobacter pylori (H.P.) eradication has led to a significant decline in peptic ulcer prevalence; however, the number of patients requiring surgical intervention remains relatively unchanged. Laparoscopy suture repair is the most commonly used procedure for perforated peptic ulcer (PPU). Whether omental patch adds any benefit than simple closure alone is not answered. METHODS: From July 2007 to August 2010, patients received emergency surgeries for PPU in our department were enrolled in this study. The demographic data, disease pattern, surgical outcomes were retrospectively collected. Patients who had previous multiple operations, with profound shock, and complicated ulcers were excluded. RESULTS: Totally 73 patients were enrolled. 26 of them received simple closure and the other 47 received simple closure plus an omental patch. There were no difference in age, gender, ASA, Boey risk score, and incidence of co-morbidities. The Mannheim Peritonitis index, median operation time and length of stay were not different between groups. CONCLUSIONS: In terms of leakage rate and surgical outcome, the maneuver to cover an omental patch on the repaired PPU did not show additional advantages compared to simple closure alone. Further prospective randomized study is required to clarify the safety and feasibility of simple closure alone without buttressing an omentum patch.

Actinomycosis mimicking recurrent carcinoma after Whipple's operation.

Actinomycosis is a rare, chronic, spreading, suppurative, granulomatous and fibrosing infection. Actinomyces are normal inhabitants of the oral cavity and gastrointestinal tract. They rarely cause disease and are seldom reported as pathogens. Herein, we reported on a 69-year-old male patient who had undergone Whipple's operation due to ampulla Vater carcinoma, and became infected with actinomycosis at the pancreaticojejunostomy, which mimicked a recurrent malignancy. He was treated with radical resection of the mass at the pancreaticojejunostomy and had an uneventful postoperative course.

Development of rainbow trout hepatoma cell lines: effect of pro-IGF-I Ea4-peptide on morphological changes and anchorage-independent growth.

Our laboratory has shown previously that recombinant rainbow trout Ea4 (rtEa4)-peptide of pro-insulin-like growth factor-I (pro-IGF-I) exhibited antitumor activities against cancer cell lines derived from various human cancer tissues (Chen et al., 2002; Kuo and Chen, 2002). To confirm that rtEa4-peptide can exhibit the same spectrum of antitumor activities in fish tumor cells, we had developed permanent single-cell clones (RTH1B1A, RTH1B1D, RTH1B2A, and RTH1B2C) from a rainbow trout liver tumor induced by dibenzo[a,l]pyrene treatment. At 135 passages, the doubling time of these single-cell clones in CO2-independent medium at 20 degrees C was 3.9, 3.5, 3.0, and 4.5 d, respectively. Reverse transcription-polymerase chain reaction analysis showed that the expression of liver signature genes (e.g., aldolase B, glucose-6-phosphatase [G-6-Pase], phosphoenolpyruvate carboxykinase [PEPCK], hepatic nuclear factor-1 [HNF-I], IGF-I, IGF-II, and growth hormone [GH] receptor-2 genes) and CYP1A1 and CYP1A3 genes was detected in these four single-cell clones. Furthermore, results of in vitro colony formation assay in a soft-agar medium showed different degrees of colony formation activities among them. These results confirmed that the single-cell clones were derived from the rainbow trout liver. Treatment of RTH1B1D with recombinant trout Ea4-peptide resulted in the induction of a dose-dependent morphological change and the suppression of colony formation in a soft-agar medium. In addition, both morphological change and reduction of colony formation were also observed in permanent transfectants of RTH1B1D cells carrying a trout Ea4-peptide gene or its human counterpart, hEb-peptide gene. These results confirm our earlier observations that trout pre-IGF-I Ea4-peptide and hEb possess activities counteracting malignant properties of cancer cells in vitro.