Bariatric surgery: to bleed or not to bleed? This is the question.

BACKGROUND: Bariatric surgery procedures are the most successful and durable treatment for morbid obesity. Hemorrhage represents a life-threatening complication, occurring in 1.3-1.7% of bariatric surgeries. MATERIALS AND METHODS: We examined patients undergoing Bariatric Surgery from July 2017 to June 2020 (Group A) and those operated from July 2020 to June 2022 (Group B) in our Department. Starting from July 2020 we have implemented intraoperative measures to prevent postoperative bleeding, increasing mean arterial pressure (MAP) by 30% compared to preoperative and reducing the pneumoperitoneal pressure of CO2 to 8 mmHg in the last 15 min of the operation. RESULTS: The study gathered 200 patients divided into the two described groups. The mean age of Group A is 44 ± 8.49 and 43.73 ± 9.28. The mean preoperative BMI is 45.6 kg/m2 ± 6.71 for Group A and 48.9 ± 7.15 kg/m2 for Group B. Group A recorded a mean MAP of 83.06 ± 18.58 mmHg and group B a value of 111.88 ± 12.46 mmHg (p value < 0.05 and z-score is 4.15226 and the value of U is 13,900). We observed 9 cases of bleeding in group A, most of them being treated with medical therapy and transfusions; only 1 hemodynamically unstable patient underwent re-laparoscopy. We reported only 2 cases of bleeding in group B, one of which required blood transfusions. CONCLUSION: From our study we can conclude that increasing mean arterial pressure (MAP) by 30% compared to preoperative and reducing the pneumoperitoneum pressure of CO2 to 8 mmHg in the last 15 min of the operation led to a decrease in bleeding cases in group B and, most importantly, all the bleedings were easily controllable with medical therapy and/or transfusions. These measures allowed us to reduce postoperative bleeding.

Is Emergency Surgery Back to Pre-Covid-19 Era? Our Cohort Study.

Introduction: The aim of this study is to analyze the progress of hospitalizations and how the emergency operations in our Department of Medical and Surgical Sciences of the Foggia Hospital have changed qualitatively and quantitatively from pre-Covid-19 to today. Methods: Our cohort-study was conducted by analyzing four groups of patients admitted in emergency to our department from 2019 to 2022. Results: We observed a total of 150 patients for the group 1, 25 patients for the group 2, 71 patients for the group 3 and 110 for the group 4, of these 20 were emergency admission during 2019, 16 during 2020, 31 during 2021 and 10 during 2020 (p 0.05); 130 were elective admission during 2019, 9 during 2020, 40 during 2021 and 100 during 2022 (p 0.05). Of the emergency admissions 11 were operated during the no covid period in 2019, 14 during 2020, 29 during 2021, 6 during 2022. Conclusions: The contraction of hospitalizations for urgent and emergency conditions during the first lockdown has been accompanied by positive implications. The measures employed in hospitals to contain the infection determined a reduction in COVID cases, allowing the nearly complete resumption of the surgical activity provided in the pre-COVID era.

Energy Based Vessel Sealing Devices in Thyroid Surgery: A Systematic Review to Clarify the Relationship with Recurrent Laryngeal Nerve Injuries.

Background and objectives: The principal complications associated with thyroid surgery consist in postoperative recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, intra-operative and post-operative hemorrhage. In this paper, structured as a literature review, we describe the current knowledge and the technical improvements currently employed in the field of thyroid surgery, focusing on the contribution of energy based devices in relation with the reduction of the operating time and the odds of possible complication. Materials and methods: a relevant systematic literature search on Pubmed was carried out including works from 2004 through 2019, selecting studies providing information on the energy based devices employed in surgeries and statistic data concerning RNL (transient and permanent) injury and operative time. Results: Nineteen studies were reviewed, dealing with 4468 patients in total. The operative variables considered in this study are: employed device, number of patients, pathological conditions affecting the patients, surgical treatment, RNL injury percentage and the operating time, offering an insight on different patient conditions and their relative operative outcomes. A total of 1843 patients, accounting to the 41.2% of the total pool, underwent the traditional technique operation, while 2605 patients (58.3%) were treated employing the energy based devices techniques. Thyroidectomy performed by approaches different from traditional (for example robotic, MIVAT (Mini Invasive Video Assisted thyroidectomy)) were excluded from this study. Conclusions: The energy-based vessel sealing devices in study, represent a safe and efficient alternative to the traditional clamp-and-tie hand technique in the thyroidal surgery scenario, granting a reduction in operating time while not increasing RNL injury rates. According to this information, a preference for energy based devices techniques might be expressed, furthermore, a progressively higher usage rate for these devices is expected in the near future.

Can robotic gastric bypass be considered a valid alternative to laparoscopy? Our early experience and literature review.

Background: Robotic bariatric surgery serves as an alternative to laparoscopy. The technology provides the surgeon with an accurate three-dimensional view, allowing complex maneuvers while maintaining full control of the operating room. Hypothesis: We report our experience with this innovative surgery compared with laparoscopy during Roux-en-Y gastric bypass to demonstrate its safety and feasibility. The aim of this study is to evaluate potential differences between the robotic and laparoscopic techniques. Materials and methods: Our study retrospectively identified 153 consecutive obese patients who underwent either laparoscopic or robotic gastric bypass (RGB) procedures over a 2-year period at the Department of Medical and Surgical Sciences, University of Foggia. Data on demographics, operative time, conversion rate, length of hospital stay, and mortality were collected and compared between two groups of patients: 82 patients who underwent laparoscopic procedures and 71 who underwent robotic procedures. Results: We analyzed 153 patients who underwent gastric bypass with a mean age of 42.58 years, of whom 74 were female; 71 were treated with a robotic approach and 82 with a laparoscopic approach. The mean operative time was 224.75 ± 10.4 min for RGB (including docking time) and 101.22 min for laparoscopic gastric bypass (LGB) (p < 0.05), which is statistically significant. The median length of stay was 4.1 days for the RGB group and 3.9 days for the LGB group (p = 0.89). There is only one conversion to laparoscopy in the RGB group. We observed only one case of postoperative complications, specifically one episode of endoluminal bleeding in the laparoscopic group, which was successfully managed with medical treatment. No mortality was observed in either group. Conclusion: The statistical analysis shows to support the robotic approach that had a lower incidence of complications but a longer operative duration. Based on our experience, the laparoscopic approach remains a technique with more haptic feedback than the robotic approach, making surgeons feel more confident.This study has been registered on ClinicalTrial.gov Protocol Registration and Results System with this ID: NCT05746936 for the Organization UFoggia (https://clinicaltrials.gov/ct2/show/NCT05746936).

Metastatic melanoma causing small bowel perforation: A case report.

INTRODUCTION AND IMPORTANCE: Metastatic localization of melanoma often affects the gastrointestinal tract, with reference to the small intestine. CASE PRESENTATION: In this work we present the clinical course of a patient affected by a surgically treated melanoma of the right conjunctiva, suddenly manifesting abdominal symptomatology. The abdominal computed tomography scan (CT scan) show evidence of free air into the peritoneal cavity, cholecystitis and brain lesions highly suspicious for metastases. Patient underwent emergency surgery, consisting of ileo-cecal resection, cholecystectomy, with the construction of an ileostomy. The histological examination diagnosed multiple ileal and gallbladder localizations of pigmented epithelial melanoma, and localization. CLINICAL DISCUSSION: The treatment of conjunctival melanoma consists in surgical removal. Distant metastases frequently affect the gastrointestinal tract, leading to the necessity to assess patients with abdominal symptoms, in order to avoid emergency scenarios such as the one reported in our study. CONCLUSIONS: Intra-abdominal metastases from melanoma are an event that should not be underestimated, because if detected in time, they can be treated with surgery resulting in a clear improvement in the prognosis. Late diagnosis of intestinal metastases can cause an acute abdomen scenario frequently caused by intestinal obstruction or gastrointestinal bleeding.

Clinical Usefulness of the Valsalva Manoeuvre to Improve Hemostasis during Thyroidectomy.

Bleeding after total thyroidectomy remains a rare event that affects early postoperative morbidity, occurring in 0.3% to 4.2% of cases. Intraoperative bleeding is an unpleasant complication, and it is often easily manageable, although postoperative bleeding may represent a life-threatening condition for the patient. The purpose of our study was to clarify the role of the Valsalva manoeuvre to reduce postoperative bleeding. Between January 2019 to February 2022, 250 consecutive patients were listed for thyroid surgery at our surgical department. The study cohort consisted of 178 patients, divided into two groups based on the execution of the Valsalva manoeuvre. There was no difference in the duration of surgery between groups. Group B had fewer reinterventions for bleeding. Group A had a significantly greater volume of drainage output than Group B. Cervical haematoma can compromise a patient's life, so bleeding control is crucial. Our results show that using a simple and safe Valsalva manoeuvre can improve the postoperative course with a significant reduction in drainage output, but does not prevent the risk of reoperation for hemorrhage.