Anterior reconstruction of the esophageal hiatus: a novel approach for the repair of large diaphragmatic hernias.

Introduction: Paraesophageal hernias (PEH) often require surgical repair. The standard approach, primary posterior hiatal repair, has been associated with a high recurrence rate. Over the past few years, we have developed a new approach for repairing these hernias, which we believe restores the original anatomy and physiology of the esophageal hiatus. Our technique includes anterior crural reconstruction with routine anterior mesh reinforcement and fundoplication. Objective: To determine the safety and the clinical success of anterior crural reconstruction with routine mesh reinforcement. Material and methods: Data were collected retrospectively on 178 consecutive patients who had a laparoscopic repair of a symptomatic primary or recurrent PEH between 2011 and 2021 using the above technique. The primary outcome was clinical success, and the secondary outcome was 30 days of major complications and patient satisfaction. This was assessed by imaging tests, gastroscopies, and clinical follow-up. Results: Mean follow-up was 65 (SD 37.1) months. No intraoperative or 30 days postoperative mortality or major complications were recorded. Recurrence rate requiring a re-operation was 8.4% (15/178). Radiological and gastroenterological evidence of minor type 1 recurrence was 8.9%. Conclusion: This novel technique is safe with satisfactory long-term results. The outcome of our study will hopefully motivate future randomized control trials.

Mesh fixation using novel bio-adhesive coating compared to tack fixation for IPOM hernia repair: in vivo evaluation in a porcine model.

BACKGROUND: Mesh fixation in hernia repair is currently based on penetrating sutures or anchors, with proven early and late complications such as pain, adhesions, erosions, and anchor migration. In an attempt to reduce these complications, a bio-adhesive-based self-fixation system was developed. The purpose of this study was to assess the performance and safety of this novel self-adhesive mesh (LifeMesh™) by comparing it with standard tack fixation. METHODS: A full-thickness abdominal wall defect was created bilaterally in 24 pigs. The defects were measured 14 days later, and laparoscopic intraperitoneal onlay mesh (IPOM) repairs were performed. In each animal, both LifeMesh and a titanium tack-fixed control, either uncoated polypropylene mesh (PP) or composite mesh (Symbotex™), were used. After 28 and 90 days, we performed macroscopic evaluation and analyzed the fixation strength, shrinkage, adhesion scores, and histopathology in all samples. RESULTS: Measurements at both time points revealed that LifeMesh had fully conformed to the abdominal wall, and that its fixation strength was superior to that of the tack-fixated Symbotex and comparable to that of the tack-fixated PP. Shrinkage in all groups was similar. Adhesion scores with LifeMesh were lower than with PP and comparable with Symbotex at both time points. Histology demonstrated similar tissue responses in LifeMesh and Symbotex. Lack of necrosis, mineralization, or exuberant inflammatory reaction in all three groups pointed to their good progressive integration of the mesh to the abdominal wall. By 28 days the bio-adhesive layer in LifeMesh was substantially degraded, allowing a gradual tissue ingrowth that became the main fixation mode of this mesh to the abdominal wall. CONCLUSIONS: The excellent incorporation of LifeMesh to the abdominal wall and its superior fixation strength, together with its low adhesion score, suggest that LifeMesh may become a preferred alternative for abdominal wall repair.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery.

BACKGROUND: Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges. METHODS: An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria. RESULTS: In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies. CONCLUSIONS: Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

[FLEXIBLE ENDOSCOPY IN THE HANDS OF THE SURGEON - THE ISRAELI SURGEON'S POINT OF VIEW].

INTRODUCTION: The flexible endoscope was developed over 50 years ago as a diagnostic tool for the gastrointestinal (GI) tract. Since then, many therapeutic interventions were developed using the endoscope, mostly by surgeons. In the past decade, following technological developments and improvements made in light sources and video, more advanced procedures were developed, and the flexible endoscope is slowly becoming a powerful surgical tool that enables performing advanced procedures that replace traditional surgery, such as intra-operative endoscopy for exact localization of pathologies, active guidance of the surgical acts during surgery, treatment of common diseases of the GI tract and interventions to treat post-operative complications. The use of the flexible endoscope by surgeons varies between regions. Whereas it is a mandatory part of surgical residency in North America, Australia and parts of Asia, in other parts of the world, including Israel, flexible endoscopy is not accessible to surgeons. In this review we chart the reasons for this phenomenon and define the needs for change so that flexible endoscopy will become a common surgical tool in Israel.

A preclinical animal study of a novel, simple, and secure duct and vessel occluder for laparoscopic surgery.

BACKGROUND: Secure occlusion of large blood vessels and ductal structures is critical to all surgeries and remains a challenge in many minimally invasive procedures. This study compares in vivo use of the Amsel Occluder (AO) for secure laparoscopic blood vessel and duct closure, with one of the many commercially available hemoclips (Ligaclip®), in the porcine model. METHODS: Laparoscopic closure of vessels and ducts was performed on 12 swine to compare the ease of use, safety and efficacy of the AO with a hemoclip, as well as the tissue response at > 30 days (10 swine). All vessels and ducts were occluded and then transected between the occluding clips. Any bleeding or leakage was noted. In the chronic study, confirmation of satisfactory vessel occlusion post nephrectomy was determined by laparotomy as well as by contrast angiography and venography. The tissue response and healing was evaluated by a histopathological study for the effects of any biological incompatibilities. RESULTS: In the acute laparoscopic study, a total of 24 occlusions between 2 and 10 mm were performed with the AO (n = 19) and hemoclip (n = 5). In the chronic study, 5 nephrectomies (AO n = 3, hemoclip N = 2) and 5 cholecystectomies (AO n = 3, hemoclip n = 2) were performed with survival ranging from 42 to 72 days. One pig who sustained a splenic injury at trocar insertion and suffered a delayed ruptured spleen with massive hemorrhage on postoperative day 22. Unlike occlusion with the AO, multiple hemoclips were used for each vessel occlusion. Histopathological examination showed no difference in the tissue response and healing of the AO and hemoclip. CONCLUSIONS: The Amsel Vessel occluder delivered laparoscopically provides an occlusion similar to a hand-sewn transfixion suture, is simple to use, and creates an occlusion which is not only more secure, but also as safe with respect to the health of the surrounding tissues, as that of the widely used hemoclip (Ligaclip®).

First experience with THE AUTOLAP™ SYSTEM: an image-based robotic camera steering device.

BACKGROUND: Robotic camera holders for endoscopic surgery have been available for 20 years but market penetration is low. The current camera holders are controlled by voice, joystick, eyeball tracking, or head movements, and this type of steering has proven to be successful but excessive disturbance of surgical workflow has blocked widespread introduction. The Autolap™ system (MST, Israel) uses a radically different steering concept based on image analysis. This may improve acceptance by smooth, interactive, and fast steering. These two studies were conducted to prove safe and efficient performance of the core technology. METHODS: A total of 66 various laparoscopic procedures were performed with the AutoLap™ by nine experienced surgeons, in two multi-center studies; 41 cholecystectomies, 13 fundoplications including hiatal hernia repair, 4 endometriosis surgeries, 2 inguinal hernia repairs, and 6 (bilateral) salpingo-oophorectomies. The use of the AutoLap™ system was evaluated in terms of safety, image stability, setup and procedural time, accuracy of imaged-based movements, and user satisfaction. RESULTS: Surgical procedures were completed with the AutoLap™ system in 64 cases (97%). The mean overall setup time of the AutoLap™ system was 4 min (04:08 ± 0.10). Procedure times were not prolonged due to the use of the system when compared to literature average. The reported user satisfaction was 3.85 and 3.96 on a scale of 1 to 5 in two studies. More than 90% of the image-based movements were accurate. No system-related adverse events were recorded while using the system. CONCLUSION: Safe and efficient use of the core technology of the AutoLap™ system was demonstrated with high image stability and good surgeon satisfaction. The results support further clinical studies that will focus on usability, improved ergonomics and additional image-based features.

Multi-port versus single-port cholecystectomy: results of a multi-centre, randomised controlled trial (MUSIC trial).

BACKGROUND: Single-port laparoscopic surgery as an alternative to conventional laparoscopic cholecystectomy for benign disease has not yet been accepted as a standard procedure. The aim of the multi-port versus single-port cholecystectomy trial was to compare morbidity rates after single-access (SPC) and standard laparoscopy (MPC). METHODS: This non-inferiority phase 3 trial was conducted at 20 hospital surgical departments in six countries. At each centre, patients were randomly assigned to undergo either SPC or MPC. The primary outcome was overall morbidity within 60 days after surgery. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov (NCT01104727). RESULTS: The study was conducted between April 2011 and May 2015. A total of 600 patients were randomly assigned to receive either SPC (n = 297) or MPC (n = 303) and were eligible for data analysis. Postsurgical complications within 60 days were recorded in 13 patients (4.7 %) in the SPC group and in 16 (6.1 %) in the MPC group (P = 0.468); however, single-access procedures took longer [70 min (range 25-265) vs. 55 min (range 22-185); P < 0.001]. There were no significant differences in hospital length of stay or pain VAS scores between the two groups. An incisional hernia developed within 1 year in six patients in the SPC group and in three in the MPC group (P = 0.331). Patients were more satisfied with aesthetic results after SPC, whereas surgeons rated the aesthetic results higher after MPC. No difference in quality of life scores, as measured by the gastrointestinal quality of life index at 60 days after surgery, was observed between the two groups. CONCLUSIONS: In selected patients undergoing cholecystectomy for benign gallbladder disease, SPC is non-inferior to MPC in terms of safety but it entails a longer operative time. Possible concerns about a higher risk of incisional hernia following SPC do not appear to be justified. Patient satisfaction with aesthetic results was greater after SPC than after MPC.

Assessment of perioperative complications following primary bariatric surgery according to the Clavien-Dindo classification: comparison of sleeve gastrectomy and Roux-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-Y gastric bypass (LRYGBP) is the gold-standard procedure for the treatment of morbid obesity. It has been reported to be somewhat more efficient and durable than laparoscopic sleeve gastrectomy (LSG). However, it is considered more invasive and, therefore, more hazardous. There is a lack of unity in complication reporting following bariatric surgery. Thus, there is a possible misconception regarding the relative safety of the two major bariatric procedures performed worldwide. This may have contributed to a shift in practice with LSG gaining momentum "at the expense" of LRYGBP. The aim of this study was to evaluate the relative safety of primary LSG and LRYGBP according to the Clavien-Dindo complication grading system. METHODS: A total of 2651 and 554 patients underwent primary LSG and LRYGBP, respectively at three high-volume centers. Thirty-day perioperative complications were recorded and graded. Length of hospital stays (LOS) and readmission rates were collected as well. RESULTS: Complications occurred in 110 (3.7%) and 24 (4.3%) patients following LSG and LRYGBP, respectively (p = 0.9). No significant difference was found between the groups regarding overall and complication-grade-specific rates. Individual complication types were unevenly distributed, but not significantly so. Patients with complications were older than those without (47 and 43 years, respectively; p = 0.01). Gender was not a risk factor for complication. Median LOS and readmission rates were not significantly different. CONCLUSIONS: LSG and LRYGBP are equally safe, at least in the perioperative period. Acknowledging and conveying this finding to surgeons and patients alike is important and might cause a pendulum shift in the distribution of bariatric procedures performed.

Concomitant cholecystectomy during laparoscopic sleeve gastrectomy.

BACKGROUND: The prevalence of cholelithiasis in morbidly obese individuals is 19-45%. Laparoscopic sleeve gastrectomy (LSG) has become one of the most performed procedures worldwide. The management of gallstones at the time of LSG is under debate. We herein report our experience with concomitant LSG and cholecystectomy. METHODS: Patients undergoing LSG, between 2006 and 2014 with symptomatic cholelithiasis (SC), underwent concomitant cholecystectomy (SGC), and were compared to those who had LSG alone. Gender, age, and BMI were noted. Preoperative ultrasonography was performed for all patients and gallstone presence was recorded. Operative time, intraoperative mishaps, perioperative complications, length of hospital stay (LOS), and the incidence of subsequent symptomatic gallbladder disease were collected as well. RESULTS: SC was present in 180 patients who underwent SGC. LSG was performed in 2,383, of whom 43 (2%) had asymptomatic cholelithiasis (AC). SGC patients had a higher percentage of females and were older (79% and 46 years vs. 62% and 43 years, respectively). BMI, LOS, and complications were similar. Operative time was prolonged by 35 min in SGC. Two patients with SGC had bile leakage. Of patients with AC, 9.3% required cholecystectomy during the first post-operative year after LSG due to evolution of symptoms, compared to only 2.7% of those with normal preoperative gallbladders. Presenting symptoms and severity of the disease were worse in the first group. CONCLUSIONS: For SC, LSC is safe and warranted. Prophylactic cholecystectomy when gallstones are absent is unnecessary. Management of AC at the time of LSG is still debatable.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery.

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Adenocarcinoma of the Gallbladder: Incidental Finding in Patients following Laparoscopic Sleeve Gastrectomy and Cholecystectomy.

BACKGROUND: Gallbladder (GB) cancer is rare. Most cases are incidentally found in specimens after a cholecystectomy. Cholelithiasis is almost always present when this diagnosis is made. Obesity is a known risk factor for gallstone formation and thus may be related to GB cancer. OBJECTIVES: To highlight the importance of evaluating the gallbladder before surgery, resecting the gallbladder whenever required, and screening the resected tissue for malignancy. METHODS: We retrospectively searched a prospectively maintained database of all bariatric procedures during the last 8 years for cases of concomitant laparoscopic sleeve gastrectomy (LSG) and laparoscopic cholecystectomy (LC). Pathologic reports of the gallbladders were reviewed. Demographic data and perioperative parameters were documented. RESULTS: Of 2708 patients reviewed, 1721 (63.55%) were females and 987 (36.45%) males. Excluded were 145 (5.35%) who had a previous cholecystectomy. Of the remaining 2563, 180 (7.02%) had symptomatic gallbladder disease and underwent LSG with LC. Of these, two females (BMI 53 kg/m2 and 47 kg/m2, both age 60) were found by histological examination to have adenocarcinoma in their GB specimens (1.11%). Both were reoperated, which included partial hepatectomy of the GB bed, resection of the cystic stump, lymph node dissection, and resection of the port sites. One patient is doing well, with no evidence of disease at a postoperative follow-up of 4 years. The second patient had recurrent disease with peritoneal spread and ascites 20 months post-surgery and died 18 months later. CONCLUSIONS: GB cancer is a rare finding in cholecystectomy specimens. The incidence of this entity might be higher in obese older females owing to the higher incidence of cholelithiasis in these patients.

Concomitant bariatric and ventral/incisional hernia surgery in morbidly obese patients.

INTRODUCTION: Ventral hernias are not uncommon in the bariatric population. Their management is technically demanding and remains controversial. Hernia complications can be lethal after bariatric surgery (BS). We herein report our experience with concomitant BS and ventral hernia repair (VHR). METHODS: We performed a retrospective analysis of a prospectively maintained database queried for combined procedures. Hernias were repaired after complete reduction (when the defect was not empty) using a dual mesh fixed to the abdominal wall with absorbable tackers. Data collected included demographics, anthropometrics, co-morbidities, peri-operative course, and intermediate weight loss and co-morbidity status. RESULTS: Between 2007 and 2012, a total of 54 patients (34 females, mean body mass index 44.2 kg/m(2)) underwent concomitant BS and VHR. The vast majority of procedures were laparoscopic sleeve gastrectomies (N = 48; 89 %). Others included laparoscopic Roux-en-y gastric bypass (RYGB), open RYGB, and laparoscopic gastric banding (two each). Six patients had complications (11 %): three leaks, two abdominal wall hematomas, and one pulmonary embolism. Hernia recurrence was noted in one patient (1.8 %). Average excess weight loss post-surgery was 49.9 ± 10.3 and 57.7 ± 9.2 % at 6 and 12 months, respectively. The total number of pre-operative co-morbidities was 110. At 12-month follow-up, 50 % (N = 56) were completely resolved and 38 % (N = 42) were improved. CONCLUSION: Concomitant BS and VHR is feasible and safe, obviating the need for two separate procedures while not hampering the outcome of either. Complication rates for the combined surgery do not seem to be adversely affected.

Advantages of minimal incision laparoscopic cholecystectomy.

BACKGROUND: Modifications to conventional laparoscopic cholecystectomy (CLC) are aimed at decreasing abdominal wall trauma and improving cosmetic outcome. Although single-incision laparoscopic surgery (SILS) provides excellent cosmetic results, the procedure is technically challenging and expensive compared to the conventional laparoscopic approach. OBJECTIVES: To describe a novel, hybrid technique combining SILS and conventional laparoscopy using minimal abdominal wall incisions. METHODS: Fifty patients diagnosed with symptomatic cholelithiasis were operated using two reusable 5 mm trocars inserted through a single 15 mm umbilical incision and a single 2-3 mm epigastric port. This technique was clubbed "minimal incision laparoscopic cholecystectomy" (MILC). RESULTS: MILC was completed in 49 patients (98%). In five patients an additional 3 mm trocar was used and in 2 patients the epigastric trocar was switched to a 5 mmtrocar. The procedure was converted to CLC in one patient. Mean operative time was 29 minutes (range 18-60) and the average postoperative hospital stay was 22 hours (range 6-50). There were no postoperative complications and the cosmetic results were rated excellent by the patients. CONCLUSIONS: MILC is an intuitive, easy-to-learn and reproducible technique and requires small changes from CLC. As such, MILC may be an attractive alternative, avoiding the cost and complexity drawbacks associated with SILS.

Mid-term follow-up after laparoscopic sleeve gastrectomy in obese adolescents.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining credibility as a simple and efficient bariatric procedure with low surgical risk. Since surgical treatment for morbid obesity is relatively rare in adolescents, few results have bten accumulated so far. OBJECTIVES: To prove the safety and efficacy of LSG turgery in an adolescent population METHODS: Data were prospectively collected regarding adolescent patients undergoing LSG. All patients underwent pre- and postoperative medical and professional evaluation by a multidisciplinary team. RESULTS: Between the years 2006 and 2011, 32 adolescents underwent LSG in our center (20 females and 12males). Mean age was 16.75 years (range 14-18 years), mean weight was 121.88 kg (83-178 kg), and mean body mass index 43.23 (35-54). Thirty-four comorbid conditions were identified. LSG was the primary bariatric procedure in all the patients. Mean operative time was 60 minutes (range 45-80 min). Tiere were two complications (6.25%): an early staple line leak and a late acute cholecystitis. There were no deaths. Mean percent excess weight loss at 1, 3, 6, 9,12, 24, 36, 48, and 60 months post-surgery was 27.9%, 41.1%, 62.6%, 79.2%, 81.7%, 71%, 75%, 102.9% and 101.6%, respectively. Comorbidities were completely resolved or ameliorated within 1 year folllowing surgery in 82.4% and 17.6%, respectively. CONCLUSIONS: LSG is feasible and safe in morbidly obese adolescents, achieving efficient weight loss and impressive resolution of comorbidities. Further studies are required to evaluate the long-term results of this procedure as well as its place among other bariatric options.

The use of virtual reality simulation to determine potential for endoscopic surgery skill acquisition.

BACKGROUND: Efficient acquisition of endoscopic technique is essential for high-level care in surgical practice. In contrast to similar substantial risk industries, there is no standard instrument capable of detecting the potential of surgical residency candidates to develop such skills. MATERIAL AND METHODS: We used the Simbionix "Lapmentor" Virtual reality simulator basic skills tasks 1, 5 and 6 to establish baseline performance of 17 subjects lacking surgical experience, then divided them into two groups. One group trained on the Lapmentor, a validated trainer. The second group trained on a video box trainer using 3 FLS tasks, which correlate with real OR performance. After completing the training program, each group was tested on its training modality and correlations were sought between performance in the screening tasks and final scores in both groups. RESULTS: Time in Lapmentor task 1 showed significant correlations with total FLS scores (R 0.807 P 0.015), in addition to other benchmark parameters. With the Lapmentor group, time on task 5 demonstrated correlation with itself on the final scores (R 0.794 P 0.011). CONCLUSIONS: Time in the Lapmentor task 1 demonstrates correlations with FLS scores, which translate to better OR performance. The Lapmentor thus shows potential to be used as a screening test for surgical talent.

Gelatin-Based Liver Phantoms for Training Purposes: A Cookbook Approach.

Background: Patients with liver pathology benefit from image-guided interventions. Training for interventional procedures is recommended to be performed on liver phantoms until a basic proficiency is reached. In the last 40 years, several attempts have been made to develop materials to mimic the imaging characteristics of the human liver in order to create liver phantoms. There is still a lack of accessible, reproducible and cost-effective soft liver phantoms for image-guided procedure training. Methods: Starting from a CT-scan DICOM file, we created a 3D-printed liver mold using InVesalius (Centro de Tecnologia da informação Renato Archer CTI, InVesalius 3 open-source software, Campinas, Brazil) for segmentation, Autodesk Fusion 360 with Netfabb (Autodesk software company, Fusion 360 2.0.19426 with Autodesk Netfabb Premium 2023.0 64-Bit Edition, San Francisco, CA, USA) for 3D modeling and Stratasys Fortus 380 mc 3D printer (Stratasys 3D printing company, Fortus 380 mc 3D printer, Minneapolis, MN, USA). Using the 3D-printed mold, we created 14 gelatin-based liver phantoms with 14 different recipes, using water, cast sugar and dehydrated gelatin, 32% fat bovine milk cream with intravenous lipid solution and technical alcohol in different amounts. We tested all these phantoms as well as ex vivo pig liver and human normal, fatty and cirrhotic liver by measuring the elasticity, shear wave speed, ultrasound attenuation, CT-scan density, MRI signal intensity and fracture force. We assessed the results of the testing performed, as well as the optical appearance on ultrasound, CT and MRI, in order to find the best recipe for gelatin-based phantoms for image-guided procedure training. Results: After the assessment of all phantom recipes, we selected as the best recipe for transparent phantoms one with 14 g of gelatin/100 mL water and for opaque phantom, the recipes with 25% cream. Conclusions: These liver gelatin-based phantom recipes are an inexpensive, reproducible and accessible alternative for training in image-guided and diagnostic procedures and will meet most requirements for valuable training.

The hepatorenal reflex contributes to the induction of oliguria during pneumoperitoneum in the rat.

BACKGROUND: Hepatic blood flow is known to decrease during pneumoperitoneum. Studies have shown that such changes affect kidney urinary output through the sympathetic pathway known as the hepatorenal reflex. This study investigated the potential role of the hepatorenal reflex in pneumoperitoneum-induced oliguria. The authors hypothesized that oliguria detectable during pneumoperitoneum is caused by activation of the hepatorenal reflex. METHODS: Denervation of the sympathetic nervous structure was performed in 15 rats by applying 1 ml of 90 % aqueous phenol solution circumferentially to the portal vein and vena cava area at their entrance to the liver. The same was applied to only the peritoneum in 15 nondenervated rats. After 2 weeks, the rats were divided into three subgroups (5 rats per subgroup) that were exposed respectively to carbon dioxide-induced pneumoperitoneum at 0, 10, and 15 mmHg for 2 h. Statistical analysis was performed using Student's t test and analyses of variance. RESULTS: Denervation did not affect the preinsufflation parameters. The denervated and the nondenervated 0-mmHg subgroups presented with similar parameters. The postinsufflation mean urine output was significantly lower in the nondenervated than in the denervated 10- and 15-mmHg subgroups (p = 0.0097). The denervated rats had a final creatinine clearance 29 % lower than the preinsufflation value (p = 0.83), whereas the nondenervated animals presented a 79 % drop in creatinine clearance (p = 0.02). CONCLUSION: The study findings indicate that the hepatorenal reflex plays an important role in the pathophysiology of oliguria that occurs during pneumoperitoneum in the rat.

The Effects of One Anastomosis Gastric Bypass Surgery on the Gastrointestinal Tract.

One anastomosis gastric bypass (OAGB) is an emerging bariatric procedure, yet data on its effect on the gastrointestinal tract are lacking. This study sought to evaluate the incidence of small-intestinal bacterial overgrowth (SIBO) following OAGB; explore its effect on nutritional, gastrointestinal, and weight outcomes; and assess post-OABG occurrence of pancreatic exocrine insufficiency (PEI) and altered gut microbiota composition. A prospective pilot cohort study of patients who underwent primary-OAGB surgery is here reported. The pre-surgical and 6-months-post-surgery measurements included anthropometrics, glucose breath-tests, biochemical tests, gastrointestinal symptoms, quality-of-life, dietary intake, and fecal sample collection. Thirty-two patients (50% females, 44.5 ± 12.3 years) participated in this study, and 29 attended the 6-month follow-up visit. The mean excess weight loss at 6 months post-OAGB was 67.8 ± 21.2%. The glucose breath-test was negative in all pre-surgery and positive in 37.0% at 6 months (p = 0.004). Positive glucose breath-test was associated with lower reported dietary intake and folate levels and higher vitamin A deficiency rates (p ≤ 0.036). Fecal elastase-1 test (FE1) was negative for all pre-surgery and positive in 26.1% at 6 months (p = 0.500). Both alpha and beta diversity decreased at 6 months post-surgery compared to pre-surgery (p ≤ 0.026). Relatively high incidences of SIBO and PEI were observed at 6 months post-OAGB, which may explain some gastrointestinal symptoms and nutritional deficiencies.

The rise of one anastomosis gastric bypass: insights from surgeons and dietitians.

One anastomosis gastric bypass/Mini Gastric Bypass (OAGB/MGB) is an emerging bariatric surgery (BS) technique. We evaluated and compared attitudes of bariatric surgeons and dietitians towards the considerations for choosing BS-type ("Decision-making"), the contributing factors to the rise of OAGB/MGB in Israel ("OAGB/MGB-rise") and notions regarding the occurrence of gastrointestinal (GI) symptoms and nutritional deficiencies following OAGB/MGB. Anonymous online surveys were distributed. The participants were asked to rate by a 10-point Likert scale (0 = not at all; 100 = very much/often) their attitudes towards "Decision-making", "OAGB/MGB-rise" and occurrence of GI symptoms and nutritional deficiencies following OAGB/MGB. For "Decision-making" and "OAGB/MGB-rise", items were considered prioritized where ≥ 50% of the group considered them as 'very-important' (rating ≥ 80). Data on age, sex, years-in-practice and main workplace were also collected. A total of 106 professionals participated in the survey (42 surgeons; 64 dietitians). The respective mean age, years-in-practice and sex were 52.3 ± 8.7 vs. 42.3 ± 9.0 years, 21.0 ± 10.8 vs. 15.5 ± 9.2 years and 85.7% vs. 3.1% males. The inter-observer agreement for prioritized items related to "Decision-making" was fair (Kappa = 0.250; P = 0.257) and both groups prioritized patient's BMI, comorbidities and compliance. The inter-observer agreement for prioritized items related to "OAGB/MGB-rise" was moderate (Kappa = 0.550; P = 0.099) and both groups prioritized ease of performance, shorter operation duration and failure of former restrictive BS. Surgeons reported lower occurrence of nutritional deficiencies and GI symptoms as adverse effects of OAGB/MGB (P ≤ 0.033). The study highlights the views of bariatric surgeons and dietitians concerning factors that underpin the rise of OABG/MGB in Israel and possible rates of GI symptoms and nutritional deficiencies associated with this modality.

Endoscopically stapled diverticulostomy for Zenker's diverticulum: results of a multidisciplinary team approach.

BACKGROUND: A variety of open and endoscopic surgical approaches for the treatment of Zenker's diverticulum have been described. In recent years, growing evidence has shown that the endoscopic techniques are superior to the open approaches in many aspects. Among the endoscopic techniques, endoscopically stapled diverticulostomy (ESD) appears to have better efficacy and safety than the other endoscopic techniques. METHODS: This study retrospectively reviewed the medical records of all the patients with Zenker's diverticulum treated surgically by the same team, which involved an ear, nose, and throat surgeon and an endoscopic surgeon. RESULTS: From January 2002 to March 2008, 55 consecutive patients with Zenker's diverticulum underwent 60 ESDs. The mean follow-up time was 32.6 months (range, 1-72 months). The mean operative time was 21.8 min (range, 5-45 min), and the average hospital stay was 2.24 days (range, 1-30 days). The treatment was technically feasible for 51 patients (93%), and initial symptom relief without recurrence was achieved for 46 patients (90.2%) after a single procedure. Five patients with recurrent symptoms underwent a successful revision ESD, with a 100% success rate among the patients for whom the procedure was technically feasible. Only two major postoperative complications (3.64%) occurred: one esophageal perforation and pneumomediastinum and one severe esophageal edema. Both patients had complete resolution of their complications with conservative treatment and no long-term sequela. CONCLUSION: The findings showed endoscopic stapled diverticulostomy to be both safe and effective. Compared with the historical results of open diverticulectomy and myotomy, the reported procedure has fewer complications and better outcomes and should become the procedure of choice for the treatment of most patients with a diagnosis of Zenker's diverticulum.