Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass in patients with gastroesophageal reflux disease: results of a multicenter study.

BACKGROUND: The main side effect of long-term laparoscopic sleeve gastrectomy is the onset of severe gastroesophageal reflux disease (GERD). OBJECTIVES: The aim of this study was to evaluate the effectiveness of gastric bypass conversion in controlling postsleeve GERD. SETTING: University Hospital and Private Hospital, France and Private Hospital, Italy. METHODS: This retrospective multicenter study included patients who underwent laparoscopic sleeve gastrectomy and suffered from postoperative GERD, who did not respond to medical treatment and were converted to laparoscopic Roux-en-Y gastric bypass. The study involved 2 French university hospitals, 4 French private centers, and an Italian public hospital. RESULTS: A total of 80 patients were reviewed. Treatment of a hiatal hernia was performed during laparoscopic sleeve gastrectomy in 3 patients, while 19 patients were operated for hiatal hernia during conversion to bypass (P = .0004). Six months after surgery, 23 of 80 patients maintained reflux symptomatology with a daily frequency, for which continued proton pump inhibitor treatment was required. The persistence of GERD was significantly more frequent among patients with previous gastric banding (n = 19) compared with patients with no history of gastric banding (n = 4, P = .02). In other words, the likelihood of having poor clinical success from conversion of the sleeve to bypass because of intractable GERD was 3 times higher if the patient had a history of gastric banding (relative risk = 2.89, odds ratio = 3.69). CONCLUSION: The results of this study show that, despite the conversion, the symptomatology of GERD does not always disappear, especially in patients with previous gastric banding.

Interleukin-32 Contributes to Human Nonalcoholic Fatty Liver Disease and Insulin Resistance.

Nonalcoholic fatty liver disease (NAFLD) is a metabolic disorder due to increased accumulation of fat in the liver and in many cases to enhanced inflammation. Although the contribution of inflammation in the pathogenesis of NAFLD is well established, the cytokines that are involved and how they influence liver transformation are still poorly characterized. In addition, with other modifiers, inflammation influences NAFLD progression to liver cirrhosis and hepatocellular carcinoma, demonstrating the need to find new molecular targets with potential future therapeutic applications. We investigated gene signatures in 38 liver biopsies from patients with NAFLD and obesity who had received bariatric surgery and compared these to 10 control patients who had received a cholecystectomy, using DNA microarray technology. A subset of differentially expressed genes was then validated on a larger cohort of 103 patients who had received bariatric surgery for obesity; data were thoroughly analyzed in terms of correlations with NAFLD pathophysiological parameters. Finally, the impact of a specific cytokine, interleukin-32 (IL32), was addressed on primary human hepatocytes (PHHs). Transcript analysis revealed an up-regulation of proinflammatory cytokines IL32, chemokine (C-X-C motif) ligand 9 (CXCL9), and CXCL10 and of ubiquitin D (UBD), whereas down-regulation of insulin-like growth factor-binding protein 2 (IGFBP2) and hypoxanthine phosphoribosyltransferase 1 (HPRT1) was reported in patients with NAFLD. Moreover, IL32, which is the major deregulated gene, correlated with body mass index (BMI), waist circumference, NAFLD activity score (NAS), aminotransferases (alanine aminotransferase [ALAT] and aspartate aminotransferase [ASAT]), and homeostasis model assessment of insulin resistance (HOMA-IR) index in patients. Consistent with an instrumental role in the pathophysiology of NAFLD, treatment of control human hepatocytes with recombinant IL32 leads to insulin resistance, a hallmark metabolic deregulation in NAFLD hepatocytes. Conclusion: IL32 has a critical role in the pathogenesis of NAFLD and could be considered as a therapeutic target in patients.

Single-Anastomosis Pylorus-Preserving Bariatric Procedures: Review of the Literature.

Single-anastomosis pylorus-preserving procedures (SAPPP) were recently introduced into bariatric surgery in order to combine the physiologic advantages of a post-pyloric reconstruction with the technical advantages of an omega loop. Surgery consists of a sleeve gastrectomy that is performed first, followed by a duodeno-enterostomy. Two main variants exist: proximal and distal SAPPP, with duodeno-jejunostomy and duodeno-ileostomy, respectively. This review describes the SAPPP reported in the literature and analyzes their outcomes in comparison with the most frequently performed bariatric techniques. Preliminary results appear as promising in terms of both safety and effectiveness on weight loss and comorbidities improvement.

Laparoscopic tension-free abdominal wall repair: impact of mesh size and of different fixation devices in a consecutive series of 120 patients.

PURPOSE: To assess the impact of mesh size and fixation devices on short-term outcomes in a consecutive series of tension-free laparoscopic abdominal wall repairs. METHODS: Data for 120 consecutive, unselected patients undergoing tension-free laparoscopic incisional (n=63) or umbilical (n=57) hernia repair were prospectively collected. A multivariate analysis was performed to evaluate variables influencing outcomes. RESULTS: Persistent seromas were observed in 13 patients (10.83%) and 2 recurrences (1.98%) occurred. Mesh size >300 cm was associated with increased hospital stay [odds ratio (OR) 4.83; 95% confidence interval (CI), 1.5-15.53; P=0.008], increased postoperative day 1 (POD1) pain assessed with visual analog scale (OR 5.51; 95% CI, 1.76-17.2; P=0.003), and the presence of complications (OR 10.4; 95% CI, 1.85-58.96; P=0.007). Body mass index >30 resulted in increased hospital stay (OR 3.05; 95% CI, 1.23-7.57; P=0.01) and increased POD1 visual analog scale (OR 2.28; 95% CI, 1-5.18; P=0.04). CONCLUSIONS: Mesh size and obesity were the main factors influencing postoperative outcomes.

Virtual neck exploration for parathyroid adenomas: a first step toward minimally invasive image-guided surgery.

OBJECTIVE: To evaluate the performance of 3-dimensional (3D) virtual neck exploration (VNE) as a modality for preoperative localization of parathyroid adenomas in primary hyperparathyroidism and assess the feasibility of using augmented reality to guide parathyroidectomy as a step toward minimally invasive imageguided surgery. DESIGN: Enhanced 3D rendering methods can be used to transform computed tomographic scan images into a model for 3D VNE. In addition to a standard imaging modality, 3D VNE was performed in all patients and used to preoperatively plan minimally invasive parathyroidectomy. All preoperative localization studies were analyzed for their sensitivity, specificity, positive predictive value, and negative predictive value for the correct side of the adenoma(s) (lateralization) and the correct quadrant of the neck (localization). The 3D VNE model was used to generate intraoperative augmented reality in 3 cases. SETTING: Tertiary care center. PATIENTS: A total of 114 consecutive patients with primary hyperparathyroidism were included from January 8, 2008, through July 26, 2011. RESULTS: The accuracy of 3D VNE in lateralization and localization was 77.2% and 64.9%, respectively. Virtual neck exploration had superior sensitivity to ultrasonography (P.001), sestamibi scanning (P=.07), and standard computed tomography (P.001). Use of the 3D model for intraoperative augmented reality was feasible. CONCLUSIONS: 3-Dimensional VNE is an excellent tool in preoperative localization of parathyroid adenomas with sensitivity, specificity, and diagnostic accuracy commensurate with accepted first-line imaging modalities. The added value of 3D VNE includes enhanced preoperative planning and intraoperative augmented reality to enable less-invasive image-guided surgery.

Three-dimensional metabolic and radiologic gathered evaluation using VR-RENDER fusion: a novel tool to enhance accuracy in the localization of parathyroid adenomas.

BACKGROUND: The aim of this study was to assess the accuracy of a novel imaging modality, three-dimensional (3D) metabolic and radiologic gathered evaluation (MeRGE), for localizing parathyroid adenomas (PAs). METHODS: Consecutive patients presenting with primary hyperparathyroidism who underwent both thin-slice cervical computed tomography (CT) and (99m)Tc-sestamibi (MIBI) scanning were included. 3D-CT reconstruction was obtained using VR-RENDER, which was used to perform 3D virtual neck exploration (3D-VNE). The MIBI scan was then fused with the 3D reconstruction to obtain 3D-MeRGE. Sensitivity, specificity, and accuracy were assessed. Parathyroid gland volume and preoperative parathormone (PTH) levels were analyzed as predictive factors of correct localization (i.e., correct quadrant). RESULTS: A total of 108 cervical quadrants (27 patients) were analyzed. Sensitivities were 79.31, 75.86, 65.51, and 58.61 % with 3D-MeRGE, 3D-VNE, MIBI, and CT, respectively. Specificity was highest with CT (94.93 %) followed by 3D-VNE (92.4 %). MIBI and 3D-MeRGE had the same specificity (88.6 %). 3D-MeRGE and 3D-VNE achieved higher accuracy than MIBI or CT alone. Mean PTH values were significantly higher in patients with lesions that were correctly identified (true positive, TP) than in those whose lesions were missed (false negative, FN) with 3D-VNE (219.60 ± 212.77 vs. 98.75 ± 12.76 pg/ml; p = 0.01) and 3D-MeRGE (217.69 ± 213.76 vs. 09.75 ± 20.48 pg/ml; p = 0.02). The mean parathyroid gland volume difference between TP and FN was statistically significant with all modalities except CT. CONCLUSIONS: 3D-MeRGE and 3D-VNE showed high accuracy for localization of PAs. 3D-MeRGE performed better than MIBI or CT alone for detecting small adenomas and those with a low PTH level.

Full laparoscopic total pancreatectomy with and without spleen and pylorus preservation: a feasibility report.

BACKGROUND/PURPOSE: Laparoscopic pancreatic surgery is gaining acceptance and clear advantages have been demonstrated in distal resection. Total pancreaticoduodenectomy (TPD) combines the operative steps of distal pancreatectomy and pancreaticoduodenectomy, but facilitates reconstruction and lowers the risk of common complications by avoiding the need for a pancreatic anastomosis. The aim of this report is to analyse the feasibility of laparoscopic total pancreaticoduodenectomy, with and without spleen and pylorus preservation. METHODS: Two patients underwent laparoscopic TPD for pancreatic intraductal mucinous neoplasm and endocrine tumors. Total splenopancreaticoduodenectomy (TSP) and pylorus- and spleen-preserving total pancreaticoduodenectomy (PSPTP) were performed. RESULTS: The two procedures were successfully completed laparoscopically. PSPTP was more time-consuming (420 vs. 360 min) and had an increased risk of hemorrhage (600 vs. 200 ml) compared with TSP. After both procedures, the postoperative outcome was uneventful and the postoperative length of hospital stay was 8 days. CONCLUSIONS: This report confirms the feasibility of full laparoscopic TPD, and presents the first full laparoscopic pylorus- and spleen-preservation technique with conservation of the splenic vessels, without robotic assistance. No conclusions can be drawn from this report, but it shows that the laparoscopic approach provides visual magnification, improved exposure, and delicate manipulation of tissues, which may reproduce the clear advantages of laparoscopic distal pancreatectomy.

Successful extracorporeal membrane oxygenation treatment for pheochromocytoma-induced acute cardiac failure.

The aim of this study is to report the case of a catecholamine-induced cardiogenic shock bridged to curative adrenalectomy using extracorporeal membrane oxygenation (ECMO) and medical management. A 37-year-old woman presented an acute cardiogenic shock due to a left-sided pheochromocytoma. Echocardiography revealed a severe global hypokinesia with a left ventricular ejection fraction of 15%. Despite maximal ionotropic support, adequate perfusion could not be achieved; and ECMO was used to bridge the patient during medical management with calcium-channel blockers. The left ventricular ejection fraction improved to 65%, and ECMO was discontinued after 11 days. An open left adrenalectomy was performed 10 days after ECMO. At 1-year follow-up, the patient is in good health with normal cardiac function. Pheochromocytomas can present with dramatic cardiovascular collapse. With timely diagnosis and medical therapy, followed by surgical resection, the cardiovascular effects can be reversed; and the condition, cured. Young patients with catecholamine-induced cardiac failure refractory to medical therapy are ideal candidates for short-term ECMO support, as the underlying cause is imminently reversible.

Mentored trainees obtain comparable operative results to experts in complex laparoscopic colorectal surgery.

PURPOSE: The aim of this study is to evaluate the impact of an expert monitoring on the quality and results of laparoscopic reversal of Hartmann's procedure (LRHP) performed by trainee surgeons by comparing their results to the expert's outcomes. METHODS: Forty-two LRHP were performed between 2000 and 2008 following a step-by-step, standardised, full laparoscopic procedure. Patients operated upon by a senior surgeon were compared to patients operated upon by trainee surgeons while being mentored by the senior surgeon. Operative time, conversion, complications and post-operative outcome were measured. RESULTS: Each group included 21 patients. All patients underwent LRHP successfully. Two procedures were converted. No significant difference was observed between the expert and the trainees: operative time, 132 min (SD ± 50) vs. 131 min (SD ± 47) and complications (2-14%), 4 vs. 2. Three complications required re-operation, and three other were treated medically, including one dilatation of an anastomosis. Post-operative outcomes were comparable (oral intake, 3 vs. 2 days; post-operative hospital stay, 6 vs. 7.5 days); no mortality occurred. CONCLUSIONS: Standardisation simplifies this difficult laparoscopic procedure and offers the same outcome whether it is performed by an expert or by mentored trainees. The complications were comparable to those occurring at experienced centres (anastomotic leak or stricture, ureteral injury, re-operation). The expert mentoring does not prevent all complications but can solve intra-operative technical problems, thus improving the trainee's confidence. Mentoring should be promoted as it can be performed locally or remotely using modern interactive technology.

Laparo-endoscopic single-site (LESS) with transanal natural orifice specimen extraction (NOSE) sigmoidectomy: a new step before pure colorectal natural orifices transluminal endoscopic surgery (NOTES®).

INTRODUCTION: We present the first human case of laparo-endoscopic single-site sigmoidectomy with transanal natural orifice specimen extraction. DISCUSSION: This technical achievement is a new step toward pure colorectal Natural Orifices Transluminal Endoscopic Surgery. It is the product of a gradual development with critical steps being conceived and standardised in years of experimental and clinical procedures.

Video. Improving functional esophageal surgery with a "smart" bougie: Endoflip.

BACKGROUND: An emerging imaging tool, the functional lumen imaging probe (Endoflip; Crospon Ltd, Galway, Ireland), provides a real-time measurement of esophagogastric junction (EGJ) capacity and diameter, which would be of particular interest in functional esophageal surgery such as Heller myotomy and antireflux procedures. This study aimed to demonstrate the intraoperative use of endoflip in the treatment of achalasia and gastroesophageal reflux disease (GERD). METHODS: In the first case, Heller myotomy was performed under endopflip guidance, for persistent dysphagia after failed endoscopic dilatation. In the second case, the endoflip was used to calibrate a Nissen fundoplication. With the patient under general anesthesia, the endoflip catheter was inserted orally and positioned to straddle the EGJ. At each stage of the procedure, the balloon was inflated by liquid filling at 40-30 ml/min. Live diameter data, cross-sectional area (CSA), and balloon pressure were displayed on the system at all times. RESULTS: Before the myotomy, the pressure in the balloon rose to 15 mm Hg at a CSA of 25 mm(2), indicating that the EGJ is rigid and tight. After the myotomy, the pressure rose to 8 mm Hg, and the CSA opened to 34 mm(2), indicating that the EGJ was now very compliant and flaccid. After the Dor fundoplication, the junction became less compliant, but it could open at its narrowest point to 35 mm(2) at a pressure of 20 mm Hg, suggesting that the EGJ was tighter but not as rigid as before. The second part of the video demonstrates that the Endoflip acted as a "smart bougie," evaluating the orientation and position of a properly constructed floppy Nissen. CONCLUSIONS: The endoflip provides a system in which physiology and anatomy are represented dynamically in the same image. This "smart bougie" could be integrated into the surgical routine to improve outcome and to facilitate surgical training and the learning curve in esophageal functional surgery.

Expanded clinical experience with 4DDome(R) composite prosthesis in elective open inguinal herniorrhaphy.

Prosthetic material composition is implicated in the phenomenon of postoperative chronic groin pain that has undermined elective open inguinal herniorrhaphy. Reported herein are our 'all-comers' experiences with a novel dual component mesh (4DDome(R)). A prospective cohort (Phase II) study was performed that involved all patients undergoing elective open inguinal herniorrhaphy during a four-year period. Conventional operative technique was used except for choice of prosthesis. The 4DDome mesh comprises a molded dome-shaped composite (10% polypropylene, 90% poly-L-lactic acid) with a lightweight polypropylene mesh overlay. Short- (1 week) and intermediate-term (18 months) clinical follow-up with examination and symptom questionnaire judged outcome while surgeons rated their approval using a visual analogue scale. One hundred ninety-six patients (mean age, 65.5 years; Mean BMI, 25.5; Mean ASA, 1.8, 178 males) underwent repair of 201 inguinal hernias by six surgeons (three residents). The majority of patients had an indirect hernia (n=119) 93 being combined with a posterior wall defect [Nyhus IIIa], whereas 66 had a direct hernia [Nyhus IIIb], and 11 had a recurrent hernia.) Mean operative time was 44.6 minutes with 92 patients being operated under local anesthesia. Ten patients developed seromas and two had hematomas early postoperatively. Median intermediate-term follow-up is currently 19 (range: 3-72) months for the 147 (75%) patients still available for contact. The incidence of chronic groin pain is 8.8%, whereas there has been one hernia recurrence. Surgeon satisfaction and confidence were high. The 4DDome provides appropriate clinical results and, therefore, appears valid for use in routine practice.

Randomized controlled trial of harmonic scalpel use during thyroidectomy.

OBJECTIVE: To compare operative factors, postoperative outcomes, and surgical complications of thyroidectomy when using the harmonic scalpel (HS) vs conventional hemostasis (CH). DESIGN: Single-blind, randomized controlled trial. SETTING: Department of Surgery, S. Chiara Hospital, University of Pisa, Pisa, Italy. PATIENTS: One hundred patients undergoing thyroidectomy. MAIN OUTCOME MEASURES: Postoperative pain, drainage volume, hypocalcemia, nerve injury, and operative time. INTERVENTION: Patients underwent total thyroidectomy in which either the HS or CH was used. RESULTS: We found no significant differences between the HS and CH groups at baseline. Postoperative pain was reduced in the HS group at 24 hours (mean visual analog scale score, 3.90 vs 5.30; P<.001) and 36 hours (2.27 vs 3.95; P<.001). Drainage volume was significantly lower in the HS group (40.1 mL vs 75.4 mL; P<.001). Transient hypocalcemia was significantly lower in the HS group (5 patients [10%] vs 16 [32%]; P=.01). No patients experienced nerve injury or permanent hypocalcemia. Mean operative times were shorter in the HS group (40.0 vs 46.7 minutes, P<.001). CONCLUSIONS: Use of the HS may reduce postoperative pain, drainage volume, and transient hypocalcemia in patients undergoing thyroidectomy. Shorter operative times and improved outcomes might justify the cost of the HS compared with that of CH.

Incidental thyroid carcinoma in a large series of consecutive patients operated on for benign thyroid disease.

BACKGROUND: The diagnosis of incidental thyroid carcinoma (ITC) in patients operated on for a benign disease is frequent. This study aims to determine both its clinical effect and the possibility of identifying this class of patients preoperatively. METHODS: A total of 998 consecutive patients (697 women and 301 men; mean age, 49.5 years) undergoing surgery for benign thyroid pathology in a single institution were studied. The mean time between first diagnosis of thyroid disease and operation was 9.0 years (range, 0-50 years). All patients underwent at least one ultrasonography before surgery, and 678 patients underwent fine-needle aspiration cytology. Patients with undetermined cytology or follicular nodules were excluded from the study. RESULTS: Histology revealed an ITC in 104 patients (10.4%): 99 had a papillary carcinoma. Mean and median diameters of ITC were 1.4 and 0.7 cm, respectively (range, 0.1-7.5 cm). In 43 patients, the tumour size was greater than 1 cm, whereas it exceeded 2 cm in 25 patients. Tumours were multicentric in 19.8% of the patients and occurred in 8.2% of patients with nodular toxic goiter, 8.7% of patients with toxic diffuse goiter and 13.8% of patients with multinodular goiter. DISCUSSION: The results confirm the high frequency of ITC. ITC was more frequent in euthyroid patients than in thyrotoxic patients (P < 0.03). Sex, age, thyroid volume and interval between diagnosis and surgery did not significantly influence its incidence. The majority of ITC was represented by microcarcinomas, but in approximately 25% of patients, the tumour size was greater than 2 cm. The role played by FNAC in excluding malignancies proved to be fairly inconclusive.