Computational framework for identifying and evaluating mutagenic and xenoestrogenic potential of food additives.

Food additives are chemicals incorporated in food to enhance its flavor, color and prevent spoilage. Some of these are associated with substantial health hazards, including developmental disorders, increase cancer risk, and hormone disruption. Hence, this study aimed to comprehend the in-silico toxicology framework for evaluating mutagenic and xenoestrogenic potential of food additives and their association with breast cancer. A total of 2885 food additives were screened for toxicity based on Threshold of Toxicological Concern (TTC), mutagenicity endpoint prediction, and mutagenic structural alerts/toxicophores identification. Ten food additives were identified as having mutagenic potential based on toxicity screening. Furthermore, Protein-Protein Interaction (PPI) analysis identified ESR1, as a key hub gene in breast cancer. KEGG pathway analysis verified that ESR1 plays a significant role in breast cancer pathogenesis. Additionally, competitive interaction studies of the predicted potential mutagenic food additives with the estrogen receptor-α were evaluated at agonist and antagonist binding sites. Indole, Dichloromethane, Trichloroethylene, Quinoline, 6-methyl quinoline, Ethyl nitrite, and 4-methyl quinoline could act as agonists, and Paraldehyde, Azodicarbonamide, and 2-acetylfuranmay as antagonists. The systematic risk assessment framework reported in this study enables the exploration of mutagenic and xenoestrogenic potential associated with food additives for hazard identification and management.

Computational screening for investigating the synergistic regulatory potential of drugs and phytochemicals in combination with 2-deoxy-D-glucose against SARS-CoV-2.

COVID-19 disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was declared a global pandemic by the World Health Organization (WHO) in March 2020. Since then, the SARS-CoV-2 virus has impacted millions of lives worldwide. Various preclinical and clinical trials on the treatment of COVID-19 disease have revealed that the drugs that work in combination are more likely to reduce reinfection and multi-organ failure. Considering the combination drug therapy, herein, we performed a systematic computational study starting with the formation of sixty-two combinations of drugs and phytochemicals with 2-deoxy-D-glucose (2-DG). The top nineteen combinations resulting from Drug-Drug Interaction (DDI) analysis were selected for individual and multiple-ligand-simultaneous docking (MLSD) study with a host target Serine Protease (TMPRSS2; PDB ID: 7MEQ) and two viral targets, Main Protease (3CLpro; PDB ID: 6LU7) and Uridylate-Specific Endoribonuclease (NSP15; PDB ID: 6VWW). We found that the resulting drugs and phytochemicals in combination with 2-DG shows better binding than the individual compounds. We performed the re-docking of the top three drug combinations by utilizing the polypharmacology approach to validate the binding patterns of drug combinations with multiple targets for verifying the best drug combinatorial output obtained by blind docking. A strong binding affinity pattern was observed for 2-DG + Ruxolitinib (NIH-recommended drug), 2-DG + Telmisartan (phase 4 clinical trial drug), and 2-DG + Punicalagin (phytochemical) for all the selected targets. Additionally, we conducted multiple-ligand-simultaneous molecular dynamics (MLS-MD) simulations on the selected targets with the 2-DG + Ruxolitinib combination. The MLS-MD analysis of the drug combinations shows that stabilization of the interaction complexes could have significant inhibition potential against SARS CoV-2. This study provides an insight into developing drug combinations utilizing integrated computational approaches to uncover their potential in synergistic drug therapy. Supplementary Information: The online version contains supplementary material available at 10.1007/s11224-022-02049-0.

Are drains useful in eTEP ventral hernia repairs? An AWR surgical collaborative (AWRSC) retrospective study.

BACKGROUND: Drain practices in minimally invasive retromuscular ventral hernia repairs have largely been transferred over from open surgery without significant review. We wished to evaluate the role of drains in these repairs. METHODS: Using the Abdominal Wall Reconstruction Surgical Collaborative (AWRSC) registry, patients with ventral hernias who underwent enhanced-view totally extraperitoneal (eTEP) repairs between February 2016 and September 2019 were evaluated. Patients with contamination or active infection within the surgical field, those who underwent an emergent or hybrid repair, or received a concomitant procedure were excluded. Propensity score matching based on the defect size, previous hernia repair status, and the use of posterior component separation (PCS) was used to match patients with drains to patients without drains. We evaluated 180-day outcomes in terms of SSIs, SSOs, and recurrence. RESULTS: 308 patients met the inclusion criteria. After propensity score matching, 48 patients with drains and 72 without drains were included in the analysis cohort. Those with drains were older with a greater likelihood of an incisional hernia, but were broadly similar for other relevant demographic and hernia-related variables. While there was no difference in the incidence of SSOs and SSIs between the two groups, we report a higher risk of SSOs needing procedural intervention (SSOPI) and recurrence, with a lengthened hospital stay in the cohort that received surgical drains. CONCLUSION: The use of surgical drains in "clean" eTEP repairs of ventral hernias appears to be common, with a selection bias for more complex cases. Based on our analysis, we found the use of drains was associated with longer hospital stays. The use of drains did not change the likelihood of suffering an SSI or SSO. However, the incidence of SSOPIs was higher despite the use of drains, which raises questions about their protective role in these repairs.

ToxDP2 Database: Toxicity prediction of dietary polyphenols.

Polyphenols are bioactive substances that minimize the risk of a variety of chronic diseases. Exposure to polyphenol bioactive compounds in our diet has increased across the globe, with amplified expectations from consumers, industry, and regulators centered on the potential benefits and essential safety of these compounds. Several data resources for beneficial properties of dietary polyphenols are present; however, toxicological information remains partial. We present a dynamic web-based database to assess dietary polyphenols' safety and fulfill the toxicity data gaps in the domain of food safety. The database (ToxDP2) comprises 415 dietary polyphenolic compounds, distributed into 15 subclasses with 25,792 collected and predicted data points. This web server facilitates the exploration of polyphenols for divergent applications. The data-driven approach on the ToxDP2 provides researchers with an understanding of polyphenols structure-function-toxicity relationships beneficial for developing nutraceuticals, pharmaceuticals, herbal supplements, and formulations.

Chemical Reactivity and Skin Sensitization Studies on a Series of Chloro- and Fluoropyrroles-A Computational Approach.

Global density functional descriptors analysis on a series of chloro- and fluoropyrroles provide vital data concerning their overall biochemical activities. In this study, a comprehensive investigation is presented for a series of chloro- and fluoropyrroles using DFT-based descriptors to elucidate physicochemical properties and their relevance to reactivity, charge transfer, site selectivity, and toxicity. Electrophilicity-based charge transfer (ECT) descriptor reveals the fact that chloro- and fluoropyrroles act as electron donors during their interaction with DNA bases. The local descriptor, namely, multiphilic descriptor conveys the activeness of specific sites in chloro- and fluoropyrroles. Further, Toxicity Prediction Komputer Assisted Technology (TOPKAT) studies on carcinogenicity bioassays using four rodent models provide the interesting fact that chloro- and fluoropyrroles exhibit a strong skin sensitization effect in these species.

Integrated QSAR and Adverse Outcome Pathway Analysis of Chemicals Released on 3D Printing Using Acrylonitrile Butadiene Styrene.

Additive manufacturing commonly known as 3D printing has numerous applications in several domains including material and biomedical technologies and has emerged as a tool of capabilities by providing fast, highly customized, and cost-effective solutions. However, the impact of the printing materials and chemicals present in the printing fumes has raised concerns about their adverse potential affecting humans and the environment. Thus, it is necessary to understand the properties of the chemicals emitted during additive manufacturing for developing safe and biocompatible fibers having controlled emission of fumes including its sustainable usage. Therefore, in this study, we have developed a computational predictive risk-assessment framework on the comprehensive list of chemicals released during 3D printing using the acrylonitrile butadiene styrene (ABS) filament. Our results showed that the chemicals present in the fumes of the ABS-based fiber used in additive manufacturing have the potential to lead to various toxicity end points such as inhalation toxicity, oral toxicity, carcinogenicity, hepatotoxicity, and teratogenicity. Moreover, because of their absorption, distribution in the body, metabolism, and excretion properties, most of the chemicals exhibited a high absorption level in the intestine and the potential to cross the blood-brain barrier. Furthermore, pathway analysis revealed that signaling like alpha-adrenergic receptor signaling, heterotrimeric G-protein signaling, and Alzheimer's disease-amyloid secretase pathway are significantly overrepresented given the identified target proteins of these chemicals. These findings signify the adversities associated with 3D printing fumes and the necessity for the development of biodegradable and considerably safer fibers for 3D printing technology.

Extended View: Totally Extra Peritoneal (e-TEP) Approach for Ventral and Incisional Hernia-Early results from a single center.

BACKGROUND: Laparoscopy for ventral hernia repair is now an established technique with its proven benefits of less pain, early recovery, low-recurrence rate as compared to open repair. Several techniques have been described such as IPOM, MILOS, TES, EMILOS, SCOLA, e-TEP. e-TEP was originally conceptualized as an alternative approach to inguinal hernia in difficult cases (obese, previous scars) and for training surgery residents. Application of this approach for ventral hernia repair has recently been reported by few surgeons. We present our experience of e-TEP approach for ventral hernia from a tertiary care center in South India over one year duration. MATERIALS AND METHODS: Electronically maintained data of patients who underwent e-TEP for ventral hernia during a period of November 2017 to November 2018 was reviewed retrospectively. Their demographic data, intraoperative details, postoperative complications and follow up data for a period of 6 months was noted. RESULTS: 171 patients underwent e-TEP approach ventral hernia repair. Mean age was 49.34 ± 10.75 years with hypertension being most common comorbidity. Mean BMI was 29.2 ± 4.1 kg/m2. Mean defect area was 51.35 ± 45.09 cm2 and mean mesh size used was 397.56 ± 208.83 cm2. Fifty patients required TAR. Mean duration of surgery was 176.75 ± 62.42 min and blood loss was 78.7 ± 24.4 ml. Mean length of stay was 2.18 ± 1.27 days. Seven cases had paralytic ileus, 5 cases had surgical site infection, and 3 cases had recurrence at 6 months follow up. CONCLUSION: e-TEP is a minimally invasive approach which is safe, feasible and also avoids placement of mesh in peritoneal cavity. Since it is a relatively new approach it requires further studies for standardization of techniques, criteria for patient selection and to study long-term outcomes.

A comparative prospective study of short-term outcomes of extended view totally extraperitoneal (e-TEP) repair versus laparoscopic intraperitoneal on lay mesh (IPOM) plus repair for ventral hernia.

BACKGROUND: Currently, minimally invasive approach is preferred for the treatment of ventral hernias. After the introduction of extended view totally extraperitoneal (e-TEP) technique, there has been a constant debate over the choice of better approach. In this study, we compare the short-term outcomes of e-TEP and laparoscopic IPOM Plus repair for ventral hernias. METHODS: This is a comparative, prospective single-center study done at GEM Hospital and research center Coimbatore, India from July 2018 to July 2019. All patients who underwent elective ventral hernia surgery with defect size of 2 to 6 cm were included. Patient demographics, hernia characteristics, operative and perioperative findings, and postoperative complications were systematically recorded and analyzed. RESULTS: We evaluated 92 cases (n = 92), 46 in each group. Mean age, sex, BMI, location of hernia, primary and incisional hernia, and comorbidity were comparable in both the groups. Mean defect size for IPOM Plus and e-TEP was 4 cm and 3.89 cm, respectively. Operative time was significantly higher for e-TEP, while postoperative pain (VAS), analgesic requirement, and postoperative hospital stay were significantly less as compared to IPOM Plus. However, 2 cases (4.35%) of e-TEP had recurrence but none in IPOM Plus group. CONCLUSION: e-TEP is an evolving procedure and comparable to IPOM Plus in terms of postoperative pain, analgesic requirement, cost of mesh, and length of hospital stay. More randomized controlled and multicentric studies are required with longer follow-up to validate our findings.

Laparoscopic iliopubic tract repair for pediatric inguinal hernia has very low recurrence: an Indian experience.

Background: The aim of this study is to document results of laparoscopic iliopubic tract (IPT) repair for inguinal hernia in the pediatric age group. Methods: Hospital records of 190 children who underwent IPT repair between January 2015 and January 2020 were analyzed retrospectively for demographic details, variations between clinical, radiological and laparoscopic diagnosis, associated pathologies, operative time, hospital stay, postoperative complications and follow-up. The internal ring was narrowed by approximating IPT to conjoint tendon using 3-0 polypropylene continuous or interrupted suture. Results: In total, 238 IPT repairs were done under general anesthesia in 190 children aged between 1 and 17 years. 7.9% of children had phimosis, and three children had hydrocele. Three patients had undescended testis and another three IPT repairs were done in cases who presented with appendicitis. Contralateral patent processus vaginalis (CPPV) was detected at the time of laparoscopy in 18.3% of cases. Thus far, 166 children had been followed, and no recurrence was observed in any of these 96 of whom have completed more than 3 years after their surgery. However, two patients developed hernia on the contralateral side. Conclusions: Laparoscopy is beneficial to pick up CPPV. Laparoscopic IPT repair for pediatric inguinal hernia is reproducible and safe with the least recurrence reported thus far. However, further follow-up is needed. Moreover, development of contralateral hernia needs to be investigated.

Laparoscopic Roux-en Y duodenojejunostomy: A safe and physiological treatment for symptomatic annular pancreas in adults.

Background: Annular pancreas is a rare, congenital, rotational anomaly of pancreas, seen usually in newborns who present with features of duodenal obstruction. However, in adults, only 24% of cases are present with duodenal obstruction. Surgery remains the procedure of choice in patients in whom symptoms can be attributed to duodenal obstruction and the goal of surgery is to relieve obstruction by bypassing the annulus. Laparoscopic Roux-en Y duodenostomy (DJ) is our preferred bypass approach for this condition. Literature search revealed that very few case reports have been published about laparoscopic management of annular pancreas, especially about duodenojejunal anastomosis. We present our experience in the laparoscopic management of symptomatic annular pancreas in adults and technique of the laparoscopic Roux-en Y DJ for annular pancreas. Materials and Methods: Between 1996 and 2016, a total of six adult patients underwent laparoscopic management for symptomatic annular pancreas. The demographic, perioperative and follow-up details were documented. Results: All surgeries were successfully performed by laparoscopic approach with no conversion to open. Five cases underwent Roux-en Y DJ and one underwent gastrojejunostomy. No major perioperative events occurred. The mean length of hospital stay was 5.6 days. Five out of six patients were followed up for 24 months, and no symptom recurrence was seen. Conclusion: Laparoscopic Roux-en Y duodenojejunostomy could be used as a safe and physiological treatment for annular pancreas in adult patients and should be preferred for the treatment of duodenal obstruction due to annular pancreas.

Laparoscopic management of epidermoid cyst in an unusual location.

The pararectal space or presacral space is a potential site for various cysts and tumours because it consists of many types of embryonic tissues. Although epidermoid cyst is a well-known entity, encountering a pararectal epidermoid cyst is relatively rare. The incidence of cystic tumours in the pararectal space has been reported to be 1 in 40 000 to 63 000 patients. Most of the tumours are asymptomatic and are incidentally discovered during routine imaging studies. Herein, we report a case of pararectal epidermoid cyst in a 51-year-old woman which was managed laparoscopically in a gastroenterology institute in South India.

Laparoscopic management of solid pseudo papillary neoplasm of pancreas in tertiary care center from south India.

BACKGROUND: Solid pseudo papillary neoplasm (SPN) of the pancreas which predominantly affects young women is a relatively indolent entity with favorable prognosis. Resection through minimal access approach helps to achieve better short term benefits. The aim of this study is to describe our experience in laparoscopic management of this disease. METHODS: A retrospective review of our prospectively maintained database revealed that 17 patients with SPN were managed with surgical resection between March 2009 and October 2016. The clinical data of these patients were then analyzed. RESULTS: Among the 17 cases of SPN, 14 were females and 3 were males. The mean age at presentation was 26.1 years (11-46 years). The most common presenting symptom was an abdominal pain (n = 10; 58.8%). A tumor was incidentally detected in 5 patients. The neoplasm was localized in the pancreatic head/neck in 6 patients and in the body/tail in 11. The median diameter of the tumors was 7.5 cm (2-13 cm). Five patients underwent pancreaticoduodenectomy, 10 had distal pancreatectomy, while median pancreatectomy or enucleation was performed in one each. All the patients were offered laparoscopic surgery; one distal pancreatectomy was converted to open in view of bleeding. The median length of stay was 7 days (5-28 days). The patients were followed up for a median period of 31 months (3-62 months). CONCLUSION: SPN is a rare neoplasm with low malignant potential and has an excellent prognosis. In our experience, laparoscopic surgical resection is safe and feasible, even for larger lesions.

First Virtual Live Conference in Healthcare.

BACKGROUND: Conferences and meetings bring together thousands of doctors from diverse locations. However, the traveling, accommodation, and arrangement of venues for conferences and meetings are expensive and a lot of time needs to be devoted to these logistics. The purpose of this article was to present our own virtual live conference experience using web conferencing and to briefly outline the basics and advantages of this technology in organization of healthcare conferences. METHODS: Web conferencing technology was used to organize an international bariatric surgery conference, allowing a large number of attendees to participate and interact from wherever they were, using merely an Internet connection with a video player on their personal computers, laptops, or smartphones. RESULTS: A virtual live conference saves a lot of time and cost and simplifies the logistics needed to organize a learning conference with worldwide participation. CONCLUSION: As far as we know, this is the first report of a virtual live conference in healthcare. We see it as the future of organizing experts as well as medical teaching conferences.

Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorithm.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed 'standalone' bariatric procedure in India. Staple line gastric leaks occur infrequently but cause significant and prolonged morbidity. The aim of this retrospective study was to analyse the management of patients with a gastric leak after LSG for morbid obesity at our institution. PATIENTS AND METHODS: From February 2008 to 2014, 650 patients with different degrees of morbid obesity underwent LSG. Among these, all those diagnosed with a gastric leak were included in the study. Patients referred to our institution with gastric leak after LSG were also included. The time of presentation, site of leak, investigations performed, treatment given and time of closure of all leaks were analysed. RESULTS: Among the 650 patients who underwent LSG, 3 (0.46%) developed a gastric leak. Two patients were referred after LSG was performed at another institution. The mean age was 45.60 ± 15.43 years. Mean body mass index (BMI) was 44.79 ± 5.35. Gastric leak was diagnosed 24 h to 7 months after surgery. One was early, two were intermediate and two were late leaks. Two were type I and three were type II gastric leaks. Endoscopic oesophageal stenting was used variably before or after re-surgery. Re-surgery was performed in all and included stapled fistula excision (re-sleeve), suture repair only or with conversion to roux-en-Y gastric bypass or fistula jujenostomy. There was no mortality. CONCLUSION: Leakage closure time may be shorter with intervention than expectant management. Sequence and choice of endoscopic oesophageal stenting and/or surgical re-intervention should be individualized according to clinical presentation.

Comparison of weight loss outcomes 1 year after sleeve gastrectomy and Roux-en-Y gastric bypass in patients aged above 50 years.

INTRODUCTION: Safe, effective weight loss with resolution of comorbidities has been convincingly demonstrated with bariatric surgery in the aged obese. They, however, lose less weight than younger individuals. It is not known if degree of weight loss is influenced by the choice of bariatric procedure. The aim of this study was to compare the degree of weight loss between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients above the age of 50 years at 1 year after surgery. MATERIALS AND METHODS: A retrospective analysis was performed of all patients more than 50 years of age who underwent LSG or LRYGB between February 2012 and July 2013 with at least 1 year of follow-up. Data evaluated at 1 year included age, sex, weight, body mass index (BMI), mean operative time, percentage of weight loss and excess weight loss, resolution/remission of diabetes, morbidity and mortality. RESULTS: Of a total of 86 patients, 54 underwent LSG and 32 underwent LRYGB. The mean percentage of excess weight loss at the end of 1 year was 60.19 ± 17.45 % after LSG and 82.76 ± 34.26 % after LRYGB (P = 0.021). One patient developed a sleeve leak after LSG, and 2 developed iron deficiency anaemia after LRYGB. The remission/improvement in diabetes mellitus and biochemistry was similar. CONCLUSION: LRYGB may offer better results than LSG in terms of weight loss in patients over 50 years of age.

Laparoscopic Undo of Fundoplication with Roux-en-Y Gastric Bypass in a Morbidly Obese Patient with Prior Nissen's Fundoplication: A Video Report.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) may be a better option for morbidly obese patients with gastroesophageal reflux (GERD) for long-term reflux control. It is recommended after fundoplication if a patient is morbidly obese with GERD with failed fundoplication or if bariatric surgery is planned with a prior successful fundoplication (Kim et al., Am Surg 80(7):696-703, 2014; Kambiz Zainabadi, Surg Endosc. 22(12):2737-40, 2008). Complete takedown of the wrap to avoid stapling over the fundoplication creating an obstructed, septated pouch is needed (Kambiz Zainabadi, Surg Endosc. 22(12):2737-40, 2008). The aim of this video was to demonstrate the technical aspect of dissection and undo of Nissen's fundoplication followed by performance of a RYGB in a morbidly obese patient with GERD with prior successful Nissen's fundoplication opting for bariatric surgery after a year. METHODS: We present a case of a 50-year-old woman with a BMI of 36.14 with previous laparoscopic Nissen's fundoplication for severe GERD (controlled after surgery) and a prior laparoscopic intraperitoneal onlay mesh repair who presented for bariatric surgery 1 year after fundoplication. She was successfully treated by laparoscopic undo of the fundoplication with RYGB. RESULTS: In this multimedia high-definition video, we present step-by-step the laparoscopic undo of a Nissen's fundoplication followed by RYGB. The procedure included lysis of all adhesions between the liver and the stomach, dissection of the diaphragmatic crura, complete takedown of the wrap, repair of the hiatal hernia, creation of a gastric pouch, creation of an antecolic Roux limb, gastrojejunal anastomosis, and jejuno-jejunal anastomosis. CONCLUSION: Laparoscopic RYGB after fundoplication in morbidly obese patients with GERD is a technically difficult but feasible option.

Concomitant Bariatric Surgery with Laparoscopic Intra-peritoneal Onlay Mesh Repair for Recurrent Ventral Hernias in Morbidly Obese Patients: an Evolving Standard of Care.

BACKGROUND AND AIMS: Repair of recurrent ventral hernias (RVHs) has a high failure rate more so in the presence of obesity. The chronic increase in intra-abdominal pressure (IAP) associated with obesity might, in part, be an important implicating factor that needs to be addressed in these patients. Laparoscopic ventral hernia repair (LVHR) done with concomitant bariatric surgery in morbidly obese patients with RVHs may avoid multiple failures. We report our preliminary experience in treating RVHs in morbidly obese patients with laparoscopic intra-peritoneal onlay mesh (IPOM) repair and concomitant bariatric surgery. METHODS: A retrospective review of all patients with a RVH who underwent concomitant bariatric surgery and laparoscopic IPOM repair at our institution from 2009 to 2013 was performed. Demographic, operative, postoperative, and follow-up data were collected. RESULTS: There were 23 patients included in the study. The mean BMI was 43.24. Fifteen patients had a previous open mesh repair, and eight had a laparoscopic IPOM repair. The patients had a median of 2 previous repairs (range 1-5 repairs). A laparoscopic sleeve gastrectomy was performed in 22 patients, and a laparoscopic Roux-en-Y gastric bypass was performed in one. The mean operating time was 112 min (65-220 min). The mean hospital stay was 3.3 days (2-8 days). A seroma was noted in four patients. No mesh infection or recurrence was noted at a median follow-up of 3.3 years (9 months to 5.5 years). CONCLUSION: Laparoscopic IPOM repair done with concomitant bariatric surgery in morbidly obese patients with RVHs seems promising with a low rate of early recurrence.

Management of Type 1 Late Sleeve Leak with Gastrobronchial Fistula by Laparoscopic Suturing and Conversion to Roux-en-Y Gastric Bypass: Video Report.

BACKGROUND: Gastrobronchial fistula (GBF) is a rare but serious complication after laparoscopic sleeve gastrectomy (LSG). It commonly appears sometime after the primary LSG. (Alharbi Ann Thorac Med. 8(3):179-80, 2013; Albanopoulos et al. Surg Obes Relat Dis. 9(6):e97-9, 2013). Surgical approach is an effective treatment. (Rebibo et al. Surg Obes Relat Dis. 10(3):460-67, 2014). The aim of this video was to demonstrate the operative management of a gastrobronchial fistula after LSG by laparoscopic suturing and conversion to a Roux-en-Y gastric bypass (RYGB). METHODS: We present the case of a 53-year-old woman, with a BMI of 50.2 who presented with a left lower lobe consolidation 7 months after LSG. Imaging revealed a gastrobronchial fistula with left lower lobe consolidation and small sub-diaphragmatic collections. Endoscopy done revealed a fistulous opening beyond the oesophago-gastric junction and a trial of endoscopic stenting failed. RESULTS: In this multimedia high definition video, we present step-by-step the operative management of a late sleeve leak with gastrobronchial fistula by laparoscopic suturing and conversion to a RYGB. The procedure included mobilization of the gastric sleeve, identification and suturing of the fistulous opening, creation of a gastric pouch, creation of an ante-colic Roux limb, gastro-jejunal anastomosis and jejuno-jejunal anastomosis. Drainage of the fistula decreased with absence of a leak on imaging and pneumonia resolved in 15 days. This patient was diagnosed 7 months postoperatively with a gastric sleeve leak and the time to fistula closure from diagnosis was 2 months. CONCLUSION: GBF is a severe complication of bariatric surgery that usually presents late in the postoperative period. GBF after LSG can be treated by surgical fistula repair and conversion of the sleeve into a RYGB.

Laparoscopic central pancreatectomy: Our technique and long-term results in 14 patients.

INTRODUCTION: Conventional pancreatic resections may be unnecessary for benign tumours or for tumours of low malignant potential located in the neck and body of pancreas. Such extensive resections can place the patient at increased risk of developing postoperative exocrine and endocrine insufficiency. Central pancreatectomy is a plausible surgical option for the management of tumours located in these locations. Laparoscopic approach seems appropriate for such small tumours situated deep in the retroperitoneum. AIMS: To assess the technical feasibility, safety and long-term results of laparoscopic central pancreatectomy in patients with benign and low malignant potential tumours involving the neck and body of pancreas. SETTINGS AND DESIGN: This study was an observational study which reports a single-centre experience with laparoscopic central pancreatectomy over a 9-year period. MATERIALS AND METHODS: 14 patients underwent laparoscopic central pancreatectomy from October 2004 to September 2013. These included patients with tumours located in the neck and body of pancreas that were radiologically benign-looking tumours of less than 3 cm in size. STATISTICAL ANALYSIS USED: The statistical analysis was done using GraphPad Prism software. RESULTS: The mean age of patients was 48.93 years. The mean operative time was 239.7 min. Mean blood loss was 153.2 ml. Mean postoperative ICU stay was 1.2 days and overall mean hospital stay was 8.07 days. There were no mortalities and no major postoperative complications. Margins were negative in all cases and with a median follow-up of 44 months, there was no recurrence. CONCLUSIONS: Laparoscopic central pancreatectomy is a feasible procedure with acceptable morbidity. In the long term, there were no recurrences and pancreatic function was well preserved.

Review of various liver retraction techniques in single incision laparoscopic surgery for the exposure of hiatus.

BACKGROUND: The main aspect of concern for upper GI procedures has been the retraction of the liver especially large left lobes as commonly encountered in Bariatric surgery. Not doing so would compromise the view of the hiatus, hence theoretically reducing the quality of the surgery and increasing the possibility of complications. The aim of this study was to review the various liver retraction techniques in single incision surgery being done at our institute and analyze them. MATERIAL AND METHODS: A retrospective study of the various techniques and a subsequent analysis was made based on advantages and disadvantages of each method. Objectively a quantitative measure of hiatal exposure was done using a scoring system based on the grade of exposure after reviewing the surgical videos. From January 2011 to January 2013 total 104 patients underwent single incision surgery with the various liver retraction techniques with following grades of exposure -liver suspension tube technique with naso gastric tubing (2.11) and with corrugated drain (2.09) needlescopic method (1.2), Umbilical tape sling (1.95), crural stitch method (2.5). Needeloscopic method has the best grade of exposure and is the easiest to start with. The average time to create the liver retraction was 2.8 to 8.6 min.There was no procedure related morbidity or mortality. CONCLUSIONS: The mentioned liver retraction techniques are cost effective and easy to learn. We recommend using these techniques to have a good exposure of hiatus, without compromising the safety of surgery in single incision surgery.