Individualized positive end-expiratory pressure with and without recruitment maneuvers in obese patients during bariatric surgery.

This study aimed to determine whether regular recruitment maneuvers (RMs) are essential for obese patients (OPs) undergoing elective laparoscopic bariatric surgery (LBS) during intraoperative ventilation with individualized positive end-expiratory pressure (PEEP). Patients were randomly assigned to two arms: the RM + PEEP-EIT arm consisted of individualized PEEP titrated by electrical impedance tomography (EIT) with two regular RMs and the PEEP-EIT arm consisted of individualized PEEP titrated by EIT without additional RMs. For these two arms together, EIT-guided PEEP varied among individuals. The partial pressure of oxygen in arterial blood to fractional inspired oxygen (PaO2 /FiO2 ) ratio in the RM + PEEP-EIT arm was higher than that in the PEEP-EIT arm at 1 h after pneumoperitoneum (p = 0.024) and at the end of surgery (p = 0.035). There was no great difference in the PaO2 /FiO2 ratio between these two arms when measured 5 min prior to postanesthesia care unit (PACU) departure and on postoperative day 1. Compared with the PEEP-EIT arm, patients in the RM + PEEP-EIT arm had significantly higher intraoperative dynamic respiratory system compliance (p < 0.001) but consumed more vasopressors (p = 0.036). Postoperative pulmonary complications occurred in 1 of 29 patients in the RM + PEEP-EIT arm compared with 2 of 31 patients in the PEEP-EIT arm. Regular lung RMs can improve intraoperative oxygenation and respiratory system compliance among OPs undergoing LBS with EIT-guided individual PEEP. However, the improvement might disappear before leaving the PACU, and regular RMs resulted in more vasopressor consumption.

Preoperative Thyroid Autoimmune Status and Changes in Thyroid Function and Body Weight After Bariatric Surgery.

BACKGROUND: Bariatric surgery has emerged as the most effective therapy for morbid obesity. There is increasing evidence that bariatric surgery could alleviate systemic inflammation and influence thyroid function. The current study aimed to investigate the associations of preoperative thyroid autoimmune status with the changes in body weight and thyroid function after bariatric surgery. METHODS: We recruited 101 patients with morbid obesity (44 men and 57 women) who received bariatric surgery at Zhongshan Hospital, Fudan University. Those who had used thyroid hormone replacement or antithyroid drugs were excluded. General linear models were used to compare the changes in body weight and thyroid function in participants with different thyroid autoimmune statuses. RESULTS: After bariatric surgery, serum-free triiodothyronine (FT3) (4.94 ± 0.73 vs 4.33 ± 0.59 pmol/L, P < 0.001) and thyroid-stimulating hormone (TSH) (3.13 ± 1.59 vs 2.26 ± 1.26 µIU/mL, P < 0.001) were significantly reduced, accompanied by reductions in BMI (42.1 ± 7.6 vs 31.4 ± 6.5 kg/m2, P < 0.001), and estimated basal metabolic rate (2002 ± 398 vs 1700 ± 336 kcal/day, P = 0.001) and an improvement in lipid profiles. Serum thyroperoxidase antibody (TPOAb) and thyroglobulin antibody (TgAb) levels also decreased significantly from 79.3 and 177.1 IU/mL to 57.8 and 66.0 IU/mL in participants with positive thyroid antibodies (P < 0.05). Further analysis showed that the positive preoperative thyroid autoimmune status was associated with less reduction in serum TSH (0.05 ± 1.59 vs - 1.00 ± 1.43 µIU/mL, P = 0.021) and BMI (- 8.3 ± 3.6 vs - 11.0 ± 4.5 kg, P = 0.049) after bariatric surgery. CONCLUSION: Our study highlights a group of patients with morbid obesity, who have positive preoperative thyroid autoimmunity and less reduction in serum TSH levels and body weight after bariatric surgery.

Endoscopic diagnosis and treatment of calcifying fibrous tumors.

BACKGROUND/AIMS: The calcifying fibrous tumor (CFT) is classified as a benign fibrous lesion, and it is a rare pathologic entity. We evaluated the feasibility, efficacy and safety of endoscopy treatment for CFT. MATERIALS AND METHODS: We retrospectively analyzed a total of 4 gastric CFTs that were treated with ESD or EFR at the endoscopic center of Zhongshan Hospital, Fudan University, in Shanghai, between Jan 2007 and Sept 2011. We used endoscopic ultrasound (EUS) to assess whether endoscopy treatment was suitable. Tumor characteristics, complications, the en bloc resection rate, and the local recurrence rate were evaluated. RESULTS: Of the 4 patients, the median age was 55.5 years old. The mean maximum size of the lesions was 1.95±0.67 (range: 1.0-2.5). The EUS features of the lesions included a mass in the muscularis propria of the gastric wall and a heterogeneous hypoechoic (1/4) or homogeneous (3/4) hypoechoic pattern. All of the endoscopic treatments were completed successfully. The en bloc resection rate was 100%. Confirmed diagnoses were made by pathologic results. No local recurrence or complications were observed during the follow-up period (ranging from 15 to 28 months). CONCLUSION: Endoscopic treatment, especially ESD/EFR, appears to be a feasible and safe procedure for CFT with relatively few complications and low mortality.

Laparoscopic direct suture of perforation after diagnostic colonoscopy.

BACKGROUND: Increasing colonoscopy use increases the incidence of iatrogenic colon perforation. Operative management of iatrogenic colonoscopic perforation is diverse. This study retrospectively reviewed our experiences in treating diagnostic colonoscopy-associated bowel perforation by laparoscopic direct suturing. METHODS: A total of 89,014 patients underwent diagnostic colonoscopy at our institution during the past 6 years. We identified 17 iatrogenic perforations (0.019 %) that were all managed by laparoscopic direct suturing. RESULTS: Perforation patients included 11 men and 6 women (mean age 60 ± 18 years). Sixteen patients (94 %) had severe comorbidities or previous abdominal surgery. Perforations were noticed by the endoscopist during the procedure in 13 cases (76 %) while the remaining 4 cases (24 %) were diagnosed within 24 h after colonoscopy. The estimated mean longitudinal perforation length was 4.4 ± 2.1 cm. Mean operation time was 2.3 ± 0.6 h, without significant blood loss or other severe complication. The mean time to bowel function return was 3.4 ± 1.2 days, the mean time to initial oral intake was 3.9 ± 2.0 days and the mean hospitalization duration was 6.8 ± 4.2 days. CONCLUSIONS: Diagnostic colonoscopic perforation occurred in less than 2/10,000 patients when colonoscopy was performed by experienced operators in our endoscopy center. Most of the perforation patients had severe comorbidities, to which the surgeon should pay close attention during colonoscopy. Laparoscopic primary suture of colon perforations caused by diagnostic colonoscopy is a safe and feasible repair method. Further efforts will definitively assess the feasibility of routinely using laparoscopic direct suture to repair colon perforations.

The laparoscopic-endoscopic cooperative surgery for the colonic calcifying fibrous tumor: one case report.

Abstract The calcifying fibrous tumor (CFT) is classified as a benign fibrous lesion, and it is a rare pathologic entity. Local excision is the preferred therapeutic approach in treating CFTs. We present the first reported case in the literature of a CFT found in the colon, and this is the first time the way we did the laparoscopic-endoscopic cooperative surgery has been introduced.

Endoscopic resection for the treatment of duodenal Brunner's adenomas.

OBJECTIVES: Brunner's adenoma is a rare benign tumor of the duodenum. The traditional management option was close follow-up and surgical tumor resection. With the development of endoscopy devices and techniques, endoscopic resection is considered an alternative treatment option. However, whether small lesions require treatment has been controversial. We planned to study the feasibility, efficacy, and safety of endoscopic resection for the treatment of Brunner's adenomas. SUBJECTS AND METHODS: In total, 30 Brunner's adenomas from 29 patients were treated with endoscopic resection between August 2007 and June 2011 in our hospital. Endoscopic ultrasonography (EUS) was performed preoperatively to evaluate tumor origin and size. Tumor characteristics, complications, en bloc resection rate, and local recurrence rates were evaluated. RESULTS: Of the 29 patients, 13 (44.8%) were men. The median age was 55 years (range, 29-72 years). The mean maximal dimension of the lesions was 1.7±0.1 cm (range, 0.6-7 cm). Overall, 9 lesions were treated with snare resection, 12 lesions were treated with conventional endoscopic mucosal resection (EMR), and 9 lesions were treated with endoscopic submucosal dissection (ESD). Only 1 case of delayed bleeding occurred on Day 2 after EMR. The en bloc resection rate was 100% (30/30). One lesion resected by EMR exhibited indeterminate tumor margins. The overall curative resection rate was 96.7% (29/30). During the follow-up period (median time, 13 months; range, 2-39 months), 1 patient, whose tumor exhibited indeterminate margins, showed recurrence 1 year after EMR; ESD was recommended. No recurrence was observed during the subsequent follow-up period. CONCLUSIONS: Our study provides evidence of the efficacy of endoscopic resection for the localized treatment of duodenal Brunner's gland adenomas with relatively few complications and a low mortality rate.

Liver function reserve in surgical treatment of patients with portal hypertension: report of 146 cases.

OBJECTIVE: To evaluate the significance of intraoperative reassessment of liver function reserve in the selection of surgical procedures to optimize therapeutic results in the treatment of portal hypertension. METHODS: The data of 146 patients with portal hypertension treated in the past 10 years were retrospectively reviewed. Posthepatitis cirrhosis was found in 118 patients, schistosomial cirrhosis in 6, alcoholic cirrhosis in 1, mixed cirrhosis in 5, and other diseases in 16. According to Child's criteria, 45 patients were classified into class A, 92 class B, and 9 class C. At operation, 33 patients were reclassified into class A, 78 class B, and 35 class C. Disconnection procedure was performed in 89 patients (61.0%) and shunt procedure in 57 (39.0%). These operations included prophylactic operations in 27 patients (18.5%) and emergency disconnection operations in 2 (1.4%). RESULTS: One patient (0.7%) died of upper gastrointestinal bleeding during operation. Early rebleeding following operation occurred in 9 patients (6.1%) (disconnection in 5 patients and shunt in 4). Early encephalopathy after operation occurred in 2 patients (1.4%) (disconnection in 1 patient and shunt in 1). A total of 98 patients (67.6%) (disconnection in 61 patients and shunt in 37) were followed up (6 months to 9 years). Bleeding occurred again in 12 patients (12.2%) (disconnection in 9 patients and shunt in 3) 17 months after operation (4 to 41 months). Late encephalopathy occurred in 6 shunt patients at 19 months (3-40 months). The late rebleeding rates of shunt patients and disconnection patients were 8.1% (3/37 patients) and 14.9% (9/61) (P>0.05) respectively. The late encephalopathy rates of shunt patients and disconnection patients were 16.2% (6/37) and 0% (0/61) respectively (P<0.01). Eight patients (5.5%) died of upper gastrointestinal bleeding (2), hepatic failure (3), liver cancer (2), and rectal cancer (1) in the period of follow-up. CONCLUSIONS: The success and effectiveness of surgical procedures for portal hypertension are closely related to the status of patient's liver function reserve. Intra-operative reassessment of hepatic function reserve is crucial. Selection of procedures based on patient's hepatic function reserve, local anatomical conditions and surgeon's experience would optimize therapeutic results.