Bariatric surgery: blessing or sometimes curse for the liver?

INTRODUCTION: Nowadays morbid obesity has become a worldwide health issue and the use of bariatric surgery undoubtedly results not only in weight reduction but also in the improvement of comorbidities. Although bariatric surgery is the optimal choice for metabolic syndrome resolution and hepatic function improvement, there is evidence that in rare cases it may lead to aggressive steatohepatitis, acute liver failure, fibrosis, and deterioration of the overall prognosis, without having fully understood the underlying pathophysiological mechanisms. CASE REPORT: In this case report we present a 45-year-old female patient with morbid obesity, body mass index 80, who underwent long-limb Roux en Y gastric bypass (LL-RYGB) and was admitted to the emergency department with jaundice and impaired liver function laboratory tests on postoperative day 90. The examinations revealed elevated bilirubin and transaminases, with prolonged prothrombin time and low albumin levels. A liver biopsy was performed and showed active steatohepatitis. The hepatic values were gradually further impaired and the decision for surgery, in order to reverse the hepatic dysfunction, was taken. A gastrostomy in the bypassed stomach was performed and the activation of the closed biliopancreatic loop led to clinical improvement and amelioration of the prognosis. CONCLUSIONS: Patients at high risk for hepatic failure after bariatric surgery should be better evaluated preoperatively and a tailor-made approach should be applied in order to avoid such a disastrous complication.

Comparison of intra-abdominal abscess formation after laparoscopic and open appendectomy for complicated and uncomplicated appendicitis: a retrospective study.

INTRODUCTION: Acute appendicitis (AA) is one of the most common causes of acute abdominal pain seen in emergency departments and appendectomy has been the preferred treatment of this disease for decades. Postoperative intra-abdominal abscess (PIAA) complicates 3% to 25% of appendectomies and the risk is highest following complicated appendicitis. However, the risk for intra-abdominal abscess formation after appendectomy is still a matter of debate. AIM: To evaluate PIAA formation after open appendectomy (OA) and laparoscopic appendectomy (LA), in particular in complicated appendicitis. MATERIAL AND METHODS: From January 2003 to December 2018, records of patients who underwent appendectomy with diagnosis of appendicitis were retrieved from a computer database for analysis. RESULTS: During the study period, 1809 appendectomies were performed in our institution (939 LAs and 850 OAs). Twenty conversion cases were recorded. There was no difference between the incidences of PIAA (LA, 3.73% (35/939) and OA, 3.41% (29/850); p > 0.05). The incidence of PIAA in those with complicated appendicitis was: LA, 11/212 (5.19%) vs. OA 14/198 (7.07%); p > 0.05. CONCLUSIONS: This retrospective study shows that the technique of appendectomy does not appear to affect the incidence of IAAs either in uncomplicated or in complicated appendicitis. However, laparoscopic appendectomy has the advantages of laparoscopic procedures, such as lower hospital stay and earlier return to activities, and should therefore be preferred for acute appendicitis.

Laparoscopic removal of a fishbone migrating from the gastrointestinal tract to the pancreas.

Laparoscopic surgery can be performed safely for the removal of a foreign body embedded in the pancreas and should be preferred instead of open surgery, whenever possible.

Outcomes of percutaneous cholecystostomy in elderly patients: a systematic review and meta-analysis.

INTRODUCTION: Percutaneous cholecystostomy (PC) represents a management option to control sepsis in patients with acute cholecystitis, who are unable to tolerate surgery. AIM: This review aimed to evaluate the outcomes of elderly patients treated with PC and compare it with emergent cholecystectomy. MATERIAL AND METHODS: An electronic search of the Embase, Medline Web of Science, and Cochrane databases was performed. Percutaneous cholecystostomy was used as the reference group, and weighted mean differences (WMD) were calculated for the effect of PC on continuous variables, and pooled odds ratios (POR) were calculated for discrete variables. RESULTS: There were 20 trials included in this review. Utilisation of PC was associated with significantly increased mortality (POR = 4.85; 95% CI: 1.02-7.30; p = 0.0001) and increased re-admission rates (POR = 2.95; 95% CI: 2.21-3.87; p < 0.0001). CONCLUSIONS: This pooled analysis established that patients treated with PC appear to have increased mortality and readmission rates relative to those managed with cholecystectomy.

Angiographic assessment of pial collaterals as a prognostic indicator following intra-arterial thrombolysis for acute ischemic stroke.

BACKGROUND AND PURPOSE: This study examines whether anatomic extent of pial collateral formation documented on angiography during acute thromboembolic stroke predicts clinical outcome and infarct volume following intra-arterial thrombolysis, compared with other predictive factors. METHODS: Angiograms, CT scans, and clinical information were retrospectively reviewed in 65 consecutive patients who underwent thrombolysis for acute ischemic stroke. Clinical data included age, sex, time to treatment, National Institutes of Health Stroke Scale (NIHSS) score on presentation of symptoms, NIHSS score at the time of hospital discharge, and modified Rankin scale score at time of hospital discharge. Site of occlusion, scoring of anatomic extent of pial collaterals before thrombolysis, and recanalization (complete, partial, or no recanalization) were determined on angiography. Infarct volume was measured on CT scans performed 24-48 hours after treatment. RESULTS: Fifty-three patients (82%) qualified for review. Both infarct volume and discharge modified Rankin scale scores were significantly lower for patients with better pial collateral scores than those with worse pial collateral scores, regardless of whether they had complete (P < .0001) or partial (P = .0095) recanalization. Adjusting for other factors, regression analysis models indicate that the infarct volume was significantly larger (P < .0001) and modified discharge Rankin scale score and discharge NIHSS score significantly higher for patients with worse pial collateral scores. Similarly, adjusting for other factors, the infarct volume was significantly lower (P = .0006) for patients with complete recanalization than patients with partial or no recanalization. CONCLUSIONS: Evaluation of pial collateral formation before thrombolytic treatment can predict infarct volume and clinical outcome for patients with acute stroke undergoing thrombolysis independent of other predictive factors. Thrombolytic treatment appears to have a greater clinical impact in those patients with better pial collateral formation.

Intra-arterial thrombolysis within three hours of stroke onset in middle cerebral artery strokes.

BACKGROUND AND PURPOSE: The Prolyse in Acute Cerebral Thromboembolism II (PROACT II) trial showed improved outcomes in patients with proximal middle cerebral artery (MCA) occlusions treated with intra-arterial (IA) thrombolysis within 6 h of stroke onset. We analyzed outcomes of patients with proximal MCA occlusions treated within 3 h of stroke onset in order to determine the influence of time-to-treatment on clinical and angiographic outcomes in patients receiving IA thrombolysis. METHODS: Thirty-five patients from three academic institutions with angiographically demonstrated proximal MCA occlusions were treated with IA thrombolytics within 3 h of stroke onset. Outcome measures included outcomes at 30-90 day follow-up, recanalization rates, incidence of symptomatic intracranial hemorrhage, and mortality in the first 90 days. The endpoints were compared to the IA treated and control groups of the PROACT II trial. RESULTS: The median admission National Institutes of Health Stroke Scale (NIHSS) score was 16 (range 4-24). The mean time to initiation of treatment was 106 min (range 10-180 min). Sixty-six percent of patients treated, had a modified Rankin Scale (mRS) score of 2 or less at 1-3 month follow-up compared to 40% in the PROACT II trial. The recanalization rate was 77% (versus 66% in PROACT II). The symptomatic intracranial hemorrhage rate was 11% (versus 10% in PROACT II) and the mortality rate was 23% (versus 25% in PROACT II). CONCLUSION: Time-to-treatment is just as important in IA thrombolysis as it is in IV thrombolysis, both for improving clinical outcomes and recanalization rates as well.