Spleen-preserving distal pancreatectomy with and without splenic vessel ligation: a systematic review.

BACKGROUND: Splenic preservation during a distal pancreatectomy (SPDP) may be performed with splenic vessel ligation, known as Warshaw's Technique (WT) or splenic vessel preservation (SVP). The consensus on which approach is best is divided. A systematic review of evidence in the literature was undertaken with the aim of analysing the merits and disadvantages of both WT and SVP. METHODS: A systematic search of medical literature from 1985-2011 was undertaken to identify all comparative studies and case series on SPDP. Non-English papers, series with < 5 patients, technical reports and reviews were excluded. The remaining articles were reviewed considering the study design, surgical technique, outcomes and complications. RESULTS: In 23 relevant studies, 356 patients underwent WT and 572 underwent SVP. In WT patients, the mean operating time (160 versus 215 min, P < 0.001), mean estimated blood loss (301 versus 390 ml, P < 0.001) and length of stay (8 versus 11 days, P < 0.001) was significantly less than the SVP patients, respectively. Considering complications, splenic infarction and splenectomy occurred more frequently in WT patients (P < 0.05). DISCUSSION: WT is technically easier to perform than SVP but has a higher incidence of subsequent splenectomies. Surgeons should be able to perform both procedures and tailor the technique according to the patient.

Effect of the learning curve on survival after laparoscopic liver resection for colorectal metastases.

BACKGROUND: Laparoscopic liver resection (LLR) is a highly demanding procedure with great variability. Previously published randomized trials have proven oncological safety of laparoscopic liver resection (LLR) as compared to open surgery. However, these were started after the learning curve (LC) was established. This leaves the question of whether the LC of LLR in the early laparoscopic era has affected the survival of patients with colorectal liver metastasis (CRLM). METHODS: All consecutive LLRs performed by a single surgeon between 2000 and 2019 were retrospectively analysed. A risk-adjusted cumulative sum (RA-CUSUM) chart for conversion rate and the log regression analysis of the blood loss identified two phases in the LC. This was then applied to patients with CRLM, and the two subgroups were compared for recurrence-free (RFS) and overall survival (OS). The analysis was repeated with propensity score-matched (PSM) groups. RESULTS: A total of 286 patients were included in the LC analysis, which identified two distinct phases, the early (EP; 68 patients) and the late (LP; 218 patients) phases. The LC was applied to 192 patients with colorectal liver metastasis (EPc, 45 patients; LPc, 147 patients). For patients with CRLM, R0 resection was achieved in 93 per cent: 100 per cent in the EPc group and 90 per cent in the LPc group (P = 0.026). Median OS and RFS were 60 and 16 months, respectively. The 5-year OS and RFS were 51 per cent and 32.7 per cent, respectively. OS (hazard ratio (h.r.) 0.78, 95 per cent confidence interval (c.i.) 0.51 to 1.2; P = 0.286) and RFS (h.r. 0.94, 95 per cent c.i. 0.64 to 1.37; P = 0.760) were not compromised by the learning curve. The results were replicated after PSM. CONCLUSION: In our experience, the development of a laparoscopic liver resection programme can be achieved without adverse effects on the long-term survival of patients with CRLM.

Formalin instillation for uncontrolled radiation induced haemorrhagic proctitis.

BACKGROUND: Radiation induced haemorrhagic proctitis is a well recognized complication of pelvic radiotherapy and its treatment is quite challenging. AIM: To evaluate the efficacy of local instillation of 4% formalin in the management of uncontrolled radiation induced haemorrhagic proctitis. METHODS: This prospective study included twenty-three patients who underwent formalin instillation. We documented the control of the symptoms, assessed the outcome of the treatment, presence of complications & long term results. RESULTS: All patients were followed for a median of 13 months. In 15 patients, the bleeding stopped after a single treatment and in 6 after a second session. Only two patients required formalin instillation for the third time. During the follow-up period all patients were reviewed systemically with reference to the pretreatment complaints. No recurrent rectal bleeding occurred, bowel frequency was decreased and no further blood transfusion was required. CONCLUSION: Local instillation of 4% formalin is an effective treatment for uncontrolled radiation induced haemorrhagic proctitis.

Preoperative liver shrinking diet for bariatric surgery may impact wound healing: a randomized controlled trial.

BACKGROUND: In bariatric surgery, preoperative very low-calorie diets (VLCD) may better meet the technical demands of surgery by shrinking the liver. However, diets may affect tissue healing and influence bowel anastomosis in an as-yet-undefined manner. OBJECTIVE: This randomized controlled trial aimed to examine the effect on collagen deposition in wounds in patients on a 4-week VLCD before laparoscopic gastric bypass. SETTING: University hospital. METHODS: The trial was undertaken in patients undergoing laparoscopic Roux-en-Y gastric bypass, with a control group (n = 10) on normal diet and an intervention group (n = 10) on VLCD (800 kcal) for 4 weeks. The primary outcome measured was expression of collagen I and III in skin wounds, with biopsies taken before and after the diet and 7 days postoperatively as a surrogate of anastomotic healing. Secondary outcome measures included liver volume and fibrosis score, body composition, operating time, blood loss, hospital stay, and complications. RESULTS: Patients in both groups were similar in age, sex, body mass index (53.4 versus 52.8 kg/m2), co-morbidities, liver volume, and body composition. Expression of mature collagen type I was significantly decreased in diet patients compared with controls after 4 weeks of diet and 7 days after surgery. This was significant decrease in liver volume (23% versus 2%, P = .03) but no difference in operating times (129 versus 139 min, P = .16), blood loss, length of stay, or incidence of complications. CONCLUSIONS: Preoperative diets shrink liver volume and decrease expression of mature collagen in wounds after surgery. Whether the latter has a detrimental effect on clinical outcomes requires further evaluation.

Endobarrier as a Pre Bariatric Surgical Intervention in High-Risk Patients: a Feasibility Study.

BACKGROUND: Obesity surgery mortality risk scoring system (OS-MRS) classifies patients into high, intermediate and low risk, based on age, body mass index, sex and other comorbidities such as hypertension and history of pulmonary embolism. High-risk patients not only have a higher mortality but are more likely to develop post-operative complications necessitating intervention or prolonged hospital stay following bariatric surgery. Endoscopically placed duodenal-jejunal bypass sleeve (Endobarrier) has been designed to achieve weight loss and improve glycaemic control in morbidly obese patients with clinically proven effectiveness. The aim of this study was to assess if pre-operative insertion of endobarrier in high-risk patients can decrease morbidity and length of stay after bariatric surgery. MATERIALS AND METHODS: Between 2012 and 2014, a cohort of 11 high-risk patients had an Endobarrier inserted (E&BS group) for 1 year prior to definitive bariatric surgery. These patients were compared against a similar group undergoing primary bariatric surgery (PBS group) during same duration. The two groups were matched for age, gender, body mass index, comorbidities, surgical procedure and OS-MRS using propensity score matching. Outcome measures included operative time, morbidity, length of stay, intensive therapy unit (ITU) stay, readmission rate, percentage excess weight loss (%EWL) and percentage total weight loss (%TWL). RESULTS: Patient characteristics and OS-MRS were similar in both groups (match tolerance 0.1). There was no significant difference in total length of stay, readmission rate, %EWL and %TWL. Operative time, ITU stay, post-operative complications and severity of complications were significantly less in the E&BS group (p < 0.05) with significant likelihood of planned ITU admissions in the PBS group (p < 0.05). CONCLUSION: Endobarrier could be considered as a pre bariatric surgical intervention in high-risk patients. It may result in improved post-operative outcomes in high-risk bariatric patients.

Laparoscopy has a therapeutic role in the management of abdominal trauma: A matched-pair analysis.

INTRODUCTION: Laparoscopy is increasingly utilised as a diagnostic tool in management of abdominal trauma; however its role in therapeutic intervention remains unexplored. The aim of this study is to compare laparoscopy with laparotomy in the treatment of abdominal trauma in haemodynamically stable patients. METHODS: A review of patients undergoing surgery for abdominal trauma between January 2004-2014 identified 25 patients who underwent laparoscopy for therapeutic intervention (TL). This group was matched with 25 similar patients undergoing laparotomy (LT). Matching of the two cohorts was based on patient characteristics, severity of injuries, haemodynamic compromise and radiological findings. Peri-operative outcomes were compared. DISCUSSION: Patient characteristics were similar in TL and LT patients for age (median 33 vs. 26 years), gender distribution and clinical presentation. Injury severity score was also similar with a median of 16 in both groups (major trauma = ISS>15, normal range 0-75). Types of injuries included; hollow viscus [bowel repair = 10 (TL) vs. 16 (LT)] and solid organs [5(TL) vs. 2 (LT)]. Median operating time was similar in both groups; 105(TL) compared to 98 (LT) minutes. Post-operative complications (1 vs. 10, p = 0.02), analgesia requirements, specifically opiate use (34 vs. 136 morphine equivalents, p = 0.002) and hospital stay (4 vs. 9 days, p = 0.03) were significantly lower in the laparoscopy group. CONCLUSIONS: Abdominal trauma in haemodynamically stable patients can be managed effectively and safely with laparoscopy by experienced surgeons. Major benefits may include lower morbidity, reduced pain, and shorter length of hospital stay.

Staple Line Bleeding in Sleeve Gastrectomy-a Simple and Cost-Effective Solution.

BACKGROUND: Staple line bleeding (SLB) is a common intraoperative complication following resection in laparoscopic sleeve gastrectomy (SG). Opinion is divided on the best measure to deal with SLB which includes expensive reinforcement strategies, suturing the staple line or diathermy. Tranexemic acid is a relatively inexpensive drug known to reduce bleeding in trauma and surgery. The aim of this study was to evaluate whether intraoperative tranexemic acid reduces staple line bleeding. METHODS: In this prospective matched comparative study of SG, one cohort of patients was administered tranexemic acid (1 g) after induction and compared to a control group. The primary outcome compared the number of staple line bleeding points requiring intervention intra-operatively. Secondary outcomes included estimated blood loss and operating time. The anaesthetic and thromboprophylaxis protocols were uniform. Operative technique and stapling equipment were identical in all patients. RESULTS: Twenty-five patients were allocated to both the control and treatment arms. Patient characteristics in both groups were similar in age (median 34 vs 43 years), body mass index (median 54.7 vs 52 kg/m(2)), gender distribution (female:male = 20:5) and co-morbidities. The treatment group receiving tranexemic acid, required significantly less number of haemostatic stitches for staple line bleeding (19 vs 46, p < 0.05), incurred less intraoperative blood loss (p < 0.01) and had quicker operating times (median 66 vs 80 min, p < 0.05). There was no difference in morbidity or mortality in both groups. CONCLUSION: Intraoperative prophylactic tranexemic acid use is a simple and economical option for effectively reducing staple line bleeds leading to significant decrease in operating times.

What is the Mechanism Behind Weight Loss Maintenance with Gastric Bypass?

Obesity is an epidemic on the rise. With the failure of non-surgical strategies, bariatric surgery has emerged as the most effective therapeutic option for the treatment of severe obesity. Among various surgical options, Roux-en-Y gastric bypass (RYGB) results in sustained weight loss and profound metabolic improvements. The traditional view that gastric bypass and bariatric surgery in general works primarily through restriction/malabsorption of nutrients has become obsolete. It is now increasingly recognised that its mechanisms of action are primarily physiologic, not mechanic. In fact, clinical and translational studies over the last decade have shown that a number of gastrointestinal mechanisms, including changes in gut hormones, neural signalling, intestinal flora, bile acid and lipid metabolism can play a significant role in the effects of this procedure on energy homeostasis. The clinical efficacy and mechanisms of action of RYGB provide a compelling evidence for the role of the gastrointestinal tract in the regulation of appetite and satiety, body weight and glucose metabolism. This review discusses the physiologic changes that occur after RYGB and that contribute to its mechanisms of action.

Two hundred seventy-five single-incision laparoscopic gastric band insertions: what have we learnt?

Single-incision surgery in the morbidly obese patient has not been widely adopted, but remains a popular choice amongst patients. In the bariatric patient, it presents its own surgical challenges with hepatomegaly and increased abdominal adiposity. Here, we present our experience of 275 single-incision laparoscopic gastric bands.Between June 2009 and April 2013, 275 obese patients underwent single-incision laparoscopic adjustable gastric banding through a single incision using a multichannel single port and via a pars flaccida approach. Prospective data collection was undertaken including operating time, additional ports and additional procedures undertaken.In this series, median operative time was 60 (range 34-170) min. An additional port was placed in 15 patients (5%), including two conversions to four-port technique (0.7%). Of these patients (n = 15), the majority were male (p < 0.0001). Reasons for additional port placement included bleeding and anatomical abnormalities. Additional port placement occurred more often within the first 50 cases (5/50, 10% vs 10/225, 4%). An umbilical incision resulted in more wound-related complications than a transverse incision in the upper abdomen (p < 0.001). There were no 30-day mortality and minimal morbidity with two wound infections resulting in band removal.Single-incision laparoscopic adjustable gastric banding can be performed safely with minimal morbidity in the morbidly obese patient, and our technique has a high rate of success for all BMIs. Following 275 single-incision band insertions additional port placements were more commonly required in male patients, BMI >45 and earlier in the learning curve.

Rhabdomyolysis in bariatric surgery: a systematic review.

BACKGROUND: Rhabdomyolysis (RML) is a rare complication of bariatric surgery. A systematic review was performed to identify risk factors and patient outcomes in morbidly obese patients undergoing bariatric surgery who develop RML. METHODS: A comprehensive search was performed between January 1990 and March 2012 using relevant MeSH terms. Studies were chosen based on predefined inclusion criteria. RML was defined as a creatine kinase of more than 1,000 IU/L. The parameters assessed included patient characteristics of the RML population, type of bariatric surgery performed, operating time, complications, presentation and diagnosis of RML. RESULTS: Twenty-two studies were analysed which included 11 case reports, two case series, six prospective and three retrospective comparative studies. Overall 145 patients with RML were reported following bariatric surgery. Acute renal failure was found in 20 patients (14 %) and was significantly more likely to occur in patients with postoperative muscle pain (p < 0.05). The mortality rate after renal failure was 25 % (n = 5). In the comparative studies, 87 RML patients were compared with 325 non-RML patients. The RML patients were more likely to be male, had a greater mean body mass index (BMI) (52 vs 48 kg/m(2), p < 0.01) and underwent a longer operation (255 vs 207 min, p < 0.01) compared to non-RML patients. CONCLUSIONS: Risk factors of developing RML following bariatric surgery include male gender, elevated BMI and prolonged operating time. Patients with a biochemical diagnosis of RML and postoperative myalgia after bariatric surgery are at increased risk of developing acute renal failure and mortality. These patients must be identified and treated promptly.

Single and multiple incision laparoscopic adjustable gastric banding: a matched comparison.

BACKGROUND: Single incision laparoscopic bariatric surgery has developed over the last few years, with single incision laparoscopic adjustable gastric banding (SILS-AGB) being performed most commonly. However, there are no randomised controlled trials and few matched studies comparing SILS-AGB to conventional laparoscopic multi-port multiport adjustable gastric banding (LAGB). Our aim was to study any differences in outcome and analgesic requirements between two matched groups of gastric band patients (SILS-AGB and LAGB). METHODS: Between June 2009 and September 2010, 111 patients underwent SILS-AGB and 99 patients underwent LAGB performed by a single surgeon (AGP). Patients were matched for age, sex, weight, BMI and co-morbidities. Forty six SILS-AGB and LAGB patients were included for analysis. Their outcomes were compared for operating times, conversions, analgesia requirements, morbidity and mortality. RESULTS: Patients characteristics between the SILS-AGB and LAGB groups were similar with no differences in their median age (44 vs 47 years), sex (m:f; 7:39 vs 4:42), body mass index (43.1 vs 44.4 kg/m(2)) or co morbidities respectively. In the SILS-AGB group the median operating time (70 min) was not significantly longer than in LAGB group (61.5 min, p = 0.07). However, SILS-AGB patients used less opiates (p < 0.01) than the LAGB patients. There was no difference in morbidity, mortality or readmission rates. CONCLUSION: SILS-AGB is a safe and feasible option and is comparable with LAGB. Post operative demand for analgesia was significantly less in the SILS-AGB group. Further comparisons of post operative pain and long term outcomes are required; however preliminary results are promising.

Enormous disfiguring thyroid swelling.

A 35 year old woman presented to us with a huge thyroid swelling (17 × 11 × 14 cm) in front of her neck which she had for the last 10 years. She was not toxic or dyspnoeic. It was multinodular with areas of firmness and cystic feeling. She had some degree of tracheal compression but no intra thoracic extension as confirmed by a CT scan of the neck. Endotracheal intubaton was done and she was operated on using a long transverse incision with division of the strap muscles for better exposure. She did not need a tracheostomy and the post operative period was uneventful. The histopathological revealed a goitre.

Roundworm in a chest drain.

A 19 year old man who suffered a stab injury in the epigastric region and had a chest drain was referred to our accident and emergency department. A chest x-ray showed left sided opacities with fundic gas in the region of the left hemithorax.A roundworm was seen in the chest tube. An exploratory laparotomy revealed a diaphragmatic tear with a laceration of the anterior wall of the stomach from which multiple roundworms were coming out and had entered the pleural cavity and then the chest drain. The tears were repaired and abdomen closed. The patient is doing well.

Concomitant tuberculosis and carcinoma colon: coincidence or causal nexus?

Two rare cases of adenocarcinoma of the caecum and ascending colon concomitant with tuberculosis at the same site are reported. The plausibility of an aetiological relationship between the two pathological conditions has been discussed along with a review of the relevant literature. Tuberculosis complicating malignant disease is a diagnostic and therapeutic challenge; and the likelihood of the two occurring together should be kept in mind especially in tuberculosis endemic areas and in patients with equivocal symptoms.

Episiotomy endometrioma masquerading as peri-anal sepsis: surgeons beware!

A 34-year-old woman with peri-anal pain and swelling was operated in the emergency setting assuming a diagnosis of a perianal abscess. No pus was revealed. Later magnetic resonance imaging (MRI) suggested induration and a mass effect in the peri-anal region. Examination under anaesthesia was repeated which revealed a mobile but firm mass. Histology from trucut biopsies diagnosed it as a peri-anal endometrioma arising from an episiotomy scar. Peri-anal endometrioma can rarely developin episiotomy scars and can be easily mistaken as an abscess by junior surgeons.

Partial fistulotomy and multiple setons in high anal fistulae.

Setons are employed in high perianal fistulae. Our study aimed to use multiple setons in addition to a partial fistulotomy in high perianal fistulae involving the sphincter complex to combine the effects of cutting and drainage of the fistulous tract. This prospective study included 16 patients over a period of 4 years who presented with high perianal fistulae. The internal opening was identified and tract laid open till the dentate line. Four prolene threads were passed along the remainder of the tract and taken out through the external opening. One was tied tightly while the others were tightened every 7 days. No patients developed major faecal incontinence. Fistula recurred in one patient within a year and one patient had occasional incontinence to flatus. Multiple setons after partial fistulotomy is an effective treatment for high anal fistulae with low incidence of incontinence and recurrence and adequate patient satisfaction.