Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition.

PURPOSE: Malnutrition after mini-gastric bypass (MGB) is a rare and dreaded complication with few data available regarding its surgical management. We aim to report the feasibility, safety, and results of laparoscopic reversal of MGB to normal anatomy (RMGB) in case of severe and refractory malnutrition syndrome after intensive nutritional support (SRMS). METHODS: A 10-year retrospective chart review was performed on patients who underwent RMGB (video included) for SRMS following MGB. RESULTS: Twenty-six of 2934 patients underwent a RMGB at a mean delay of 20.9 ± 13.4 months post-MGB. At presentation, mean body mass index (BMI), excess weight loss (%EWL), and albumin serum level were 22 ± 4.4 kg/m2, 103.6 ± 22.5%, and 25.5 ± 3.6 gr/L, respectively. Seventeen (63.5%) patients had at least one severe malnutrition related complication including severe edema in 13 (50%), venous ulcers in 2 (7.7%), infectious complications in 7 (27%), deep venous thrombosis in 5 (19.2%), and motor deficit in 5 (19.2%) patients. At surgical exploration, 8 of 12 (66.5%) patients had a biliary limb longer than 200 cm and 9 (34.6%) had bile reflux symptoms. Overall morbidity was 30.8% but lower when resecting the entire previous gastrojejunostomy with creation of a new jejunojejunostomy (8.3 vs 50%, p = 0.03). After a mean follow-up of 8 ± 9.7 months, all patients experienced a complete clinical and biological regression of the SRMS after the RMGB despite a mean 13.9 kg weight regain in 16 (61.5%) patients. CONCLUSIONS: Post-MGB SRMS and its related comorbidities are rare but dreaded conditions. Although burdened by a significant postoperative morbidity and weight regain, RMGB remains an effective option to consider, when intensive nutritional support fails.

Human bite wounds: a swiss emergency department experience.

UNLABELLED:  Human bites (HB) are the third most common bite wound diagnosed in emergency departments, after dog and cat bites. Management of HB can be challenging, given the high risk of infection associated with multiorganism-rich oral flora. Recognition and early aggressive treatment are essential steps in preventing infections and other associated complications. METHODS: A retrospective, 10-year electronic chart review was performed, which identified 104 HB. Diagnosis, treatment, and outcome were noted for each case. RESULTS: Most of the patients were male, with a male:female ratio of 4:1. A majority of patients (n = 53, 51%) presented with finger and hand injuries. Only 13.8% were bitten on the head or neck, and 25% on the upper limbs. The remainder (35.2%) of patients sustained injuries to other body parts. Twelve operations were necessary and performed by plastic and hand surgeons. More than half of the patients (60.5%) received antibiotic therapy, and 84.6% of the patients had their tetanus prophylaxis administered or received a booster by the time of treatment. Only 40.4% of patients had a post-bite serology test to rule out bloodborne viral infections, none of whom tested positive. The viral status of the biter was known in two cases. CONCLUSION: The goals of HB management are to minimize infection risk and its complications, and to prevent the transmission of systemic infections, such as hepatitis B/C and HIV. Accurate documentation and a management algorithm should be instituted in emergency departments in order to achieve these goals. .

Thromboembolism, Bleeding, and Mortality Incidence of Direct Oral Anticoagulants Versus Warfarin Postbariatric Surgery.

BACKGROUND: There is no randomized controlled trial comparing direct oral anticoagulants (DOACs) and warfarin following bariatric surgery to date. The mortality, thromboembolism, and bleeding risk of DOACs in comparison with warfarin following bariatric surgery remains unclear. We aimed to provide a clinical comparison between DOACs and warfarin for these 3 prespecified outcomes. METHODS: A systematic literature search was performed on November 10, 2019, using PubMed, Embase, clinicaltrial.gov, and Cochrane databases. Studies with adult patients who were on either warfarin or DOACs following bariatric surgery and reported the incidence of thromboembolism, bleeding, or mortality were included. Pooled incidence for these prespecified outcomes and its 95% confidence interval (CI) were calculated for each drug separately using the random-effects model, along with a nonadjusted P value comparing the 2 subgroups. RESULTS: A total of 11 studies (805 patients) were included. Comparing DOACs to warfarin, the following pooled incidences were observed for mortality (DOACs: 3.0%; 95% CI 0.4%-18.6% versus warfarin: 1.5%; 95% CI 0.8%-2.9%; P value comparing the 2 subgroups = .38), thromboembolism (DOACs: 4.9%; 95% CI 1%-21.1% versus warfarin: 1.5%; 95% CI 0.8%-2.9%; P value = .18), and bleeding (DOACs: 3.9%; 95% CI 0.7%-18.2% versus warfarin: 11.3%; 95% CI 5.7%-21.4%; P value = .23). CONCLUSION: The results of our meta-analysis remain hypothesis-generating, providing rationale for future randomized controlled trial design or well-designed comparative observational studies. Currently, it does not support the change in the current recommendation from warfarin to DOACs following bariatric surgery.

MDCT for automated detection and measurement of pneumothoraces in trauma patients.

OBJECTIVE: The size of a pneumothorax is an important index to guide the emergency treatment of trauma patients--chest tube drainage. The purpose of this study was to develop and validate an automated computer-aided volumetry scheme for detection and measurement of pneumothoraces for trauma patients imaged with MDCT. MATERIALS AND METHODS: Three pigs and 68 trauma patients with at least one diagnosed occult pneumothorax (23 women and 45 men; age range, 14-89 years; mean age, 41 +/- 19 years) were selected for the development and validation of our computer-aided volumetry scheme for pneumothorax. Computer-aided volumetry of pneumothorax consisted of five automated steps: extraction of pleural region, detection of pneumothorax candidates, delineation of the detected pneumothorax candidates, reduction of false-positive findings, and report of the volumetric measurement of pneumothoraces. RESULTS: In the animal study, our computer-aided volumetry scheme yielded a mean value of 24.27 +/- 0.64 mL (SD) compared with 25 mL of air volume manually injected in each scan. The correlation coefficients were 0.999 and 0.997 for the in vivo and ex vivo comparison, respectively. In the patient study, the sensitivity of our computer-aided volumetry scheme was 100% with a false-positive rate of 0.15 per case for 32 occult pneumothoraces > or = 25 mL. The correlation coefficient was 0.999 for manual volumetry comparison. This automated computer-aided volumetry scheme took approximately 3 minutes to finish the detection and measurement per case. CONCLUSION: The results show that our computer-aided volumetry scheme provides an automated method for accurate and efficient detection and measurement of pneumothoraces in MDCT images of trauma patients.

Self-expanding hemostatic polymer for control of exsanguinating extremity bleeding.

BACKGROUND: Prehospital management of exsanguinating extremity injuries (EEI) includes direct compression or tourniquets or both. Direct compression may be ineffective in deep wounds and requires a person committed to compressing. Tourniquets may cause severe ischemic damage and may be ineffective in proximal wounds. This study aims to examine a new self-expanding hemostatic polymer (SEHP) for control of EEI. In contact with blood, the polymer absorbs the aqueous component of blood and exerts a tamponade effect by expanding against the walls of the wound cavity. METHODS: Twenty-one pigs were subjected to a validated and reproducible model of lethal proximal extremity injury by transecting soft tissues and the femoral vessels. The pigs were left to bleed uncontrollably for 3 minutes and then randomized to receive either a standard compression dressing (Control group, N = 10) or SEHP (SEHP group, N = 11). After 5 minutes of manual compression, the dressing or SEHP were left in the wound and the animals resuscitated more than 2 hours. One animal in each group died soon after the injury before application of the dressings and was removed from final analysis. RESULTS: SEHP animals had lower blood loss (1358 mL +/- 97 mL) than the Control animals (2028 mL +/- 177 mL, p = 0.006). The mortality was 55% in the Control group and 0% in the SEHP group (p = 0.006). CONCLUSION: SEHP is a novel, light, and portable material to control EEI effectively. It does not require another person for compression nor does it compromise the circulation. As EEI occurs with alarming frequency in the battlefield, SEHP may not only present an optimal hemostatic method for military applications but also be useful in the civilian prehospital setting.

Testing of blood products in a polytrauma model: results of a multi-institutional randomized preclinical trial.

INTRODUCTION: Trauma-induced coagulopathy, acidosis, and hypothermia form a "lethal triad" that is difficult to treat and is associated with extremely high mortality. This study was performed at three academic centers to evaluate whether resuscitation with blood components could reverse the coagulopathy in a complex polytrauma model. METHODS: Yorkshire swine (40 +/- 5 kg) were subjected to a three-phase protocol: (a) "Prehospital" phase = femur fracture, hemorrhage (60% blood volume), and 30 minutes shock + infusion of saline (3x shed blood) + induction of hypothermia (33 degrees C); (b) "Early hospital" phase = grade V liver injury; and (c) "Operative" phase= liver packing. After liver packing, the animals (n = 60) were randomized to the following groups: (1) Sham-instrumentation and anesthesia without hemorrhage/injuries, (2) fresh whole blood (FWB), (3) 6% hetastarch (Hextend), (4) fresh frozen plasma/packed RBCs in 1:1 ratio (1:1 FFP/PRBC), and (5) FFP alone. Treatment volumes were equal to the volume of shed blood. Hemodynamic and physiologic parameters and coagulation profile (thrombelastography, prothrombin time, activated partial thromboplastin time, international normalized ratio, and platelets) were monitored during the experiment and for 4 hours posttreatment. RESULTS: At the end of prehospital phase, animals had developed significant acidosis (lactate >5 mmol/L and base deficit >9 mmol/L) and coagulopathy. Posttreatment mortality rates were 85% and 0% for the Hextend and blood component treated groups, respectively (p < 0.05). Hemodynamic parameters and survival rates were similar in groups that were treated with blood products (FWB, FFP, and FFP:PRBC). Animals treated with FFP and Hextend had significant anemia compared with the groups that received red blood cells (FWB and FFP:PRBC). Treatment with FFP and FFP:PRBC corrected the coagulopathy as effectively as FWB, whereas Hextend treatment worsened coagulopathy. CONCLUSIONS: In this reproducible model, we have shown that trauma-associated coagulopathy is made worse by hetastarch, but it can be rapidly reversed with the administration of blood components. Impressively, infusion of FFP, even without any red blood cells, can correct the coagulopathy and result in excellent early survival.

An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study.

BACKGROUND: Efforts to determine the suitability of low-grade pancreatic injuries for nonoperative management have been hindered by the inaccuracy of older computed tomography (CT) technology for detecting pancreatic injury (PI). This retrospective, multicenter American Association for the Surgery of Trauma-sponsored trial examined the sensitivity of newer 16- and 64-multidetector CT (MDCT) for detecting PI, and sensitivity/specificity for the identification of pancreatic ductal injury (PDI). METHODS: Patients who received a preoperative 16- or 64-MDCT followed by laparotomy with a documented PI were enrolled. Preoperative MDCT scans were classified as indicating the presence (+) or absence (-) of PI and PDI. Operative notes were reviewed and all patients were confirmed as PI (+), and then classified as PDI (+) or (-). As all patients had PI, an analysis of PI specificity was not possible. PI patients formed the pool for further PDI analysis. As sensitivity and specificity data were available for PDI, multivariate logistic regression was performed for PDI patients using the presence or absence of agreement between CT and operative note findings as an independent variable. Covariates were age, gender, Injury Severity Score, mechanism of injury, presence of oral contrast, presence of other abdominal injuries, performance of the scan as part of a dedicated pancreas protocol, and image thickness < or =3 mm or > or =5 mm. RESULTS: Twenty centers enrolled 206 PI patients, including 71 PDI (+) patients. Intravenous contrast was used in 203 studies; 69 studies used presence of oral contrast. Eight-nine percent were blunt mechanisms, and 96% were able to have their duct status operatively classified as PDI (+) or (-). The sensitivity of 16-MDCT for all PI was 60.1%, whereas 64-MDCT was 47.2%. For PDI, the sensitivities of 16- and 64-MDCT were 54.0% and 52.4%, respectively, with specificities of 94.8% for 16-MDCT scanners and 90.3% for 64-MDCT scanners. Logistic regression showed that no covariates were associated with an increased likelihood of detecting PDI for either 16- or 64-MDCT scanners. The area under the curve was 0.66 for the 16-MDCT PDI analysis and 0.77 for the 64-MDCT PDI analysis. CONCLUSION: Sixteen and 64-MDCT have low sensitivity for detecting PI and PDI, while exhibiting a high specificity for PDI. Their use as decision-making tools for the nonoperative management of PI are, therefore, limited.

Abdominal insufflation decreases blood loss without worsening the inflammatory response: implications for prehospital control of internal bleeding.

Abdominal insufflation (AI) by carbon dioxide has been shown to decrease the rate of bleeding in different swine models of abdominal organ injuries. With development of appropriate tools, AI could be used to control bleeding temporarily in the prehospital setting. Concerns have been raised about the inflammatory response to AI, which could damage organs at a later stage despite initial hemostasis. We hypothesized that AI controls bleeding without inducing an unfavorable inflammatory response. An experimental splenic injury was caused in 28 Yorkshire pigs, which were randomized to: 1) standard resuscitation (n = 14) with crystalloids to a mean arterial pressure of 60 mm Hg, or 2) standard resuscitation and AI (n = 14) to an abdominal pressure of 20 cmH2O. The experiment lasted for 30 minutes, and intra-abdominal blood loss was measured. Blood serum interleukin 1beta (IL-1beta), transforming growth factor beta1, and lung tissue heat shock protein 70 gene expression were measured at 0, 15, and 30 minutes, as markers of the inflammatory response. All animals survived to the end of the experiment. Total blood loss was significantly less in the AI group compared with the other standard resuscitation animals (733 +/- 76 vs 1094 +/- 153 mL, P = 0.049). The pH at the end of the experiment was significantly lower in the AI group (7.28 +/- 0.02 vs 7.44 +/- 0.05, P < 0.01) but there was no difference in lactate levels (1.5 +/- 0.4 vs 1.7 +/- 0.3, P = 0.7). Similarly, there was no difference in IL-1beta, transforming growth factor beta1, or lung tissue heat shock protein 70 gene expression between the two groups at any time point, although there was a trend towards lower IL-1beta levels in the AI group. Our conclusion is that AI reduces blood loss from splenic injury without a measurable effect on the early inflammatory response in a clinically relevant animal model.

Surviving blood loss without fluid resuscitation.

BACKGROUND: Patients with massive blood loss often die before delivery of definitive care, especially in austere environments. Strategies that can maintain life during evacuation and transport to higher levels of care may be lifesaving. We have previously shown that administration of histone deacetylase inhibitors (HDACI) enhance gene transcription through specific modifications of DNA-associated histone proteins. Furthermore, it protects against organ damage when given before hemorrhage. The current experiment was done to test whether administration of HDACI after lethal hemorrhage, without fluid resuscitation, would improve outcome by creating a pro-survival phenotype. METHODS: Seventy-two male Wistar-Kyoto rats (n = 12 per group) were subjected to 60% blood volume loss for 1 hour (40% arterial bleed for 10 minutes and 20% venous bleed for 50 minutes). After hemorrhage, animals were randomized to receive one of two HDACI: (1) valproic acid (VPA, 300 mg/kg in 0.25 mL saline), or (2) suberoyanilide hydroxamic acid (SAHA, 7.5 mg/kg in 0.25 mL saline). Control groups included (3) no hemorrhage (Sham), (4) no resuscitation (NR), (5) 0.9% saline resuscitation, 3 times the volume of shed blood (NS), and (6) vehicle control, 0.25 mL 0.9% saline (VEH). Hemodynamic data were recorded continuously, and physiologic parameters were measured serially. Survival for 3 hours was the primary endpoint for this experiment. RESULTS: Nonresuscitated shock (NR group) was highly lethal and only 25% of the animals survived for 3 hours. Administration of HDACI after hemorrhage (without fluid resuscitation) significantly improved survival (75% and 83% in VPA and SAHA groups, respectively, p < 0.05 vs. NR). Survival was 40%, 100%, and 100% in the VEH, Sham, and NS resuscitation groups, respectively. CONCLUSIONS: This study demonstrates that post-shock administration of HDACI can significantly improve early survival in a highly lethal model of hemorrhagic shock, even in the absence of conventional fluid resuscitation. This approach may be especially relevant for austere environments where fluids are in limited supply, such as a battlefield.

Putting life on hold-for how long? Profound hypothermic cardiopulmonary bypass in a Swine model of complex vascular injuries.

BACKGROUND: Rapid induction of profound hypothermia for emergency preservation and resuscitation can improve survival from uncontrolled lethal hemorrhage in large animal models. We have previously demonstrated that profound hypothermia (10 degrees C) must be induced rapidly (2 degrees C/min) and reversed gradually (0.5 degrees C/min) for best results. However, the maximum duration of hypothermic arrest in a clinically relevant trauma model remains unknown. METHODS: Uncontrolled lethal hemorrhage was induced in 22 swine by creating an iliac artery and vein injury, followed 30 minutes later (simulating transport time) by laceration of the descending thoracic aorta. Through a thoracotomy approach, a catheter was placed in the aorta, and cold organ preservation solution was infused using a roller pump to rapidly induce profound hypothermia (10 degrees C) which was maintained with low-flow cardiopulmonary bypass. Vascular injuries were repaired during the asanguinous hypothermic low flow period. Profound hypothermia was maintained (n = 10-12 per group) for either 60 minutes or 120 minutes. After repair of injuries, animals were rewarmed (0.5 degrees C/min) and resuscitated on cardiopulmonary bypass, and whole blood was infused during this period. Animals were monitored for 4 weeks for neurologic deficits, organ dysfunction, and postoperative complications. RESULTS: The 4-week survival rates in 60- and 120-minute groups were 92% and 50%, respectively (p < 0.05). The surviving animals were neurologically intact and had no long-term organ dysfunction, except for one animal in the 120-minute group. The animals subjected to 120 minutes of hypothermia had significantly worse lactic acidosis, displayed markedly slower recovery, and had significantly higher rates of postoperative complications, including late deaths because of infections. CONCLUSION: In a model of lethal injuries, rapid induction of profound hypothermia can prevent death. Profound hypothermia decreases but does not abolish metabolism. With current methods, the upper limit of hypothermic arrest in the setting of uncontrolled hemorrhage is 60 minutes.

Development and testing of freeze-dried plasma for the treatment of trauma-associated coagulopathy.

BACKGROUND: Trauma-induced coagulopathy is associated with an extremely high mortality. We have recently shown that survival can be improved by correction of coagulopathy through early, aggressive infusion of Fresh Frozen Plasma (FFP). However, FFP is a perishable product, and its use is impractical in challenging environments such as a battlefield. Development of shelf-stable, easy to use, low volume, lyophilized, Freeze-Dried Plasma (FDP) can overcome the logistical limitations. We hereby report the development and testing of such a product. METHODS: Plasma separated from fresh porcine blood (n = 10) was either stored as FFP, or lyophilized to produce the FDP. For in vitro testing, the FDP was rehydrated with distilled water and the pH, temperature, and osmolarity were adjusted to match the thawed FFP. Laboratory analysis included measurements of prothrombin time (PT), partial thromboplastin time, fibrinogen levels, and clotting factors II, VII, and IX. To test in vivo efficacy, swine were subjected to multiple injuries (femur fracture and grade V liver injury) and severe hemorrhagic shock (60% blood loss associated with "lethal triad" of coagulopathy, acidosis, and hypothermia), and resuscitated with FFP or FDP (n = 6/group; plasma volumes equal to the volume of shed blood). No treatment, and resuscitation with fresh whole blood served as the control groups (n = 6/group). Coagulation profiles (thromboelastography, PT, partial thromboplastin time, international normalized ratio, fibrinogen) were measured serially during the experiment, and for 4 hours posttreatment. RESULTS: In vitro analysis revealed no differences in the coagulation profiles of FFP and FDP. The lyophilization process did not decrease the activity levels of the measured clotting factors. In the swine model, multiple injuries and hemorrhagic shock caused a 50% to 70% increase in PT (p = 0.03), and infusion of FDP and FFP were equally effective in correcting the coagulopathy. CONCLUSION: Plasma can be lyophilized and freeze-dried to create a logistically superior product without compromising its hemostatic properties. This product may be suitable for use in austere environments, such as a battlefield, for the treatment of trauma-associated coagulopathy.

Early discharge after nonoperative management for splenic injuries: increased patient risk caused by late failure?

BACKGROUND: With increasing experience and knowledge about nonoperative management of splenic injury (NOMSI), patients are being discharged early and possibly placed at risk for late failure of NOMSI and its associated complications. To evaluate if blunt trauma patients managed by NOMSI can be safely discharged early, because failure after the third day from injury occurs infrequently and is not associated with added morbidity. METHODS: The medical records of patients who failed NOMSI from January 1993 to December 2005 in an academic level 1 trauma center were reviewed. Patients who failed NOMSI within 3 days (early failure) were compared with patients who failed it after 3 days (late failure) to identify characteristics that may help predict late failure. Primary outcomes were complications and death related to late failure. RESULTS: Of 691 patients admitted with blunt trauma to the spleen, 499 (72%) had NOMSI and 36 (7%) failed it. Early failure was recorded in 26 patients (5%) and late failure in 10 (2%). Late bleeding was the cause of failure in all patients with late failure and occurred in 8 +/- 6 (mean +/- SD) days after admission (4-8 days in 7 patients and 12-22 days in 3). When comparing age, Injury Severity Score, hemotocrit on admission, preoperative blood transfusions, and grade of splenic injury, no differences were found between patients with early and late failure. All but 1 patient with late failure were still in the hospital for associated injuries at the time of failure. No patient died, had delayed diagnosis, or suffered added morbidity because of late failure. CONCLUSION: Late failure occurs infrequently, unpredictably, and almost always in patients who are still in the hospital for associated injuries. In-hospital observation beyond the third day after injury is not necessary for most patients with splenic injury, who have no other reason to remain hospitalized.

Abdominal insufflation for control of bleeding after severe splenic injury.

BACKGROUND: To date, there is no rapid method to control intracavitary bleeding without an operation. Over 70% of trauma deaths from uncontrollable internal bleeding occur early after injury before an operation is feasible. Abdominal insufflation (AI) by carbon dioxide has been shown to reduce the rate of bleeding after intra-abdominal injury in pigs. The concept was proven in highly lethal models of severe vascular and liver injuries. Similar injuries in humans would result in immediate exsanguination and low likelihood for any intervention. We hypothesized that AI would similarly reduce bleeding in a model of moderate but persistent bleeding from a splenic injury. This model represents a clinically relevant scenario of continuous bleeding, which does not kill the patient immediately but may ultimately result in death if not managed early. METHODS: A new model of splenic injury was applied on 19 pigs, randomized to standard resuscitation (SR, N = 10) or standard resuscitation with AI to 20 cm H2O (SRAI, N = 9). For 30 minutes, the pigs were bled and the hemodynamics recorded. At 30 minutes, the abdomen was opened and free blood was collected and measured. Outcomes were blood loss, mean arterial pressure, hemoglobin, lactate levels, and arterial blood gases at the end of the experiment. RESULTS: All pigs survived to the end of the experiment. Blood loss was lower (1,114 +/- 486 mL vs. 666 +/- 323 mL, p = 0.03) and final mean arterial pressure higher (64 +/- 12 mm Hg vs. 54 +/- 8 mm Hg, p = 0.04) in SRAI when compared with those in SR animals. Heart rate, arterial blood gases, oxygen saturation, hemoglobin, and lactate levels were similar in the two groups, except there was a more acidotic pH among SRAI animals (7.27 +/- 0.06 vs. 7.47 +/- 0.21, p = 0.02). CONCLUSIONS: AI is a novel method to control intra-abdominal bleeding temporarily. With proper portable instruments and first-responder training, this is a technique that can potentially be used in the field to save lives from intra-abdominal exsanguination.

Laparoscopic sleeve gastrectomy after failed gastric banding: is it really effective? Six years of follow-up.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a valuable surgical option to rescue laparoscopic adjustable gastric banding (LAGB) failures. OBJECTIVES: The aim of this study was to determine whether conversion to LSG after failed LAGB (CLSG) is a well-tolerated and effective rescue procedure compared with primary LSG (PLSG) in the long term. SETTING: University hospital, France. METHODS: A retrospective review of data concerning consecutive patients receiving a LSG between February 2008 and December 2014 was conducted. Mortality, postoperative complications, and weight loss outcomes were analyzed. RESULTS: Of 701 LSG, 601 (85.7%) were PLSG and 100 (14.3%) were CLSG. The mortality rate was 0%. Overall morbidity was comparable between the primary and conversion group (10% versus 6%, P = .27). The mean percentage of excess weight loss at 3, 36, and 72 months was 34.9%, 72.1%, and 57.2% after PLSG and 22.6%, 51.2% and 29.8% after CLSG (P<.05). The failure rate (mean percentage of excess weight loss<50%) was higher in the CLSG group during the first 5 postoperative years (P < .001) with more than two thirds of the CLSG considered as having failed at 60 months. Patients who underwent band ablation as a result of insufficient weight loss or weight regain presented the worst results after conversion to LSG. CONCLUSION: In this study, the conversion of failed LAGB to LSG in 2 steps indicated a safety profile comparable to that of primary LSG but was significantly less effective from the early postoperative course (3 mo) up to 6 years postoperatively. CLSG may not be the best option because a third operation may be needed as a result of insufficient weight loss.

Long-Term Outcomes of the Laparoscopic Adjustable Gastric Banding: Weight Loss and Removal Rate. A Single Center Experience on 301 Patients with a Minimum Follow-Up of 10 years.

BACKGROUND: Obesity is a chronic disease that requires procedures to enable to maintain good long-term results. Laparoscopic adjustable gastric banding (LAGB) studies with a long-term follow-up are limited and have often given conflicting results. We report our results in terms of banding life span and weight loss in a cohort of 301 patients operated on LAGB with a minimum follow-up of 10 years. METHODS: All patients who underwent LAGB at our university hospital between 1998 and 2004 were included in this study. The main outcome was band survival and complications that led to band removal, and the secondary outcome was weight loss. We present raw data and data after imputation for patients lost at follow-up. RESULTS: Most patients were women (83 %), and the mean body mass index (BMI) baseline was 45.2 ± 6.7. The pars flaccida technique was performed in 50.9 % of the patients. All patients had at least 10 years of follow-up (range 10-16 years). Data were available at 10 years for 79.7 % and at 15 years for 80.6 %. Band survival was 65.8 % at 10 years and 53.3 % at 15 years. Mean excess weight loss (EWL) at 5, 10, and 15 years was 41.4, 38.7, and 35.1 %, respectively. CONCLUSION: Despite the encouraging short-term results, LAGB shows long-term disappointing results in terms of weight loss and complication rates. The removal rate increases with time (about 3-4 % per year), and at 15 years, almost half of the bands had been removed.

Rare Neurological Complications After Sleeve Gastrectomy.

BACKGROUND: Bariatric surgery is considered to be the most effective treatment of morbid obesity and improvement of obesity-related comorbidities, such as type II diabetes. However, both peripheral and central neurological complications can occur after bariatric surgery. Such complications tend to occur more frequently after bypass surgery than after sleeve gastrectomy (SG). The objective of this study was to identify the patients that presented post-operative neurological complications after undergoing SG and describe the incidence, presentation, and management of these complications. METHODS: This was a retrospective study of 592 cases of SG performed between 2009 and 2014 with a special focus on patients who presented neurological complications. RESULTS: Of the 592 SG cases, only seven (1.18 %) patients presented neurological complications. All patients had uneventful post-operative course, but all reported feeding difficulties, accompanied by severe dysphagia, and rapid weight loss, with a mean weight loss of 35 kg (30-40 kg) 3 months after SG. All patients were readmitted owing to neurological symptoms that included paresthesia, abolition of deep tendon reflexes of the lower limbs, muscle pain, and motor and sensitive deficits in some cases. There were two cases of Wernicke's encephalopathy. All patients were treated for neuropathy secondary to vitamin B1 deficiency and had a significant improvement and/or resolution of their symptoms. CONCLUSIONS: Neurological complications after SG are rare and are often preceded by gastrointestinal symptoms, rapid weight loss, and lack of post-operative vitamin supplementation. Re-hospitalization and multidisciplinary team management are crucial to establish the diagnosis and initiate treatment.

Presentation and surgical management of leaks after mini-gastric bypass for morbid obesity.

BACKGROUND: Few data exist about the characteristics and management of enteric leaks after mini-gastric bypass (MGB). OBJECTIVES: We aimed to describe the incidence, presentation, and surgical management of enteric leaks in patients who underwent laparoscopic MGB for morbid obesity. SETTING: Private practice. METHODS: An 8-year, 9-month retrospective chart review was performed on patients who had enteric leak requiring reoperation after MGB at a single institution. RESULTS: Thirty-five of 2321 patients were included. Ninety-seven percent had symptoms. Arterial hypertension and heavy smoking were predicting factors of leaks occurrence post-MGB (P<.01). Enteric leak was diagnosed by systematic upper gastrointestinal series in 4 pts (11.4%) and by computed tomography with oral water soluble contrast in 4 of 31 pts (13%). In the other 27 patients, diagnosis of the leak was made intraoperatively. Eleven patients (32%) had leak arising from the gastric stapler line (type 1), 4 (11%) from the gastrojejunal anastomosis (type 2), and 20 (57%) from undetermined origin. The most common presentation was intra-abdominal abscess in type 1 and leaks of undetermined origin and generalized peritonitis in type 2. One third of the patients who underwent reoperation developed well-drained chronic fistula into the irrigation-drainage system, with complete healing in all patients without any further procedure. The mean hospital stay was 19 days with no mortality reported. CONCLUSION: Enteric leak leading to intra-abdominal sepsis post-MGB is rare (1.5%) An operative aggressive management based on clinical symptoms is the treatment of choice allowing no postoperative leak-related mortality and complete healing.

Inguinal Hernia Repair Using Self-adhering Sutureless Mesh: Adhesix™: A 3-Year Follow-up with Low Chronic Pain and Recurrence Rate.

To review our experience and outcomes after inguinal hernia repair using the lightweight self-adhering sutureless mesh "Adhesix™" and demonstrate the safety and efficacy of this mesh. This is a 3-year retrospective study that included 143 consecutive patients who underwent 149 inguinal hernia repairs at our department of surgery. All hernias were repaired using a modified Lichtenstein technique. Preoperative, perioperative, and postoperative data were prospectively collected. Incidence of chronic pain, postoperative complications, recurrence, and patient satisfaction were assessed three years postoperatively by conducting a telephone survey. We had 143 patients with a mean age of 58 years (17-84), who underwent 149 hernia repairs using the Adhesix™ mesh. Ninety-two per cent (131 patients) were males. Only 10 patients (7%) had a postoperative pain for more than three years. In our series, neither age nor gender was predictive of postoperative pain. Only one patient had a hematoma lasting for more than one month and only four patients (2.8%) had a recurrence of their hernia within three years of their initial surgery. Ninety per cent of the patient expressed their satisfaction when surveyed three years after their surgery. In conclusion, the use of the self-adhering sutureless mesh for inguinal hernia repair has been proving itself as effective as the traditional mesh. Adhesix™ is associated with low chronic pain rate, recurrence rate, and postoperative complications rate, and can be safely adopted as the sole technique for inguinal hernia repair.

Two-step conversion surgery after failed laparoscopic adjustable gastric banding. Comparison between laparoscopic Roux-en-Y gastric bypass and laparoscopic gastric sleeve.

BACKGROUND: Despite its worldwide popularity, laparoscopic adjustable gastric banding (LAGB) requires revisional surgery for failures or complications, in 20-60% of cases. The purpose of this study was to compare in terms of efficacy and safety, the conversion of failed LAGB to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy. (LSG). METHODS: The bariatric database of our institution was reviewed to identify patients who had undergone conversion of failed LAGB to LRYGB or to LSG, from November 2007 to June 2012. RESULTS: A total of 108 patients were included. Of these, 74 (68.5%) underwent conversion to LRYGB and 34 to LSG. All of the procedures were performed in 2-stage and laparoscopically. The mean follow-up for the LRYGB group was 29.1±17.9 months while for the LSG patients was 24.2±14.3 months. The mean body mass index (BMI) prior LRYGB and LSG was 45.6±7.8 and 47.5±5.6 (P = .09), respectively. Postoperative complications occurred in 16.2% of the LRYGB patients and in 2.9% of the LSG group (P = .04). Mean percentage of excess weight loss was 59.9%±16.2% and 70.2%±16.7% in LRYGB, and it was 52.2%±11.4% and 59.9%±14.4% in LSG at 12 months (P = .007) and 24 months (P = .01) after conversion. CONCLUSION: In this series, LRYGB and LSG are both effective and adequate revisional procedure after failure of LAGB. While LRYGB seems to ensure greater weight loss at 24 months follow-up, LSG is associated with a lower postoperative morbidity.