Comparison of gastrojejunostomy techniques and anastomotic complications: a systematic literature review.

BACKGROUND: There are several ways to perform the gastrojejunostomy (GJ) anastomosis in laparoscopic Roux-en-Y gastric bypass (LRYGB). Surgeons typically use a variation of three techniques: Hand-sewn anastomosis (HSA), Linear stapled (LS) and Circular stapled anastomosis (CSA). The purpose of this literature review is to determine which of the GJ techniques, if any, is superior and results in the least amount of postoperative complications, with a specific focus on rates of marginal ulcers, postoperative bleeding, and strictures. METHODS: PubMed, Embase, and Cochrane electronic databases were consulted for studies on LRYGB procedures utilizing a GJ anastomosis, from January 1, 2015 to December 31, 2019. Cochrane and PRISMA screening methods were used to select the studies. RESULTS: Eleven studies published between 2015 and 2019 were selected and included 135,899 patients that underwent LRYGB with a GJ anastomosis. Sample sizes ranged from 114 to 49,331 patients. Four studies reported that CSA had statistically significant higher rates of marginal ulcers when compared to HSA and LS techniques. Three studies concluded that CSA had statistically significant higher rates of postoperative bleeding when compared to HSA and LS. Five studies observed that CSA had statistically significant higher rates of strictures when compared to HSA and LS techniques. There was no consensus whether HSA or LS was superior in terms of reduced postoperative complications. CONCLUSION: This study revealed statistically significant increases in rates of postoperative bleeding, marginal ulcer, and strictures with the use of mechanical circular staplers at the GJ anastomosis in LRYGB. Based on our results, avoiding the use of mechanical circular staplers can result in fewer postoperative complications. Nevertheless, there are limitations to retrospective studies which may influence the results and therefore a randomized controlled trial directly comparing HSA, CSA, and LS should be performed to truly determine which technique is superior.

Laparoscopy in penetrating abdominal trauma is a safe and effective alternative to laparotomy.

INTRODUCTION: Diagnostic laparoscopy (DL) is an increasingly used modality when approaching penetrating abdominal trauma (PAT). Trauma surgeons can utilize this minimally invasive technique to quickly assess for injury in hemodynamically stable patients. DL with a confirmed injury can be repaired through therapeutic laparoscopy (TL) or conversion to exploratory laparotomy (EL). This study analyzes the use of laparoscopy as a first-line therapy for hemodynamically stable patients with PAT. METHODS: Data were reviewed of patients presenting with PAT between December 2006 and September 2016. A retrospective analysis was conducted to analyze demographics, baseline presentations, treatment protocols and outcomes. RESULTS: A total of 56 patients with PAT were initially treated with laparoscopy. Injuries included stab wounds (n = 48) and gunshot wounds (n = 8). Patients were divided into three groups: DL, DL to TL, and DL to EL. Ten patients (17.9%) required conversion to laparotomy (DL to EL). Of the 46 patients who did not require conversion, 33 patients (71.7%) underwent DL, while 13 patients (28.3%) required TL (DL to TL). There were no differences in postoperative complication rates between the groups (p = 0.565). The mean lengths of hospital stay for DL, DL to TL, and DL to EL were 3.1, 2.7, and 8.1 days, respectively (p = 0.038). No missed injuries or mortalities occurred in any of the groups. CONCLUSION: Laparoscopy can be utilized for hemodynamically stable patients with PAT. DL can be converted to TL in the hands of a skilled laparoscopist. In this study, we analyze the use of DL over a 10-year period in patients who presented to our level 1 trauma center with PAT. We also provide a comprehensive review of literature to create clear definitions, and to clarify a systematic stepwise approach of how to effectively perform DL and TL. This study adds to the body of literature supporting the role of laparoscopy in PAT, and advances the discussion regarding management.

Portomesenteric thrombosis after robotic sleeve gastrectomy.

Portomesenteric thrombosis is an important but rarely reported complication following bariatric surgery. It has been suggested that the incidence of portal vein thrombosis is directly related to many risk factors inherent in the bariatric population as well as factors related to local and systemic effects of laparoscopic surgery. Possible aetiologies vary from systemic inherited hypercoagulable states to a direct inflammatory reaction of portosystemic vessels. Here we present a case report of a 47-year-old obese women who underwent a robotic sleeve gastrectomy with subsequent development of a main portal vein, complete right intrahepatic portal vein and splenic vein thrombosis ultimately found to have a compound mutation of the methylenetetrahydrofolate reductase C677T and A1298C alleles.

Ruptured hepatic aneurysm as first presenting symptom of polyarteritis nodosa.

Polyarteritis nodosa (PAN) is an inflammatory vasculitis that creates regions of stenosis and aneurysm formation. The authors describe a 66-year-old female with hepatic artery rupture as the first presentation of undiagnosed PAN, presenting with abdominal pain followed by hemorrhagic shock. This aneurysm was suture ligated with a successful outcome. A mesenteric arteriogram demonstrated lesions consistent with PAN including aneurysms of the left gastric branches, right and left hepatic arteries, and beaded appearance of the iliac artery. However, she developed massive pulmonary embolism from which she did not recover after discharge. Postmortem examination confirmed left hepatic artery aneurysm rupture and changes consistent with PAN on gross anatomical examination and histology. This report provides a unique overview of the disease process through imaging, gross anatomic specimen and pathology. Life-threatening hepatic artery aneurysm rupture is an uncommon presentation of PAN which may benefit readers in creating a more robust differential diagnosis.

A unique surgical emergency: ileosigmoid knotting.

Ileosigmoid knot (ISK) is a rare cause of bowel obstruction that leads to gangrenous bowel necrosis. In this condition, the ileum and sigmoid colon wrap around each other, causing a knot and strangulation of both structures. ISK is extremely rare in North America; most cases are reported in Asia and Africa. Furthermore, ISK typically presents in adults in their fourth decade or older. Here we present the rare case of an ISK in a 14-year-old male.

Splenic abscess following laparoscopic cholecystectomy: a case report of a rare disease and a review of its management.

Splenic abscess is a rare disease that has several predisposing factors. Case reports have documented post-surgical development of splenic abscesses, most commonly after laparoscopic sleeve gastrectomy. We present the case of a 69-year-old female with gallstone pancreatitis who underwent an uncomplicated laparoscopic cholecystectomy. The hospital course was complicated by persistent postoperative leukocytosis with a CT scan demonstrating a moderate sized splenic abscess. Interventional radiology was consulted for percutaneous drainage, and the patient was subsequently discharged home in stable condition. Splenic abscess is an important entity to remember as it is associated with significant mortality. Prompt treatment is vital for improving patient survival. Image guided percutaneous interventions have been increasing used and carry numerous benefits compared to surgical approaches. However, there is a paucity of data comparing the efficacy of percutaneous and surgical therapies. Percutaneous interventions can be successfully performed when the abscess is unilocular/bilocular, has a discrete wall, has no internal septations, or has thin liquid content. Further investigation through multicenter, prospective, randomized clinical trials are needed to analyze treatment options.

Undiagnosed hypothyroidism presenting with sigmoid volvulus.

The incidence of hypothyroidism presenting with sigmoid volvulus, a phenomenon known as myxedema pseudovolvulus, is exceedingly rare. A male in his late thirties presented to our institution with a chief complaint of abdominal pain. The patient underwent CT scan, which was consistent with massive colonic dilatation with sigmoid volvulus. He was taken to the operating room for exploration and was found to have sigmoid volvulus and underwent a segmental resection. Postoperatively, the patient was newly diagnosed with severe hypothyroidism.

Effusive-constrictive tuberculous pericarditis in the setting of penetrating abdominal trauma.

Tuberculous pericarditis is rare in developed nations and is most commonly associated with effusive-constrictive pericarditis. We present the case of a 33-year-old man with a self-inflicted mid-abdominal stab wound. The patient underwent an exploratory laparotomy, revealing a grade IV pancreatic transection and injuries to the portal vein, right renal vein, inferior vena cava and the superior mesenteric vein. Repair of the vessels was performed and a pancreaticojejunostomy with a gastrojejunostomy was created for the pancreatic injury. The patient's hospital course was complicated by tuberculous effusive-constrictive pericarditis requiring emergent median sternotomy with opening of the pericardial sac and eventual expiration. The final cultures from the pericardial fluid demonstrated tuberculosis.

An uncommon case of severe accidental hypothermia in an urban setting.

Accidental hypothermia is an uncommon presentation in urban settings. Here we present a patient admitted with a core temperature of 26.6°C (80°F) and a serum potassium of 8.5 mmol/l who subsequently went into cardiac arrest. After > 90 min of active cardiopulmonary resuscitation and peak serum potassium of >12 mmol/l, the patient had a spontaneous return of circulation. The patient's hospital course was complicated by compartment syndrome of his forearm; however, he was discharged home without any lasting neurological damage.

Imp (IGF-II mRNA-binding protein) is expressed during spermatogenesis in Drosophila melanogaster.

Drosophila spermatogenesis results in the production of sixty­four ~2-mm spermatozoa from an individual founder cell. Little is known, however, about the elongation of spermatids to such an extraordinary length. In a partial screen of a GFP-tagged protein trap collection, four insertions were uncovered that exhibit expression toward the tail ends of spermatid cysts and within the apical tip of the testis, suggesting that these protein traps may represent genes involved in spermatid elongation and pre-meiotic spermatogenesis, respectively. Inverse PCR followed by cycle sequencing and BLAST revealed that all four protein traps represent insertions within Imp (IGF-IImRNA binding protein), a known translational regulator. Testis enhancer trap analysis also reveals Imp expression in the cells of the apical tip, suggesting transcription of Imp prior to the primary spermatocyte stage. Taken together, these results suggest a role for Imp in the male germline during both spermatid elongation and premeiotic spermatogenesis.