Controversial Role of Robot in Primary and Revisional Bariatric Surgery Procedures: Review of the Literature and Personal Experience.

Laparoscopy is the surgical standard of care for bariatric procedures; however, during the last two decades, the robotic approach has gained increasing interest. It is currently considered a safe and effective alternative to laparoscopy. This literature review investigates the role of the robotic approach for primary and revisional bariatric procedures, with the particular aim of comparing this technique with the standard-of-care laparoscopic approach. The feasibility of robotic dissection and suturing could have potential advantages: robotics may prevent the risk of leak and bleeding and other surgical complications, determining potential benefits in terms of operative time, length of hospital stay, and learning curve. Considering primary procedures, the literature reveals no advantages in robotic versus the laparoscopic approach for adjustable gastric banding and sleeve gastrectomy. Robotic Roux-en-Y gastric bypass is associated with a longer operative time and a shorter hospital length of stay than laparoscopy. The robotic approach in revisional surgery has been proven to be safe and effective. Despite the longer operative time, the robotic platform could achieve a lower bleeding rate compared with laparoscopy. The surgeon's selection criteria related to referrals to the robotic approach of difficult-perceived cases could represent a bias. In conclusion, robotic surgery can be considered a safe and effective approach in both primary and revisional bariatric surgery, despite the lack of evidence to support its routine use in primary bariatric surgery. However, in revisional bariatric surgery and in surgical complex procedures, the robotic approach could have potential benefits in terms of surgical complications and learning curves.

Atraumatic Splenic Rupture in a SARS-CoV-2 Patient: Case Report and Review of Literature.

Splenic rupture in the absence of trauma or previously diagnosed disease is rare. Due to the delay of diagnosis and treatment, this is a potentially life-threatening condition. We report a case of atraumatic splenic rupture in a SARS-CoV-2 patient. This report is of particular interest as it first identifies SARS-CoV-2 infection as a possible cause of spontaneous rupture of the spleen. A 46-year-old Caucasian woman presented at the emergency department pale and sweaty, complaining of syncopal episodes, tachycardia, hypotension, diarrhea, intense abdominal pain, diffuse arthromyalgia, and fever from the day before. RT-PCR was positive for SARS-CoV-2 infection. CT scan demonstrated extensive hemoperitoneum due to rupture of the splenic capsule. The patient required an emergency open splenectomy because of an unresponsive hemorrhagic shock. At the end of the surgery, the patient was relocated to a COVID-19 dedicated facility. COVID-19 is a new disease of which all manifestations are not yet known. Inpatients affected by SARS-CoV-2 infection with abdominal pain and spontaneous splenic rupture should be considered to avoid a delayed diagnosis.

How can lean thinking improve ERAS program in bariatric surgery?

INTRODUCTION: Enhanced recovery after bariatric surgery protocol (ERABS) decreased length of hospital stay (LOS) without influencing clinical outcomes. ERABS improved logistics aspects in operating room (OR) with OR time savings. Lean management was used to reorganize OR logistics and to improve its efficiency. This study analyzed clinical and OR logistic aspects in ERABS protocols. METHODS: Retrospective analysis of prospectively maintained database of obese patients undergoing bariatric surgery from 2017 to 2019 was performed. Since September 2018, patients were treated with ERABS protocol (ERABS group). All patients treated with a standard protocol between January 2017 and September 2018 (control group) were compared to ERABS group. Preoperative (anthropometric data, surgical and medical history) and intraoperative (type of procedure) were analyzed in two groups. LOS was the primary outcomes parameter analyzed; complications, readmissions and reoperations within 30 days were the secondary outcomes. Logistic endpoints were evaluated in time saving and efficiency: surgical time, team work time and total anesthesia time. RESULTS: 471 patients underwent bariatric surgery: 239 patients (control group) compared to 232 patients (ERABS group). ERABS presented more previous surgical history rate (p = 0.04) compared to control group with difference of type of procedure performed (p < 0.001). Roux-en-Y gastric bypass was mainly procedure in both groups (61.1% in control group compared to 52.6% in ERABS groups). Mean LOS was shorter in ERABS (3.16 days) compared to control group (4.81 days) with no difference in clinical outcomes rate. All logistics endpoints showed a time savings in ERABS group compared to control group (surgical procedure, total anesthesia and team work time, p < 0.001). In multivariate analysis, LOS was associated to ERAS status (IRR 0.722; p < 0.0001), team work time (IRR 1.002; p = 0.002), surgical procedure time (IRR 1.002; p < 0.0001). ERAS status was not associated with complication neither readmission, but surgical procedure time was a factor associated with complication (IRR 1.011; p = 0.0008). CONCLUSION: This study confirmed that ERABS protocol is safe and a feasible alternative with improved LOS. OR reorganization and logistic efficiency achieved using lean management helped reduce all OR times and these are likely related to the improvement in LOS and complication.

Telemedicine Implementation on a Bariatric Outpatient Clinic During COVID-19 Pandemic in Italy: an Unexpected Hill-Start.

BACKGROUND: SARS-CoV2 outbreak has challenged NHS of many countries. Generalized restriction of movement, together with unprecedented pressure on Health System, disrupted routine care for non-COVID-19 patients. Telemedicine has been promoted to reduce the risk of infections and to offer medical assistance to the restricted population. This paper is aimed to evaluate the impact of tele-consulting technology in a single bariatric center. MATERIALS AND METHODS: Our outpatient clinic reorganized the service from on-site to long-distance video consultations. All patients received a satisfaction questionnaire. The main goals were to evaluate patient compliance and to assess patient satisfaction. RESULTS: Of the 33 booked patients who were offered a teleconsultation, 19 (57.6%) participated in the video-call. No significant differences were found between participants and non-participants in terms of age and gender ratio. Urban area residents were 57.9% of the participants versus 42.8% of the non-participants group. Of the participants, 52.6% completed the survey reporting levels of satisfaction ranging from high to very high. CONCLUSION: Telemedicine has been advocated as a useful tool to relieve pressure on the overwhelmed Health Systems during the COVID-19 pandemic. However, e-health technologies are not yet widely adopted. Our initial experience, also compared with national data relating to the digital divide, suggests that the absence of basic computer skills and the lack of confidence with video-call systems may be patient-specific barriers for the implementation of telemedicine. In this context, telemedicine implementation can run up against various patient-related barriers, and several challenges remain for e-health to be integrated into outpatient practice.

The N-terminal Acetylation of α-Synuclein Changes the Affinity for Lipid Membranes but not the Structural Properties of the Bound State.

The aggregation of α-synuclein (αS), a protein abundant at presynaptic terminals, is associated with a range of highly debilitating neurodegenerative conditions, including Parkinson's disease (PD), dementia with Lewy bodies (DLB) and multiple system atrophy (MSA). Emerging evidence indicates that the interaction of αS with lipid membranes defines both its physiological function and pathological effects. The characterisation of the modes of membrane binding by αS is therefore crucial to clarify the balance between normal and aberrant behaviour of this protein. Here we used solid-state nuclear magnetic resonance (ssNMR) spectroscopy to probe the nature of the N-terminally acetylated form of αS (NTAc-αS) bound to synaptic-like lipid vesicles. This post-translational modification is prevalent for the physiological form of αS and modulates the binding to lipid bilayers. By probing the structure, dynamics and membrane topology of NTAc-αS, we found that N-terminal acetylation does not alter significantly the conformational and topological properties of the membrane-bound state of αS, despite increasing its propensity for binding. Taken together, our data and previous characterisations of the cytosolic state of NTAc-αS clarify that the role of the N-terminal acetylation is to regulate the binding affinity of αS for synaptic vesicles without altering the structural properties of the bound state.

Combined anterior and posterior open treatment in infected pancreatic necrosis.

OBJECTIVE: To compare the results of combined anterior and posterior open treatments (lesser sac marsupialization (LSM) + lumbostomy, LSM + L) in patients with infected pancreatic necrosis (IPN) with a previous experience of isolated LSM and with data in literature. MATERIALS AND METHODS: Thirty-four consecutive patients operated on for IPN from 1981 to 2005 were divided into two groups based on the surgical technique used: single LSM (n = 23; period A, 1981-1998) and combined LSM + L (n = 11; period B, 1999-2005). RESULTS: The postoperative mortality rate was 38.1 (n = 8) and 9% (n = 1) during period A and B, respectively. The most important cause of death was recurrent or persistent sepsis with multiple organ failure. The overall postoperative surgical morbidity was 57 (n = 13) and 27.2% (n = 3) in the two consecutive groups. CONCLUSIONS: IPN is a challenging condition associated with high mortality mainly because of a persistence of sepsis despite surgery. A comparative analysis of many proposed operative procedures is difficult because of the heterogeneity in the reported series. Open approaches seem to be more effective in controlling local infection and systemic sepsis. Combining open anterior and posterior approaches is in our experience an appropriate surgical treatment in IPN patients.

Botulinum toxin in gastric submucosa reduces stimulated HCl production in rats.

BACKGROUND: Botulinum toxin blocks acetylcholine release from nerve endings and acts as a long term, reversible inhibitor of muscle contraction as well as of salivary, sweat gland, adrenal and prostatic secretions. The aim of the present study is to investigate whether gastric submucosal injection of botulinum toxin type A reduces stimulated gastric production of HCl. METHODS: Sixty-four rats were randomized in two groups and laparotomized. One group was treated with botulinum toxin-A 10 U by multiple submucosal gastric injections, while the second group was injected with saline. Two weeks later, acid secretion was stimulated by pyloric ligation and acid output was measured. Body weight, food and water intake were also recorded daily. RESULTS: HCl production after pyloric ligation was found to be significantly lower in botulinum toxin-treated rats (657 +/- 90.25 micromol HCl vs. 1247 +/- 152. P = 0.0017). Botulinum toxin-treated rats also showed significantly lower food intake and weight gain. CONCLUSIONS: Botulinum toxin type A reduces stimulated gastric acidity. This is likely due either to inhibition of the cholinergic stimulation of gastric parietal cells, or to an action on the myenteric nervous plexuses. Reduction of growth and food intake may reflect both impaired digestion and decreased gastric motility.

Abdominal wall closure with ePTFE--Goretex Dual Mesh after detensive laparotomy for abdominal compartment syndrome.

INTRODUCTION: Detensive laparotomy is the first choice treatment for abdominal compartment syndrome (ACS). Tension free closure of the abdominal wall with the use of prosthesis is a broadly diffused technique; the polypropylene and the ePTFE (expanded polytetrafluoroethylene--Goretex Dual Mesh) are the most commonly used materials. MATERIALS AND METHODS: We report our experience on five patients affected by ACS submitted to detensive laparotomy and positioning of a wide Goretex Dual Mesh prosthesis. RESULTS: In our initial experience ACS has been treated with success through detensive laparotomy and there were no complications related to the use of Goretex. DISCUSSION: Even though limited, our initial clinical experience is favorable to the use of Goretex Dual Mesh as first choice material for reconstruction of the abdominal wall after detensive laparotomy for ACS.