Single anastomosis sleeve ileal (SASI) bypass versus sleeve gastrectomy: a case-matched multicenter study.

BACKGROUND: The present study aimed to compare the outcome of single anastomosis sleeve ileal (SASI) bypass and sleeve gastrectomy (SG) in regards weight loss, improvement in comorbidities at 12 months of follow-up, and postoperative complications. METHODS: This was a case-matched, multicenter analysis of the outcome of patients who underwent SG or SASI bypass. Patients who underwent SASI bypass were matched with an equal number of patients who underwent SG in terms of age, sex, BMI, and comorbidities. The main outcome measures were excess weight loss (EWL) at 6 and 12 months after surgery, improvement in medical comorbidities, and complications. RESULTS: A total of 116 patients (97 female) of a mean age of 35.8 years were included. Fifty-eight patients underwent SASI bypass and an equal number underwent SG. %EWL at 6 months postoperatively was similar between the two groups. SASI bypass conferred significantly higher %EWL at 12 months than SG (72.6 Vs 60.4, p < 0.0001). Improvement in type 2 diabetes mellitus (T2DM) and gastroesophageal reflux disease (GERD) after SASI bypass was better than SG (95.8% Vs 70% and 85.7% Vs 18.2%, respectively). SASI bypass required longer operation time than SG (108.7 Vs 92.8 min, p < 0.0001). Complications occurred in 12 (20.7%) patients after SG and 4 (6.9%) patients after SASI bypass (p = 0.056). CONCLUSION: The %EWL at 12 months after SASI bypass was significantly higher than after SG. SASI bypass conferred better improvement in T2DM and GERD than SG. Both procedures had similar weight loss at 6 months postoperatively and comparable complication rates.

Oncologic safety and bowel function after ultralow anterior resection with or without intersphincteric resection for low lying rectal cancer: Comparative cross sectional study.

BACKGROUND: Despite acceptable oncologic outcomes of sphincter preserving surgeries for low rectal cancer, bowel dysfunction occurs. This study aimed to compare the oncologic and functional bowel outcomes between ultralow anterior resection (ULAR) and intersphincteric resection (ISR) for low rectal cancer. METHODS: One hundred sixty-four patients who underwent ULAR with or without ISR for low rectal cancer between December 2010 and May 2018 were included. The Wexner and Memorial Sloan Kettering Cancer Center (MSKCC) scores were used to evaluate the bowel function of patients. Overall survival (OS) and disease-free survival (DFS) were compared between patients. RESULTS: The ISR group had higher incidence of major fecal incontinence than the ULAR group (75.9% vs 49.3%; P = .016). The median Wexner score decreased from 12 to 9 (P = .062) at 1-year follow-up. However, the frequency and urgency/soilage subscales of MSKCC score improved significantly in the ULAR group. ISR and follow-up interval less than 1-year significantly increased the major incontinence risk. The OS in the ULAR and ISR groups was 91.4% and 91.7%. Whereas the DFS in both groups was 79% and 79.2%, respectively. CONCLUSION: ULAR and ISR are comparable in oncologic outcomes. Severe bowel dysfunctions and major incontinence were noted in ISR group. Careful selection of patients is mandatory.

Assessment of the Correlation Between Preoperative and Immediate Postoperative Gastric Volume and Weight Loss After Sleeve Gastrectomy Using Computed Tomography Volumetry.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has achieved excellent results in treatment of morbid obesity. The present study aimed to evaluate the impact of the preoperative gastric volume, volume of the remaining gastric pouch, and volume of the resected stomach on weight loss after LSG. METHODS: Patients with morbid obesity who underwent LSG were investigated by CT volumetry before and 1 week after LSG to measure the volume of the stomach before and after the procedure, and the volume of the resected stomach was also calculated. The percentage of excess weight loss (EWL) and decrease in body mass index (BMI) at 6 months postoperatively were measured and correlated with preoperative and postoperative gastric volumes. RESULTS: Forty-seven patients (44 females) were included to the study. A significant decrease in the gastric volume and BMI after LSG was noted. Preoperative gastric volume was positively correlated with preoperative BMI (r = 0.723, p < 0.00001) but not correlated with %EWL at 6 months. The volume of the remaining gastric pouch was positively correlated with BMI at 6 months postoperatively (r = 0.597, p < 0.00001) and negatively correlated with %EWL (r = -0.7495, p < 0.00001). The correlation between the size of resected stomach and %EWL was statistically insignificant, yet the mean percentage of the resected stomach was directly correlated to %EWL. CONCLUSION: The preoperative volume of the stomach was positively correlated with baseline BMI, but not correlated with %EWL. The size of the remaining gastric pouch and the percentage of the resected stomach had significant impact on %EWL after LSG.

Posterolateral versus lateral internal anal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial.

BACKGROUND: Lateral internal anal sphincterotomy (LIS) is considered the treatment of choice for chronic anal fissure. This study aimed to compare the outcome of standard LIS and posterolateral internal sphincterotomy (PLIS) at 5 o'clock position as regards healing of anal fissure, improvement in symptoms, and complications. METHODS: Patients with chronic anal fissure were randomly allocated to one of two groups; group I underwent PLIS and group II underwent LIS. Patients were compared regarding the duration of healing of anal fissure, improvement in anal pain as recorded by visual analogue scale (VAS), complications, particularly fecal incontinence (FI) and changes in the anal pressures. RESULTS: Eighty (49 females) patients were included to this trial. The mean age of patients was 35.5 years. The duration of healing was significantly shorter in group I than in group II (4.1 ± 1.7 vs 5.8 ± 1.4 weeks; p < 0.0001). Group I achieved significantly lower pain score at 1 month postoperatively than group II (1.1 ± 0.9 vs 1.7 ± 0.98; p = 0.005). Two (2.5%) of group I patients and six (10%) of group II patients experienced minor FI postoperatively. The postoperative reduction in the mean resting anal pressure in group I was significantly higher than that in group II. CONCLUSION: Time to complete healing was significantly shorter and pain score was significantly lower after PLIS than after LIS which can be due to more reduction in the resting anal pressure after PLIS. Continence disturbances occurred after PLIS less frequently than after LIS; however, no significant differences between the two techniques were noted. TRIAL REGISTRATION: www.clinicaltrials.gov NCT03426449.

Novel Approach of Treatment of Pilonidal Sinus Disease With Thrombin Gelatin Matrix as a Sealant.

BACKGROUND: Sacrococcygeal pilonidal sinus disease is a condition caused by insertion of fallen hair shafts into the skin. Different types of operations have been described for the management of pilonidal sinus, yet none of them have proven to be superior to the others. Recently, sealants like fibrin glue have been successfully used. OBJECTIVE: This study aimed to assess the efficacy of thrombin gelatin matrix as a new sealant for pilonidal sinus treatment. DESIGN: This was a prospective study conducted from March 2013 to March 2015. SETTINGS: The study was conducted in private hospitals in Mansoura City. PATIENTS: The study included 36 male patients (72%) and 14 female patients (28%), with a median age of 22 years. INTERVENTIONS: Fifty patients with pilonidal sinus were admitted and treated with thrombin gelatin matrix injection. MAIN OUTCOME MEASURES: Incidence and time of pilonidal sinus recurrence, postoperative pain and complications, duration of hospital stay, healing status, and time to return to work were recorded. RESULTS: The median duration of symptoms was 13 months, median operative time was 18 minutes, and median hospital stay was 6 hours. All of the procedures were conducted as day-case surgeries. Median follow-up duration was 24 months. Three patients (6%) had a breakdown of the sealant, and the wound was managed with daily dressings. Recurrence at 1 year was observed in 2 patients (4%). A total of 96% of patients were satisfied with the outcome of the procedure, and 92% of patients resumed their daily activities within 3 days. LIMITATIONS: Follow-up for a longer duration is required to ascertain the efficacy of this new technique. The cost of this treatment might be challenging for resource-limited communities. CONCLUSIONS: Management of pilonidal sinus using thrombin gelatin matrix, despite being expensive, is an effective, simple treatment that is easy to perform and associated with low recurrence rate, minimal morbidity, and rapid recovery.

Impact of preoperative body mass index on the final outcome after laparoscopic sleeve gastrectomy for morbid obesity.

OBJECTIVE: Laparoscopic sleeve gastrectomy (LSG) is a popular bariatric surgery due to its excellent results and limited morbidity. Our study aims to assess the efficacy of LSG in terms of loss of weight and co-morbidity improvement and to evaluate the impact of preoperative body mass index (BMI) on the final outcome. MATERIAL AND METHODS: The data of 173 patients who underwent LSG were analyzed. Laparoscopic sleeve gastrectomy was indicated only for patients with BMI >40. Mean postoperative BMI, co-morbidity improvement, operative data and complications, length of hospital stay and excess weight loss were evaluated and recorded. RESULTS: This study included 151 females and 22 males with a mean age of 37.6 years. Patients were divided into two groups according to their BMI (group I <50, group II >50). Mean preoperative BMI was 53.8 kg/m2. Mean operative time was 120 minutes. Mean duration of hospital stay was 3.2 days. Mean postoperative BMI decreased to 47.3 kg/m2 at 1 year. Excess weight loss was 43.1% at 6 months, 71.1% at 1 year, and 87.5% at 5 years. Group I showed a significantly shorter length of hospital stay, more improvement of laboratory parameters and more reduction in BMI as compared to group II. There was one mortality and six cases had gastric staple line leakage. CONCLUSION: Laparoscopic sleeve gastrectomy is an efficient treatment to achieve significant weight loss that is maintained up to 5 years of follow up, also it improves some of the obesity related co-morbidities. This beneficial impact of LSG appears to be significantly higher in patients with BMI <50.

Effects of ovarian failure on submucosal collagen and blood vessels of the anal canal in postmenopausal women.

BACKGROUND: Estrogen and progesterone receptors are expressed in the anal canal. Fecal control deteriorates after menopause. This phenomenon is related to decreased circulating levels of estrogen and progesterone due to ovarian failure at menopause. AIM OF WORK: To study the effects of estrogen and progesterone on inflammatory cells, submucosal collagen fibers, and vascular plexus of the anal canal of postmenopausal women. SUBJECTS AND METHODS: Experiments were performed on samples of anorectal tissue obtained from 40 women, 19 menstruating (group I), and 21 postmenopausal women (group II). Investigations included immunohistochemistry of estrogen and progesterone receptors and CD34. RESULTS: In negative estrogen receptors (ER) and progesterone receptors (PR), inflammatory cells, submucosal blood vessels, collagen type I were nonsignificantly changed in postmenopausal women relative to menstruating women (P > 0.05) whereas, in positive ER and PR, inflammatory cells and collagen I were significantly increased and submucosal blood vessels were significantly decreased in postmenopausal women relative to menstruating women (P < 0.05). CONCLUSION: Estrogen and progesterone, in menstruating women, produce beneficial effects by decreasing incidence of inflammation and increasing anal canal submucosal blood vessels number and collagen types I, thus both hormones have a positive effect on anal compliance and pressure.

Short-term Outcome of Single-Anastomosis Plication Ileal Bypass (SAPI) in Treatment of Morbid Obesity.

PURPOSE: This prospective study aimed to report the short-term outcome of the single-anastomosis plication ileal (SAPI) bypass in the treatment of morbid obesity. METHODS: Adult patients with morbid obesity who underwent SAPI procedure were recruited to this prospective study. SAPI procedure involved plication of the greater curvature of the stomach in two rows then performing a stapled side-to-side anastomosis between an ileal loop and the gastric antrum. Body mass index (BMI), percentage excess weight loss (%EWL), percentage total weight loss (%TWL), and improvement in comorbidities were recorded at 6 and 12 months postoperatively. RESULTS: The present study included 56 patients (48 female) of a mean age of 37.3 years. There was a significant decrease in BMI at 6 months (37.2 ± 9.3) and 12 months (31.5 ± 7.8) as compared with the baseline BMI (47.9 ± 5.7). The %EWL at 12 months was 72.5 ± 16.2, significantly higher than its value at 6 months (50.1 ± 15.6). The %TWL at 12 months was 36.4 ± 6.4, significantly higher than its value at 6 months (24.9 ± 6.3). All patients with DM showed remission or improvement in their diabetic state. Improvement in hyperlipidemia and hypertension was recorded in 81.8% and 77.8% of patients, respectively. Postoperative complications were recorded in five (8.9%) patients. CONCLUSION: SAPI procedure achieved significant reduction in body weight and BMI, significant %EWL, and satisfactory improvement in comorbidities at 12 months after surgery. Longer follow-up of patients is needed to reach more solid conclusions on the efficacy and safety of this new technique.

Helicobacter pylori, Sleeve Gastrectomy, and Gastroesophageal Reflux Disease; Is there a Relation?

PURPOSE: Sleeve gastrectomy (SG) is an effective bariatric procedure, yet can be associated with complications as gastroesophageal reflux disease (GERD). The present study aimed to investigate the prevalence of Helicobacter pylori (H. pylori) in SG specimens, its relation with GERD, and its impact on postoperative outcomes. METHODS: All SG specimens received in the pathology laboratory were reviewed. The prevalence of H. pylori in SG specimens was recorded. Patients with H. pylori infection who received triple therapy were compared with patients without H pylori in terms of baseline characteristics, preoperative GERD and its outcome postoperatively, development of new-onset GERD, staple line complications, and weight loss. RESULTS: The records of 176 patients were reviewed; 69 (39.2%) were positively tested on H. pylori infection. Patients with H. pylori had higher body mass index (BMI) (RR = 1.51), greater incidence of preoperative GERD (RR = 1.67), and complained more of dyspepsia (RR = 1.87). Eradication of H. pylori was achieved in 67 (97.1%) of 69 patients. Postoperative improvement in GERD symptoms (44.4% Vs 19%, p = 0.036) and dyspepsia (85.7% Vs 51.7%, p = 0.007) was higher in patients with H. pylori with confirmed eradication of infection than patients without H. pylori. Both groups had similar operation time, postoperative BMI, excess weight loss, staple line complications, and new-onset GERD. CONCLUSIONS: More than one-third of patients with morbid obesity had H. pylori infection. Morbidly obese patients with H. pylori infection may be more prone to develop GERD symptoms; yet after eradication of the infection, they may also experience better improvement in symptoms after SG.

Fasting Ghrelin and Postprandial GLP-1 Levels in Patients With Morbid Obesity and Medical Comorbidities After Sleeve Gastrectomy and One-anastomosis Gastric Bypass: A Randomized Clinical Trial.

BACKGROUND: Sleeve gastrectomy (SG) and one-anastomosis gastric bypass (OAGB) are among the commonly performed bariatric procedures. This randomized study aimed to compare SG and OAGB in terms of weight loss, improvement in comorbidities, and change in serum ghrelin and glucagon-like peptide-1 (GLP-1) levels. PATIENTS AND METHODS: This was a prospective randomized trial on patients with morbid obesity associated with medical comorbidities who were randomly assigned to 1 of 2 equal groups; group I underwent SG and group II underwent OAGB. Outcome measures were percent of excess weight loss (%EWL), improvement in comorbidities, change in the venous levels of fasting ghrelin and postprandial GLP-1 at 12 months after surgery, in addition to operation time and complications. RESULTS: Forty patients (38 female) of a mean age of 33.8 years and mean body mass index of 48.6 kg/m2 were included. Operation time in group II was significantly longer than in group I (86 vs. 52.87 min; P<0.001). There were 6 recorded complications (1 in group I and 5 in group II, P=0.18). The %EWL, %total weight loss, and %excess body mass index loss at 6 and 12 months postoperatively were significantly higher in group II than in group I. Both groups had similar rates of improvement in comorbidities. Group I had significantly lower ghrelin and GLP-1 levels postoperatively at 6 and 12 months, respectively, as compared with group II. CONCLUSIONS: OAGB was associated with significantly higher EWL than SG. The reduction in fasting ghrelin and postprandial GLP-1 serum levels at 12 months after SG was significantly higher than that after OAGB.

Laparoscopic Single Anastomosis Sleeve Ileal (SASI) Bypass for Patients With Morbid Obesity: Technical Description and Short-term Outcomes.

BACKGROUND: Morbid obesity has been recognized as a public health crisis, particularly in developed countries. Single anastomosis sleeve ileal (SASI) bypass has been introduced as a novel bariatric and metabolic procedure. The present study aimed to describe the technical steps and assess the short-term outcomes of SASI bypass in patients with super morbid obesity. PATIENTS AND METHODS: Adult patients of both sexes with body mass index (BMI) ≥50 kg/m underwent SASI bypass and were followed for 12 months postoperatively. Changes in BMI, excess weight loss (EWL), and improvement in comorbidities were recorded on follow-up. RESULTS: Twenty patients (17 female) of the mean age of 35.4 years were included in the study. The mean preoperative BMI (53.7±5.9) showed a significant decrease at 6 months (39.9±5.2) and then at 12 months (33.6±6) postoperatively. The mean %EWL was 44.3±7.8 at 6 months and 65.2±12.6 at 12 months. All patients with diabetes mellitus, osteoarthritis, and reflux esophagitis showed resolution at 12 months after the SASI bypass. Complications were recorded in 2 patients and no mortality was reported. CONCLUSIONS: SASI bypass is an effective and safe bariatric procedure that confers significant loss of weight and improvement in medical comorbidities. As compared with previous studies on patients with lower BMI, patients with super morbid obesity attained lower %EWL but similar resolution of diabetes mellitus at 12 months after SASI bypass.

Single-Anastomosis Plication Ileal Bypass (SAPI) in Treatment of Morbid Obesity.

BACKGROUND: This report aimed to demonstrate the technical steps and preliminary outcome of a novel bariatric procedure, the single-anastomosis plication ileal bypass (SAPI), for the treatment of morbid obesity. MATERIALS AND METHODS: Totally, 5 female patients with morbid obesity underwent SAPI procedure. The procedure consisted of 2 steps; the first step involved greater curvature plication done in a standardized manner, and the second step involved performing a stapled side-to-side anastomosis between an ileal loop 300 cm distal to the duodenojejunal junction and the gastric antrum. Body mass index (BMI) and percentage excess weight loss (%EWL) at 4 months postoperatively were measured. RESULTS: The median age of patients was 38 years. The mean preoperative BMI decreased from 47.3±7.1 kg/m to 36.3±6.1 at 4 months, postoperatively. The mean %EWL at 4 months after SAPI was 51.5±10.8. The mean operation time was 66±5.47 minutes. The median hospital stay was one day. No postoperative complications were recorded. CONCLUSIONS: Despite the small numbers included, the preliminary results of this report show that SAPI is a promising bariatric procedure that achieved significant decrease in BMI and satisfactory excess weight loss. Long-term follow-up of larger number of patients is necessary to reach more firm conclusions on the efficacy and safety of this novel technique.

Identifying Patients at High Risk of Having Pulmonary Dysfunction Before Laparoscopic Bariatric Surgery and Its Impact on Postoperative Pulmonary Complications.

Background: Morbid obesity is associated with variable degrees of pulmonary dysfunction that may predispose to postoperative complications. This study aimed to identify high risk patients to have pulmonary dysfunction before bariatric surgery in terms of age, sex, and body mass index (BMI) and the impact of pulmonary dysfunction on postoperative pulmonary complications. Methods: Prospective database of patients with morbid obesity who underwent bariatric surgery was reviewed. Data on patients' demographics, parameters of pulmonary function tests, and postoperative pulmonary complications were collected. The correlation between patients' age, sex and BMI, and pulmonary function was investigated using Pearson's correlation coefficient test. Results: Ninety-seven patients (82 female) with morbid obesity were included in the study. Twenty-eight (28.9%) patients had pulmonary dysfunction. Patients >40 years had higher odds of pulmonary dysfunction than patients ≤40 years (odds ratio [OR]: 2.54, P = .05). Male patients had significantly higher odds of pulmonary dysfunction than female patients (OR: 2.5, P = .03). Patients with BMI >50 had significantly higher odds of pulmonary dysfunction than patients with BMI <50 (OR: 4.9, P = .002). Patients with pulmonary dysfunction had significantly higher odds of developing pulmonary complications than patients with normal spirometry (OR: 9.13, P = .009). Conclusion: Around 30% of patients undergoing bariatric surgery had pulmonary dysfunction. Pulmonary dysfunction in preoperative spirometry was able to predict postoperative pulmonary complications. Men, patients older than 40 years, and superobese individuals had higher odds of having pulmonary dysfunction and are at higher risk to develop pulmonary complications after bariatric surgery.

Correlation Between the Number of Ghrelin-Secreting Cells in the Gastric Fundus and Excess Weight Loss after Sleeve Gastrectomy.

BACKGROUND: Weight loss after laparoscopic sleeve gastrectomy (LSG) has been mainly attributed to the restriction of gastric volume; however; other factors may contribute to weight loss after LSG. This study aimed to investigate the correlation between the number of ghrelin-secreting cells in the gastric fundus and excess weight loss (EWL) at 12 months after LSG. METHODS: The surface area of the gastric fundus was measured postoperatively in square centimeter. Histopathologic examination of the gastric fundus was made to estimate the number of ghrelin-secreting cells per square centimeter then was multiplied by the surface area of the fundus to calculate the total number of ghrelin-secreting cells in the fundus. The number of ghrelin-secreting cells was correlated with EWL and BMI at 12 months postoperatively. RESULTS: The present study included 39 patients of a mean age of 33.7 years. The mean %EWL at 12 months was 59.7 ± 12.7. The mean total number of ghrelin-producing cells in the gastric fundus was 26,228.4 ± 16,995.3. The total number of ghrelin-secreting cells had a weak positive correlation with BMI at 12 months (r = 0.2891, p = 0.07), and weak negative correlation with %EWL (r = - 0.1592, p = 0.33). CONCLUSION: There was a weak correlation between the total number of ghrelin-producing cells in the gastric fundus and plasma ghrelin levels with EWL after LSG.

Impact of Pyloric Injection of Magnesium Sulfate-Lidocaine Mixture on Postoperative Nausea and Vomiting After Laparoscopic Sleeve Gastrectomy: a Randomized-Controlled Trial.

BACKGROUND: One of the most common adverse effects of laparoscopic sleeve gastrectomy (LSG) is postoperative nausea and vomiting (PONV). The present study aimed to assess the impact of local injection of a mixture of magnesium sulfate and lidocaine into the pylorus on gastric intraluminal pressure (ILP) and PONV after LSG. METHODS: Patients with morbid obesity who underwent LSG were randomly allocated to one of two equal groups: treatment group (pyloric injection of a mixture of magnesium sulfate and lidocaine) and control group (pyloric injection of normal saline). PONV and antiemetic requirements were recorded at 6 and 24 h postoperatively. RESULTS: Seventy patients (63 female) with a mean age of 34.6 ± 9.9 years were included. The mean preoperative and postoperative gastric ILP was comparable in the two groups. The pyloric injection of magnesium sulfate-lidocaine mixture resulted in 31% reduction in the mean gastric ILP (19.4 ± 4.7 mmHg before injection to 13.4 ± 4.1 mmHg after injection, p < 0.0001). Pyloric injection of saline did not result in significant change in ILP (19.9 ± 4.9 vs 20.3 ± 5.1 mmHg). Of the treatment group patients, 17.1% had significant PONV at 6 h compared to 91.4% of control group patients (p < 0.0001). At 24 h, none of the treatment group patients had significant PONV versus 40% of the control group patients (p < 0.0001). CONCLUSION: Pyloric injection of magnesium sulfate-lidocaine mixture during LSG resulted in lower incidence of PONV and less use of antiemetic medications in the first 24 h after LSG without being associated with higher complication rate.

Impact of Ultrasound-Guided Transversus Abdominis Plane Block on Postoperative Pain and Early Outcome After Laparoscopic Bariatric Surgery: a Randomized Double-Blinded Controlled Trial.

BACKGROUND: Based on the promising results of transversus abdominis plane (TAP) block in various abdominal procedures, this study aimed to investigate its effect on postoperative pain and early outcome after laparoscopic bariatric procedures. METHODS: Patients with morbid obesity were randomly assigned to one of two equal groups; group I had US-guided TAP block upon completion of the bariatric procedure and before recovery from general anesthesia and group II did not have TAP block. All procedures were performed laparoscopically with a standardized five-trocar technique. RESULTS: Ninety-two patients of a mean age of 34.7 years and mean BMI of 49.5 kg/m2 were included. The mean pain score in group I was significantly lower than group II at 1 and 6 h postoperatively, whereas no significant differences in pains scores at 12 and 24 h between the two groups were observed. Eight patients in group I required rescue opioid analgesia within the first 24 h postoperatively, compared with 24 patients in group II (P < 0.0001). The postoperative nausea and vomiting (PONV) score at 24 h was significantly lower in group I than group II. Group I required a significantly shorter time to full ambulation and to pass flatus compared with group II. Hospital stay was similar in the two groups. CONCLUSION: Using US-guided TAP block in adjunct with laparoscopic bariatric surgery managed to achieve lower pain scores, lower opioid requirements, lower PONV scores, earlier ambulation, shorter time to pass flatus, and comparable hospital stay and complication rate to the control group.

Efficacy and safety of botulinum toxin in treatment of anismus: A systematic review.

AIM: To evaluate the efficacy and safety of botulinum toxin type A (BTX-A) in the management of patients with anismus. METHODS: An organized search of published literature was conducted using electronic databases including: PubMed/MEDLINE, and Cochrane Central Register of Controlled Trials, also an internet-based search using "Google Scholar" service was conducted. Both comparative and observational studies were included. We excluded irrelevant articles, editorials, case reports, reviews, and meta-analyses. The studies that followed the patients less than 6 mo were excluded. Variables collected were demographic data of the patients, technique of BTX-A injection and number of sessions, short-term and long-term clinical improvement, post-injection changes in electromyography (EMG), defecography, manometry, and balloon expulsion test, and complications recorded after BTX-A injection. RESULTS: Seven studies comprising 189 patients were included in the review. The median age of the patients was 41.2 years and female-to-male ratio was 1.3:1. The median dose of BTX-A injected per procedure was 100 IU (range, 20-100 IU). Lateral injection was done in five trails and combined lateral and posterior injections in two trials. Three studies used endorectal ultrasonography-guided technique, one study used EMG-guided technique, whereas the remaining three studies used manual palpation with the index finger. The median percentage of patients who reported initial improvement of symptoms was 77.4% (range 37.5%-86.7%), this percentage declined to a median of 46% (range 25%-100%) at 4 mo after injection of BTX-A. Rates of improvement evaluated by balloon expulsion test, EMG, and defecography ranged between (37.5%-80%), (54%-86.7%), and (25%-86.6%), respectively. Fourteen (7.4%) patients developed complications after injection of BTX-A. Complication rates across the studies ranged from 0% to 22.6%. CONCLUSION: Initial satisfactory improvement of symptoms after BTX-A injection remarkably deteriorated after 3 mo of the procedure. However, repeated injection may provide better sustained results with no additional morbidities. Further analysis of more patients is necessary to conclude the safety of BTX-A for the treatment of anismus.

Potential value of estrogen receptor beta expression in colorectal carcinoma: interaction with apoptotic index.

PURPOSE: The study was designed to investigate the clinicopathological correlations, relationship to apoptotic index, and prognostic significance of estrogen receptor beta expression in colorectal carcinoma. METHODS: The study was carried out on 40 patients with newly diagnosed colorectal cancer. The patients' data were collected prospectively and the 2 years overall survival was the endpoint. Estrogen receptor beta expression was assessed by immunohistochemistry. Apoptotic body index was calculated by counting apoptotic cells using the modified TUNEL assay. RESULTS: Estrogen receptor beta positivity was detected in 65% of colorectal cancer cases, while estrogen receptor alpha positivity was found in only 7% of cases. The rate of estrogen receptor beta immunoreactivity was significantly higher in low-grade colorectal tumors. The median apoptotic index in estrogen receptor beta positive cases was significantly higher than in estrogen receptor beta negative cases (6% versus 3%; p = 0.01). The median overall survival was higher in estrogen receptor beta positive cases (22 versus 18 months); however, the difference was not statistically significant. CONCLUSIONS: The study results reinforce the importance of the estrogen receptor beta rather than the estrogen receptor alpha in colorectal cancer. Lack of estrogen receptor beta expression is associated with loss of differentiation and decreased apoptosis. Future studies should include validation of estrogen receptor beta as a prognostic marker and exploration of its role as a target in the management of colorectal cancer.