Small bowel obstruction secondary to barbed sutures in bariatric surgery: a cautionary tale.

BACKGROUND: Laparoscopic bariatric surgery relies on technically challenging intracorporeal suturing for critical parts of the operation. Barbed sutures have been developed to provide an alternative to suturing for certain manoeuvres within a procedure. Barbed sutures theoretically negate the need for knot tying and allow for continuous application of tension; however the barbs can unintentionally adhere to surrounding tissues. We describe a case series of three patients who developed V-Loc™ (barbed) suture related small bowel obstruction (SBO) to promote awareness of this unusual but preventable complication. METHODS: Medical records of patients diagnosed with V-Loc™ related SBO between 2018 and 2021 at a tertiary centre were reviewed. Data regarding presentation, diagnosis, management and outcomes were obtained. RESULTS: Three patients were identified where V-Loc™ sutures were aetiologically related to early post-surgical small bowel obstruction secondary to small bowel adherence to barbed suture tail or adhesions between barbed suture tail and unintended viscera. In these cases, non-absorbable V-Loc™ sutures were used to close the small bowel mesenteric defect at Roux-en-Y gastric bypass surgery. All patients required adhesiolysis at re-look laparoscopy prior to resolution. All patients were discharged home well after relook laparoscopy. CONCLUSION: Overly long or exposed V-Loc™ suture tails can result in SBO following laparoscopic bariatric surgery. Cutting the suture tail as close as practical to the final throw of the suture and/or covering exposed suture ends may prevent this complication.

Effect of laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass on body composition.

BACKGROUND: There is limited data with respect to body composition changes for laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB). The objective of this study was to analyse changes in body composition between these two procedures during the first year after bariatric surgery. METHODS: A prospective study was performed in patients undergoing bariatric surgery at two tertiary hospitals between 2017 and 2023. Body composition was assessed with dual-energy x-ray absorptiometry immediately before surgery, and at 1-, 6-, 12-, 18- and 24-months post-operatively, with a subgroup analysis performed for patients who undertook a scan at 18- and 24-months. Total weight loss (TWL), body mass index (BMI), fat mass (FM), lean body mass (LBM) and bone mineral content (BMC) parameters were compared between SG and RYGB. RESULTS: Forty-five patients were included in this series (SG n = 30, RYGB n = 15). There was a significant reduction in mean %TWL of 26.94 ± 8.86% and mean BMI of 11.12 ± 3.70 kg/m2 over 12-months. LBM accounted for 17.8% of TWL over 12-months, SG and RYGB did not differ in terms of loss of FM or LBM. For both procedures, the loss of LBM appeared to plateau at 6-months post-operatively. The only statistically significant finding between the two procedures was that RYGB resulted in an additional 0.06 kg loss compared with SG. CONCLUSION: SG and RYGB have been shown to have comparable weight loss and body composition changes in the short-to-medium term following surgery. LBM reduction was most significant in the early post-operative period across the entire cohort.

Hilab System Device in an Oncological Hospital: A New Clinical Approach for Point of Care CBC Test, Supported by the Internet of Things and Machine Learning.

The complete blood count (CBC) is a highly requested test that is generally restricted to centralized laboratories, which are limited by high cost, being maintenance-demanding, and requiring costly equipment. The Hilab System (HS) is a small, handheld hematological platform that uses microscopy and chromatography techniques, combined with machine learning (ML) and artificial intelligence (AI), to perform a CBC test. This platform uses ML and AI techniques to add higher accuracy and reliability to the results besides allowing for faster reporting. For clinical and flagging capability evaluation of the handheld device, the study analyzed 550 blood samples of patients from a reference institution for oncological diseases. The clinical analysis encompassed the data comparison between the Hilab System and a conventional hematological analyzer (Sysmex XE-2100) for all CBC analytes. The flagging capability study compared the microscopic findings from the Hilab System and the standard blood smear evaluation method. The study also assessed the sample collection source (venous or capillary) influences. The Pearson correlation, Student t-test, Bland-Altman, and Passing-Bablok plot of analytes were calculated and are shown. Data from both methodologies were similar (p > 0.05; r ≥ 0.9 for most parameters) for all CBC analytes and flagging parameters. Venous and capillary samples did not differ statistically (p > 0.05). The study indicates that the Hilab System provides humanized blood collection associated with fast and accurate data, essential features for patient wellbeing and quick physician decision making.

Sand accumulation in the digestive tract of rabbits (Oryctolagus cuniculus) and guinea pigs (Cavia porcellus): The role of the appendix.

We determined location and amount of accumulated sand in the gastrointestinal tract (GIT) of rabbits (Oryctolagus cuniculus) and guinea pigs (Cavia porcellus) fed diets containing external (silicate) abrasives. Computed tomographic abdominal images of rabbits (n = 44) and guinea pigs (n = 16) that each received varying numbers (4-7) of different diets for 14 days each (total n = 311 computed tomographs), and radiographs of dissected GIT and presence of silica in GIT content (n = 46 animals) were evaluated. In rabbits, the majority of accumulated sand was located in the caecal appendix, an elongated, intestinal structure in the left side of the abdomen. The 'wash-back' colonic separation mechanism in rabbits may be partly responsible for a retrograde transport of sand back to the caecum, where dense, small particles accumulate in the appendix. The appendix likely acted as a reservoir of these particles, leading to significant effects not only of the momentary but also of the previous diet on recorded sand volumes in the rabbits. Guinea pigs have no caecal appendix and a colonic separation mechanism not based on a 'wash-back'. Less sand accumulation was found in their GIT without a specific location pattern, and there were less previous diet effects in this species. None of the rabbits or guinea pigs developed clinical signs of obstruction during the study, and the recorded sand volumes represented 1.0 ± 1.2% of the 14-d sand intake in rabbits and 0.2 ± 0.2% in guinea pigs. Accumulation of sand in volumes up to 10 cm3 in the GIT of rabbits does not seem to cause clinical health impairment. Large inter-individual differences in rabbits indicate inter-individual variation in proneness to sand accumulation. The reason for the presence of a sand-trapping caecal appendix in animals that are, due to their burrowing lifestyle and feeding close to the ground, predestined for accidental sand ingestion, remains to be unveiled.

The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia.

Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.

Laparoscopic Management of Abdominal Apoplexy.

Abdominal apoplexy, otherwise known as intraperitoneal idiopathic spontaneous haemorrhage, is a rare condition that presents as a diagnostic dilemma and is associated with high mortality. Symptoms and signs typically are similar to other conditions presenting with upper abdominal peritonitis. Intraabdominal haemorrhage can occur from many different causes, including trauma, iatrogenic, ruptured aneurysm, gynaecological conditions, malignancy, and inflammatory or autoimmune processes. Spontaneous or idiopathic causes are much rarer. Prompt diagnosis and ligation of the bleeding vessel usually result in a good outcome. Most cases described involve males in the fifth and sixth decade of life who present in the setting of hypertension and known atherosclerotic disease and are managed with laparotomy or are diagnosed at autopsy. We present a case of abdominal apoplexy managed laparoscopically in a healthy 20-year-old male with no pre-existing medical conditions. This case highlights the importance to consider abdominal apoplexy in any demographic.

Laparoscopic or open appendicectomy for suspected appendicitis in pregnancy and evaluation of foetal outcome in Australia.

BACKGROUND: Recent data suggest that laparoscopic appendicectomy (LA) in pregnancy is associated with higher rates of foetal loss when compared to open appendicectomy (OA). However, the influence of gestational age and maternal age, both recognized risk factors for foetal loss, was not assessed. METHOD: This was a multicentre retrospective review of all pregnant patients who underwent appendicectomy for suspected appendicitis from 2000 to 2012 across seven hospitals in Australia. Perioperative data and foetal outcome were evaluated. RESULTS: Data on 218 patients from the seven hospitals were included in the analysis. A total of 125 underwent LA and 93 OA. There were seven (5.6%) foetal losses in the LA group, six of which occurred in the first trimester, and none in the OA group. After matching using propensity scores, the estimated risk difference was 5.1% (95% confidence interval (CI): 1.4%, 9.8%). First trimester patients were more likely to undergo LA (84%), while those in the third were more likely to undergo OA (85%). Preterm delivery rates (6.8% LA versus 8.6% OA; CI: -12.6%, 5.3%) and hospital length of stay (3.7 days LA versus 4.5 days OA; CI: -1.3, 0.2 days) were similar. CONCLUSION: This is the largest published dataset investigating the outcome after LA versus OA while adjusting for gestational and maternal age. OA appears to be a safer approach for pregnant patients with suspected appendicitis.

Esophageal Apoplexy.

Oesophageal apoplexy or intramural haematoma of the oesophagus (IHE) is a rare condition with a pattern of presentation that can mimic sinister pathologies. Diagnosis requires a high index of suspicion, and the exclusion of an oesophageal perforation or oesophageal malignancy is important. Investigations include computer topography (CT) and contrast swallow studies as well as a gastroscopy. Management is mainly supportive with resolution of symptoms typically occurring rapidly. We present two cases of this rare condition, with accompanying images.

Nucleophilic substitution reactions at liquid/liquid interfaces: molecular dynamics simulation of a model S(N)1 dissociation reaction at the water/carbon tetrachloride interface.

The ionic dissociation step of the nucleophilic substitution reaction t-BuCl --> t-Bu(+) + Cl(-) is studied at the water/carbon tetrachloride interface using molecular dynamics computer simulations. The empirical valence bond approach is used to couple two diabatic states, covalent and ionic, in the electronically adiabatic limit. The umbrella sampling technique is used to calculate the potential of mean force along the reaction coordinate (defined as the t-Bu to Cl distance) at several interface regions of varying distances from the Gibbs dividing surface. We find a significant increase of the ionic dissociation barrier height and of the reaction free energy at the interface relative to bulk water. This is shown to be due to the reduced polarity of the interface which causes a destabilization of the pure ionic state. However, deformation to the neat interface structure in the form of water protrusions into the organic phase may provide partial stabilization of the ionic species. The importance of these structural effects is examined by repeating the calculations with an artificially smooth interface. The destabilization of the ionic state at the interface also manifests itself with a rapid (picosecond time scale) recombination dynamics of the ions to form the parent molecule followed by a slow vibrational relaxation.

A molecular-dynamics study of a model S(N)1 dissociation reaction at the water liquid/vapor interface.

The thermodynamics and dynamics of a model S(N)1 reaction: t-BuCl --> t-Bu+ + Cl- is studied at the water liquid/vapor interface using molecular-dynamics computer simulations. The empirical valence bond approach is used to couple two diabatic states, covalent and ionic, in the electronically adiabatic limit. Umbrella sampling calculations are used to calculate the potential of mean force along the reaction coordinate (defined as the t-Bu to Cl distance) in bulk water and in several locations at the interface. We find a significant increase of the dissociation barrier height and of the reaction free energy at the interface relative to the bulk. This is shown to be due to the reduced polarity of the interface. Reactive flux correlation function calculations show significant deviation of the rate constant from the transition-state theory: The transmission coefficients range from 0.49 in the bulk to 0.05 above the Gibbs surface. The low transmission coefficient at the interface despite the lower friction is shown to be due to slow vibrational relaxation.

Photodissociation of ICN at the liquid/vapor interface of water.

The photodissociation of ICN adsorbed at the liquid/vapor interface of water is studied using classical molecular dynamics with nonadiabatic surface hopping. The cage escape, geminate recombination to form ICN and INC and the subsequent vibrational relaxation of these two molecules (on their ground electronic states) is compared with the same process in bulk water and with previous photodissociation studies at liquid interfaces. We find that the reduced surface density and weaker solvent-solute interactions give rise to reduced rate of nonadiabatic transitions and that the probability for cage escape at the interface is significantly enhanced due to the possibility that one or both of the photodissociation fragments desorb into the gas phase. The overall desorption probability varies from 75% to 92% for ICN initially located just below the Gibbs surface (50% bulk density) to ICN located just above the Gibbs surface, respectively. The corresponding geminate recombination probabilities are 18% and 9%, respectively. The vibrational relaxation rate of the recombined ICN is slower than in the bulk by a factor of 2.3.