Staple Line Reinforcement Using SEAMGUARD® versus Suture Over Sewing During Laparoscopic Sleeve Gastrectomy for Super Morbidly Obese Patients: A Prospective Randomized Clinical Trial.

Itroduction: Although theoretically a simple procedure, laparoscopic sleeve gastrectomy (LSG) can be followed by life-threatening complications. Early postoperative complications include staple line bleeding and leakage. Staple line reinforcement (SLR) has been used to decrease these complications. There are various methods for reinforcement of staple line such as suture over sewing, placing omental flap, using buttressing material, and spraying fibrin glue along the staple line. However, it is controversial whether SLR reduces the rate of staple line complications or not. MATERIALS AND METHODS: A prospective randomized clinical trial included 200 super morbidly obese patients randomized into two groups: Group 1 with reinforcement of the staple line by SEAMGUARD® (Gore Medical, Newark, Delaware) and Group 2 with reinforcement of the staple line using suture over sewing. RESULTS: The mean operative time was significantly shorter in Group 1 than Group 2 (62.6 ± 14.5 vs. 84.7 ±15.8 min, p=0.02). Intraoperative blood loss was significantly lower in Group 1 than Group 2 (17.1± 19.1 vs. 56.8 ± 27.9ml, p=0.00). Staple line hematomas were significantly higher in Group 2. There was no difference in postoperative bleeding between the two groups. No leak was reported in both groups. The cost was higher in Group 1. CONCLUSION: Reinforcing the staple line in laparoscopic sleeve gastrectomy using suturing is equal to SEAMGUARD® in all aspects except shorter operative time and lower intraoperative blood loss with SEAMGUARD®.

Effect of Ramadan intermittent fasting on inflammatory markers, disease severity, depression, and quality of life in patients with inflammatory bowel diseases: A prospective cohort study.

BACKGROUND: Intermittent fasting (IF) during the month of Ramadan is part of the religious rituals of Muslims. The effect of intermittent fasting on disease activity in inflammatory bowel diseases (IBD) is still unknown. This is the first study to assess the effect of IF during Ramadan on inflammatory markers in patients diagnosed with IBD. The effects on clinical disease activity, quality of life, and levels of depression were also assessed. METHODS: Patients diagnosed with ulcerative colitis (UC) or Crohn's disease (CD) who intended to observe Ramadan fasting were recruited. The following were assessed immediately before and at the end of Ramadan: Serum CRP and stool calprotectin, partial Mayo score, Harvey Bradshaw index (HBI), Simple IBD questionnaire (SIBDQ), and Hamilton depression scale questionnaire. RESULTS: 80 patients diagnosed with IBD were recruited (60 UC, 20 CD). Serum CRP and stool calprotectin did not show a significant change before vs after fasting (median CRP 0.53 vs 0.50, P value = 0.27, Calprotectin 163 vs 218 respectively, P value = 0.62). The partial Mayo score showed a significant rise after fasting (median 1 before vs 1 after fasting, mean: 1.79 vs 2.33 respectively, P value = 0.02). Harvey-Bradshaw index did not show a significant change after fasting (median 4 vs 5, P value = 0.4). Multiple linear regression revealed that older age and a higher baseline calprotectin were associated with a higher change in Mayo score after fasting (P value = 0.02 and P value = 0.01, respectively). No significant change was detected in SIBDQ or Hamilton depression scale scores. CONCLUSIONS: In patients diagnosed with UC, IF during Ramadan was associated with worsening of clinical parameters, the effect was more pronounced in older patients and those with higher baseline calprotectin levels. However, IF during Ramadan was not associated with an adverse effect on objective inflammatory markers (CRP and calprotectin).

Preliminary experience with laparoscopic common bile duct exploration.

BACKGROUND: Herein we present our experience with laparoscopic common bile duct exploration (LCBDE) in managing common bile duct stones. METHODS: Data of 129 consecutive patients who underwent laparoscopic cholecystectomy (LC) and LCBDE done at our institutes from April 2011 through June 2016 were prospectively recorded and retrospectively reviewed. RESULTS: Since 2011, 3012 laparoscopic cholecystectomy were performed at our institutes, intraoperative cholangiogram (IOC) was done in 295 (9.8%) patients which detected choledocholithiasis in 129 (4.3%) of them. LCBDE was successful to clear the common bile duct (CBD) in 123/129 (95.4%). Six patients underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) because of incomplete CBD clearance (4 cases), symptomatic stenosed papilla (2 cases). LCBDE was performed in 103 patients via trans-cystic approach and choledochotomy one in 26 patients. In the choledochotomy group, seven patients had primary closure of the CBD, CBD was closed over T-tube in nine patients whereas the remaining 10 patients the CBD was closed over antegrade inserted stent. The median time of hospital stay was 4 (range; 1-15) days. No patients showed retained CBD stones with mean follow up was 9 ± 3.4 months. CONCLUSION: LCBDE is a safe and cost effective option for CBD stones in short-term outcome and can be performed provided proper laparoscopic expertise and facilities are available.

Evaluation of Safety and Feasibility of Using LigaSure During Clipless Single-Incision Laparoscopic Cholecystectomy: A Prospective Clinical Study.

Background: Single-incision laparoscopic cholecystectomy (SILC) is a minimally invasive procedure designed to minimize the number and size of the incisions needed for cholecystectomy. Titanium clips are traditionally used to close the cystic duct and artery. Although it is considered safe, dislodgement can result in bleeding and biliary leakage. Using LigaSure for duct sealing is still controversial. The aim of this study was to evaluate the safety and feasibility of using LigaSure to close the cystic duct during SILC. Methods: A prospective study over two years was conducted at the General Surgery Department, Mansoura University Hospital, on 102 patients, 51 in each group. They underwent SILC using LigaSure (Group 1) or titanium clips (Group 2) to control the cystic duct and artery. Results: The data analyzed included demographic data, operative time, intra- and postoperative complications, postoperative pain, and hospital stay. The operative time was significantly shorter in LigaSure group (68.5 ± 9.8 versus 72.9 ± 10.6 minutes in the clips group, P .03). There was no significant difference between the two groups regarding postoperative bile leak or bleeding. However, two cases in Group 1 and four cases in Group 2 were converted to multiple port laparoscopic cholecystectomy; this was statistically nonsignificant. Postoperative pain and hospital stay showed no significant difference between the two groups. Two patients in each group developed port-site incisional hernia. Conclusions: Clipless SILC using LigaSure is a feasible and safe procedure with acceptable morbidity with shorter operative time than SILC using clips. Nevertheless, the risk of port-site incisional hernia should be explained to the patients.

Impact of laparoscopy on the perioperative outcomes of penetrating abdominal trauma.

BACKGROUND: Penetrating abdominal trauma (PAT) poses a significant challenge to trauma surgeons. Laparotomy is still the most popular procedure for managing PAT but has high morbidity and mortality rates. Presently, laparoscopy aims to provide equal or superior visualization compared to open approaches but with less morbidity, postoperative discomfort, and recovery time. The aim of this research is to assess the impact of laparoscopy on the management of PAT. METHODS: This was a retrospective observational study carried out at the Emergency Hospital of Mansoura University/Egypt and at King Faisal Medical Complex, Taif/KSA from September 2014 to September 2018. All hemodynamically stable patients with PAT who were managed by laparoscopy were included in this study. Data extracted for analysis included demographic information, criteria of abdominal stabs, type of management, and perioperative outcome. RESULTS: Forty patients were recruited in this research and the male-to-female ratio was 5.6:1. The mean age of the patients was 31.4 ± 12.318 years. During the laparoscopic procedure, no peritoneal penetration was observed in 4 patients (negative laparoscopy), while peritoneal penetration was observed in the remaining 36 patients. No visceral injuries were noted in 2 patients of the 36 patients with peritoneal penetration, while the remaining 34 patients had intra-abdominal injuries. CONCLUSION: Laparoscopy performed on hemodynamically stable trauma patients was found to be safe and technically feasible. It also reduced negative and non-therapeutic laparotomies and offered paramount therapeutic and diagnostic advantages for traumatic diaphragmatic injuries.

Partial splenic embolization versus splenectomy for the management of hypersplenism in cirrhotic patients.

BACKGROUND: Hypersplenism occurs in patients with chronic liver disease, and splenectomy is the definitive treatment. However, the operation may be hazardous in patients with poor liver function. In recent years, partial splenic embolization (PSE) has been widely used in patients with hypersplenism and cirrhosis. This study was conducted to assess the safety and efficacy of PSE compared to splenectomy in the management of hypersplenism in cirrhotic patients. METHODS: This study comprised 40 patients with hypersplenism secondary to cirrhosis. They were divided into two groups, each including 20 patients. The first group of patients were treated by PSE using polyvinyl alcohol particles to achieve embolization of at least 50% of the distal branches of the splenic artery. Postembolization arteriography and computed tomography were performed to document the extent of devascularization. Patients in the second group were treated by splenectomy with or without devascularization and left gastric ligation according to the presence or absence of esophageal varices. RESULTS: There was marked improvement in platelet and leukocytic counts in both groups, and the counts remained at appropriate levels during the follow-up period. All patients in the first group had problems related to postembolization syndrome that abated by the first week. One patient in the first group died from myocardial infarction. No deaths occurred in the second group. Asymptomatic portal vein thrombosis developed in one patient in the first group that was treated with anticoagulation, and another patient developed splenic abscess treated by splenectomy with a good outcome. In the second group, three patients developed portal vein thrombosis, one of them being readmitted 4 months postoperatively with mesenteric vascular occlusion; that patient underwent a resection anastomosis with good outcome. CONCLUSIONS: Partial splenic embolization is an effective therapeutic modality for the treatment of hypersplenism secondary to chronic liver disease. It is a simple, rapid procedure that is easily performed under local anesthesia; and it allows preservation of adequate splenic tissue to safeguard against overwhelming infection.

Right Coronary Artery Stent Dislodgment during Primary Percutaneous Coronary Intervention. To Leave or to Retrieve?

Coronary stent dislodgment and embolization are rare and challenging complications of percutaneous coronary intervention that may result in serious and fatal complications attributed to the loss of blood flow of the coronary, cerebral, or peripheral circulations. Percutaneous management is successful in most cases using different techniques and devices, but surgery may be required. We report two cases of stent dislodgment during primary PCI for the right coronary artery with different management approaches and outcomes.

Latif's point: A new point for Veress needle insertion for pneumoperitoneum in difficult laparoscopy.

INTRODUCTION: Creating pneumoperitoneum is the most challenging step during laparoscopy. The periumbilical area is the classic site for Veress needle insertion. We adopted a new access point for peritoneal insufflation. METHODS: We introduced a new point for Veress needle insertion to create pneumoperitoneum during difficult laparoscopic procedures. The needle is placed between the xiphoid process and the right costal margin, and it then proceeds toward the patient's right axilla. We collected data to compare using this new method of peritoneal insufflation with using Palmer's point for pneumoperitoneum. RESULTS: Since 2013, we have used this new technique in 570 patients (first group) and Palmer's point in 459 patients (second group). Among these patients, 196 patients (20%) had had previous abdominal operations, 98 patients (10%) had irreducible ventral hernia, and 735 patients (70%) were morbidly obese. The two groups were comparable in terms of patient characteristics. The mean time to create pneumoperitoneum in the first group was 0.8 ± 0.002 min compared to 1.08 ± 0.007 min in the second group (P ≤ 0.5). The mean number of punctures was 1.57 ± 1.02 in the first group compared to 2.9 ± 1.5 in the second group (P≤ 0.5); in the first group, 97% were successful on the first attempt entry, whereas this figure was 91% in second group. In the first group, the liver was punctured in 13 patients without any further complications; no other viscera were punctured. In the second group, gastric puncture occurred in 5 cases, transverse colon in 2 cases, and omental injury in 12 cases. CONCLUSION: This new access point may represent a safe, fast, and easy way to create pneumoperitoneum, as well as a promising alternative to Palmer's point in patients who are not candidates for classic midline entry.

Management Options for Twisted Gastric Tube after Laparoscopic Sleeve Gastrectomy.

PURPOSE: This study aims to determine the incidence, etiology, and management options for symptomatic gastric obstruction caused by axially twisted sleeve gastrectomy. METHODS: In this retrospective study, we reviewed medical charts of all morbidly obese patients who underwent laparoscopic sleeve gastrectomy. Patients who developed gastric obstruction symptoms and were diagnosed with twisted sleeve gastrectomy were identified and included in this study. RESULTS: From October 2005 to December 2015, there are 3634 morbidly obese patients who underwent laparoscopic sleeve gastrectomy (LSG). Eighty-six (2.3%) patients developed symptoms of gastric obstruction. Forty-five (1.23%) patients were included in this study. The mean time of presentation was 59.8 days after surgery. Upper GI contrast study was done routinely, and it was positive for axial twist in 37 (82%) patients. Abdominal CT with oral and IV contrast was done in eight (18%) when swallow study was equivocal. Endoscopic treatment was successful in 43 patients (95.5%). Sixteen patients were successfully managed by endoscopic stenting, and 29 patients had balloon dilation. The average numbers of dilation sessions were 1.7. Out of these 29 patients, 18 responded well to a single session of dilatation and did not require any further dilatation sessions. Two patients who failed to respond to three subsequent sessions of balloon dilation underwent laparoscopic adhesiolysis and gastropexy. CONCLUSIONS: Endoscopic stenting is an effective tool in management of axial rotation of sleeved stomach. Balloon dilation can also be effective in selected cases. Few cases might require laparoscopic adhesiolysis and gastropexy.

Impact of Botulinum Neurotoxin Pyloric Injection During Laparoscopic Sleeve Gastrectomy on Postoperative Gastric Leak: a Clinical Randomized Study.

BACKGROUND: The most frequent and most feared complication after laparoscopic sleeve gastrectomy (LSG) is gastric leak (GL). We hypothesize that botulinum neurotoxin (botulinum type A (BTX-A)) injection into the pyloric sphincter muscle at the time of operation may decrease the risk of postoperative GL. METHODS: Consecutive patients with morbid obesity (MO) treated by LSG were enrolled. Patients were randomly allocated into two groups: group I (intrapyloric BTX-A injection was performed) and group II (no injection was performed). The primary outcome measure was number of patients developing GL. Secondary outcome measures were percent of excess weight loss, postoperative complications, and their management. RESULTS: One hundred and fifteen patients (86 (74.8 %) females) were randomized into two groups of 57 patients (group I) and 58 patients (group II). Four patients in group II developed GL versus no patient in group I (P = 0.04). Ten patients in group I and two in group II developed refractory epigastric pain (P = 0.01). Other complication rates were comparable for both groups. Mean preoperative BMI of patients in both groups had significantly decreased from 54.64 ± 6.82 to 42.99 ± 5.3 at 6 months and to 39.09 ± 5.14 at 12 months (P < 0.001). CONCLUSIONS: LSG is an effective, safe, and minimally invasive procedure for treatment of MO. No patient in whom pyloric BTX-A injection was performed developed postoperative GL versus four patients in whom injection was not performed. The difference in GL rate was statistically significant, thus favoring the use of pyloric BTX-A injection during LSG.

Optimal level of sympathectomy for primary palmar hyperhidrosis: T3 versus T4 in a retrospective cohort study.

BACKGROUND: To compare the results obtained with T3 versus T4 sympathectomy in treatment of primary palmar hyperhidrosis (PH). METHODS: By retrospective review of medical records of patients with PH who underwent thoracoscopic sympathectomy from February, 2009 to September, 2012. The patients were categorized into two groups: T3 group underwent T3 sympathectomy and T4 group underwent T4 sympathectomy. Patients were evaluated according to the results of sweating, compensatory hyperhidrosis (CH), degree of satisfaction, complications and recurrence. Mean follow up was 19 ± 7 months. RESULTS: A total of 274 consecutive patients with PH were included in this study. There were 169 females and 105 males, with mean age of 29 ± 11 years. 129 patients underwent T3 sympathectomy (T3 group). The T4 group included 145 patients who underwent T4 sympathectomy. 71.7% patients of T4 group did not complain of CH in comparison to 25.6% patients in group T3 (P = 0.001) and the incidence of mild to moderate CH was higher in the T3 group than T4 (64.4% vs. 26.9%; p = 0.001). T4 group showed a great significance in the (very satisfied category) in comparison to T3 group (P = 0.001). The incidence of over-dry hands was significantly lower in group T4 (0.7%, 1 out of 145) than in group T3 (8.5%, 11 out of 129). The recurrence rate was similar in the two groups (0.8% vs. 1.4%; P = 0.19). CONCLUSION: Video-assisted T3 or T4 sympathectomy is a safe and effective procedure for treatment of palmar hyperhidrosis. T4 sympathectomy appears associated with less severe dryness and CH than T3 sympathectomy at long-term follow-up.