Enhancing bariatric surgery safety for patients refusing blood transfusions: a specialized protocol with comprehensive technical measures.

Bariatric surgery has become a leading treatment for obesity, with techniques such as Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) demonstrating notable success in sustained weight loss and improved quality of life. Technological advancements and improved techniques have enhanced the safety of these procedures. The surgical procedures of Jehovah's Witnesses, who refuse blood transfusions as part of their beliefs, pose unique challenges and have rarely been addressed in the context of bariatric surgery. This report aimed to investigate the safety of bariatric surgery in patients who refuse blood transfusion, with an established protocol to minimize the risk of bleeding. We examined the prospectively collected data of Jehovah's Witness patients who underwent bariatric surgery from 2019 to 2023. The surgeries were conducted following a protocol that included specific measures to prevent bleeding. Data were reviewed for demographics, anthropometrics, comorbidities, preoperative medications, operative time, blood loss, length of hospital stay, hemoglobin level, drainage volume, tranexamic acid use, and postoperative 30-day complications. Eleven Jehovah's Witness patients underwent bariatric surgery, including 10 LSG and 1 LRYGB. A patient with iron deficiency anemia underwent intravenous iron treatment before the surgery. There were no intraoperative complications or major postoperative complications. All patients maintained stable hemodynamics postoperatively. Only one patient encountered nausea-vomiting, classified as a minor complication. One patient experienced a small amount of hemorrhagic drainage, which transitioned to serous after tranexamic acid infusion. Bariatric surgery can be performed safely with established protocols in patients who refuse blood transfusions.

Establishing Optic Nerve Diameter Threshold Sensitive and Specific for Optic Atrophy Diagnosis.

PURPOSE: To determine a potential threshold optic nerve diameter (OND) that could reliably differentiate healthy nerves from those affected by optic atrophy (OA) and to determine correlations of OND in OA with retinal nerve fiber layer (RNFL) thickness, visual acuity (VA), and visual field mean deviation (VFMD). METHODS: This was a retrospective case control study. Magnetic resonance (MR) images were reviewed from individuals with OA aged 18 years or older with vision loss for more than 6 months and an OA diagnosis established by a neuro-ophthalmologist. Individuals without OA who underwent MR imaging of the orbit for other purposes were also collected. OND was measured on coronal T2-weighted images in the midorbital section, 1cm posterior to the optic disc. Measurements of mean RNFL thickness, VA and VFMD were also collected. RESULTS: In this study 47 OA subjects (63% women, 78 eyes) and 75 normal subjects (42.7% women, 127 eyes) were assessed. Healthy ONDs (mean 2.73 ± 0.24 mm) were significantly greater than OA nerve diameters (mean 1.94 ± 0.32 mm; P < 0.001). A threshold OND of ≤2.3 mm had a sensitivity of 0.92 and a specificity of 0.93 in predicting OA. Mean RNFL (r = 0.05, p = 0.68), VA (r = 0.17, p = 0.14), and VFMD (r = 0.18, p = 0.16) were not significantly associated with OND. CONCLUSION: ONDs are significantly reduced in patients with OA compared with healthy nerves. A threshold OND of ≤2.3 mm is highly sensitive and specific for a diagnosis of OA. OND was not significantly correlated with RNFL thickness, VA, or VFMD.

Machine Learning Insights: Predicting Hepatic Encephalopathy After TIPS Placement.

PURPOSE: To develop and assess machine learning (ML) models' ability to predict post-procedural hepatic encephalopathy (HE) following transjugular intrahepatic portosystemic shunt (TIPS) placement. MATERIALS AND METHODS: In this retrospective study, 327 patients who underwent TIPS for hepatic cirrhosis between 2005 and 2019 were analyzed. Thirty features (8 clinical, 10 laboratory, 12 procedural) were collected, and HE development regardless of severity was recorded one month follow-up. Univariate statistical analysis was performed with numeric and categoric data, as appropriate. Feature selection is used with a sequential feature selection model with fivefold cross-validation (CV). Three ML models were developed using support vector machine (SVM), logistic regression (LR) and CatBoost, algorithms. Performances were evaluated with nested fivefold-CV technique. RESULTS: Post-procedural HE was observed in 105 (32%) patients. Patients with variceal bleeding (p = 0.008) and high post-porto-systemic pressure gradient (p = 0.004) had a significantly increased likelihood of developing HE. Also, patients having only one indication of bleeding or ascites were significantly unlikely to develop HE as well as Budd-Chiari disease (p = 0.03). The feature selection algorithm selected 7 features. Accuracy ratios for the SVM, LR and CatBoost, models were 74%, 75%, and 73%, with area under the curve (AUC) values of 0.82, 0.83, and 0.83, respectively. CONCLUSION: ML models can aid identifying patients at risk of developing HE after TIPS placement, providing an additional tool for patient selection and management.

Machine Learning Models in Prediction of Treatment Response After Chemoembolization with MRI Clinicoradiomics Features.

PURPOSE: To evaluate machine learning models, created with radiomics and clinicoradiomics features, ability to predict local response after TACE. MATERIALS AND METHODS: 188 treatment-naïve patients (150 responders, 38 non-responders) with HCC who underwent TACE were included in this retrospective study. Laboratory, clinical and procedural information were recorded. Local response was evaluated by European Association for the Study of the Liver criteria at 3-months. Radiomics features were extracted from pretreatment pre-contrast enhanced T1 (T1WI) and late arterial-phase contrast-enhanced T1 (CE-T1) MRI images. After data augmentation, data were split into training and test sets (70/30). Intra-class correlations, Pearson's correlation coefficients were analyzed and followed by a sequential-feature-selection (SFS) algorithm for feature selection. Support-vector-machine (SVM) models were trained with radiomics and clinicoradiomics features of T1WI, CE-T1 and the combination of both datasets, respectively. Performance metrics were calculated with the test sets. Models' performances were compared with Delong's test. RESULTS: 1128 features were extracted. In feature selection, SFS algorithm selected 18, 12, 24 and 8 features in T1WI, CE-T1, combined datasets and clinical features, respectively. The SVM models area-under-curve was 0.86 and 0.88 in T1WI; 0.76, 0.71 in CE-T1 and 0.82, 0.91 in the combined dataset, with and without clinical features, respectively. The only significant change was observed after inclusion of clinical features in the combined dataset (p = 0.001). Higher WBC and neutrophil levels were significantly associated with lower treatment response in univariant analysis (p = 0.02, for both). CONCLUSION: Machine learning models created with clinical and MRI radiomics features, may have promise in predicting local response after TACE. LEVEL OF EVIDENCE: Level 4, Case-control study.

MRI Signal Intensity Varies Along the Course of the Normal Optic Nerve.

BACKGROUND: MRI can help distinguish various causes of optic neuropathy including optic neuritis. Importantly, neuromyelitis optica spectrum disorder (NMOSD) has a propensity to cause enhancement of the prechiasmatic optic nerves. To determine whether the prechiasmatic optic nerve (PC-ON) demonstrates a different intensity from the midorbital optic nerve (MO-ON) on MRI among patients without optic neuropathy. METHODS: Data were retrospectively obtained from 75 patients who underwent brain MRI for an ocular motor nerve palsy between January 2005 and April 2021. Inclusion criteria were patients aged 18 years or older with visual acuities of at least 20/25 and no evidence of optic neuropathy on neuro-ophthalmic examination. A total of 67 right eyes and 68 left eyes were assessed. A neuroradiologist performed quantitative intensity measurements of the MO-ON and PC-ON on precontrast and postcontrast T1 axial images. Normal-appearing temporalis muscle intensity was also measured and used as a reference to calculate an intensity ratio to calibrate across images. RESULTS: The mean PC-ON intensity ratio was significantly higher than the MO-ON intensity ratio on both precontrast (19.6%, P < 0.01) and postcontrast images (14.2%, P < 0.01). Age, gender, and laterality did not independently affect measurements. CONCLUSIONS: The prechiasmatic optic nerve shows brighter intensity ratios on both precontrast and postcontrast T1 images than the midorbital optic nerve among normal optic nerves. Clinicians should recognize this subtle signal discrepancy when assessing patients with presumed optic neuropathy.

Correct Stapling Technique in Laparoscopic Sleeve Gastrectomy: Are We Increasing the Bleeding? A Prospective Cohort Study.

Introduction: Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric surgery procedure. Bleeding is the most common complication of this surgery and mostly occurs from the staple line. The aim of this study was to evaluate whether waiting between compression and firing during the stapling phase reduces the postoperative bleeding. Methods: A total of 325 patients who underwent LSG between April and July 2022 were analyzed prospectively. In terms of postoperative bleeding, the two groups, which we waited 30 seconds between staple firings and the no wait group, were compared. Results: The mean age of patients was 37.36 (±11.12) years and mean body mass index was 45.18 (±3.1) kg/m2. Eleven patients needed transfusion. The rate of haemorrhagic complications was 3.38% (Group 1% 6.21 and Group 2% 1.11) (P = .012). The duration of surgery was ∼10 minutes longer in the study group, which we waited (P = .0001). Conclusions: During the stapling stage in LSG, waiting between compression and firing can help reduce postoperative bleeding.

Effect of bariatric surgery procedures on serum cytokine and Nesfatin-1 levels.

BACKGROUND: and Purpose: Obesity is known to cause chronic inflammation. We aimed to evaluate the changes in Nesfatin-1 and serum cytokine levels of patients who underwent sleeve gastrectomy or gastric bypass surgery. METHODS: A total of 30 patients with BMI>35 and undergoing bariatric surgery were divided in two group, sleeve gastrectomy (SG) (group-1), Roux-en-Y gastric bypass (RYGB) (group-2). Demographic data, weight, BMI, AST, ALT, blood glucose, CRP values, and IL-1ß, IFN-α, IFN-γ, TNF-α, MCP-1, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IL-18, IL-23, IL-33 cytokine, and Nesfatin-1 values were noted at the time of hospitalization and in the 6th month postoperative follow-up. RESULTS: The mean age of the patients was 37.56 ± 11.73 years, and there were 16 females and 14 males in the study. Body weight and excess body weight change were slightly higher in RYGB patients than in SG patients. In RYGB and SG patients, a significant decrease was found in glucose, AST, ALT, CRP, IL-6, IL-10, and IL-18 values compared to the preoperative period, and serum Nesfatin-1 levels were significantly increased in RYGB patients and not significantly in SG patients. There were also significant decreases in IL-1ß levels in RYGB patients. On the other hand, a decrease in cytokines was observed in both surgical methods, except for IL-17A, although it was not significant. CONCLUSION: The present study showed that there is also a regression in inflammation, which can be associated with NLRP3 inflammasome, due to weight loss after bariatric surgery, more specifically in RYGB.

Prediction of Response of Hepatocellular Carcinoma to Radioembolization: Machine Learning Using Preprocedural Clinical Factors and MR Imaging Radiomics.

PURPOSE: To create and evaluate the ability of machine learning-based models with clinicoradiomic features to predict radiologic response after transarterial radioembolization (TARE). MATERIALS AND METHODS: 82 treatment-naïve patients (65 responders and 17 nonresponders; median age: 65 years; interquartile range: 11) who underwent selective TARE were included. Treatment responses were evaluated using the European Association for the Study of the Liver criteria at 3-month follow-up. Laboratory, clinical, and procedural information were collected. Radiomic features were extracted from pretreatment contrast-enhanced T1-weighted magnetic resonance images obtained within 3 months before TARE. Feature selection consisted of intraclass correlation, followed by Pearson correlation analysis and finally, sequential feature selection algorithm. Support vector machine, logistic regression, random forest, and LightGBM models were created with both clinicoradiomic features and clinical features alone. Performance metrics were calculated with a nested 5-fold cross-validation technique. The performances of the models were compared by Wilcoxon signed-rank and Friedman tests. RESULTS: In total, 1,128 features were extracted. The feature selection process resulted in 12 features (8 radiomic and 4 clinical features) being included in the final analysis. The area under the receiver operating characteristic curve values from the support vector machine, logistic regression, random forest, and LightGBM models were 0.94, 0.94, 0.88, and 0.92 with clinicoradiomic features and 0.82, 0.83, 0.82, and 0.83 with clinical features alone, respectively. All models exhibited significantly higher performances when radiomic features were included (P = .028, .028, .043, and .028, respectively). CONCLUSIONS: Based on clinical and imaging-based information before treatment, machine learning-based clinicoradiomic models demonstrated potential to predict response to TARE.

A Case Report of Malaria Infection Following Laparoscopic Sleeve Gastrectomy.

A 41-year-old woman from the Democratic Republic of the Congo underwent laparoscopic sleeve gastrectomy (LSG) as a surgical treatment for obesity. Despite an unremarkable preoperative evaluation, the patient developed a fever and elevated C-reactive protein (CRP) levels postoperatively. Physical examination findings, laboratory tests, and imaging studies ruled out surgical complications, leading to the consideration of infectious causes. A thorough patient history revealed a residence in a malaria-endemic region with a history of recurrent malaria episodes. In addition to her complaints, the patient developed pancytopenia. The blood smear revealed the presence of ring forms of Plasmodium falciparum in red blood cells, along with other species of Plasmodium. The rapid diagnostic test (RDT) showed a positive result for the P. falciparum antigen, a negative result for the P. vivax antigen, and a positive result for the pan-antigen. Based on these findings, a mixed malaria infection was considered for the patient, and she was transferred to an advanced infectious disease hospital for specific typing and further treatment. The patient received prompt treatment and was discharged in stable condition. Malaria could potentially be among the uncommon factors leading to fever after bariatric surgery in patients from malaria-endemic countries. Surgical stress may exacerbate the course of a malaria infection.

Sleeve gastrectomy in situsinversustotalis case.

Laparoscopic sleeve gastrectomy surgery is a procedure that has become more common in the past 10 years. Situsinversustotalis is an extremely rare condition. SG can be performed safely in SIT patients. However, pre-operative multidisciplinary evaluation is very important. In this article, we present a 25-year-old female patient with a body mass index of 47.6 who had no idea that she had SIT until pre-operative tests revealed it. The patient was discharged on the 3rd post-operative day without any problem. We would like to emphasize the importance of imaging even if the patient does not have any disease or risk before bariatric surgery. We believe that more studies should be done with SIT and bariatric surgery.

Acute Intrathoracic Migration With Incarceration of Laparoscopic Sleeve Gastrectomy Due to Incomplete Hiatal Hernia Repair.

Concomitant hiatal hernia repair during laparoscopic sleeve gastrectomy (LSG) is recommended if it is detected. Intrathoracic sleeve migration (ITSM) is a sliding hiatal hernia that develops after LSG. In this article, we present an early ITSM due to an incomplete repair of a hiatal hernia. An obese patient had hiatal hernia in the preoperative endoscopy. After LSG, the defect was repaired with anterior cruroplasty. Vomiting attacks were observed after the operation. Based on clinical signs and radiological findings, laparoscopic exploration was indicated. During the reoperation, an acute entrapment of the upper portion of the sleeve was observed, which had migrated through the hiatus. This suture was undone. There was no gastric ischemia. No additional hiatal repair was attempted. The operation was sufficient to alleviate the symptoms. The patient was discharged on the second postoperative day uneventfully. Until the most recent follow-up, the patient has progressed with adequate weight loss, without complaints of reflux and without proton pump inhibitors ITSM with incarceration is a complication that can occur after incomplete hiatal repair. Failure to perform hiatal repair with proper technique can be attributed to this complication.

Incidental detection of gastrointestinal stromal tumors during laparoscopic sleeve gastrectomy. What to do?

INTRODUCTION: We evaluated and characterized the incidental GISTs during laparoscopic sleeve gastrectomy in our clinic. METHODS: All GISTs identified during laparoscopic sleeve gastrectomy between January 2015 and December 2017 were evaluated. Typical demographic, clinicopathologic, treatment, location, resection margins, immunohistochemistry (CD 34, CD 117, ASMA, desmin and S100) and criteria for oncological aggressiveness (tumor size, number of mitoses, presence or absence of tumor necrosis) data were recorded. RESULTS: Within the 800 bariatric surgeries at our institution, 7 GISTs were identified (0.87%). The median age of the patients was 32 years (age range: 24-42 years). The mean BMI was found to be 40.66 kg/m2 (range: 35-44 kg/m2). All GIST cases were found in the stomach samples. All tumors were not larger than 20 mm. All tumors were found close to the greater curvature of the stomach; in five cases, tumors were located in a single focus, while in 1 case, it was located both in the corpus and fundus. CD117 and CD34 were found to be positive in the pathological examination of all parts. In addition, desmin, smooth muscle actin (SMA) and S-100 were also positively stained. No complications or mortality were observed in this series. CONCLUSION: Tumor resection with a negative surgical margin may be considered complete oncologic treatment in case of presence of very low or low risk classification of postoperative GIST recurrence. After GIST resection, all patients should remain under long-term postoperative care. KEY WORDS: Bariatric surgery, Incidental gastrointestinal stromal tumors, Obesity, Sleeve gastrectomy.

Contrast enhancement in cerebral adrenoleukodystrophy: a comparison of T1 TSE and MPRAGE sequences.

PURPOSE: To compare conventional T1 TSE with MPRAGE for enhancement detection in cerebral adrenoleukodystrophy (CALD). MATERIALS AND METHODS: Contrast-enhanced T1 TSE and MPRAGE sequences of 34 CALD patients demonstrating enhancement were evaluated. Contrast ratios were calculated by drawing ROIs to the most enhancing part of demyelination and normal-appearing deep white matter on both T1 TSE and MPRAGE. A comparison was performed between ratios using paired T test. RESULTS: Mean age of 34 included male children was 8 (5-11 years). There was no statistically significant difference between T1 TSE and MPRAGE ratios. However, in 4 out of 34 examinations, minimal contrast enhancement was noted only in T1 TSE sequence. CONCLUSION: Our data indicate that both T1 TSE and MPRAGE sequences are valuable in determining contrast enhancement in CALD. Although there is not a statistically significant difference between the two techniques, T1 TSE sequence appears to be more sensitive for low degree of enhancement.

GammaTile® brachytherapy in the treatment of recurrent glioblastomas.

BACKGROUND: GammaTile® (GT) is a recent U.S. Food and Drug Administration (FDA) cleared brachytherapy platform. Here, we report clinical outcomes for recurrent glioblastoma patients after GT treatment following maximal safe resection. METHODS: We prospectively followed twenty-two consecutive Isocitrate Dehydrogenase (IDH) wild-type glioblastoma patients (6 O6-Methylguanine-DNA methyltransferase methylated (MGMTm); sixteen MGMT unmethylated (MGMTu)) who underwent maximal safe resection of recurrent tumor followed by GT placement. RESULTS: The cohort consisted of 14 second and eight third recurrences. In terms of procedural safety, there was one 30-day re-admission (4.5%) for an incisional cerebrospinal fluid leak, which resolved with lumbar drainage. No other wound complications were observed. Six patients (27.2%) declined in Karnofsky Performance Score (KPS) after surgery due to worsening existing deficits. One patient suffered a new-onset seizure postsurgery (4.5%). There was one (4.5%) 30-day mortality from intracranial hemorrhage secondary to heparinization for an ischemic limb. The mean follow-up was 733 days (range 279-1775) from the time of initial diagnosis. Six-month local control (LC6) and twelve-month local control (LC12) were 86 and 81%, respectively. Median progression-free survival (PFS) was comparable for MGMTu and MGMTm patients (~8.0 months). Median overall survival (OS) was 20.0 months for the MGMTu patients and 37.4 months for MGMTm patients. These outcomes compared favorably to data in the published literature and an independent glioblastoma cohort of comparable patients without GT treatment. CONCLUSIONS: This clinical experience supports GT brachytherapy as a treatment option in a multi-modality treatment strategy for recurrent glioblastomas.

Inflammatory Scores: Comparison and Utility in HCC Patients Undergoing Transarterial Chemoembolization in a North American Cohort.

BACKGROUND: The purpose of this study is to determine and compare the ability of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), aspartate-aminotransferase-to-lymphocyte ratio (ALRI), systemic-inflammation index (SII) and lymphocyte count to predict oncologic outcomes in hepatocellular carcinoma (HCC) patients undergoing transarterial chemoembolization (TACE). MATERIALS AND METHODS: A single-center retrospective review of 296 patients who were treated for 457 HCCs was performed. Pre- and post-treatment laboratory and treatment outcome variables were collected. Objective radiologic response (ORR), progression-free survival (PFS), and overall survival (OS) were evaluated. Patients were categorized into above and below median scores and compared. RESULTS: The median pretreatment NLR, PLR, ALRI, SII, and lymphocyte count were 2.7 (range: 0.4-55), 88.3 (range: 0.1-840), 71.8 (range: 0.1-910), 238.1 (range: 0.1-5150.8), and 1 (range: 0.1-5.2) 103/µL, respectively. Patients with above median ALRI scores were less likely to achieve an ORR as compared to those with below median ALRI values (132 (132/163, 81%) vs 150 (150/163, 92%), p = 0.004). On univariate analysis, patients with above median pretreatment NLR (HR 1.41, 95% CI: 1.09-1.83, p = 0.01) and below median lymphocyte count (HR 0.69, 95% CI: 0.53-0.92, p = 0.01) had significantly worse PFS. The relationship between PFS and NLR (p = 0.08) as well as lymphocytes (p = 0.20) no longer remained on multivariate analysis. On univariate analysis, below median pretreatment NLR (HR 1.72, 95% CI: 1.2-2.45, p = 0.003) and ALRI (HR 1.52, 95% CI: 1.05-2.2); p = 0.03) as well as above median lymphocyte count (HR 0.48, 95% CI: 0.34-0.7, p < 0.0001) were associated with improved OS. The significant relationship between lymphocytes and OS remained on multivariate analysis (HR 0.50, 95% CI: 0.28-0.9, p = 0.02), but the relationship with NLR (p = 0.94) did not persist. CONCLUSION: NLR is predictive of PFS and OS in patients with HCC undergoing TACE and may be superior to other inflammatory scores (PLR, ALRI, and SII) in this setting. However, lymphocyte count may be most predictive of OS.