The Impact of Blood Pressure Switching (from Controlled Hypotension to Late Elevated Blood Pressure) During Laparoscopic Sleeve Gastrectomy: Controlled Clinical Trial.

PURPOSE: Laparoscopic sleeve gastrectomy (LSG) is the most done bariatric procedure. Bleeding and leak are the most common associated complications. Elevation of systolic blood pressure (SBP) leads to discovering the bleeding sites but results in a bloody field and increases the operative time. Controlled hypotension shortens the operative time, reduces tissue edema, and improves field vision. We aimed to test controlled hypotension during LSG. MATERIAL AND METHODS: This was a randomized controlled trial that included 200 patients who were operated by LSG, randomly assigned to 2 equal groups: group 1, operated with controlled hypotensive anesthesia, and group 2, operated with elevated SBP to 140 mmHg. RESULTS: Of the patients, 162 (81%) were females, and 38 (19%) were male. The mean BMI was 45.7 kg/m2. The mean age was 41.7 years. The operative time was 36.43 ± 6.73 min in group 1 vs. 44.71 ± 5.47 min in group 2. The mean of total number of used gauzes and clips was 2.70 ± 3.49 in group 1 vs. 8.83 ± 3.15 in group 2. The mean amount of drain output was 37.65 ± 21.90 ml in group 1 vs. 74.00 ± 16.54 ml in group 2. The mean drop in the postoperative hematocrit was 0.08 in group 1 vs. 0.22 in group 2. The incidence of postoperative bleeding was 0% in group 1 vs. 1% in group 2. CONCLUSIONS: Controlled hypotensive anesthesia in LSG reduces the operative time, reduces the intraoperative bleeding, and improves the operative field.

Single-Anastomosis Sleeve Jejunal (SAS-J) Bypass as Revisional Surgery After Primary Restrictive Bariatric Procedures.

PURPOSE: Single-anastomosis sleeve jejunal (SAS-J) bypass is the modification of a single-anastomosis sleeve ileal (SASI) bypass with a short biliary limb. SAS-J bypass is reported to be a good primary bariatric procedure. This study aimed to evaluate the results of SAS-J bypass as a revisional surgery after failed primary restrictive bariatric procedures. MATERIAL AND METHODS: This was a prospective cohort study including 43 patients who underwent SAS-J bypass as a revisional surgery for weight regain after laparoscopic sleeve gastrectomy (LSG), laparoscopic adjustable gastric band (LAGB), or laparoscopic gastric plication. RESULTS: Of the total patients, 35 (81.4%) were female, and 8 (18.6%) were male. The mean BMI was 46.3 kg/m2. The mean age was 41 years. Thirty-two patients (74.4%) had a failed sleeve, 9 (20.9%) had a failed LAGB, and 2 (4.7%) had a failed gastric plication. The mean operative time was 104 min. Intra-abdominal bleeding occurred in 1 case (2.3%), and intraluminal bleeding occurred in 3 cases (7%). No case (0%) developed a leak. The percentage of excess weight loss (%EWL) reached 76.5% after 1 year. Type 2 diabetes mellitus remission occurred in all diabetic patients, hypertension remitted in 80%, hyperlipidemia remitted in 83.3%, and obstructive sleep apnea syndrome improved in all cases. Gastroesophageal reflux disease (GERD) symptoms were improved in 86.7% of patients. Significant biliary gastritis occurred in 4 patients (9.3%). Dumping syndrome was reported in 4 patients (9.3%). CONCLUSIONS: SAS-J bypass was effective as a salvage surgery after failed restrictive bariatric procedures, but long-term follow-up is needed.

Single anastomosis sleeve jejunal (SAS-J) bypass as a treatment for morbid obesity, technique and review of 1986 cases and 6 Years follow-up. Retrospective cohort.

BACKGROUND: Santoro's operation is a sleeve gastrectomy with transit bipartition. The operation aims to maintain passage to the duodenum to minimize nutritional deficiency. This procedure is rapidly changed to single anastomosis sleeve ileal (SASI) bypass. SAS-J bypass is a modification of SASI with a short biliary limb. MATERIAL AND METHODS: This study is a retrospective study of prospectively collected data. The study includes a comprehensive review of 1986 patients who underwent SAS-J bypass over 6 years. The total number is used to evaluate the perioperative data. One- and two-year follow-up was used to evaluate weight loss and comorbidities; follow-up of more than 5 years was used to obtain long-term results. RESULTS: In this study, 70.4% of patients were female and 29.6% were male. The mean body mass index (BMI) was 44.7. The mean age was 42 years. Regarding comorbidities, 25.8% of the patients had type 2 diabetes, 31% were hypertensive, 14.2% had sleep apnea syndrome, 6.6% had gastroesophageal reflux disease (GERD), and 39.6% had hyperlipidemia. Of the 1294 patients who complete one-year follow up, %EWL reached 87%. Blood glucose levels were normalized in 98.5% of patients, hypertension remitted in 93%, hyperlipidemia improved in 97%, SAS is improved in all cases, and GERD improved in 89% of patients. After 5 years, 94 patients' BMI decreased from 44.3 to 28.3 without significant nutritional deficiency. CONCLUSIONS: Laparoscopic SAS-J bypass is an effective and simple alternative bariatric procedure at short- and long-term follow-up.

Intra-capsular total thyroid enucleation versus total thyroidectomy in treatment of benign multinodular goiter. A prospective randomized controlled clinical trial.

BACKGROUND: Due to high recurrence rate after subtotal thyroidectomy, most of centers have shifted to total thyroidectomy as a surgical treatment for benign multinodular goiter (BMNG), but serious complications, as laryngeal nerve affection & hypocalcaemia, are still present. This study aimed to evaluate treatment of BMNG using intra-capsular total thyroid enucleation in comparison to standard total thyroidectomy. PATIENTS &METHODS: This is a prospective randomized controlled clinical trial conducted in a hospital in the period from December 2009 to December 2015. Of total 224 patients with clinically BMNG. 112 patients operated by intracapsular total thyroid enucleation (ITTE group) and the other 112 patients operated by standard total thyroidectomy (STT group). The minimal follow up period was 36 months. RESULTS: The mean operative time in ITTE group was (93.7 ± 9.6 min) compared to (86.9 ± 8.3 min) in STT group. Transient recurrent laryngeal nerve (RLN) palsy was 0% in ITTE group VS 7.1% in STT group. No cases (0%) developed permanent RLN palsy in ITTE group VS 0.9% in STT group. Symptomatic transient hypocalcaemia occurred in 1.8% in ITTE group VS 11.6% in STT group. No cases (0%) developed permanent hypocalcaemia in ITTE group VS 0.9% in STT group. No recurrence (0%) in both groups after minimal 3 years of follow up. CONCLUSION: Intracapsular Total thyroid enucleation technique is safe with the least serious complications, especially RLN injury and hypoparathyroidism, with no recurrence, but this technique still not radical so couldn't be used in suspicious cases for malignancy.

Retroinfundibular laparoscopic cholecystectomy versus standard laparoscopic cholecystectomy in difficult cases.

BACKGROUND: Laparoscopic cholecystectomy becomes the gold standard surgical procedure for treating gallstones. Standard laparoscopic cholecystectomy (SLC) requires proper dissection of Calot's triangle to achieve the critical view of safety. This may be difficult in certain conditions, resulting in higher incidence of bile duct injury and conversion to open. We aimed to compare the outcomes of laparoscopic cholecystectomy by retroinfundibular (RI) approach to that of SLC, in difficult cases. PATIENTS AND METHODS: This study is prospective cohort study, in which 60 patients were operated by SLC and 65 patients by laparoscopic cholecystectomy by RI approach. RESULTS: From the total 125 cases, 95 (76%) patients were male and 30 (24%) were female. The mean age was 59.5 ± 5.5 years. The mean operative time in SLC group was 128 ± 17 min VS. 114 ± 10 min in RI group. Conversion to open occurred in 10% in SLC group VS. 1.5% in RI group. Biliary injury occurred in 3.3% in SLC group VS. 0% in RI group. The mean hospital stay in SLC was 3.7 ± 5.3 days VS. 2.1 ± 0.3 days in RI group. CONCLUSION: In difficult cholecystectomy, RI approach is feasible and safe alternative to SLC.

Karydakis Flap With Compressing Tie-over Interrupted Sutures Without Drain versus Standard Karydakis for Treatment of Sacrococcygeal Pilonidal Sinus Disease.

BACKGROUND: Sacroccygeal pilonidal sinus disease is a worldwide health problem, affecting young adults, mainly males, with a tendency for recurrence. Various modalities have been used for treating this condition. The Karydakis procedure is one of most commonly used asymmetric flaps for treating this condition. OBJECTIVE: The study aimed to evaluate the Karydakis procedure with tie-over compressing sutures instead of the routine use of a drain in the treatment pilonidal sinus. DESIGN: This prospective randomized controlled clinical study was conducted between January 2010 and January 2015. SETTINGS: The study was conducted at Minia University Hospital. PATIENTS: The study included 154 patients. Patients were randomly assigned into 2 equal groups. INTERVENTIONS: The patients in group 1 were operated on by the standard Karydakis procedure, and the patients in group 2 were operated on by the Karydakis procedure with tie-over compressing sutures without a drain. MAIN OUTCOMES AND MEASURES: The primary outcomes measured were the incidence of seroma formation, wound complications, length of hospital stay, off-work time, and recurrence rate. RESULTS: All patients were discharged on the same day of surgery in group 2 compared with a mean hospital stay of 4.9 ± 2.4 days in group 1. No patients developed seroma in group 2 compared with 7.8% in group 1. In group 2, 1.3% of patients developed wound infection compared with 9.1% in group 1. The average time for return to work in group 2 was 10.2 ± 1.4 days compared with 12.6 ± 4 days in group 1. No recurrences were noted in group 2 compared with 2.6% in group 1. LIMITATIONS: The feedback about postoperative pain and patient satisfaction about the scar were not investigated. The extent of the disease in both groups was not investigated. The duration of follow-up too short to accurately weight recurrence rate. CONCLUSION: Karydakis flap with tie-over compressing interrupted sutures without a drain is safe, 1-day surgery with the lowest complications rate.