Medium-Term Outcomes after Reversal of Roux-en-Y Gastric Bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) can be reversed into normal anatomy (NA) or into sleeve gastrectomy (NASG) to address undesired side effects. Concomitant hiatal hernia repair (HHR) may be required. Before reversal, some patients benefit from placement of a gastrostomy, mostly to predict the result of recreating the native anatomy. METHODS: Retrospective study on mid-term effects of RYGB reversal to NA and NASG, including clinical and weight evolution, surgical complications, and incidence of gastro-esophageal reflux (GERD). RESULTS: Undesired side effects leading to reversal included early dumping syndrome, hypoglycemia, malnutrition, severe diarrhea and excessive nausea and vomiting. Twenty-five participants to the study, 13 NA, 12 NASG, and 15 HHR. Mean follow-up time was 5.3 ± 2.3 years. Reversal corrected early dumping, malnutrition, diarrhea, and nausea/vomiting. For hypoglycemic syndrome, resolution rate was 6/8 (75%). NA caused significant weight regain (14.2 ± 13.7 kg, (p = .003)). NASG caused some weight loss (4.8 ± 15.7 kg (NS)). Gastrostomy placement gave complications at reversal in five of seven individuals. Eight patients suffered a severe complication, including leaks (one NA vs. three NASGs). Eight out of 14 (57.1%) patients who previously had never experienced GERD developed de novo GERD after reversal, despite HHR. CONCLUSIONS: RYGB reversal is effective but pre-reversal gastrostomy and concomitant HHR may be aggravating factors for complications and development of de novo GERD, respectively.

Histamine restores hemorrhage induced hypotension by activating cholinergic neurons in nucleus tractus solitarius.

The purpose of the current study is to investigate the functional connections between the central histaminergic and cholinergic systems at NTS level in hypotensive condition. Experiments were carried out in male Wistar Albino rats. The hypotension was achieved by withdrawing a total volume of 1.5ml blood/100g bodyweight over a period of 10min. A microdialysis study was performed in NTS area to measure extracellular ACh and Ch levels. The hemorrhage produced a severe and long-lasting decrease in mean arterial blood pressure (MAP) and increase in extracellular ACh and Ch levels in NTS. Administration of histamine intracerebroventricularly (i.c.v.) or into the NTS reversed the hemorrhagic hypotension by increasing MAP and heart rate. I.c.v. injection of histamine also caused the additional increase in extracellular ACh and Ch levels. Moreover, central histamine injection augmented intracytoplasmic AChE immunoreactivity in NTS. These changes were completely blocked by histaminergic H1 receptor antagonist chlorpheniramine, but histaminergic H2 receptor blocker ranitidine and histaminergic H3/H4 receptor antagonist thioperamide failed to produce these effects. In conclusion, these findings are interpreted that brain histaminergic H1 receptor activation by central histamine injection may promote cholinergic stimulation in the NTS and subsequently reverses the hypotension.

Brain thromboxane A2 via arachidonic acid cascade induces the hypothalamic-pituitary-gonadal axis activation in rats.

The current study was designed to determine the effect of centrally administrated arachidonic acid (AA) on plasma gonadotropin hormone-releasing hormone (GnRH), follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone level, and sperm parameters, and to show the mediation of the central cyclooxygenase (COX) to thromboxane A2 (TXA2) signaling pathway in AA-induced hormonal and sperm parameter effects. Studies were performed in male Sprague-Dawley rats. A total of 150 or 300 µl/5 µl doses of AA were injected intracerebroventricularly (icv). AA significantly caused dose- and time-dependent increases in plasma FSH, LH and testosterone levels of animals, but not plasma GnRH level. AA also significantly increased sperm motility of the rats without change sperm number. Pretreated with ibuprofen, a nonselective COX inhibitor (250 µg/5 µl; icv), and furegrelate, a TXA2 synthesis inhibitor (250 µg/5 µl; icv), prevented AA-evoked increase in plasma FSH, LH and testosterone levels, and sperm motility. In conclusion, our findings show that centrally administered AA increases plasma FSH, LH and testosterone levels and sperm motility of conscious male rats. Moreover, according to our findings, central COX-TXA2 signaling pathway mediates these AA-induced effects.

Uniform talc delivery during video-assisted thoracoscopic pleurodesis.

Video-assisted thoracoscopic talc pleurodesis is a highly effective technique to manage recurrent pneumothorax or pleural effusion. However, inhomogenous talc delivery might be a cause of failure. We report a simple and inexpensive technique for uniform talc dispersion with complete covering of the pleural space during video-assisted thoracoscopic pleurodesis.

Symptomatic adenomyomatosis of the gallbladder--report of a case.

Adenomyomatosis of the gallbladder is a benign and degenerative condition of the gallbladder, characterized by proliferation of the mucosa of the gallbladder wall, forming invaginations and diverticula, penetrating a thickened muscular layer: the so-called Rokitansky-Aschoff sinuses (RAS). Most of the patients with adenomyomatosis remain asymptomatic. Hence adenomyomatosis is usually an incidental finding, either on ultrasonography performed for the detection of stones or by histologic examination of surgical gallbladder specimens. Only occasionally does adenomyomatosis not associated with cholelithiasis cause right upper quadrant pain. We report a case of symptomatic adenomyomatosis of the gallbladder. Clinical findings, etiology, diagnosis and therapy are discussed.

Technique for introducing large composite mesh while performing laparoscopic incisional hernioplasty.

BACKGROUND: Incisional hernias are treated laparoscopically in an increasing number of cases. The simplest technique is the peritoneal onlay technique. Composite mesh, consisting of one layer of polypropylene mesh, destined to face the abdominal wall, and one layer of less adhesion-inducing material, destined to face the bowel, has been developed in an effort to avoid intraperitoneal adhesion formation and viscus erosion. While probably superior, this type of mesh is very bulky, easily damaged, and hence extremely difficult to be safely introduced through conventional trocars. METHODS: We present a simple technique to safely introduce intraperitoneally large sheets of composite mesh, without the need for larger-bore cannulas. After temporarily removing one of the 10 mm trocars, the mesh is rolled as tightly as possible and placed in a sterile bag, which is then easily introduced intraperitoneally through the trocar opening. RESULTS: Between September 1999 and January 2000 the technique was successfully used in 12 patients. CONCLUSION: This simple trick protects the mesh while making its intraperitoneal introduction straightforward. It is quick, cheap, and easily reproducible.

Laparoscopic pyloric exclusion after endoscopic retrograde cholangiopancreatography perforation.

We describe a laparoscopic technique of pyloric exclusion with gastroenterostomy and common bile duct T tube insertion for obvious perforation at endoscopic retrograde cholangiopancreatography with papillotomy. The patient was operated on immediately after diagnosis of the lesion. The postoperative sequellae were very comparable to those of elective laparoscopic common bile duct exploration. We believe this approach is interesting, especially in the current era of frequent litigation.

Causes of dissatisfaction in some patients after adjustable gastric banding.

BACKGROUND: The laparoscopic application of the adjustable gastric band has gained widespread acceptance as a gastric restrictive procedure. The weight loss been well documented. This paper evaluates the patients' satisfaction. METHODS: Between April 1995 and July 1999, 82 consecutive patients underwent the Lap-Band procedure. RESULTS: Follow-up is 100%. The satisfaction index is high. 80% of all patients are extremely pleased or pleased. 15% of patients are displeased or extremely displeased. 5% have no opinion. The reason for low satisfaction differ, but 3 groups can be distinguished: 1) patients who suffered surgical complications; 2) patients who did not benefit from the procedure; 3) most importantly, patients who suffered psychological complications. CONCLUSION: Gastric Banding is a safe, standardized and effective operation, with good acceptance by the patients. More efforts have to be made to improve patient selection and to avoid surgical complications. Most importantly, more focus is needed on the psychological aspect of the procedure and its consequences.

Evaluation of telesurgical (robotic) NISSEN fundoplication.

BACKGROUND: The laparoscopic surgical approach has proven its benefit for the patient. There are however several shortcomings, which have triggered considerable research for improvement. One improvement may be the introduction of telesurgery by the interposition of a computer interface between surgeon and patient. MATERIAL AND METHODS: A prospective randomized study was conducted in an advanced laparoscopic procedure, Nissen fundoplication. The control group underwent the conventional laparoscopic approach, while the investigational group underwent the telesurgical approach. RESULTS: Feasibility was 100%. The procedure was more time consuming in the Telesurgical group, at all stages of the operation. Mortality was nil and morbidity was comparable in both groups. CONCLUSION: The telesurgical approach is feasible in advanced laparoscopic procedures like Nissen fundoplication. At the present time there is however no obvious added benefit from this new technique.

Laparoscopic inflatable band with Roux-en-Y gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) leaves a large blind gastric segment, which is inaccessible for conventional endoscopy. METHOD: A case is reported, describing a variation of laparoscopic RYGBP by partitioning the stomach by an inflatable band rather than by stapling or division. RESULTS: The stomach was partitioned into a proximal 15 cc pouch and a distal part by an adjustable gastric band. A RYGBP was fashioned from the proximal pouch. 9 patients were treated with this technique: 7 as an initial procedure and 2 after previous gastric banding which had been followed by insufficient weight loss. 1 of these latter patients developed erosion of the band through the gastrojejunostomy 7 months postoperatively. CONCLUSION: Laparoscopic proximal RYGBP with inflatable-band gastric partitioning is feasible. Erosion of the band though the gastrojejunostomy, however, might be a serious side-effect of this technique.

Video-assisted thoracoscopic repair of an intercostal pulmonary hernia.

Pulmonary hernias are extremely rare. They are usually treated with open surgical procedures. We describe a case in which a large, spontaneously acquired intercostal pulmonary hernia was successfully repaired by video-assisted thoracoscopic surgery (VATS).

Hand-assisted laparoscopic splenectomy for hydatid cyst.

Splenic hydatidosis is a rare condition. We performed a hand-assisted laparoscopic splenectomy for a large hydatid cyst localized in the center of the spleen. We discuss the advantages of the "helping hand."

An unusual case of small bowel obstruction.

A patient with small bowel obstruction due to a fruit pith (peach) is presented. The diagnostic work up, the treatment and a review of the literature in the matter of obstructions due to swallowed goods are presented. Intestinal obstruction due to ingested organic material is a clinical entity on its own, and careful history taking can give a clue for diagnosis.

An unusual low-abdominal tumor: cystadenoma of the seminal vesicle.

Cystadenoma of the seminal vesicle is an extremely rare benign tumor, which to our findings has only been mentioned earlier in seven previous reports. It is a benign and mostly multilocular tumor, thought to originate from embryologic remnants. Preoperative diagnosis is rarely made. Complete extirpation is the correct treatment. We present this first Belgian case with a discussion of imaging techniques, symptomatology, pathology, diagnosis, and treatment.

Common bile duct stone caused by a foreign body: a case report and literature review.

Foreign bodies are very rare in the common bile duct. We report an unusual case of transient obstructive jaundice, due to a choledochal stone formed around an ingested woody fiber. Review of the literature.