Is an Early Resumption of a Regular Diet After Laparoscopic Roux-en-Y Gastric Bypass Safe?

BACKGROUND: Return to a normal diet is a crucial step after bariatric surgery. Proximal anastomosis is a source of concern for early feeding as the passage of solid food through a recent anastomosis could well increase pressure and the risk of leakage. This study aims to assess the safety of an early normal diet after a laparoscopic Roux-en-Y gastric bypass (LRYGB). MATERIALS AND METHODS: All consecutive patients undergoing primary LRYGB between January 2015 and December 2020 were included prospectively. Three postoperative pureed diets were compared at 4 weeks, 2 weeks, and 1 week. All-cause morbidity at 90 days was the main outcome. Overall complications, severe complications (Clavien-Dindo ≥ grade 3a), length of hospital stay, number of emergency, and unplanned consultations during the 3 postoperative months were recorded for each group. RESULTS: Three hundred and sixty-seven patients with a mean BMI of 42.10 kg/m2 (± SD: 4.78) were included. All-cause morbidity at 90 days was 11.7% (43/367) and no significant difference was observed between the 3 groups. Adjustment for patients and operative cofounders did not demonstrate any increased risk of postoperative complications between the 3 groups, with an odds ratio of 1, 1.23(95% CI [0. 55-2.75]), and 1.14 (95% CI [0.49, 2.67]) for groups 1, 2, and 3 respectively. Severe complications (Clavien-Dindo ≥ grade 3a) and emergency or unplanned consultations were also similar in the 3 groups. CONCLUSION: Return to a normal diet 1 week after LRYGB did not increase short-term morbidity and unplanned consultations. It may be safe and contribute to patient comfort.

Degenerated Serous Cystic Tumor of the Pancreas: Case Report and Literature Review of an Aggressive Presentation of a Benign Tumor.

BACKGROUND Serous cystic tumors of the pancreas are known to present a benign nature and course, not requiring surgery in the absence of symptoms. In rare cases, these benign tumors may present aggressive characteristics such as local infiltration and lymph node and distant metastases. In such cases, a surgical approach may be necessary. CASE REPORT We present the case of a 79-year-old woman with an asymptomatic cytologically suggested caudal serous cystic tumor infiltrating the spleen and the splenic vein. This tumor was discovered in a computed tomography scan in the setting of evaluating distant spreading of a primary malignant neoplasm of the rectum. Suspicious malignant signs on imaging dictated a surgical approach and a distal splenopancreatectomy was carried out in the same operative time as the transanal resection of the rectal lesion. The nature of the pancreatic neoplasm was confirmed by histology, but 2 lymph nodes out of 4 retrieved were positive. The postoperative course was uneventful. No adjuvant treatment was proposed. Imaging control 6 months after surgery was not indicative of relapse. CONCLUSIONS Serous cystic adenomas of the pancreas, although generally considered benign neoplasms, may present with characteristics of malignancy. Moreover, they may prove difficult to differentiate from other malignant neoplasms by non-surgical modalities. Although current guidelines and data from the literature provide controversial information regarding management of these clinical entities, in the presence of suspicious radiological aspects, surgical resection could be considered.

Impact of the presence of median arcuate ligament on biliary complications after liver transplantation.

INTRODUCTION: The presence of median arcuate ligament (MAL) during orthotopic liver transplantation (OLT) may cause a significant reduction in the arterial hepatic flow. The aim of the present study is to investigate the impact of MAL on biliary complications in patients who underwent OLT. METHODS: We performed a retrospective case-control study among patients who underwent OLT in Geneva University Hospital between 2007 and 2017, depending on the presence or absence of MAL. The matching was performed according to age, gender, lab-MELD score at the time of OLT and type of donor (living or dead). The presence of MAL was assessed by an expert liver radiologist on the preoperative CT angiographic evaluation. RESULTS: The incidence of MAL was 6.1% (19 patients). Baseline characteristics were comparable between the two groups. No significant difference in biliary complications was found between patients with and without MAL (37% and 24%, respectively). No patient presented hepatic artery thrombosis. After logistic regression, in patients with MAL, the MAL release and gastroduodenal artery preservation compared to no treatment, showed an odds ratio for post-OLT biliary complications of 1.5 and 1.25, respectively. There was no difference in overall graft survival and in hazard for biliary complications between patients with and without MAL. CONCLUSION: In the present study, we did not find any difference in the prevalence of biliary and arterial complications between patients with and without MAL. The choice of MAL treatment did not influence in a significant way the overall outcome and development of complications. However, if, at the end of arterial reconstruction, the arterial flow is not adequately established, MAL needs to be treated with the least invasive technique.

The Use of a Stoma Rod/Bridge to Prevent Retraction: A Systematic Review.

PURPOSE: We evaluated evidence related to the use of a rod (bridge) to prevent stoma retraction during loop ostomy construction. METHODS: We completed a systematic review of the literature. We searched MEDLINE, EMBASE, and COCHRANE databases up to December 4, 2019. We posed the following question based on a PICO format. Do adult patients undergoing ostomy surgery experience less stomal retraction when compared to patients managed without placement of a stoma rod? FINDINGS: Our initial search returned 182 articles; after reading studies in full, 5 articles were identified that collectively enrolled 1058 participants. Four studies were randomized controlled trials and one was a prospective cohort study. Meta-analysis could not be performed because of the small number of studies and the heterogeneity of outcomes measurements. The incidence of stoma retraction ranged between 0%-8% in patients managed with a rod and 0.78%-8.2% in patients with no rod. The number of reported adverse events was low. Placement of a stoma rod was associated with more adverse outcomes than in patients managed without a rod. Adverse events included local edema, stoma necrosis, skin necrosis, peristomal moisture-associated skin damage (irritant dermatitis), peristomal abscess, bleeding, and mucocutaneous separation. CONCLUSIONS: Stoma rod does not seem to reduce the risk of stoma retraction and might result in other adverse events. IMPLICATIONS: We recommend avoidance of stoma rod/bridge placement during ostomy surgery.

Fluorescence-based bowel anastomosis perfusion evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry.

BACKGROUND: Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry. METHODS: Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications. RESULTS: A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013-0.89 mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not. CONCLUSION: The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery.

Introduction of a specialized consultation prior to insertion of totally implantable access venous devices: Impact on cancellation rate and patient satisfaction.

OBJECTIVES: Preoperative consultation is usually not performed before insertion of a totally implantable venous access device (TIVAD). In our experience, an incomplete preoperative assessment, a predictable medical condition contraindicating surgery, or no-show patients the day of surgery led to several surgery cancellations. Therefore, we introduced a specific preoperative surgical consultation for TIVAD that took place shortly before surgery. The aim of the present study is to evaluate the patients' satisfaction and to establish the rate of cancellation after the adoption of this strategy. METHODS: Two-hundred and four patients who benefited from the preoperative consultation before TIVAD insertion from August 2014 to August 2016 were included. Satisfaction of patients and cancellation rate were documented. RESULTS: With that strategy, no TIVAD insertion was either delayed or cancelled. The overall level of satisfaction was high (91.8%); 184 patients (90.2%) judged the consultation useful in preparation for the surgery. The surgical procedure met their expectations in 92.2% of cases. Patients known for a psychiatric comorbidity were more likely to express dissatisfaction. CONCLUSIONS: The introduction of a specific preoperative surgical consultation for TIVAD insertion led to a high level of patients' satisfaction. After the preoperative consultation, no cancellation was recorded. Special approaches have to be considered for patients with a psychiatric comorbidity.

[How to manage patients with a suspicion of gallstone migration into the common bile duct ?] / Comment prendre en charge les patients avec suspicion de migration de calcul dans la voie biliaire principale ?

Symptomatic cholelithiasis associated with modified liver and pancreas function tests should raise the suspicion of a gallstone migration into the common bile duct (CBD). CBD evaluation is mainly done by endoscopic ultrasound or magnetic resonance cholangio-pancreatography. CBD stone retrieval is performed by endoscopic retrograde cholangio-pancreatography (ERCP). Patients at low-risk of CBD stone should be treated by cholecystectomy without further investigation, whereas high-risk patients should undergo CBD clearance before cholecystectomy. For intermediate-risk patients, we recommend initial cholecystectomy with intraoperative cholangiogram, followed if necessary by postoperative ERCP.

Une lithiase biliaire symptomatique associée à une perturbation des tests hépato-pancréatiques doit faire suspecter une migration de calcul dans la voie biliaire principale (VBP). L'évaluation de la VBP se fait essentiellement par écho-endoscopie et cholangio-pancréatographie par résonance magnétique, tandis qu'une cholangio-pancréatographie rétrograde endoscopique (ERCP) permet d'extraire des calculs de la voie biliaire. Les patients à risque faible de calcul de la VBP peuvent être traités par cholécystectomie sans autre investigation, tandis qu'il faudra s'assurer de la vacuité de la VBP avant la cholécystectomie pour les patients à risque élevé. Pour ceux à risque intermédiaire, nous recommandons la cholécystectomie d'emblée avec cholangiographie peropératoire, suivie si nécessaire d'une ERCP post-opératoire.

Combination of Adenomyoma and Adenomyomatous Hyperplasia of the Ampullary System: A First Case Report.

Adenomyoma and adenomyomatous hyperplasia are benign tumor-like lesions that rarely involve the major or minor duodenal papilla. We report the case of a 73-year-old patient who underwent a cephalic duodenopancreatectomy due to clinical and radiological evidence of underlying malignant neoplasm. The histopathology results revealed the unusual association of a major duodenal papilla adenomyoma and an adenomyomatous hyperplasia of the minor papilla. Because of their resemblance to pancreatic malignancy, the diagnosis of these lesions is particularly challenging. In most cases, it is established postoperatively, after histopathological examination of the surgical specimen.

Complex abdominal wall defect repair using biologic porcine matrix.

BACKGROUND: The management of patients with complex abdominal wall defect (CAWD) is challenging, and requires appropriate surgical planning, and intensive patient preparation in order to minimize postoperative complications. The aim of this work was to review the management of CAWD using one-stage repair with biologic mesh. METHODS: We retrospectively reviewed patients with CAWD having undergone repair with biologic mesh between January 2013 and October 2014. Demographics, preoperative assessment, intraoperative management and postoperative outcomes were assessed. RESULTS: A total of 15 patients were included. Biologic mesh was used for hernia repair with primary fascial closure (N.=12) or for bridging of the abdominal wall defect (N.=3). Seven patients presented postoperative complications Clavien-Dindo grade ≥3, and among them six required reoperation but no one required the mesh explantation. After a follow-up period of 12 months, four patients presented hernia recurrence and two required a later surgery. CONCLUSIONS: The use of biologic mesh allows single-stage repair of complex abdominal wall defects. The procedure involves significant postoperative morbidity, and requires intensive preoperative multidisciplinary preparation.

Liver Trauma During Combined Liposuction and Abdominoplasty: A Rare but Potentially Lethal Complication.

Liposuction is a well-established procedure that is generally safe. However, rare complications can occur. The authors report on a 38-year-old woman who underwent combined abdominoplasty and liposuction at a private clinic. Four hours after the procedure, severe hypovolemic shock developed and required emergency transfer to a tertiary-care center. After primary fluid resuscitation, abdominal ultrasonography and computerized tomography revealed severe right-sided liver trauma, with active bleeding and free intra-abdominal fluid. Two attempts at right hepatic artery embolization failed to fully control the bleeding, and surgical hemostasis was required. After a 2-week hospitalization, the patient was discharged, and she returned to work 3 months later. Although it appears that this is the first reported case of liver trauma during liposuction, this potential complication should be kept in mind and identified early to permit efficient and effective management.

Association of TSH concentrations and thyroid autoimmunity with IVF outcome in women with TSH concentrations within normal adult range.

BACKGROUND/AIMS: This study aimed to evaluate the association of thyroid-stimulating hormone (TSH) concentrations and presence of thyroid autoimmunity (TAI) with the live birth rate in euthyroid women undergoing in vitro fertilization (IVF). METHODS: This study of retrospective design included 158 euthyroid women (TSH 0.5-4.5 µIU/ml) who underwent IVF from January 2006 to December 2010. Thyroid parameters were measured on day 3 of the previous nontreatment cycle. Women were subgrouped and analyzed according to their TSH concentrations (low: 0.5-2.5 vs. high: 2.6-4.5 µIU/ml) and TAI (present vs. absent). RESULTS: No difference in the live birth rate was found between the TSH (low: 34.2% vs. high: 36.8%, p = 0.763) or TAI (present: 26.7% vs. absent: 34.3%, p = 0.568) subgroups. CONCLUSION: This study found no evidence that increased TSH concentrations or the presence of TAI determined before IVF affect the live birth rate in euthyroid women. A better insight into the role of thyroid function during application of IVF is needed.

The role of allopurinol's timing in the ischemia reperfusion injury of small intestine.

INTRODUCTION: Allopurinol acts protectively in the ischemia reperfusion injury of the small intestine. The aim of this experimental study is to define the ideal time of administration of allopurinol, in experimental models of ischemia/reperfusion. MATERIALS AND METHODS: We used 46 rabbits that were divided into four groups. Group A was the control. In Group B allopurinol was administered 10 min before ischemia and in Group C 2 min before reperfusion. In Group D, allopurinol was administered before ischemia and before reperfusion in half doses. Blood samples were collected at three different moments: (t1) prior to ischemia, (t2) prior to reperfusion, and (t3) after the end of the reperfusion, in order to determine superoxide dismutase (SOD) and neopterin values. Specimens of the intestine were obtained for histological analysis and determination of malondialdehyde (MDA). RESULTS: In Group A, mucosal lesions were more extensive compared to those of the other three groups. Similarly, MDA, SOD and neopterin values were significantly higher. On the contrary, Group D showed the mildest mucosal lesions, as well as the lowest MDA, SOD and neopterin values. Finally, the lesions and the above mentioned values were bigger in Group C than in Group D. CONCLUSIONS: The administration of allopurinol attenuates the production and damage effect of free oxygen radicals during ischemia reperfusion of the small intestine, thus protecting the intestinal mucosa. Its maximum beneficial action is achieved when administered both before ischemia and before reperfusion of the small intestine.

Enterobius vermicularis: a rare cause of appendicitis.

OBJECTIVE: Although appendicitis is one of the most common causes of emergency surgery, parasites are rarely found associated with inflammation of the appendix. The aim of this study is to establish the prevalence of Enterobius vermicularis in surgically removed appendices, as well as to determine its possible role in the pathogenesis of appendicitis. METHODS: A retrospective analysis of all the appendices removed during the last 20 years at a tertiary university hospital. Appendices removed during the course of another intra-abdominal procedure were excluded from the study. RESULTS: All 1085 surgical specimens removed from patients with clinical appendicitis were evaluated. Enterobius vermicularis was found in seven appendices (0.65%) with clinical symptoms of appendicitis. The parasite was most frequently identified in appendices without pathological changes (6/117). There was no case of chronic appendicitis presenting E. vermicularis infestation, while the parasite was rarely related to histological changes of acute appendicitis (1/901). CONCLUSION: The results suggest that the presence of E. vermicularis in the appendix might cause appendiceal pain (colic), but can rarely be associated with pathologic findings of acute appendicitis.