Sleeve gastrectomy with duodenoileal bipartition using linear magnets: feasibility and safety at 1-year follow-up.

BACKGROUND: Single-anastomosis metabolic/bariatric surgery procedures may lessen the incidence of anastomotic complications. This study aimed to evaluate the feasibility and safety of performing side-to-side duodenoileal (DI) bipartition using magnetic compression anastomosis (MCA). In addition, preliminary efficacy, quality of life (QoL), and distribution of food through the DI bipartition were evaluated. METHODS: Patients with a body mass index (BMI) of ≥35.0 to 50.0 kg/m2 underwent side-to-side DI bipartition with the magnet anastomosis system (MS) with sleeve gastrectomy (SG). By endoscopic positioning, a distal magnet (250 cm proximal to the ileocecal valve) and a proximal magnet (first part of the duodenum) were aligned with laparoscopic assistance to inaugurate MCA. An isotopic study assessed transit through the bipartition. RESULTS: Between March 14, 2022 to June 1, 2022, 10 patients (BMI of 44.2 ± 1.3 kg/m2) underwent side-to-side MS DI. In 9 of 10 patients, an SG was performed concurrently. The median operative time was 161.0 minutes (IQR, 108.0-236.0), and the median hospital stay was 3 days (IQR, 2-40). Paired magnets were expelled at a median of 43 days (IQR, 21-87). There was no device-related serious advanced event within 1 year. All anastomoses were patent with satisfactory diameters after magnet expulsion and at 1 year. Respective BMI, BMI reduction, and total weight loss were 28.9 ± 1.8 kg/m2, 15.2 ± 1.8 kg/m2, and 34.2% ± 4.1%, respectively. Of note, 70.0% of patients reported that they were very satisfied. The isotopic study found a median of 19.0% of the meal transited through the ileal loop. CONCLUSION: Side-to-side MCA DI bipartition with SG in adults with class II to III obesity was feasible, safe, and efficient with good QoL at 1-year follow-up. Moreover, 19% of ingested food passed directly into the ileum.

Side-to-side magnetic duodeno-ileostomy in adults with severe obesity with or without type 2 diabetes: early outcomes with prior or concurrent sleeve gastrectomy.

BACKGROUND: Conventional metabolic/bariatric surgical anastomoses with sutures/staples may cause severe adverse events (AEs). OBJECTIVES: The study aim was to evaluate the feasibility, safety, and effectiveness of primary and revisional side-to-side duodeno-ileostomy (DI) bipartition using a novel magnetic compression anastomosis device (Magnet Anastomosis System [MS]). SETTING: Multicenter: private practices and university hospitals. METHODS: In patients with body mass index ([BMI, kg/m2] ≥35.0 to ≤50.0 with/without type 2 diabetes [T2D] glycosylated hemoglobin [HbA1C > 6.5 %]), two linear MS magnets were delivered endoscopically to the duodenum and ileum with laparoscopic assistance and aligned, initiating magnet fusion and gradual DI (MagDI). The MagDI-after-SG group had undergone prior sleeve gastrectomy (SG); the MagDI + SG group underwent concurrent SG. AEs were graded by Clavien-Dindo Classification (CDC). RESULTS: Between November 22, 2021 and May 30, 2023, 43 patients (88.0% female, mean age 43.7 ± 1.3 years) underwent the study procedures. The MS met feasibility criteria of magnet device placement, creation of patent anastomoses confirmed radiologically, and magnet passage in 100.0% of patients. There were 64 AEs, most were CDC grade I and II, significantly fewer in the MagDI-after-SG group (P < .001). No device-related AEs including anastomotic leakage, bleeding, obstruction, infection, or death. The MagDI-after-SG group experienced 6-month mean weight loss of 8.0 ± 2.5 kg (P < .01), 17.4 ± 5.0% excess weight loss (EWL). The MagDI + SG group had significantly greater weight loss (34.2 ± 1.6 kg, P < .001), 66.2 ± 3.4% EWL. All patients with T2D improved. CONCLUSIONS: In early results of a multicenter study, the incisionless, sutureless Magnet System formed patent, complication-free anastomoses in side-to-side DI with prior or concurrent SG.

[Interviewing relatives with a view to organ donation from a deceased person]. / Entretien avec les proches en vue du don d'organes d'une personne décédée.

Talking to a deceased patient's next of kin about organ donation is a sensitive, emotionally-charged collective practice. It must be prepared and organized by the coordination and resuscitation team. The quality of the support and follow-up offered to the deceased's family and friends remains essential.

First human surgery using a surgical assistance robotics device for laparoscopic cholecystectomies.

BACKGROUND: Over the past 20 years, surgeons involved in soft tissue minimally invasive surgery have experienced the pros and cons of both conventional and tele-robotic laparoscopic approaches. The Maestro System, developed by Moon Surgical (Paris, France) aims to overcome the challenges inherent to both approaches thanks to a new concept that augments the surgeon's performance at the bedside during a laparoscopic procedure. METHODS: The current study aims to present the first human experience with laparoscopic cholecystectomy with the Maestro system on 10 patients. RESULTS: All ten procedures were completed successfully. No significant complications related to the use of the Maestro system werenoted. CONCLUSION: Our preliminary observations appear to support the benefits of the Maestro system in non-emergent laparoscopic cholecystectomies. It goes without saying that further research is necessary to demonstrate the safety of this approach in other procedures.

Evaluation of the SafeHeal Colovac+ anastomosis protection device after low anterior resection for rectal cancer: the safe anastomosis feasibility evaluation (SAFE) 2019 trial.

BACKGROUND: Protective ileostomy (PI) is the current standard of care to protect the anastomosis after low anterior resection (LAR) for rectal cancer, but is associated with significant morbidity. Colovac is an anastomosis protection device designed to shield the anastomosis from fecal content. A second version (Colovac+) was developed to limit the migration risk during the implantation period. The objective of this clinical trial was to evaluate the preliminary efficacy and safety of the Colovac+. METHODS: This was a prospective, multicenter, pilot study aiming to enroll 15 patients undergoing LAR with Colovac+ placement. After 10 days, a CT scan was performed to evaluate the anastomosis and the Colovac+ was retrieved endoscopically. During the 10-day implantation and 3-month follow-up period, we collected data regarding predefined efficacy and safety endpoints. The primary endpoint was the rate of major (Clavien-Dindo III-V) postoperative complications related to the Colovac+ or LAR procedure. RESULTS: A total of 25 patients were included (68% male), of whom 15 were consecutively treated with the Colovac+ and Vacuum Loss Alert System. The Colovac+ was successfully implanted in all 15 patients. No major discomfort was reported during the implantation period. The endoscopic retrieval was performed in 14/15 (93%) patients. The overall major postoperative morbidity rate was 40%, but none of the reported complications were related to the Colovac+. A device migration occurred in 2 (13%) patients, but these were not associated with AL or stoma conversion. Overall, Colovac+ provided effective fecal diversion in all 15 patients and was able to avoid the PI in 11/15 (73%) patients. CONCLUSIONS: Colovac+ provides a safe and effective protection of the anastomosis after LAR, and avoids the PI in the majority (73%) of patients. The improved design reduces the overall migration rate and limits the clinical impact of a migration.

Dynamic three-dimensional printing: The future of bronchoscopic simulation training?

High-fidelity models are required for technical mastery of bronchoscopic procedures in the fields of anaesthesia, intensive care, surgery and respiratory medicine. Our group has created a three-dimensional (3D) airway model prototype to emulate physiological and pathological movement. Developed from the concepts of our previously described 3D printed paediatric trachea for airway management training, this model produces movements created by injection of air or saline through a side Luer Lock port. The anaesthesia and intensive care applications of the model could include bronchoscopic navigation through narrow pathologies and simulated bleeding tumours. It also has the potential to be used to practice placement of a double-lumen tube and broncho-alveolar lavage among other procedures. For surgical training, the model has high tissue realism and allows for rigid bronchoscopy. The novel and high-fidelity 3D printed airway model with dynamic pathologies represents capability to provide both generic and patient-specific advancement for all modes of anatomical representation. The prototype illustrates the potential of combining the fields of industrial design with clinical anaesthesia.

Side-to-side magnet anastomosis system duodeno-ileostomy with sleeve gastrectomy: early multi-center results.

INTRODUCTION: Gastrointestinal anastomoses with classical sutures and/or metal staples have resulted in significant bleeding and leak rates. This multi-site study evaluated the feasibility, safety, and preliminary effectiveness of a novel linear magnetic compression anastomosis device, the Magnet System (MS), to form a side-to-side duodeno-ileostomy (DI) diversion for weight loss and type 2 diabetes (T2D) resolution. METHODS: In patients with class II and III obesity (body mass index [BMI, kg/m2] ≥ 35.0- ≤ 50.0 with/without T2D [HbA1C > 6.5%]), two linear MS magnets were delivered endoscopically to the duodenum and ileum with laparoscopic assistance and aligned, initiating DI; sleeve gastrectomy (SG) was added. There were no bowel incisions or retained sutures/staples. Fused magnets were expelled naturally. Adverse events (AEs) were graded by Clavien-Dindo Classification (CDC). RESULTS: Between November 22, 2021 and July 18, 2022, 24 patients (83.3% female, mean ± SEM weight 121.9 ± 3.3 kg, BMI 44.4 ± 0.8) in three centers underwent magnetic DI. Magnets were expelled at a median 48.5 days. Respective mean BMI, total weight loss, and excess weight loss at 6 months (n = 24): 32.0 ± 0.8, 28.1 ± 1.0%, and 66.2 ± 3.4%; at 12 months (n = 5), 29.3 ± 1.5, 34.0 ± 1.4%, and 80.2 ± 6.6%. Group mean respective mean HbA1C and glucose levels dropped to 1.1 ± 0.4% and 24.8 ± 6.6 mg/dL (6 months); 2.0 ± 1.1% and 53.8 ± 6.3 mg/dL (12 months). There were 0 device-related AEs, 3 procedure-related serious AEs. No anastomotic bleeding, leakage, stricture, or mortality. CONCLUSION: In a multi-center study, side-to-side Magnet System duodeno-ileostomy with SG in adults with class III obesity appeared feasible, safe, and effective for weight loss and T2D resolution in the short term.

Implications of bacteriological study in complicated and uncomplicated acute appendicitis.

Purpose: Bacteriological sample in the presence of intraabdominal free fluid is necessary to adapt the antibiotherapy and to prevent the development of resistance. The aim was to evaluate the differences between uncomplicated (UAA) and complicated acute appendicitis (CAA) in terms of bacterial culture results and antibiotic resistance, and to evaluate the factors linked with CAA. Methods: We performed a single-center, retrospective observational study of all consecutive patients who presented with appendicular peritonitis and underwent emergent surgery in a tertiary referral hospital in Brussels, Belgium, between January 2013 and December 2020. The medical history, parameters at admission, bacterial culture, antibiotic resistance, and postoperative outcomes of 268 patients were analyzed. UAA was considered catarrhal or phlegmonous inflammation of the appendix. CAA was considered gangrenous or perforated appendicitis. Results: Positive microbiological cultures were significantly higher in the CAA group (68.2% vs. 53.4%). The most frequently isolated bacteria in UAA and CAA cultures were Escherichia coli (37.9% and 48.6%). Most observed resistances were against ampicillin (28.9% and 21.7%) and amoxicillin/clavulanic acid (16.4% and 10.5%) in UAA and CAA, respectively. A higher Charlson comorbidity index, an elevated white blood cell count, an open procedure, and the need for drainage were linked to CAA. Culture results, group of bacterial isolation, and most common isolated bacteria were not related to CAA. Conclusion: CAA presented a higher rate of positive cultures with increased identification of gram-negative bacteria. Bacterial culture from the peritoneal liquid does not reveal relevant differences in terms of antibiotic resistance.

Toward Emulating Human Movement: Adopting a Data-Driven Bitmap-Based "Voxel" Multimaterial Workflow to Create a Flexible 3D Printed Neonatal Lower Limb.

It is increasingly common to produce physical anatomical medical models using high-fidelity multiproperty 3D printing to assist doctor-patient communication, presurgical planning, and surgical simulation. Currently, most medical models are created using image thresholding and traditional mesh-based segmentation techniques to produce mono-material boundaries (STL file formats) of anatomical features. Existing medical modeling manufacturing methods restrict shape specification to one material or density, which result in anatomically simple 3D printed medical models with no gradated material qualities. Currently, available high-resolution functionally graded multimaterial 3D printed medical models are rigid and do not represent biomechanical movement. To bypass the identified limitations of current 3D printing medical modeling workflows, we present a bitmap-based "voxel" multimaterial additive manufacturing workflow for the production of highly realistic and flexible anatomical models of the neonatal lower limb using computed tomographic ("CT") data. By interpolating and re-slicing a biomedical volumetric data set at the native 3D printer z resolution of 27 µm and using CT scan attenuation properties (Hounsfield units) to guide material mixing ratios, producing highly realistic models of the neonatal lower limb at a significantly faster rate than other manufacturing methods. The presented medical modeling workflow has considerable potential to improve medical modeling manufacturing methods by translating medical data directly into 3D printing files aiding in anatomical education and surgical simulation practices, especially in neonatal research and clinical training.

Impact of the COVID-19 Pandemic and Lockdown on Gastric Bypass Results at 1-Year Follow-up.

PURPOSE: The COVID-19 pandemic caused a lockdown in many countries, which induced negative dietary habits and sedentary behavior. Studies suggest that weight loss of patients undergoing bariatric surgery was equally affected. The aim was to evaluate the impact of COVID-19 on weight loss, obesity-related comorbidities, and nutritional status at 1-year follow-up after gastric bypass (GB). METHODS: Retrospective observational case-control study of patients undergoing primary GB in a tertiary referral Belgian center. COVID-19 period group was composed by those whose 1-year postoperative period was affected by the COVID-19 pandemic and lockdown: from October 1, 2019, to March 31, 2020. The control group was composed of patients operated from October 1, 2018, to March 31, 2019. Electronic clinical records were reviewed searching: baseline characteristics, weight and comorbidities evolution, and biochemical values. RESULTS: A total of 47 patients in the COVID-19 period group and 66 in the non-COVID-19 period group were analyzed. There were no significant differences in baseline characteristics. A reduced weight loss was observed at 1-year follow-up, in terms of percentage of excess weight loss (%EWL) (82.4% [SD: 21.6] vs. 82.4% [SD: 21.6]; p: 0.043) and body mass index (BMI) (27.8 kg/m2 [IQR: 25.8-30.0] vs. 26.2 kg/m2 [IQR: 24.6-28.6]; p: 0.029) for COVID-19 period group vs. non-COVID-19 period group, respectively. There was a similar reduction of obesity-related comorbidities, without clinically significant differences in the nutritional follow-up. CONCLUSION: The COVID-19 pandemic and lockdown had an impact on weight loss at 1-year follow-up after gastric bypass.

Slacklining: A narrative review on the origins, neuromechanical models and therapeutic use.

Slacklining, the neuromechanical action of balance retention on a tightened band, is achieved through self-learned strategies combining dynamic stability with optimal energy expenditure. Published slacklining literature is recent and limited, including for neuromechanical control strategy models. This paper explores slacklining's definitions and origins to provide background that facilitates understanding its evolution and progressive incorporation into both prehabilitation and rehabilitation. Existing explanatory slacklining models are considered, their application to balance and stability, and knowledge-gaps highlighted. Current slacklining models predominantly derive from human quiet-standing and frontal plane movement on stable surfaces. These provide a multi-tiered context of the unique and complex neuro-motoric requirements for slacklining's multiple applications, but are not sufficiently comprehensive. This consequently leaves an incomplete understanding of how slacklining is achieved, in relation to multi-directional instability and complex multi-dimensional human movement and behavior. This paper highlights the knowledge-gaps and sets a foundation for the required explanatory control mechanisms that evolve and expand a more detailed model of multi-dimensional slacklining and human functional movement. Such a model facilitates a more complete understanding of existing performance and rehabilitation applications that opens the potential for future applications into broader areas of movement in diverse fields including prostheses, automation and machine-learning related to movement phenotypes.

Slacklining: An explanatory multi-dimensional model considering classical mechanics, biopsychosocial health and time.

This paper aims to overcome slacklining's limited formulated explanatory models. Slacklining is an activity with increasing recreational use, but also has progressive adoption into prehabilitation and rehabilitation. Slacklining is achieved through self-learned strategies that optimize energy expenditure without conceding dynamic stability, during the neuromechanical action of balance retention on a tightened band. Evolved from rope-walking or 'Funambulus', slacklining has an extensive history, yet limited and only recent published research, particularly for clinical interventions and in-depth hypothesized multi-dimensional models describing the neuromechanical control strategies. These 'knowledge-gaps' can be overcome by providing an, explanatory model, that evolves and progresses existing standards, and explains the broader circumstances of slacklining's use. This model details the individual's capacity to employ control strategies that achieve stability, functional movement and progressive technical ability. The model considers contributing entities derived from: Self-learned control of movement patterns; subjected to classical mechanical forces governed by Newton's physical laws; influenced by biopsychosocial health factors; and within time's multi-faceted perspectives, including as a quantified unit and as a spatial and cortical experience. Consequently, specific patient and situational uses may be initiated within the framework of evidence based medicine that ensures a multi-tiered context of slacklining applications in movement, balance and stability. Further research is required to investigate and mathematically define this proposed model and potentially enable an improved understanding of human functional movement. This will include its application in other diverse constructed and mechanical applications in varied environments, automation levels, robotics, mechatronics and artificial-intelligence factors, including machine learning related to movement phenotypes and applications.

High SARS-CoV-2 Seroprevalence in Healthcare Workers in Bukavu, Eastern Democratic Republic of Congo.

Among 359 healthcare workers (HCW) employed in Panzi General Referral Hospital located in Bukavu in the Democratic Republic of Congo, 148 (41.2%) tested positive for SARS-CoV-2 antibodies. Thirty-three (22.3%) of the 148 personnel with positive serology reported symptoms evoking a prior COVID-19 illness. None of the infected HCWs reported COVID-related hospitalization, and all of them recovered. Our findings indicate high and underestimated circulation of SARS-CoV-2 within the Bukavu area.

A three-dimensional (3D) printed paediatric trachea for airway management training.

There is a deficit of commercially available paediatric airway models for anaesthesia airway management training, particularly for infant front-of-neck access and customised airway planning. Acknowledging this, we created a three-dimensional printed prototype for an affordable, high-fidelity training device, incorporating realistic tactile feedback, reproducibility and potential for modification for specific patient pathologies. Our model, created on a Stratasys Polyjet J750™ (Rehovot, Israel) printer, is a novel and useful educational tool in paediatric airway management, and we are pleased to share access to this resource with readers. Our work adds credence to three-dimensional printing as an accessible, reproducible and pluripotent technology in clinical anaesthesia.

Fluorescence of Deep Infiltrating Endometriosis During Laparoscopic Surgery: A Preliminary Report on 6 Cases.

BACKGROUND: The standard treatment of rectovaginal deep infiltrating endometriosis nodules (RVDIEN) consists in their surgical removal. RVDIEN are anatomically neovascularized. Indocyanine green (ICG) reveals vascularized structures when becoming fluorescent after exposure to near-infrared (NIR) light. This study aims to evaluate if fluorescence-guided surgery can improve the laparoscopic resection of RVDIEN, thus avoiding a rectal perforation. MATERIALS AND METHODS: Patients with a symptomatic RVDIEN, scheduled for a laparoscopic rectal shaving, were enrolled in the study. Technically, the RVDIEN was targeted and removed with the help of the NIR imager device Image 1 Spies (Karl Storz GmBH & Co KG, Tuttlingen, Germany) or Visera Elite II (Olympus Europe SE & Co KG, Hamburg, Germany), after an intraoperative, intravenous injection of ICG (0.25 mg/kg). RESULTS: Six patients underwent a fluorescence-guided laparoscopic shaving procedure for the treatment of a nonobstructive RVDIEN. Fluorescence of the RVDIEN was observed in all the patients. In one patient, once the main lesion was removed, the posterior vaginal fornix still appeared fluorescent and was removed. No intraoperative rectal perforation occurred. The postoperative hospital stay was 2 days. No postoperative rectovaginal fistula occurred within a median follow-up of 16 months (range = 2-23 months). CONCLUSION: In this preliminary study, fluorescence-guided laparoscopy appeared to help in separating the RVDIEN from the healthy rectal tissue, without rectal perforation. Moreover, this technique was helpful in deciding if the resection needed to be enlarged to the posterior vaginal fornix.

Three Trocars Laparoscopic Total Gastrectomy + D2 Lymphadenectomy with Intracorporeal Manual Esojejunostomy.

BACKGROUND: Minimally invasive surgery (MIS) is proved to be feasible and safe oncologically. In the past decade, a new philosophy of MIS, reducing abdominal trauma and improving the cosmetic results, has been popularized. 1-3 The authors report a three trocars laparoscopic total gastrectomy + D2 lymphadenectomy for lesser curvature gastric adenocarcinoma. VIDEO: A 52-year-old woman presenting a nondifferentiated gastric adenocarcinoma at the incisura angularis was admitted at consultation. Preoperative workup showed a T3N+M0 tumor. After neoadjuvant chemotherapy, laparoscopy was scheduled. Three trocars (5, 12, 5 mm) were placed in the abdomen. The operative field's exposure was improved by temporary percutaneous sutures. En bloc total gastrectomy and omentectomy was performed with a D2 lymphadenectomy, including the nodes of the stations 1, 2, 3, 4, 5, 6, 7, 8a, 8p, 9, 10, 11p, 11d, and 12a. Completely manual end-to-side esophago-jejunal anastomosis (Fig. 1a, b) and linear mechanical side-to-side jejuno-jejunal anastomosis were realized with the closure of both mesenteric and mesocolic defects. The specimen was retrieved through a suprapubic access. RESULTS: Operative time was 4 hours and 45 minutes (anastomosis: 30), and perioperative bleeding was 100 cc. Pathologic report confirmed nondifferentiated adenocarcinoma, mucinous, G3, infiltrating entirely the gastric wall, with 63 (4 positive) nodes removed; 7 edition UICC stage: pT4aN2aM0; keratine AE1/AE3 negative, HER2/neu, and HER2/CEP17 nonamplified. During postoperative follow-up, no recurrence was detected after 2 years. CONCLUSIONS: Reduced port laparoscopic surgery provides the same quality of oncologic surgery as conventional multitrocar laparoscopy with added superior cosmesis and reduced abdominal trauma.

A New Reusable Platform for TransAnal Minimally Invasive Surgery: First Experience.

INTRODUCTION: TransAnal Minimally Invasive Surgery (TAMIS) has generated interest and attracted research in the last decade. This approach is used to treat primary benign and malignant diseases, but it can also be adopted to resolve colorectal complications, such as leak and fistula, bleeding and stenosis. A new reusable transanal platform formed by a new port and monocurved instruments has been invented and here presented. MATERIALS AND METHODS: The first experience included 13 patients submitted to TAMIS for rectal adenocarcinoma (8), immediate colorectal leak (1), early rectovaginal fistula (1), late colorectal fistula (1), immediate colorectal bleeding (1), and benign stenosis (1). Mean age was 62.3 years (38-74), and mean BMI was 25.2 kg/m2 (20.5-32.1). RESULTS: Mean operative time for transanal total mesorectal excision (TME) was 149.2 minutes (96-193) and for the other procedures 80.6 minutes (15-163). Mean operative bleeding was 51.1 cc (0-450). Mean hospital stay was 5.0 days (2-8). The 3 patients with coloanal anastomosis presented diarrhea postoperatively. No other early postoperative complications were registered. Pathologic report in the oncologic diseases showed that a mean number of 14.7 nodes (16-20) were removed. After a mean follow-up of 8 months (1-14), there were no late complications in any of the 13 patients treated. CONCLUSION: TAMIS is a feasible alternative approach to treat rectal cancer and a completely new technique to manage colorectal complications. Moreover, this new transanal platform offers surgeons a satisfactory working ergonomy, with no increase in cost of the procedures, because entirely reusable materials are adopted.

Treatment of rape-induced urogenital and lower gastrointestinal lesions among girls aged 5 years or younger.

OBJECTIVE: To evaluate outcomes after treatment of rape-induced urogenital and lower gastrointestinal lesions among young girls. METHODS: In a retrospective study, data were assessed from girls aged 5 years or younger who were treated for sexual-assault-related injuries at the General Referral Hospital, Panzi, Bukavu, Democratic Republic of Congo, between 2004 and 2014. Data were obtained from review of charts, records of the mother's impressions and physical examinations, and photographic evidence. Elective surgery had been reserved for patients experiencing fecal and/or urinary incontinence. RESULTS: Overall, 205 girls aged 5 years or younger presented with rape injuries: 162 (79.1%) had only mucocutaneous lesions, 22 (10.7%) had musculocutaneous lesions, and 21 (10.2%) had musculocutaneous lesions complicated by fecal and/or urinary incontinence. Among the 21 girls who underwent perineal surgery, two with fecal and urinary incontinence and perforation of the peritoneum of Douglas pouch were additionally treated by laparoscopy. Among 16 patients with fecal incontinence, the continence score had improved significantly at 10.4 months after surgery (P<0.001). Concomitant urinary incontinence subsided for four of five patients but persisted for one who had a gunshot wound to the vagina. Cosmetic outcome was normal in 19 cases. CONCLUSION: For rape survivors aged 5 years or younger, a treatment strategy by which surgery is reserved for incontinent patients provided good cosmetic and functional outcomes.

Metabolic consequences of the incorporation of a Roux limb in an omega loop (mini) gastric bypass: evaluation by a glucose tolerance test at mid-term follow-up.

BACKGROUND: In the technique used in our department, Roux-en-Y gastric bypass (RYGB) anatomically only differs from the mini- or omega loop gastric bypass (OLGB) by the incorporation of an isolated alimentary limb, called the Roux limb. The metabolic consequences of the incorporation of a Roux limb are unknown. OBJECTIVES: To evaluate differences in glucose and insulin dynamics between RYGB and OLGB in normoglycemic patients, by submitting them to a glucose challenge after stabilization of their weight. METHODS: Nondiabetic patients who had undergone OLGB 4 years earlier were matched with nondiabetic patients who had undergone RYGB around the same time and with healthy controls. Participants underwent oral (OGTT) and intravenous glucose tolerance test (IVGTT). Endpoints of the study were: progression of plasma glucose and insulin, changes in their concentration [calculated by area under the curve (AUC)] at OGTT and IVGTT, incretin effect and incidence of hypoglycemia. RESULTS: Each of the three groups comprised 14 participants. At OGTT, plasma glucose and insulin incremental values were comparable after OLGB and RYGB, and substantially higher than in controls. Overall glucose concentration, however, did not vary across the three groups. Thirty-minute and overall insulin plasma concentration, indicators of early and total insulin secretion, respectively, was significantly higher in both bypass groups than in controls, and was greatest in OLGB. Severe hypoglycemia occurred in one out of two patients in both bypass groups. At IVGTT, no differences were registered across the three groups and no participant experienced hypoglycemia. The incretin effect was higher after OLGB than after RYGB, but the difference was not statistically significant. CONCLUSIONS: The incorporation of a Roux limb in a loop gastric bypass appears to create a statistically nonsignificant tendency toward reducing insulin hypersecretion observed at OGTT after OLGB, and consequently toward tapering the incretin effect.