Elective incisional hernia repair: lower risk of postoperative wound infection with laparoscopic versus open repair.

Introduction: The superiority of laparoscopic repair over open repair of incisional hernias (IHs) in the elective setting is still controversial. Our study aimed to compare the postoperative outcomes of laparoscopic and open elective IH repair in an Asian population. Methods: This retrospective study was conducted in an acute general hospital in Singapore between 2010 and 2015. Inclusion criteria were IH repair in an elective setting, IHs with diameter of 3-15 cm, and location at the ventral abdominal wall. We excluded patients who underwent emergency repair, had recurrent hernias or had loss of abdominal wall domain (i.e. hernia sac containing more than 30% of abdominal contents or any solid organs). Postoperative outcomes within a year such as recurrence, pain, infection, haematoma and seroma formation were compared between the two groups. Results: There were 174 eligible patients. The majority were elderly Chinese women who were overweight. Open repair was performed in 49.4% of patients, while 50.6% underwent laparoscopic repair. The mean operation time for open repair was 116 minutes (116 ± 60.6 minutes) and 139 minutes (136 ± 64.1 minutes) for laparoscopic repair (P = 0.079). Within a year after open repair, postoperative wound infection occurred in 15.1% of the patients in the open repair group compared to 1.1% in the laparoscopic group (P = 0.0007). Postoperative pain, recurrence and haematoma/seroma formation were comparable. Conclusion: Elective laparoscopic IH repair has comparable outcomes with open repair and may offer the advantage of reduced postoperative wound infection rates.

Revisional One-Anastomosis Gastric Bypass After Restrictive Index Surgery-a Metaanalysis and Comparison with Revisional Roux-en-Y Gastric Bypass.

BACKGROUND: One-anastomosis gastric bypass (OAGB) was established as a recognized bariatric procedure in the 2018 International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) position statement. This study evaluates the outcomes of revisional OAGB (rOAGB) after a restrictive index procedure, and to compare it to revisional RYGB (rRYGB). METHODS: A literature search was performed according to the PRISMA guidelines on papers published from inception till February 2020. Original studies involving patients who underwent rOAGB after a primary failed restrictive procedure were included. The primary outcome measured was postrOAGB weight loss. Secondary outcome measures include comorbidity resolution, operative duration, length of stay, morbidity, and mortality. RESULTS: A total of 21 studies with 1377 patients were included. Five studies compared rOAGB versus rRYGB. Majority of the patients (76%) were female, with mean age of 43.5 years old. Mean body mass index (BMI) before revisional surgery was 41.6 kg/m2. The most common biliopancreatic limb length was 200 cm. Percentage of excess weight loss after rOAGB increases to a maximum of 76.0% at 48 months postsurgery. rOAGB resulted in a pooled prevalence of diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea resolution of 74.9%, 48.4%, 63.2%, and 75.7% respectively. When compared to rRYGB, rOAGB demonstrated greater weight loss, comparable metabolic syndrome resolution, but with a shorter operating time. Morbidity and mortality rates were low across all studies. CONCLUSIONS: rOAGB has potential as an alternative revisional surgery, with weight loss profiles and rates of metabolic syndrome resolution that are comparable to rRYGB.

Impact of bariatric surgery on serum uric acid levels and the incidence of gout-A meta-analysis.

Gout is characterized by high serum uric acid (SUA) levels and arthritis. It is associated with obesity and metabolic syndrome. Bariatric surgery has been associated with decreased SUA levels and overall gout incidence. This meta-analysis aims to summarize the current evidence on bariatric surgery, gout and SUA levels. A literature review was performed on papers published from 2000 up till December 2018. Original studies investigating the impact of bariatric surgery on SUA levels or gout incidence were evaluated. Twenty studies with a total of 5,233 patients were analysed. Majority (n=14) had a follow-up duration of at least 12 months. The mean preoperative body mass index (BMI) was 45.2kg m-2 . The mean preoperative SUA level was 6.5mg dL-1 . Subgroup analysis demonstrated a mean decrease in SUA levels (-0.73mg dL-1 ) from the third postoperative month onwards, which was sustained until the third postoperative year (-1.91mg dL-1 ). There was a rise in SUA levels in the first post-operative month. Meta-regression analyses demonstrated a proportionate linear relationship between the change in BMI and SUA levels. Post-bariatric surgery weight loss is associated with reduced SUA levels and decreased incidence of gout attacks. However, this is only evident from the third post-operative month onwards.

A rare case of bipartite combined tumour of the oesophagus.

BACKGROUND: Bipartite combined oesophageal tumours are an exceedingly rare entity and much less is known about the natural history of these tumours following curative surgery. The authors present a case of a bipartite combined oesophageal tumour comprising of sarcomatoid carcinoma and small cell carcinoma with early postoperative recurrence. CASE PRESENTATION: A 63-year-old Chinese male with a smoking history presents with hemoptysis on a background of dysphagia and odynophagia for 1 month. An endoscopic evaluation found an exophytic oesophageal tumour with contact bleeding for which biopsy of this lesion returned as a malignant high-grade tumour where immunohistochemistry staining was unable to establish the lineage of the tumour. Differential diagnoses include sarcomatoid carcinoma and malignant undifferentiated sarcoma. With the provisional diagnosis of a high-grade oesopheageal sarcoma, the patient underwent minimally invasive McKeown's oesophagectomy. Final histological assessment was pT1bN0 with two histological types of malignancy within a single tumour-70% poorly differentiated spindle cell squamous carcinoma and small cell carcinoma. He was planned for adjuvant chemotherapy in view of the small cell carcinoma component after the resolution of the postoperative infective collections. A computed tomographic scan performed 4 months postoperatively demonstrated metastasis to the lung, pleura, thoracic nodes and liver. Biopsy of the largest lung nodule confirmed small cell neuroendocrine carcinoma with features similar to the small cell carcinoma component in the prior oesophagectomy specimen. He was thereafter initiated on palliative chemotherapy aimed at three weekly carboplatin and etoposide aimed at a total of 4 cycles with peglasta support. Etoposide was stopped during the first cycle due to asymptomatic bradycardia. The regime was then converted to carboplatin with irinotecan for 5 cycles. Repeat computed tomographic scan performed 3 weeks after the completion of chemotherapy showed a complete response of lung and liver metastasis and no evidence of local recurrence or distant metastasis. CONCLUSION: The management of bipartite combined oesophageal tumours should be guided by its more aggressive component. Bipartite combined oesophageal tumours with a small cell carcinoma component are believed to demonstrate aggressive tumour biology likened to that of primary oesophageal small cell carcinoma. Preoperative confirmation of a combined tumour may be challenging, and biopsy results may only yield one of the two components. The more aggressive component is usually a small cell carcinoma, for which the mainstay of therapy is platinum-based chemotherapy rather than surgery.

Outcomes After Metabolic Surgery in Asians-a Meta-analysis.

BACKGROUND: Obesity and type 2 diabetes mellitus (T2DM) are now increasingly epidemic in Asia. As obesity and T2DM have different disease patterns in Asians compared to Westerners, outcomes after metabolic surgery may differ. The aim of this meta-analysis was to gather the current available evidence on the outcomes after metabolic surgery in Asians. METHODS: A literature search was conducted in September 2017. Four outcome measures were examined: (1) % excess weight loss (EWL), (2) post-intervention body mass index (BMI), (3) T2DM resolution or improvement, and (4) hypertension resolution. RESULTS: Thirteen publications with a total of 1052 patients were analyzed, of which nine were randomized controlled trials, and four were case-matched studies. All the studies had a minimum follow-up duration of at least 1 year. % EWL was significantly higher in those who have undergone Roux-en-Y gastric bypass (RYGB) (SMD 0.53, 95% CI 0.12 to 0.94) versus sleeve gastrectomy (SG). T2DM resolution/improvement was favorable in those who have undergone RYGB (pooled OR 1.39, 95% CI 0.53 to 3.67) versus SG, although not statistically significant. Hypertension resolution was not significantly different between patients who have undergone SG versus RYGB (pooled OR 0.96, 95% CI 0.44 to 2.11). CONCLUSION: RYGB results in better weight loss compared to SG in Asians, but the rate of T2DM resolution/improvement and improvement of hypertension appears to be similar. In Asian patients without symptoms of gastro-esophageal reflux disease in whom metabolic surgery is performed mainly for T2DM and metabolic syndrome, SG may be the surgery of choice.

Laparoscopic versus Open Omental Patch Repair for Early Presentation of Perforated Peptic Ulcer: Matched Retrospective Cohort Study.

Introduction. The aim of this study was to compare the outcomes between laparoscopic and open omental patch repair (LOPR versus OR) in patients with similar presentation of perforated peptic ulcer (PPU). The secondary aim was to evaluate the outcomes according to the severity of peritonitis. Methods. All patients who underwent omental patch repair at two university-affiliated institutes between January 2010 and December 2014 were reviewed. Matched cohort between LOPR and OR groups was achieved by only including patients that had ulcer perforation <2 cm in size and symptoms occurring <48 hours. Outcome measures were defined in accordance with length of stay (LOS), postoperative complications, and mortality. Results. 148 patients met the predefined inclusion criteria with LOPR performed in 40 patients. Outcome measures consistently support laparoscopic approach but only length of hospital stay (LOS) achieved statistical significance (LOPR 4 days versus OR 5 days, p < 0.01). In a subgroup analysis of patients with MPI score >21, LOPR is also shown to benefit, particularly resulting in significant shorter LOS (4 days versus 11 days, p < 0.01). Conclusion. LOPR offers improved short-term outcomes in patients who present within 48 hours and with perforation size <2 cm. LOPR also proved to be more beneficial in high MPI cases.

Abdominal schwannomas: case report with literature review.

Schwannomas are rare tumors that arise from Schwann cells in neural sheaths. They are commonly found in the central nervous system, spinal cord, or peripheral nerves of the body. Occasionally, they occur in the gastrointestinal tract, with the stomach being the most common site. However, colorectal and retroperitoneal schwannomas are very rare. Preoperative diagnosis is often difficult and definitive treatment entails surgical excision. We herein present 3 cases of intraabdominal schwannomas.