Perigastric Abscess Resection During Roux-en-Y Bypass Surgery After Gastric Banding.

Laparoscopic adjustable gastric banding (LAGB) has a low rate of perioperative morbidity and mortality, while long-term complications are not rare. band erosion may be insidious and the patient may be asymptomatic. We present an unusual case of a 51-year-old patient who developed an intra-abdominal abscess after LAGB and required a resectional Roux-en-Y gastric bypass procedure. The patient's perioperative course was uneventful.  Removal of the abscess with partial gastrectomy and completion of a RYGB was safe and feasible.

Expectant management in delayed presentation of war casualties with penetrating abdominal trauma.

INTRODUCTION: While the management of acute civilian abdominal injuries is well established, The literature regarding the management of battle-related abdominal injuries presented in a delayed fashion is scarce. The objective of this study was to investigate the safety of non-operative management approach in delayed evacuation of battle-related abdominal injuries. METHODS: Clinical records of thirty-seven hemodynamically normal patients with battle related injuries and Computed Tomography (CT) findings of penetrating abdominal trauma were retrospectively studied. RESULTS: All 37 patients suffered penetrating abdominal injuries during the civil war in Syria. In this complex scenario, the casualties presented after a minimum 12-hour delay to our hospital. All patients had abnormal abdominal CT scans with no clinical peritoneal signs. Twenty-one [of the 37] patients exhibited 29 hard signs on CT scan. Of these, 17 patients were treated non-operatively and 4 underwent exploratory laparotomy (of which 2 were non-therapeutic). Sixteen patients exhibited a total of 75 soft signs on CT scan; 15 were treated non-operatively and one underwent non-therapeutic laparotomy. No complications were recorded in either the operative or non-operative groups. In total, 32 patients (86%) were treated non-operatively. Five patients (14%) underwent exploratory laparotomy (3 of which were non-therapeutic). Length of stay was dependent on the unique requirements of each individual patient as determined by the state department for returning across the border. CONCLUSION: We propose that in battle related casualties, acute survivable penetrating abdominal trauma may be safely treated non-operatively in selected patients who are hemodynamically normal and in whom there is an absence of abdominal pain or tenderness on repeated clinical assessment.

Early Outcomes and Mid-Term Safety of One Anastomosis Gastric Bypass Are Comparable with Roux-en-Y Gastric Bypass: a Single Center Experience.

BACKGROUND: The use of one anastomosis gastric bypass (OAGB) has increased in recent years. However, the efficacy and safety outcomes of this procedure remain under debate. Here, we compare our early outcome and mid-term safety of OAGB with primary Roux-en-Y gastric bypass (RYGB). METHODS: This was a retrospective study using computerized electronic medical records data of patients who underwent RYGB or OAGB as a primary procedure from February 2012 to February 2019 in our bariatric center. Data collected included demographics, weight-outcomes, adverse events, hospital readmission, reoperation rates, and mortality following both procedures. RESULTS: A total of 314 patients were included (132 RYGB and 182 OAGB). Operative time and costs were significantly lower for OAGB (80 vs. 125 min, p<0.01 and 2018.8 vs. 2912.3 USD, p < 0.01, respectively), but length of hospital stay was longer (4.06 ± 0.67 days vs. 3.58 ± 0.79, p < 0.0001). At 12 months post-surgery, the percentage of excess body mass index loss was comparable between the two groups, but the change in body mass index (BMI) was significantly higher in the OAGB group. Early (< 30 days) and late (> 30 days) surgical adverse events were also similar between the two groups. CONCLUSION: Comparable short- and mid-term outcomes and adverse events are found for primary OAGB and RYGB. OAGB is not inferior to RYGB as a primary bariatric procedure for the treatment of obesity.

Transanal Minimally Invasive Proctectomy With Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Iatrogenic Rectourethral Fistulas.

INTRODUCTION: Rectourethral fistula is an uncommon pathology, usually iatrogenic, occurring as a complication of surgical or ablative treatments for prostate or rectal cancer. Among other surgical techniques, restorative ultralow rectal anterior resection may be an option of last resort to achieve fistula closure avoiding the need for a permanent stoma. This article aims to describe a transanal minimally invasive-assisted Turnbull-Cutait technique for radiated rectourethral fistulas with a complementary video. TECHNIQUE: Turnbull-Cutait pull-through with delayed coloanal anastomosis technique with a proctectomy by transanal minimally invasive surgery and loop ileostomy was performed in 3 patients who developed delayed rectourethral fistula after prostate cancer treatment. Ileostomy was reversed after fistula closure confirmation. RESULTS: The first patient had brachytherapy with no surgery. The second patient had radical prostatectomy and adjuvant radiotherapy, developing the fistula after a pelvic abscess drained transrectally. The third patient underwent prostatectomy and brachytherapy, developing the fistula after transanal endoscopic microsurgery resection of a rectal villous polyp. Surgical intervention and postoperative recovery was uneventful. Fistula closure was confirmed in the 3 cases, and all ileostomies were closed without further recurrence at follow-up. CONCLUSIONS: Transanal minimally invasive proctectomy-assisted Turnbull-Cutait procedure for the treatment of rectourethral fistula is a new combination of already existing techniques, enabling the creation of safe colorectal anastomosis in high-risk cases. Given the difficulty obtaining healing with sphincter preservation in cases of postradiation rectourethral fistula, this technique aids in fistula closure and restoration of the intestinal continuity, and potentially represents an added resource in the surgical armamentarium for this challenging pathology.

The Impact of Ethnic Differences Between Israeli-Jews and Israeli-Arabs on Post-bariatric Surgery Weight Loss: a Prospective Cohort Analysis.

Previous studies from different countries have shown that ethnic diversity may have an important effect on clinical outcome following bariatric procedures. Israel has an ethnic diverse population but there is limited information about this effect on surgery outcome. We carried out a 3-year institutional, prospective comparative data collection study among Jewish and Arab patients in Israel undergoing primary bariatric surgery. Percent of total weight loss (%TWL) and change in body mass index (BMI) were assessed. The results revealed no difference between Arab and Jewish participants in %TWL nor BMI change. Differences in absolute BMI values were all accounted for by the initial between-group difference in the pre-operative BMI. Comorbidity resolution at 1 year post-surgery was not significantly different between the groups.

Biliopancreatic Limb Obstruction Due to an Unexpected Variant of Internal Hernia After Roux-en-Y Gastric Bypass.

Small bowel obstruction due to internal hernia (IH) is a well-known late complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). A reliable and immediate diagnosis of IH is important for optimal and timely management of patients with a history of LRYGB. Mesenteric defects that are created during a LRYGB include the following: (1) through the transverse mesocolon defect, (2) through the entero-enterostomy mesenteric defect, and (3) through the space between the mesentery of Roux limb and transverse mesocolon (Petersen's space). The aim of this case is to present an unusual variant of IH after LRYGB that was laparoscopically explored and treated.

The use of Ursolit for gallstone prophylaxis following bariatric surgery: a randomized-controlled trial.

BACKGROUND: Although bariatric surgery (BS) predisposes patients to development of gallstone formation, a preventive strategy is still in debate. AIM: To compare the incidence of gallstone formation between patients treated with ursodeoxycholic acid (UDCA) vs. placebo for a duration of 6 months following BS. METHODS: This multicenter randomized, double-blind controlled trial entails treatment with UDCA vs. an identical-looking placebo. The primary outcome was gallstone formation, as measured by abdominal ultrasound. RESULTS: The data of 209 subjects were enrolled in the study, and 92 subjects completed the study and were analyzed (n = 46 for each study group). The high dropout rate was mainly due to difficulties in adding more medications and swallowing the pill. Among the subjects who completed the study, 77.2% were women, and their mean age and pre-surgery BMI were 42.2 ± 10.2 years and 44.4 ± 6.1 kg/m2, respectively. Gallstone formation was recorded in 45.7% (n = 21) vs. 23.9% (n = 11) of subjects among placebo vs. UDCA groups, respectively, p = 0.029. Subgroup-analysis, according to surgery type, found that the results were significant only for SG subjects (p = 0.041), although the same trend was observed for OAGB/RYGB. Excess Weight Loss percent (%EWL) at 6 months post-surgery was 66.0 ± 17.1% vs. 71.8 ± 19.5% for the placebo and UDCA groups, respectively; p = 0.136. A trend towards a reduction in prescribed comorbidity medications was noted within-groups during the follow-up period, as compared to baseline, with no between-group differences (p ≥ 0.246). Moreover, no between-group differences were found for blood test results (p ≥ 0.063 for all). CONCLUSION: Administration of UDCA significantly decreased gallstone formation at 6 months at following BS. CLINICALTRIALS. GOV NUMBER: NCT02319629.

Laparoscopic Conversion of Roux-en-Y Gastric Bypass to Sleeve Gastrectomy for Postprandial Hyperinsulinemic Hypoglycemia.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) has proven to be a safe and effective treatment for obesity and its related comorbidities. However, RYGB may lead to uncommon, but occasionally difficult to treat complications such as postprandial hyperinsulinemic hypoglycemia (PHH) [1]. PHH is a condition characterized by hypoglycemic symptoms occurring 1-3 h after a meal, accompanied by low plasma glucose levels, typically preceded by a rise in both glucose and insulin concentrations [2]. The incidence of PHH is unknown and is probably underdiagnosed, as many patients are asymptomatic. The goal for the treatment of PHH after RYGB are to moderate postprandial fluctuations in plasma glucose, reduce insulin secretion, and ultimately reduce hypoglycemia [3]. Therapeutic options can be divided into medical and surgical. In cases of refractory patients, surgical treatment options include partial or total pancreatectomy, or a RYGB reversal procedure accompanied by gastric pouch restriction [4, 5]. METHODS: We present a 27-year-old female who underwent RYGB for morbid obesity. Two years post-surgery, she was referred to the ER due to tremor, palpitations, and syncope. On investigation, her capillary glucose was as low as 37 mg%. The hypoglycemic episodes repeated a few times a day. A comprehensive investigation included a 72 h fasting test, blood tests-serum C peptide and insulin, plasma sulfonylurea, anti-insulin ab, abdominal CT, MRI, octreotide test, and EUS. None of the tests showed any pathology, and she was given the diagnosis of PHH and was treated medically with diazoxide and acrabose without improvement. Surgical options were discussed with the patient and a conversion of the RYGB to sleeve gastrectomy was scheduled. RESULTS: In this video, we show how to revise an RYGB to treat PHH, by converting the RYGB to a sleeve gastrectomy. The intervention starts by restoring the normal anatomy of the small bowel with resection of the 100-cm Roux limb. Then, the greater curvature of the bypassed stomach was resected. A standard LSG around a 34Fr bougie was performed. A gastro-gastric anastomosis was fashioned between the pouch and the remnant stomach. The patient's operative and post-operative course was unremarkable with no further hypoglycemic episodes to date after 1-year follow-up. CONCLUSIONS: This technique was shown to be safe and effective as a part of the surgical treatment of post- bariatric PHH.

Outcome of Delayed Cholecystectomy after Percutaneous Cholecystostomy for Acute Cholecystitis.

BACKGROUND: Recent studies have suggested that urgent cholecystectomy is the preferred treatment for acute cholecystitis. However, initial conservative treatment followed by delayed elective surgery is still common practice in many medical centers. OBJECTIVES: To determine the effect of percutaneous cholecystostomy on surgical outcome in patients undergoing delayed elective cholecystectomy. METHODS: We conducted a retrospective analysis of all patients admitted to our medical center with acute cholecystitis who were treated by conservative treatment followed by delayed cholecystectomy between 2004 and 2013. Logistic regression was calculated to assess the association of percutaneous cholecystostomy with patient characteristics, planned surgical procedure, and the clinical and surgical outcomes. RESULTS: We identified 370 patients. Of these, 134 patients (36%) underwent cholecystostomy during the conservative treatment period. Patients who underwent cholecystostomy were older and at higher risk for surgery. Laparoscopic cholecystectomy was offered to 92% of all patients, yet assignment to the open surgical approach was more common in the cholecystostomy group (16% vs. 3%). Cholecystostomy was associated with significantly higher conversion rates to open approach (26% vs. 13%) but was not associated with longer operative time, hemorrhage, surgical infections, or bile duct or organ injuries. CONCLUSIONS: Treatment with cholecystostomy is associated with higher conversion rates but does not include other major operative-related complications or poorer clinical outcome.

Laparoscopic Repair of a Large Paraesophageal Hernia with Migration of the Stomach into the Mediastinum Creating an Upside-Down Stomach.

Upside-down stomach is a relatively rare type of a large paraesophageal hernia characterized by the migration of the stomach into the posterior mediastinum. Upside-down stomach is prone to severe complications and therefore surgery is recommended even in asymptomatic patients. A 62-year-old male presented with frequent abdominal pain with nausea and vomiting that persisted for one year. The patient was obese with fatty liver and was treated medically for gastroesophageal reflux disease (GERD) for 4 years. On upper gastrointestinal CT study a level-IV paraesophageal hernia was detected with upside-down stomach, and he was referred for elective surgery. Laparoscopic surgery included reduction of the stomach into the abdominal cavity followed by dissection of the paraesophageal membrane and hernia sac. The hiatal defect was closed using a wound closure device and nonabsorbable sutures. The defect closure was reinforced using Physiomesh tucked anteriorly and sutured posteriorly to the diaphragm. Follow-up was uneventful and the patient is free of complaints. The results of this surgical intervention support previous reports that laparoscopic repair with the use of biological mesh in the setting of large paraesophageal hernia should be favorably considered.