What has changed? The impact of the COVID-19 pandemic on the management of acute biliary pancreatitis.

BACKGROUND: The COVID-19 pandemic thoroughly changed the daily practices of medicine. We retrospectively evaluated the impact of the COVID-19 pandemic on our management strategies for patients with acute biliary pancreatitis (ABP). METHODS: A total of 91 patients with ABP who were treated at Trakya University Faculty of Medicine between March 15, 2019 and March 15, 2021 were retrospectively recruited. Patients were classified as pre-COVID and COVID-era patients. The comorbidity markers, data from laboratory tests, inflammatory markers, and radiological examinations were evaluated. Length of stay, need for an intensive care unit, morbidity, mortality, recurrent ABP, and definitive treatment rates were evaluated, and the data of the two periods were compared. RESULTS: Two groups of patients, 57 in the pre-COVID period and 34 in the COVID period, were included in the study. We found that ABP admissions decreased significantly during periods of increased national COVID-19 diagnoses. Type 2 diabetes mellitus was significantly higher in the COVID period patients (P=0.044), and COVID patients had significantly higher total (P=0.004), direct bili-rubin (P=0.007), and lipases (P<0.001). The cholecystectomy rate after an attack decreased from 26% in the pre-COVID period to 15.6% during COVID. CONCLUSION: COVID strikingly reduced the admissions of ABP patients in the early stages of the disease to hospitals, leading to inevitable admissions in advanced severity. Moreover, a significant increase was detected in the recurrence rates of ABP. This can be explained by the reduction in cholecystectomy performed.

Mid-term Results of Laparoscopic Conversion of Gastric Bypass to Duodenal Switch for Weight Regain: the Review of the Literature and Single-Center Experience.

BACKGROUND: Weight regain after Roux-en-Y gastric bypass (RYGB) is a nightmare for the patients and the surgeons and is mostly regarded as "irreversible." However, conversions to duodenal switch (DS) have been done previously with promising success. The current paper reports a single center's mid-to-long-term follow-up outcomes. METHODS: The data from all patients undergoing a conversion of RYGB (and one anastomosis gastric bypass (OAGB)) to DS were reviewed retrospectively. The demographic, operative, and weight loss parameters were analyzed, including age, duration of surgery, weight loss, body mass index (BMI), and morbidity/mortality. RESULTS: Seventeen patients were operated on between January 2013 and December 2021. The mean BMI was 45 kg/m2 (33-70) before conversion. The overall average %EWL was 74.4%, the least was 52% at 6 months, and the most was 91% at 24 and 36 months. All comorbidities resolved after conversion. One patient had a gastro-gastrostomy leak needing prompt surgical repair on the same day of diagnosis. Three patients had other complications: a duodenal stump leak, an intrabdominal abscess, and an ileus. All resolved without surgery. One sudden death happened on the 5th postoperative day. CONCLUSION: Laparoscopic conversion of gastric bypass operations to DS is a complicated procedure that may have severe complications despite excessive patience and expertise but can be performed in a single step. The mid-to-long-term outcomes are promising for weight loss and control of associated co-morbidities.

Evaluation of celiac artery and common hepatic artery variations by CT-angiography and new classification model.

PURPOSE: Knowledge of anatomical variations is important in all interventional procedures. This study aims to evaluate the variations and prevalence of celiac trunk (CeT) and its branches. METHODS: The computerized tomography-angiography (CT-A) findings of 941 adult patients were evaluated retrospectively. Variations of the CeT and common hepatic artery (CHA) were evaluated according to the number of branches and their origin. Findings were compared with classical classification methods. A new classification model has been defined. RESULTS: Normal (complete) trifurcation was detected in 856 (90.9%) of them, where left gastric artery (LGA), splenic artery (SpA) and CHA branches were derived from the CeT. Among 856 complete trifurcation cases, 773 (90.3%) had non-classical trifurcation patterns. The rate of classic trifurcation was 8.8%, while non-classic trifurcation was 82.1% in all cases. In one case (0.1%), LGA and left hepatic artery together and right hepatic artery and SpA together appeared as a double bifurcation. Complete celiacomesenteric trunk was observed only in 4 (0.42%) cases. In seven cases (0.7%), LGA, SpA and CHA were coming out of abdominal aorta (AAo) independently. CHA normal anatomy (Michels Type I) was detected in 618 (65.5%) patients. We found that 49 (5.2%) of our cases were ambiguous according to the Michels Classification. We have described five different variations of hepatic arteries directly arising from the AAo. CONCLUSION: Preoperative recognition of anatomical variations of CeT, superior mesenteric artery and CHA is of primary importance in both surgical and radiological procedures. With careful evaluation of CT-angiographies, it is possible to detect rare variations.

Relationship between SIRI, SII values, and Alvarado score with complications of acute appendicitis during the COVID-19 pandemic.

BACKGROUND: The aim of the study was to investigate the clinical variations of Systemic Inflammatory Response Index (SIRI), Systemic Inflammation Index (SII), and Alvarado Score during the COVID-19 pandemic period. METHODS: Between March 2019 and March 2021, 161 consecutive patients who had surgery due to acute appendicitis were ret-rospectively recruited from Trakya University in Edirne, Turkey. Group I included patients who had surgery during the COVID-19 pandemic and Group II included patients who had surgery before the COVID-19 pandemic period. A total of 80 patients volunteered for Group I and 81 patients for Group II. The neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio, and lymphocyte/monocyte ratio were calculated. SII was calculated by the formula: platelet (P) × neutrophil (N)/lymphocyte (L). NLR was calculated by dividing the neutrophil count by the number of lymphocytes. SIRI was defined as follows: SIRI = (neutrophil × monocyte/lymphocyte). The Alvarado score was also calculated by using patient history, clinical examination, and laboratory findings. RESULTS: There was a significant difference between the two groups in terms of displacing pain, nausea/vomiting, right lower quad-rant tenderness, rebound, hyperthermia, leukocytosis, and total Alvarado score (p<0.001). There was a significant difference between two groups in comparison of C-reactive protein, SIRI, and SII values (p<0.001). Group I patients had higher values of these parameters than Group II. CONCLUSION: Based on the results obtained from this study, we conclude that COVID-19 pandemic has caused an increase in patients with acute appendicitis admitted to the hospital. This late diagnosis of acute appendicitis caused more complications during COVID-19 pandemic. Alvarado score, SIRI, and SII can be used as a marker to indicate whether complications of acute appendicitis occurred pre- or post-operatively. Therefore, Alvarado score, SIRI, and SII are directly proportional to the complication of acute appendicitis.

Single-port transumbilical laparoscopic cholecystectomy: A prospective randomised comparison of clinical results of 140 cases.

INTRODUCTION: A novel single port access (SPA) cholecystectomy approach is described in this study. We have designed a randomised comparative study in order to elucidate any possible differences between the standard treatment and this novel technique. MATERIALS AND METHODS: Between July 2009 and March 2010, 140 adult patients with gallbladder pathologies were enrolled in this multicentre study. Two surgeons (RV and UB) randomised patients to either a standard laparoscopic (SL) approach group or to an SPA cholecystectomy group. Two types of trocars were used for this study: the TriPort™ and the SILS™ Port. Outcomes including blood loss, operative time, complications, length of stay and pain were recorded. RESULTS: There were 69 patients in the SPA group and 71 patients in the SL group. The mean age of the patients was 43.2 (17-77) for the SPA group and 42.6 (19-70) for the SL group. The mean operative time was 63.9 min in the SPA group and 58.4 min in the SL group. For one patient, the SPA procedure was converted to a standard laparoscopic technique and to open approach in the SL group. Complications occurred in eight patients: Five seromas (two in the SPA group) and three hernias (one in the SPA group).The mean hospital stay was 38.5 h in the SPA group and 24.1 h in the SL group. Pain was evaluated and was 2 in the SPA and 2.9 in the SL group, according to the visual analogue scale (VAS) after 24 h (P<0.001). The degree of satisfaction was higher in the SPA group (8.3 versus 6.7). Similar results were found for the aesthetic result (8.8 versus 7.5). (P<0.001). CONCLUSION: Single-port transumbilical laparoscopic cholecystectomy can be feasible and safe. When technical difficulties arise, early conversion to a standard laparoscopic technique is advised to avoid serious complications. The SPA approach can be undertaken without the expense of additional operative time and provides patients with minimal scarring. The cosmetic results and the degree of satisfaction appear to be significant for the SPA approach.

Single-port transumbilical laparoscopic appendectomy: a preliminary multicentric comparative study in 87 patients with acute appendicitis.

Introduction. Laparoscopic appendectomy (LA) has been performed in many approaches such as open, laparoscopic and recently Single Port Access (SPAA). In order to elucidate its potential advantages, we compared the two laparoscopic approaches. Methods. 87 patients were included in a multicentric study for suspected appendicitis in order to perform (SPAA) appendectomy or laparoscopic appendectomy (LA). All outcomes, including blood loss, operative time, complications, and length of stay and pain were recorded prospectively. Results. There were 46 patients in the SPAA group and 41 in the LAG with a mean operative time of 40,4 minutes in the SPAA group and 35,0 minutes in the LA group. Only one patient was converted to an open approach. We described only 2 complications. Pain was graded 2,8 in the SPAA group and 2,9 in the LA group, according to the AVS after 24 hours. Patients in the SPAA Group were more satisfied (7,5 versus 6,9) (P < 0.05). Same results were found for the cosmetic result (8,6 versus 7,4) (P < 0.05). Conclusion. Using the single port approach feasible and safe. The true benefit of the technique should be assessed by new randomised controlled trials.

Pure SILS Floppy Nissen Fundoplication with Hiatal Repair: A Case Report.

Background. Single-incision laparoscopic surgery has recently became popular on behalf of inventing less invasive procedures. In this paper, we present a case of Pure SILS Nissen Fundoplication. Patient and Methods. In February 2010 a 29-year old male patient with a 4 cm sliding hiatus hernia presenting with reflux symptoms had undergone a standard floppy Nissen Fundoplication with a hiatus repair via single 2 cm incision in umbilicus. Results. The procedure had obeyed the standard natural orifice surgery rules, and no needlescopic assistance for any stage of the operation was used so to be a pure single-incision procedure. The operation lasted for 120 minutes without any need of conversion, and the patient was discharged the following day of operation. Conclusion. In the recent time, hybrid single incision laparoscopy techniques have been defined with the use of extra-abdominal supplements for retraction of liver or stomach for Nissen procedure. In addition the main issue in single-incision upper GI and/or hiatus surgery is still the retraction of liver. We succeeded to retract the left lobe of liver through the incision and completed the operation without any need for supplemental access besides the umbilical incision till the end. SILS Hiatus Surgery can be safely and effectively done but the issue needs further clinical studies to state the efficacy when compared to standard laparoscopy.

SILS Incisional Hernia Repair: Is It Feasible in Giant Hernias? A Report of Three Cases.

Aim. Three incisional ventral abdominal wall hernias were repaired by placing a 20 × 30 cm composite mesh via single incision of 2 cm. Methods. All three cases had previous operations and presented with giant incisional defects clinically. The defects were repaired laparoscopically via single incision with the placement of a composite mesh of 20 × 30 cm. Nonabsorbable sutures were needed to hang and fix the mesh only in the first case. Double-crown technique was used in all of the cases to secure the mesh to the anterior abdominal wall. Results. The mean operation time was 120 minutes. The patients were mobilized and led for oral intake at the first postoperative day. No morbidity occurred. Conclusion. Abdominal incisional hernias can be repaired via single incision with a mesh application in experienced centers.

A New Era in Minimally Invasive Liver Resection (MILR) Single-Incision Laparoscopic Liver Resection (SIL-LR): The First Two Cases.

Laparoscopy has gained a place in everyday surgical routine as an alternative surgical approach that decreases morbidity and postoperative hospitalization. Single port laparoscopic surgery has been introduced as a further development of laparoscopy. The feasibility and safety of single port laparoscopy is under extensive evaluation in specialized laparoscopic centers. Nevertheless, wide acceptance of the technique requires adequate documentation of the advantages of the approach over conventional laparoscopy and further refinement of surgical instrumentation to overcome intraoperative ergonomic problems.

Our early experiences with single-incision laparoscopic surgery: the first 32 patients.

BACKGROUND: Most of the laparoscopic surgeons have been attempting to reduce incisional morbidity and improve cosmetic outcomes by using fewer and smaller ports. Single-incision laparoscopic surgery (SILS) is a new laparoscopic procedure. Herein we would like to present our experiences. PATIENTS AND METHODS: Between January 2009 and October 2009, data of the 32 patients who were operated through SILS are evaluated prospectively. There were 22 females and 10 males with a mean age of 45.1±14.8 years. Ten splenectomies for idiopathic thrombocytopenic purpura, 16 cholecystectomies for acute cholecystitis or asymptomatic gallstones, 3 appendectomies for acute appendicitis, one distal pancreatosplenectomy for Renal Cell Cancer metastases, 1 adrenalectomy for Conn Syndrome and 1 case of liver resection for hepatic adenoma were carried out. The most common splenectomy indication was idiopathic thrombocytopenic purpura, cholecystectomy indication was acute cholecystitis (n=8), and asymptomatic cholelithiasis (n=8), appendectomy indication was acute appendicitis, distal pancreatosplenectomy indication was renal cell cancer metastases, adrenalectomy indication was Conn syndrome and liver resection indication was left hepatic mass in between segments 1 and 2. SILS was carried out successfully in 31 patients. Only in 1 patient conversion was required owing to bleeding. RESULTS: All procedures were carried out through a 2-cm umbilical incision. There was no mortality and morbidity recorded. CONCLUSIONS: In experienced hands of minimally invasive surgeons, SILS incision laparoscopic surgery could be carried out successfully in a wide range of surgical operations. However, to be able to show the differences between Standard laparoscopic surgery and single SILS, prospective randomized comparative studies are required.

Single incision laparoscopic pancreas resection for pancreatic metastasis of renal cell carcinoma.

BACKGROUND: Transumbilical single incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain, reduced need for analgesia, and thus accelerated recovery. Herein, we report the first transumbilical single incision laparoscopic pancreatectomy case in a patient who had renal cell cancer metastasis on her pancreatic corpus and tail. METHODS: A 59-year-old female who had metastatic lesions on her pancreas underwent laparoscopic subtotal pancreatectomy through a 2-cm umbilical incision. RESULTS: Single incision pancreatectomy was performed with a special port (SILS port) and articulated equipment. The procedure lasted 330 minutes. Estimated blood loss was 100mL. No perioperative complications occurred. The patient was discharged on the seventh postoperative day with a low-volume (20mL/day) pancreatic fistula that ceased spontaneously. Pathology result of the specimen was renal cell cancer metastases. CONCLUSION: This is the first reported SILS pancreatectomy case, demonstrating that even advanced surgical procedures can be performed using the SILS technique in well-experienced centers. Transumbilical single incision laparoscopic pancreatectomy is feasible and can be performed safely in experienced centers. SILS may improve cosmetic results and allow accelerated recovery for patients even with malignancy requiring advanced laparoscopic interventions.