Single anastomosis sleeve ileal (SASI) bypass versus sleeve gastrectomy: a case-matched multicenter study.

BACKGROUND: The present study aimed to compare the outcome of single anastomosis sleeve ileal (SASI) bypass and sleeve gastrectomy (SG) in regards weight loss, improvement in comorbidities at 12 months of follow-up, and postoperative complications. METHODS: This was a case-matched, multicenter analysis of the outcome of patients who underwent SG or SASI bypass. Patients who underwent SASI bypass were matched with an equal number of patients who underwent SG in terms of age, sex, BMI, and comorbidities. The main outcome measures were excess weight loss (EWL) at 6 and 12 months after surgery, improvement in medical comorbidities, and complications. RESULTS: A total of 116 patients (97 female) of a mean age of 35.8 years were included. Fifty-eight patients underwent SASI bypass and an equal number underwent SG. %EWL at 6 months postoperatively was similar between the two groups. SASI bypass conferred significantly higher %EWL at 12 months than SG (72.6 Vs 60.4, p < 0.0001). Improvement in type 2 diabetes mellitus (T2DM) and gastroesophageal reflux disease (GERD) after SASI bypass was better than SG (95.8% Vs 70% and 85.7% Vs 18.2%, respectively). SASI bypass required longer operation time than SG (108.7 Vs 92.8 min, p < 0.0001). Complications occurred in 12 (20.7%) patients after SG and 4 (6.9%) patients after SASI bypass (p = 0.056). CONCLUSION: The %EWL at 12 months after SASI bypass was significantly higher than after SG. SASI bypass conferred better improvement in T2DM and GERD than SG. Both procedures had similar weight loss at 6 months postoperatively and comparable complication rates.

Oncologic safety and bowel function after ultralow anterior resection with or without intersphincteric resection for low lying rectal cancer: Comparative cross sectional study.

BACKGROUND: Despite acceptable oncologic outcomes of sphincter preserving surgeries for low rectal cancer, bowel dysfunction occurs. This study aimed to compare the oncologic and functional bowel outcomes between ultralow anterior resection (ULAR) and intersphincteric resection (ISR) for low rectal cancer. METHODS: One hundred sixty-four patients who underwent ULAR with or without ISR for low rectal cancer between December 2010 and May 2018 were included. The Wexner and Memorial Sloan Kettering Cancer Center (MSKCC) scores were used to evaluate the bowel function of patients. Overall survival (OS) and disease-free survival (DFS) were compared between patients. RESULTS: The ISR group had higher incidence of major fecal incontinence than the ULAR group (75.9% vs 49.3%; P = .016). The median Wexner score decreased from 12 to 9 (P = .062) at 1-year follow-up. However, the frequency and urgency/soilage subscales of MSKCC score improved significantly in the ULAR group. ISR and follow-up interval less than 1-year significantly increased the major incontinence risk. The OS in the ULAR and ISR groups was 91.4% and 91.7%. Whereas the DFS in both groups was 79% and 79.2%, respectively. CONCLUSION: ULAR and ISR are comparable in oncologic outcomes. Severe bowel dysfunctions and major incontinence were noted in ISR group. Careful selection of patients is mandatory.

Identifying Patients at High Risk of Having Pulmonary Dysfunction Before Laparoscopic Bariatric Surgery and Its Impact on Postoperative Pulmonary Complications.

Background: Morbid obesity is associated with variable degrees of pulmonary dysfunction that may predispose to postoperative complications. This study aimed to identify high risk patients to have pulmonary dysfunction before bariatric surgery in terms of age, sex, and body mass index (BMI) and the impact of pulmonary dysfunction on postoperative pulmonary complications. Methods: Prospective database of patients with morbid obesity who underwent bariatric surgery was reviewed. Data on patients' demographics, parameters of pulmonary function tests, and postoperative pulmonary complications were collected. The correlation between patients' age, sex and BMI, and pulmonary function was investigated using Pearson's correlation coefficient test. Results: Ninety-seven patients (82 female) with morbid obesity were included in the study. Twenty-eight (28.9%) patients had pulmonary dysfunction. Patients >40 years had higher odds of pulmonary dysfunction than patients ≤40 years (odds ratio [OR]: 2.54, P = .05). Male patients had significantly higher odds of pulmonary dysfunction than female patients (OR: 2.5, P = .03). Patients with BMI >50 had significantly higher odds of pulmonary dysfunction than patients with BMI <50 (OR: 4.9, P = .002). Patients with pulmonary dysfunction had significantly higher odds of developing pulmonary complications than patients with normal spirometry (OR: 9.13, P = .009). Conclusion: Around 30% of patients undergoing bariatric surgery had pulmonary dysfunction. Pulmonary dysfunction in preoperative spirometry was able to predict postoperative pulmonary complications. Men, patients older than 40 years, and superobese individuals had higher odds of having pulmonary dysfunction and are at higher risk to develop pulmonary complications after bariatric surgery.

Impact of Ultrasound-Guided Transversus Abdominis Plane Block on Postoperative Pain and Early Outcome After Laparoscopic Bariatric Surgery: a Randomized Double-Blinded Controlled Trial.

BACKGROUND: Based on the promising results of transversus abdominis plane (TAP) block in various abdominal procedures, this study aimed to investigate its effect on postoperative pain and early outcome after laparoscopic bariatric procedures. METHODS: Patients with morbid obesity were randomly assigned to one of two equal groups; group I had US-guided TAP block upon completion of the bariatric procedure and before recovery from general anesthesia and group II did not have TAP block. All procedures were performed laparoscopically with a standardized five-trocar technique. RESULTS: Ninety-two patients of a mean age of 34.7 years and mean BMI of 49.5 kg/m2 were included. The mean pain score in group I was significantly lower than group II at 1 and 6 h postoperatively, whereas no significant differences in pains scores at 12 and 24 h between the two groups were observed. Eight patients in group I required rescue opioid analgesia within the first 24 h postoperatively, compared with 24 patients in group II (P < 0.0001). The postoperative nausea and vomiting (PONV) score at 24 h was significantly lower in group I than group II. Group I required a significantly shorter time to full ambulation and to pass flatus compared with group II. Hospital stay was similar in the two groups. CONCLUSION: Using US-guided TAP block in adjunct with laparoscopic bariatric surgery managed to achieve lower pain scores, lower opioid requirements, lower PONV scores, earlier ambulation, shorter time to pass flatus, and comparable hospital stay and complication rate to the control group.

Impact of Pyloric Injection of Magnesium Sulfate-Lidocaine Mixture on Postoperative Nausea and Vomiting After Laparoscopic Sleeve Gastrectomy: a Randomized-Controlled Trial.

BACKGROUND: One of the most common adverse effects of laparoscopic sleeve gastrectomy (LSG) is postoperative nausea and vomiting (PONV). The present study aimed to assess the impact of local injection of a mixture of magnesium sulfate and lidocaine into the pylorus on gastric intraluminal pressure (ILP) and PONV after LSG. METHODS: Patients with morbid obesity who underwent LSG were randomly allocated to one of two equal groups: treatment group (pyloric injection of a mixture of magnesium sulfate and lidocaine) and control group (pyloric injection of normal saline). PONV and antiemetic requirements were recorded at 6 and 24 h postoperatively. RESULTS: Seventy patients (63 female) with a mean age of 34.6 ± 9.9 years were included. The mean preoperative and postoperative gastric ILP was comparable in the two groups. The pyloric injection of magnesium sulfate-lidocaine mixture resulted in 31% reduction in the mean gastric ILP (19.4 ± 4.7 mmHg before injection to 13.4 ± 4.1 mmHg after injection, p < 0.0001). Pyloric injection of saline did not result in significant change in ILP (19.9 ± 4.9 vs 20.3 ± 5.1 mmHg). Of the treatment group patients, 17.1% had significant PONV at 6 h compared to 91.4% of control group patients (p < 0.0001). At 24 h, none of the treatment group patients had significant PONV versus 40% of the control group patients (p < 0.0001). CONCLUSION: Pyloric injection of magnesium sulfate-lidocaine mixture during LSG resulted in lower incidence of PONV and less use of antiemetic medications in the first 24 h after LSG without being associated with higher complication rate.

Efficacy and safety of botulinum toxin in treatment of anismus: A systematic review.

AIM: To evaluate the efficacy and safety of botulinum toxin type A (BTX-A) in the management of patients with anismus. METHODS: An organized search of published literature was conducted using electronic databases including: PubMed/MEDLINE, and Cochrane Central Register of Controlled Trials, also an internet-based search using "Google Scholar" service was conducted. Both comparative and observational studies were included. We excluded irrelevant articles, editorials, case reports, reviews, and meta-analyses. The studies that followed the patients less than 6 mo were excluded. Variables collected were demographic data of the patients, technique of BTX-A injection and number of sessions, short-term and long-term clinical improvement, post-injection changes in electromyography (EMG), defecography, manometry, and balloon expulsion test, and complications recorded after BTX-A injection. RESULTS: Seven studies comprising 189 patients were included in the review. The median age of the patients was 41.2 years and female-to-male ratio was 1.3:1. The median dose of BTX-A injected per procedure was 100 IU (range, 20-100 IU). Lateral injection was done in five trails and combined lateral and posterior injections in two trials. Three studies used endorectal ultrasonography-guided technique, one study used EMG-guided technique, whereas the remaining three studies used manual palpation with the index finger. The median percentage of patients who reported initial improvement of symptoms was 77.4% (range 37.5%-86.7%), this percentage declined to a median of 46% (range 25%-100%) at 4 mo after injection of BTX-A. Rates of improvement evaluated by balloon expulsion test, EMG, and defecography ranged between (37.5%-80%), (54%-86.7%), and (25%-86.6%), respectively. Fourteen (7.4%) patients developed complications after injection of BTX-A. Complication rates across the studies ranged from 0% to 22.6%. CONCLUSION: Initial satisfactory improvement of symptoms after BTX-A injection remarkably deteriorated after 3 mo of the procedure. However, repeated injection may provide better sustained results with no additional morbidities. Further analysis of more patients is necessary to conclude the safety of BTX-A for the treatment of anismus.

Potential value of estrogen receptor beta expression in colorectal carcinoma: interaction with apoptotic index.

PURPOSE: The study was designed to investigate the clinicopathological correlations, relationship to apoptotic index, and prognostic significance of estrogen receptor beta expression in colorectal carcinoma. METHODS: The study was carried out on 40 patients with newly diagnosed colorectal cancer. The patients' data were collected prospectively and the 2 years overall survival was the endpoint. Estrogen receptor beta expression was assessed by immunohistochemistry. Apoptotic body index was calculated by counting apoptotic cells using the modified TUNEL assay. RESULTS: Estrogen receptor beta positivity was detected in 65% of colorectal cancer cases, while estrogen receptor alpha positivity was found in only 7% of cases. The rate of estrogen receptor beta immunoreactivity was significantly higher in low-grade colorectal tumors. The median apoptotic index in estrogen receptor beta positive cases was significantly higher than in estrogen receptor beta negative cases (6% versus 3%; p = 0.01). The median overall survival was higher in estrogen receptor beta positive cases (22 versus 18 months); however, the difference was not statistically significant. CONCLUSIONS: The study results reinforce the importance of the estrogen receptor beta rather than the estrogen receptor alpha in colorectal cancer. Lack of estrogen receptor beta expression is associated with loss of differentiation and decreased apoptosis. Future studies should include validation of estrogen receptor beta as a prognostic marker and exploration of its role as a target in the management of colorectal cancer.

Effects of ovarian failure on submucosal collagen and blood vessels of the anal canal in postmenopausal women.

BACKGROUND: Estrogen and progesterone receptors are expressed in the anal canal. Fecal control deteriorates after menopause. This phenomenon is related to decreased circulating levels of estrogen and progesterone due to ovarian failure at menopause. AIM OF WORK: To study the effects of estrogen and progesterone on inflammatory cells, submucosal collagen fibers, and vascular plexus of the anal canal of postmenopausal women. SUBJECTS AND METHODS: Experiments were performed on samples of anorectal tissue obtained from 40 women, 19 menstruating (group I), and 21 postmenopausal women (group II). Investigations included immunohistochemistry of estrogen and progesterone receptors and CD34. RESULTS: In negative estrogen receptors (ER) and progesterone receptors (PR), inflammatory cells, submucosal blood vessels, collagen type I were nonsignificantly changed in postmenopausal women relative to menstruating women (P > 0.05) whereas, in positive ER and PR, inflammatory cells and collagen I were significantly increased and submucosal blood vessels were significantly decreased in postmenopausal women relative to menstruating women (P < 0.05). CONCLUSION: Estrogen and progesterone, in menstruating women, produce beneficial effects by decreasing incidence of inflammation and increasing anal canal submucosal blood vessels number and collagen types I, thus both hormones have a positive effect on anal compliance and pressure.