Modified Hepatobiliary Scintigraphy for the Diagnosis of Bile Reflux in One-Anastomosis Gastric Bypass Surgery: a Prospective Multicenter Study.

PURPOSE: One-anastomosis gastric bypass (OAGB) is a relatively simple surgical procedure for those afflicted with severe obesity. Studies reported symptomatic biliary reflux gastritis and esophagitis as predominant complications. Hepatobiliary scintigraphy (HIDA) is the least invasive test for the diagnosis of bile reflux, with good sensitivity, patient tolerability, and reproducibility. The aim of this study was to define an optimized HIDA scintigraphy protocol for demonstrating bile reflux in post-OAGB patients. MATERIAL AND METHODS: We conducted a prospective multicenter study. Patients after OAGB with dyspeptic complaints were included. All patients underwent HIDA scan with a dedicated protocol for demonstrating bile reflux; prevalence and severity were reported. RESULTS: Nineteen patients were included, 18 females and one male, with mean age of 41.8 years and mean time of 22.4 months from operation to the scan. Bile reflux into the gastric pouch was documented in 11 patients (53%). Reflux to the stomach pouch was severe in three patients (27%), moderate in two patients (18%), and mild in six patients (55%). Bile reflux into the esophagus was documented in four patients (21%), severe reflux in one patient (25%), and mild in the other three (75%). A correlation was found between complaints of vomiting, heartburn and regurgitation, and findings of esophagitis on gastroscopy in patients with vs. without reflux. CONCLUSIONS: The tailored HIDA scan protocol detected bile reflux in more than half of the post-OAGB patients included in the study, with a high diagnostic sensitivity.

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.

Novel Transgastric Endoluminal Segmental Esophagectomy and Primary Anastomosis Technique: A Hybrid Transgastric Thoracoscopic Esophagectomy for the Treatment of High Grade Dysplasia and Early Esophageal Cancer in a Porcine Ex vivo Model.

Multiple modalities are currently employed in the treatment of high grade dysplasia and early esophageal carcinoma. While they are the subject of ongoing investigation, surgery remains the definitive modality for oncological resection. Esophagectomy, however, is traditionally a challenging surgical procedure and carries a significant incidence of morbidity and mortality. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are considerably less invasive alternatives to esophagectomy in the diagnosis and treatment of high grade dysplasia, early esophageal squamous cell carcinoma and adenocarcinoma. However, many early esophageal cancer patients, with favorable histology, who could benefit from endoscopic resection, are referred for formal esophagectomy due to lesion characteristics such as unfavorable lesion morphology or recurrence after previous endoscopic resection. In this study we present a novel, hybrid thoracoscopic transgastric endoluminal segmental esophagectomy with primary anastomosis for the potential treatment of high grade dysplasia and early esophageal cancer in a porcine ex vivo model as a proposed bridge between endoscopic resection and the relatively high mortality and morbidity formal esophagectomy procedure. The novel technique consists of thoracoscopic esophageal mobilization in addition to transgastric endoluminal segmental esophagectomy and anastomosis utilizing a standard circular stapler. The technique was found feasible in all experimental subjects. The minimally invasive nature of this novel procedure as well as the utility of basic surgical equipment and surgical skill is an important attribute of this method and can potentially make it a treatment option for many patients who would otherwise be referred for a formal esophagectomy.

The role of bariatric surgery in normalization of the coagulation profiles.

BACKGROUND: Bariatric surgery achieves appropriate excess weight loss, controlling related co-morbidities, including coagulation abnormalities. OBJECTIVE: We investigated the change in the coagulation profile after postoperative weight stabilization, correlating between EWL ratio and change in the coagulation profile. SETTING: This study took place in our teaching institution (university setting). METHODS: Between the years 2012 and 2014, 67 patients underwent surgery; 47 patients underwent laparoscopic sleeve gastrectomy (SG) and 20 patients underwent Roux-en-Y gastric bypass (RYGB). Average follow-up of postoperative thromboelastography (TEG) parameters was 30 ± 10.8 months (12-77). Average body mass index (BMI) before surgery was 41.7 ± 4.6kg/m2, average percentage of EWL at the time of data collection was 79%. Patients were divided into 3 groups, 6 patients had EWL < 50%, 13 had an EWL > 100%, and 48 had EWL between 50% and 100%. EXCLUSION CRITERIA: use of anticoagulation, antiplatelet, or contraceptive medications; known thrombophilic, renal, hepatic, and hematologic diseases/disorders. Two follow-up groups: 1-2 years and over 2 years. Patients underwent pre and postoperative TEG coagulation studies, including maximal amplitude (MA), and clot strength (G). RESULTS: Coagulation profile improved after bariatric surgery. Most prominent change seen in MA and G. There was a linear correlation between the EWL ratio and improvement of MA values starting at 50% EWL peaking at 60%-70%. There was no difference in the coagulation profile after surgery in the two surgery groups (SG and RYGB). CONCLUSIONS: Achieving appropriate weight loss after bariatric surgery improves the coagulation profile as measured by TEG, probably decreasing thromboembolic risk in those patients. We recommend expanding the current indication for bariatric surgery to include patients with altered coagulation profile measured by TEG.

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.

Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Are Correlated with Complicated Diverticulitis and Hinchey Classification: A Simple Tool to Assess Disease Severity in the Emergency Department.

BACKGROUND AND AIM: Rapid identification of patients with complications related to acute diverticulitis who require urgent intervention in the emergency department (ED) is essential. The aim of our study was to determine the role of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting severity of diverticulitis as assessed by Hinchey classification. PATIENTS AND METHODS: We performed a single retrospective study in EMMS Nazareth Hospital from 4/2014 to 4/2018. Patients were categorized into two groups: group A with mild to moderate complicated diverticulitis (Hinchey 1-2) and group B with severe complicated diverticulitis (Hinchey 3-4). RESULTS: Two hundred twenty-five patients were included. Two hundred seven patients were in group A, and 18 patients were in group B. On univariate analysis, age, NLR, and PLR correlated with advanced Hinchey classification and disease severity (stages 3-4) (OR 1.038, 95% CI 1.001-1.076, P=0.0416; OR 1.192, 95% CI 1.093-1.300, P < 0.0001; and OR 1.011, 95% CI 1.005-1.017, P=0.0005, respectively). On multivariate logistic regression analysis, the NLR and PLR remain significantly correlated with Hinchey 3-4 (OR 1.174, 95% CI 1.071-1.286, P=0.0006, and OR 1.008, 95% CI 1.001-1.015, P=0.0209, respectively). The area under the curve (AUC) for the NLR and PLR on univariate analysis was 0.7526 and 0.6748, respectively, and 0.7760 and 0.7391 on multivariate logistic regression analysis, respectively, and receiver-operating characteristic (ROC) curves were drawn. CONCLUSION: The NLR and PLR independently associated with diverticulitis severity and positively correlated with advanced Hinchey classification. This simple available laboratory tool can be implemented into clinical practice to optimize patient management.

The role of rapid on-site evaluation on diagnostic accuracy of endoscopic ultrasound fine needle aspiration for pancreatic, submucosal upper gastrointestinal tract and adjacent lesions.

BACKGROUND AND AIM: Our aim was to assess adequacy and diagnostic accuracy of endoscopic ultrasound-fine needle aspiration (EUS-FNA) specimens with or without rapid on-site evaluation (ROSE) from pancreatic, upper gastrointestinal tract (UGIT) and adjacent masses. METHOD: A retrospective cohort study based on patients' files who underwent EUS-FNA in Galilee Medical Center in a 4 years period. Number of needle passes, repeated EUS and ROSE effect on tissue adequacy and diagnostic accuracy were reported. RESULTS: One-hundred sixty-one patients were included. Ninety-three patients (57.7%) underwent EUS-FNA without ROSE (group A) compared to 68 patients (42.3%) with ROSE (group B). The most common location was in the pancreas (55% in group A vs 81% in group B). Addition of ROSE yielded a significantly higher specimen adequacy (65% in group A vs 92.6% in group B (Chi-Square < 0.0001, OR 6.72, 95% CI 2.45-18.38). The matching rate (accuracy) between ROSE diagnosis and final histopathological diagnosis was noticed in 61 out of 68 patients (89.7%, 95% CI 0.7993-0.9576). The Kappa coefficient correlations of matching rate between ROSE and final histopathological diagnosis of all lesion and in pancreatic lesions were 0.7558, (95% CI 0.625-0.887) and 0.7814, (95% CI 0.639-0.924), respectively. CONCLUSIONS: EUS-FNA with ROSE significantly improve specimen adequacy and was associated with high diagnostic accuracy.

Unlimited-Length Proctocolectomy Utilizing Sequential Intussusception and Pull-Through: Novel Clean Endolumenal NOTE-Assisted Technique With Transanal Natural Orifice Specimen Extraction Without Rectal Stump Opening in a Porcine Model.

Transanal, hybrid natural orifice translumenal endoscopic surgery (NOTES) and NOTES-assisted natural orifice specimen extraction techniques hold promise as leaders in the field of natural orifice surgery. We report the feasibility of a novel NOTES assisted technique for unlimited length, clean, endolumenal proctocolectomy in a porcine model. This technique is a modification of a transanal intussusception and pull-through procedure recently published by our group. Rectal mobilization was achieved laparoscopically; this was followed by a transanal recto-rectal intussusception and pull-through (IPT). IPT was established in a stepwise fashion. First, the proximal margin of resection was attached laparoscopically to the shaft of the anvil of an end-to-end circular stapler with a ligature around the rectum. Second, this complex was pulled transanally to produce IPT. To achieve an unlimited-length proctocolectomy, the IPT step was repeated several times prior to bowel resection. This was facilitated by removing the ligature applied in the first step of this procedure. Once sequential IPT established the desired length of bowel to be resected, a second ligature was placed around the rectum approximating the proximal and distal resection margins. The specimen was resected and extracted by making a full-thickness incision through the 2 bowel walls. The anastomosis was achieved by deploying the stapler. The technique was found to be feasible. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. The minimally invasive nature of this evolving technique as well as its aseptic bowel manipulation has the potential to limit the complications associated with abdominal wall incision and surgical site infection.