Impact of indocyanine green on prolonged air leak in minimally invasive segmentectomy.

BACKGROUND: Video-assisted thoracoscopic segmentectomies have become the gold standard for the treatment of early-stage non-small cell lung cancer less than two centimeters. The main difficulty is the identification of intersegmental boundary lines which dictate postoperative morbidities. METHODS: We conducted a retrospective study to compare the perioperative outcomes of patients who underwent minimally invasive segmentectomy using the traditional deflation-inflation method or the novel indocyanine green (ICG) technique. Using a prospectively maintained database, we performed a retrospective analysis of 197 consecutive anatomical segmentectomies, from 2020 to 2023. Clinical effectiveness, postoperative complications, and histological data were compared. RESULTS: A total of 73 (37%) patients had the inflation-deflation method and 124 (63%) had the intravenous ICG method. There were no significant differences in chest tube duration, prolonged air leak, postoperative complications, and postoperative hospital stays. Surgical margin width was also similar between the two groups. The multivariable analysis confirmed these results. Lastly, intravenous ICG brought no additional value in complex segmentectomies. CONCLUSION: This monocentric and retrospective analysis found no added value of the intravenous ICG on the perioperative results of minimally invasive segmentectomies. The place of this novel technique in the surgical armamentarium remains to be defined. Specific indications such as complex segmentectomy or patients with chronic pulmonary disease require further study.

Case reports: a variety of clinical presentations and long-term evolution of Bochdalek hernias.

Bochdalek hernias are the most common congenital diaphragmatic hernias, followed by Morgagni hernias. The failure of closure of the pleuroperitoneal membrane results in a posterolateral foramen, which can remain silent until adulthood. They remain a rare pathology with nearly a hundred cases published. Its clinical presentation is variable, making its diagnosis challenging for clinicians. Additionally, its symptoms are not necessarily representative of the content of the hernia. Its management is balanced between the abdominal and the thoracic approaches. However, no guidelines or algorithms are available to help surgeons in the decision-making process. We report here four consecutive cases of symptomatic Bochdalek hernias. Each case has a singular presentation, and we share how they were approached at our institution. In particular, this series shows no reoccurrence in 10+ years of follow-up in two cases and 20+ in one case, underlying the importance of surgical management when Bochdalek hernias are symptomatic.

Aberrant left gastric vein: what should surgeons know?

PURPOSE: Aberrant left gastric vein is a rare variant and hardly known by surgeons. Its misidentification may lead to accidental bleeding. More importantly, it can also be the root of hypertensive gastropathy in cirrhotic patients and tumor spread in patients with gastric cancer. Here, we describe and provide imaging data of the three patterns of aberrant left gastric veins. METHODS: Over the past 5 years, three cases were noted, each one corresponding to one of the three variants. RESULTS: Aberrant left gastric vein is a rare anatomical entity and has rarely been reported. Its normal anatomy and variants, embryological origins, radiological analysis, and clinical implications are all discussed, bringing light to what surgeons should know when encountering an aberrant left gastric vein. CONCLUSION: Surgeons should be aware of the types of ALGV, its associated arterial variations, the presence of pseudolesion or not, and the potential atrophy of liver segment.

Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures.

OBJECTIVE: To define "best possible" outcomes for secondary bariatric surgery (BS). BACKGROUND: Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. METHODS: Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years. RESULTS: The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ±â€Š10 years, 8.4 ±â€Š5.3 years after primary BS, with a BMI 35.2 ±â€Š7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. CONCLUSION: Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Mesenchymal Stem Cells and Platelet Rich Plasma Therapy to Treat Leak After Sleeve Gastrectomy.

BACKGROUND: One of the most feared and life-threatening complications after sleeve gastrectomy (SG) is staple line leak, with an incidence between 1 and 4%. Stable patients may be managed conservatively, with antibiotics, percutaneous drainage and endoscopy-based treatment. We propose mesenchymal stem cells (MSC) and platelet rich plasma (PRP) therapy as an innovative technique to treat leak after SG. MATERIAL AND METHODS: Bone marrow MSCs is obtained by centrifugation of tibial puncture specimen. A peripheral whole blood sample is retrieved from the patient and centrifuged to obtain PRP. During endoscopy, the first 10 mL are injected in 4quadrants (equal volume) in the submucosae around the internal orifice. The second 10 mL are injected in the wall of the fistula tract. RESULTS: The immediate course following the endoscopy was uneventful in both reported cases. The leaks healed in 30 and 42 D, respectively. Oral nutrition was progressively started during the third WK and fourth WK following the injection for both patients. No adverse event was noted during the follow-up period. CONCLUSION: The management of fistulas post SG is controversial and actual available treatments present a relatively prolonged healing time. MSC administration retains a high potential value in the treatment of these fistulas. Further studies and wider clinical trials are mandatory to determine the impact of MSC administration.

The Impact of Previous History of Bariatric Surgery on Outcome of COVID-19. A Nationwide Medico-Administrative French Study.

PURPOSE: To determine the risk of invasive mechanical ventilation and death in obese individuals with a history of bariatric surgery (BS) admitted for COVID-19. METHODS: All obese inpatients recorded during a hospital stay by the French National Health Insurance were included, and their electronic health data were reviewed retrospectively. Patients who had undergone bariatric surgery comprised the BS group and patients with obesity but no history of BS served as controls. The primary outcome was COVID-19-related death and the secondary outcome was the need for invasive mechanical ventilation. RESULTS: 4,248,253 obese individuals aged 15-75 years were included and followed for a mean observation time of 5.43 ± 2.93 years. 8286 individuals with a previous diagnosis of obesity were admitted for COVID-19 between January 1 and May 15, 2020. Of these patients, 541 had a history of BS and 7745 did not. The need for invasive mechanical ventilation and death occurred in 7% and 3.5% of the BS group versus 15% and 14.2% of the control group, respectively. In logistic regression, the risk of invasive mechanical ventilation was independently associated with increasing age, male sex, and hypertension, and mortality was independently associated with increasing age, male sex, history of heart failure, cancer, and diabetes, whereas BS had an independent protective effect. Two random exact matching tests confirmed the protective effect of BS. CONCLUSION: This nationwide study showed that BS is independently associated with a reduced risk of death and invasive mechanical ventilation in obese individuals with COVID-19.

Results of Standard Stapler Closure of Pancreatic Remnant After Distal Spleno-Pancreatectomy for Adenocarcinoma.

Background/Aim: The purpose of this study was to evaluate the results of stapled closure of the pancreatic remnant after cold-knife section of the pancreatic isthmus and distal pancreatectomy for adenocarcinoma. Methods: A retrospective evaluation of 57 consecutive patients undergoing distal spleno-pancreatectomy for adenocarcinoma was performed. The pancreatic isthmus was systematically straight-sectioned with a cold knife, and the remnant was stapled close without additional stitches or adjuncts. The study's main endpoints were postoperative mortality, the occurrence of a pancreatic fistula, the need for a re-operation, the postoperative length of stay in the hospital, the rate of re-admission, and late survival. Results: Postoperative mortality was absent. Seventeen patients (29.8%) presented a pancreatic fistula of grade A in seven cases (41.2%), grade B in eight cases (47.1%), and grade C in two cases (11.8%). Re-operation was required in the two patients (3.5%) with grade C fistula in order to drain an intra-abdominal abscess. The mean postoperative length of stay in the hospital was 15 days (range, 6-62 days). No patient required re-admission. Twenty-nine patients (50.8%) were alive and free from disease, respectively, 12 patients (21.1%) at 12 months, 13 patients (22.8%) at 60 months, and four patients (7.0%) at 120 months from the operation. The remaining patients died of metastatic disease 9-37 months from the operation. Lastly, disease-related mortality was 49.1%. Conclusion: Stapler closure of the pancreatic remnant allows good postoperative results, limiting the formation of pancreatic fistula to the lower limit of its overall reported incidence.

Prevalence of NASH/NAFLD in people with obesity who are currently classified as metabolically healthy.

BACKGROUND: While metabolic health in obesity may confer a protective status, recent studies indicate that nonalcoholic fatty liver disease (NAFLD) or even nonalcoholic steatohepatitis (NASH) may exist in this category of individuals. Although cardiovascular and diabetic risks have been well described, the risk of NAFLD and NASH among this population requires further investigation. OBJECTIVE: Our goal was to compare the prevalence of steatosis, NAFLD, and NASH between individuals with metabolically healthy obesity (MHO) and individuals with metabolically abnormal obesity (MAO) and to identify preoperative risk factors for these conditions in a prospective cohort with morbid obesity scheduled for bariatric surgery. SETTINGS: Tertiary referral university hospital in France. METHODS: The prospective cohort included 837 bariatric patients who also had an intraoperative liver biopsy between 2002 and 2015. Obese individuals fulfilling none of the criteria in the strict definition of metabolic syndrome were considered metabolically healthy. Preoperative blood samples and liver pathology examinations were reviewed. Steatosis, NAFLD, and NASH were carefully identified allowing comparison of prevalence and risk factors between the 2 cohorts. RESULTS: In total, 149 patients (17.8%) had MHO and the remaining 688 (82.2%) had MAO. The cohort with MHO was significantly younger, had a significantly lower glycosylated hemoglobin, a lower homeostasis model assessment of insulin resistance, and increased C-reactive protein. In individuals with MHO, 44 patients (29.5%) had at least moderate steatosis (>33% macrovesicular steatosis) and 5.4% had NASH. Using logistic regression, waist circumference was positively associated with NASH, whereas body mass index and alanine aminotransferase were significantly associated with severe steatosis (>66%). CONCLUSION: Our study indicates that obese individuals without metabolic syndrome may develop subclinical liver involvement. Therefore, the occurrence of NAFLD and NASH in this population needs further investigation.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Vascular Resection for Pancreatic Cancer: Tips and Tricks.

BACKGROUND: Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) with vascular resection for pancreatic cancer has been rarely reported in the literature. Several critical steps are required to achieve a safe radical resection under laparoscopy while respecting oncologic principles of radicality. METHODS: Prospectively collected data on a consecutive series of patients undergoing radical antegrade modular pancreatosplenectomy (RAMPS) were retrospectively reviewed for the purpose of this study. Patients were divided into two groups based on the surgical approach and the need for vascular resection, and data were compared. The surgical technique is reported in detail focusing on the different modalities of vascular resection. RESULTS: Twenty-three patients (male/female ratio, 12/11; mean age, 73 years) underwent RAMPS between July 2014 and October 2018 at our institution. Of these, 17 had a laparoscopic approach and six a standard open approach. All patients in the open group underwent complex vascular reconstructions while four out of 17 (23.5%) underwent laparoscopic vascular resection. One patient in the laparoscopic approach required a vascular reconstruction with graft interposition, which combined the two approaches. There was no mortality, and the complication rate and the duration of surgery were comparable between the two groups. CONCLUSION: L-RAMPS with vascular resection is feasible and safe in selected cases when performed by advanced pancreatic surgeons with experience in laparoscopic surgery.

Bariatric Surgery in the Setting of Liver Cirrhosis with Portal Hypertension: the Confection and Particularities of Roux-en-Y Gastric Bypass in a High-Risk Patient.

INTRODUCTION: Morbid obesity is associated with the occurrence of non-alcoholic fatty liver disease, which may progress to cirrhosis. Although weight loss is the treatment of choice, surgical management can be challenging at the stage of cirrhosis. The aim of this video report is to present the confection and the features of a Roux-en-Y gastric bypass (RYGB) in the setting of liver cirrhosis. METHODS: We present the case of a 60-year-old man with a weight of 115 kg and a corresponding BMI of 38.9 kg/m2, with non-alcoholic steatohepatitis (NASH)-related liver cirrhosis. The latter was compensated (Child-Turcott-Pugh score at A6) but the patient had already undergone three esophageal variceal ligations. Portal hypertension with splenomegaly was clearly visible on preoperative workup. RESULTS: In this video, we show how to perform RYGB in a case of liver cirrhosis, with a focus on common pitfalls. The main risks remain perioperative bleeding due to portal hypertension and impaired coagulation, as well as the decompensation of the cirrhosis. A careful preoperative nutritional and hepatological evaluation is mandatory since the perioperative risk of morbidities is higher. CONCLUSION: RYGB is a feasible option in selected patients with morbid obesity and cirrhosis. These patients ideally should be managed in centers having experience in bariatric surgery and hepatology.

Surgical Management of Small Intestinal Bacterial Overgrowth After Roux-en-Y Gastric Bypass.

INTRODUCTION: Small intestinal bacterial overgrowth (SIBO) is a common adverse effect after laparoscopic Roux-en-Y gastric bypass (LRYGB) and may be responsible for chronic diarrhea, abdominal pain, and discomfort. Although its pathophysiology is still unclear, surgical management may be appropriate in selected cases. METHODS: In this video, we present a surgical revision of LRYGB, 12 years after the initial surgery, for late postoperative chronic diarrhea. The diagnosis of SIBO was finally established and associated with a dilated jejuno-jejunostomy diagnosed through a small bowel follow-through. RESULTS: Revision of the RYGB was performed by resecting the dilated jejunostomy and fashioning a new one with a shorter Roux-en-Y limb. During follow-up, the patient showed fast improvement and complete resolution of symptoms was obtained at 12 months. CONCLUSION: SIBO may be responsible for postoperative chronic diarrhea in RYGB patients, possibly in the long term, and it is often misdiagnosed. Primary treatment is conservative with appropriate dietary measures, antibiotics, and probiotics but surgical management can be very effective in selected patients presenting with failure of prolonged medical treatment and an anatomic abnormality.

Combined Laparoscopic Revision of the Gastric Pouch and Distalization of the Roux Limb After Failure of Weight Loss Following Roux-en-Y Gastric Bypass.

PURPOSE: After failed Roux-en-Y gastric bypass (RYGB), the choice of a secondary procedure falls into many pathways: revision of the gastric pouch, distalization of the bypass (DRYGB), addition of an adjustable gastric band, and conversion to a duodenal switch (BPD/DS). MATERIAL AND METHODS: We present the case of a 54-year-old man with initial BMI of 51.5 kg/m2, who first underwent laparoscopic sleeve gastrectomy (SG) in 2010. In 2012, he underwent a RYGB procedure, and in 2015, a pouch resizing for weight regain. In 2018, he reached a BMI of 41.2 kg/m2. A 3D volumetric CT scan measured a gastric pouch volume of 220 cm3 and a gastrojejunal anastomosis diameter of 20 mm. RESULTS: As shown in the video, the patient underwent a combined revision of the gastric pouch and the gastrojejunal anastomosis associated to the distalization of the Roux limb. The gastrojejunal anastomosis is identified, and vertical division of the stomach is performed along a 36 French bougie, in order to create a 30 cm3 gastric pouch. Then, the jejunojejunal anastomosis is identified, and the Roux limb at the jejunojejunostomy is divided and transposed distally 100 cm to create a total alimentary length of 250 cm. The postoperative course was uneventful. At 1 year, his BMI was 31.2 kg/m2. No nutritional deficiencies were noted. CONCLUSION: Combined laparoscopic pouch resizing and distalization are safe and can lead to adequate weight loss. This technique allows the combination of an added restriction and malabsorption to the previous RYGB and could lead to an improved weight loss.

MRI characteristics in acute ischemic stroke patients with preceding direct oral anticoagulant therapy as compared to vitamin K antagonists.

BACKGROUND: Despite the utility of neuroimaging in the diagnostic and therapeutic management of patients with acute ischemic stroke (AIS), imaging characteristics in patients with preceding direct oral anticoagulants (DOAC) compared to vitamin K antagonists (VKA) have hardly been described. We aimed to determine presence of large vessel occlusion (LVO), thrombus length, infarction diameter, and occurrence of hemorrhagic transformation in AIS patients with preceding DOAC as compared to VKA therapy. METHODS: Using a prospectively collected cohort of AIS patients, we performed univariate and multivariable regression analyses regarding imaging outcomes. Additionally, we provide a sensitivity analysis for the subgroup of patients with confirmed therapeutic anticoagulation. RESULTS: We included AIS in patients with preceding DOAC (N = 75) and VKA (N = 61) therapy, median age 79 (IQR 70-83), 39% female. Presence of any LVO between DOAC and VKA patients (29.3% versus 37.7%, P = 0.361), and target LVO for endovascular therapy (26.7% versus 27.9%, P = 1.0) was equal with a similar occlusion pattern. DOAC as compared to VKA were associated with a similar rate of target LVO for EVT (aOR 0.835, 95% CI 0.368-1.898). The presence of multiple lesions and characteristics of the thrombus were similar in DOAC and VKA patients. Acute ischemic lesion diameter in real world patients was equal in patients taking DOAC as compared to VKA. Lesion diameter in VKA patients (median 13 mm, IQR 6-26 versus median 20 mm, IQR 7-36, P = 0.001), but not DOAC patients was smaller in the setting of confirmed therapeutic VKA. The frequency of radiological hemorrhagic transformation and symptomatic intracranial hemorrhage in OAC patients was low. Sensitivity analysis considering only patients with confirmed therapeutic anticoagulation did not change any of the results. CONCLUSION: Preceding DOAC treatment showed equal rates of LVO and infarct size as compared to VKA in AIS patients. This study adds to the knowledge of imaging findings in AIS patients with preceding anticoagulation.

Endovascular Stroke Treatment and Risk of Intracranial Hemorrhage in Anticoagulated Patients.

Background and Purpose- We aimed to determine the safety and mortality after mechanical thrombectomy in patients taking vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Methods- In a multicenter observational cohort study, we used multiple logistic regression analysis to evaluate associations of symptomatic intracranial hemorrhage (sICH) with VKA or DOAC prescription before thrombectomy as compared with no anticoagulation. The primary outcomes were the rate of sICH and all-cause mortality at 90 days, incorporating sensitivity analysis regarding confirmed therapeutic anticoagulation. Additionally, we performed a systematic review and meta-analysis of literature on this topic. Results- Altogether, 1932 patients were included (VKA, n=222; DOAC, n=98; no anticoagulation, n=1612); median age, 74 years (interquartile range, 62-82); 49.6% women. VKA prescription was associated with increased odds for sICH and mortality (adjusted odds ratio [aOR], 2.55 [95% CI, 1.35-4.84] and 1.64 [95% CI, 1.09-2.47]) as compared with the control group, whereas no association with DOAC intake was observed (aOR, 0.98 [95% CI, 0.29-3.35] and 1.35 [95% CI, 0.72-2.53]). Sensitivity analyses considering only patients within the confirmed therapeutic anticoagulation range did not alter the findings. A study-level meta-analysis incorporating data from 7462 patients (855 VKAs, 318 DOACs, and 6289 controls) from 15 observational cohorts corroborated these observations, yielding an increased rate of sICH in VKA patients (aOR, 1.62 [95% CI, 1.22-2.17]) but not in DOAC patients (aOR, 1.03 [95% CI, 0.60-1.80]). Conclusions- Patients taking VKA have an increased risk of sICH and mortality after mechanical thrombectomy. The lower risk of sICH associated with DOAC may also be noticeable in the acute setting. Improved selection might be advisable in VKA-treated patients. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064. Systematic Review and Meta-Analysis: CRD42019127464.

Feasibility and Efficiency of Sutureless End Enterostomy by Means of a 3D-Printed Device in a Porcine Model.

Objective. The aim of this study is to present a 3-dimensional (3D)-printed device to simply perform abdominal enterostomy and colostomy. Summary Background Data. Enterostomy and colostomy are frequently performed during abdominal surgery. 3D-printed devices may permit the creation of enterostomy easily. Methods. The device was designed by means of a CAD (computer-aided design) software, Rhinoceros 6 by MC Neel, and manufactured using 3D printers, Factory 2.0 by Omni 3D and Raise 3D N2 Dual Plus by Raise 3D. Colostomy was scheduled on a human cadaver and on 6 Pietrain pigs to test the device and the surgical technique. Results. The test on the cadaver showed that the application of the device was easy. Test on porcine models confirmed that the application of the device was also easy on the living model. The average duration of the surgical procedure was 32 minutes (25-40 minutes). For the female pigs, return to full oral diet and recovery of a normal bowel function was observed at postoperative day 2. The device fell by itself on average on the third day. Until day 10, when euthanasia was practiced, the stoma mucosa had a good coloration indicating a perfect viability of tissues. No complications were observed. Conclusions. This is the first study that describes the use of a 3D-printed device in abdominal surgery. End-type colostomy using a 3D-printed device can be safely and easily performed in an experimental porcine model, without postoperative complications. Further studies are needed to evaluate its utility in the clinical setting.