Late Complications after Laparoscopic Longitudinal Gastrectomy - Case Report.

INTRODUCTION: Bariatric surgery is now widely regarded as the most effective treatment for morbid obesity. It aims to enhance patients' health by achieving long-lasting weight loss, reducing associated comorbidities, and improving their quality of life. CASE REPORT: The case involves a 51-year-old female patient who underwent sleeve gastrectomy eight years ago to address morbid obesity (Body Mass Index (BMI) = 43). Subsequently, the patient developed gastric obstructive syndrome, leading to diagnostic investigations including repeated upper digestive endoscopies and native computed tomography. These examinations revealed the presence of a hiatal hernia. In 2021, the patient underwent fundoplication type Dor with anterior hemivalve. However, post-surgery, the patient's condition did not improve, with persistent symptoms including regurgitation, heartburn, difficulty ingesting food, sensation of gastric fullness, and epigastralgia. Further exploratory procedures, including upper digestive endoscopy, abdominal computed tomography with contrast substance, and barium transit with contrast substance, led to the diagnosis of mediogastric stenosis postgastrectomy longitudinal, necessitating surgical intervention. This finding prompted a surgical approach involving distal gastric resection and restoration of digestive tract continuity through Hoffmeister-Finsterer gastro-jejunal anastomosis. Following the surgery, the patient's postoperative symptoms showed improvement. DISCUSSION: Several other studies have demonstrated that the incisura angularis is the most common site of obstruction, as was observed in our study. This particular location appears to be more prone to narrowing, likely attributable to its angular shape. The linear staple line in this area can create a locus minoris resistentiae for kinking, as well as increase the risk of true stenosis if stapling is performed too close to the incisura angularis. CONCLUSIONS: Bariatric surgery should not be considered as the initial treatment option. However, in cases where it becomes necessary, postoperative monitoring is essential to prevent complications or address them promptly.

The visceral adipose tissue bacterial microbiota provides a signature of obesity based on inferred metagenomic functions.

BACKGROUND: Metabolic inflammation mediated obesity requires bacterial molecules to trigger immune and adipose cells leading to inflammation and adipose depot development. In addition to the well-established gut microbiota dysbiosis, a leaky gut has been identified in patients with obesity and animal models, characterized by the presence of a tissue microbiota in the adipose fat pads. METHODS: To determine its potential role, we sequenced the bacterial 16 S rRNA genes in the visceral adipose depot of patients with obesity. Taking great care (surgical, biochemical, and bioinformatic) to avoid environmental contaminants. We performed statistical discriminant analyses to identify specific signatures and constructed network of interactions between variables. RESULTS: The data showed that a specific 16SrRNA gene signature was composed of numerous bacterial families discriminating between lean versus patients with obesity and people with severe obesity. The main discriminant families were Burkholderiaceae, Yearsiniaceae, and Xanthomonadaceae, all of which were gram-negative. Interestingly, the Morganellaceae were totally absent from people without obesity while preponderant in all in patients with obesity. To generate hypotheses regarding their potential role, we inferred metabolic pathways from the 16SrRNA gene signatures. We identified several pathways associated with adenosyl-cobalamine previously described to be linked with adipose tissue development. We further identified chorismate biosynthesis, which is involved in aromatic amino-acid metabolism and could play a role in fat pad development. This innovative approach generates novel hypotheses regarding the gut to adipose tissue axis. CONCLUSIONS: This innovative approach generates novel hypotheses regarding the gut to adipose tissue axis in obesity and notably the potential role of tissue microbiota.

A Comprehensive Summary of the Current Understanding of the Relationship between Severe Obesity, Metabolic Syndrome, and Inflammatory Status.

At present, obesity, as a part of metabolic syndrome, represents the leading factor for disability, and is correlated with higher inflammation status, morbidity, and mortality. The purpose of our study is to add new insights to the present body of knowledge regarding the correlations between chronic systemic inflammation and severe obesity, which cannot be treated without considering other metabolic syndrome conditions. Biomarkers of high-level chronic inflammation are recognized as important predictors of pro-inflammatory disease. Besides the well-known pro-inflammatory cytokines, such as WBCs (white blood cells), IL-1 (interleukin-1), IL-6 (interleukin-6), TNF-alpha (tumor necrosis factor-alpha), and hsCRP (high-sensitivity C-reactive protein), as well as anti-inflammatory markers, such as adiponectin and systemic inflammation, can be determined by a variety of blood tests as a largely available and inexpensive inflammatory biomarker tool. A few parameters, such as the neutrophil-to-lymphocyte ratio; the level of cholesterol 25-hydroxylase, which is part of the macrophage-enriched metabolic network in adipose tissue; or levels of glutamine, an immune-metabolic regulator in white adipose tissue, are markers that link obesity to inflammation. Through this narrative review, we try to emphasize the influence of the weight-loss process in reducing obesity-related pro-inflammatory status and associated comorbidities. All data from the presented studies report positive results following weight-loss procedures while improving overall health, an effect that lasts over time, as far as the existing research data show.

A comparative analysis of three types of parathyroidectomies in renal hyperparathyroidism Single centre prospective cohort of 77 patients.

BACKGROUND: There is no consensus regarding optimal timing or best surgical procedure for refractory renal hyperparathyroidism patients. We aim to compare the results after three types of parathyroidectomies performed for sHPT in a single referral centre. METHODS: This study included patients on chronic hemodialysis submitted to three types of parathyroidectomy between 2010 and 2017. The primary outcome measure was relief of the symptoms and normalization of the main biochemical parameters. RESULTS: All symptoms improved significantly after surgery, especially osteoatricular pains. iPth dropped significantly immediately and during the follow up in all 3 groups; on short term, iPth values for group C(tPtx) were significantly lower compared to the other 2 subgroups (p=0.009). Furthermore, 5 patients from group C presented iPth values <12 pg/ml one year post-surgery, though this values tend to improve after. Patients from group B and C developed most often acute postoperative hypocalcemia, and persistent hyperparathyroidism was encountered especially after sPtx(10.3%). CONCLUSION: Significant improvement of both symptoms and biochemical parameters was noted in the majority of cases, regardless the parathyroidectomy type. tPtx is frequently followed by chronic hypoparathyroidism and subtotal parathyroidectomy is followed by a higher number of persistent and recurrent sHPT. KEY WORDS: Secondary hyperparathyroidism, Parathyroidectomy, Parathyroid autotransplant.

A prospective follow-up study on completion thyroidectomy for well-differentiated thyroid cancer. A single-center report.

BACKGROUND: Completion thyroidectomy (cT) becomes a choice after any type of less than total thyroid surgery, when a "total" would have been indicated on primary intervention if malignancy diagnosis had been available. The study main aim is to define predictive factors of malignancy in the thyroid remnant and to assess the morbidity risk after cT according to the type of initial intervention. MATERIAL AND METHOD: Sixty-three patients on whom cT was performed were finally included with 61 surgeries performed in our department. RESULTS: Or cohort included 55 (87.3%) women and 8 men (12.7%), with a mean age of 48.3 on whom were primary performed 34 lobectomies with isthumusectomies (LwI=53.96%) and 29 subtotal thyroidectomies or hemithyroidectomies (STT=46.03%). Histopathological examination after reintervention detected malignancy in 30.15% of excised thyroid remnants (19 patients), in the majority of these cases microcarcinoma. We found statistically significant correlations between the risk of malignancy in the thyroid remnant and both the primary thyroid tumor multicentricity (p=0,001) and its extracapsular and/or vascular invasion (p=0,006) respectively. The time span between the two interventions ranged from 3 days to 12 months (mean 63 days). No 30-day mortality occurred in our group of patients. We noted 3 cases of RLN palsy (4.76%) of which one permanent (1.58%) and 12 cases (19.04%) of postoperative hypoparathyroidism, of which two (3.17%) permanent. CONCLUSIONS: Multicentricity and capsular and/ or vascular invasion of the initial tumor are factors predictive of malignancy in the remnant thyroid. The rate of postoperative hypoparathyroidism is higher after initial subtotal thyroidectomy. KEY WORDS: Completion thyroidectomy, Incidental parathyroidectomy, Multifocality, Thyroid cancer.

Fatal Hypocalcaemia Due to Hungry Bone Syndrome with Secondary Refractory HyperParathyroidism After Parathyroidectomy: A Case Report.

INTRODUCTION: Hungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcaemia associated with hypophosphatemia and hypomagnesaemia, and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and preoperative high bone turnover. [1]. CASE REPORT: This report concerns a dialysed patient who underwent surgical treatment for secondary refractory hyperparathyroidism. Haemodialysis was carried out pre-operatively, and subsequently, a total parathyroidectomy with auto-transplantation of parathyroid tissue in the sternocleidomastoid muscle (SCM) was performed. Rapid and progressive hypocalcaemia symptoms developed during the second day postoperatively. Acute cardiac symptoms with tachyarrhythmia, haemodynamic instability and finally asystole occurred, which required cardiopulmonary resuscitation (CPR). The ionic calcium level was 2.2 mg/dL being consistent with a diagnosis of HBS. A second cardiac arrest unresponsive to CPR followed an initial period of normal sinus rhythm. Death ensued shortly after. Before death, the ionic calcium was 3.1 mg/dL. CONCLUSION: HBS, after parathyroidectomy in patients with secondary hyperparathyroidism (SHPT), may be severe, prolonged and sometimes fatal. Generally, HBS symptomatology is that of a mild hypocalcaemia. It can, however, include heart rhythm disturbances with haemodynamic alterations requiring intensive care measurements and even cardiopulmonary resuscitation. A close clinical and laboratory post-parathyroidectomy monitoring of dialysed patients is of the utmost importance.

Subtotal parathyroidectomy versus total parathyroidectomy with autotransplant in secondary hyperparathyroidism ­ a single-centre prospective cohort of 43 patients.

INTRODUCTION: The need for parathyroidectomy remains high in the group of patients on long-term dialysis with medically refractory secondary hyperparathyroidism (sHPT). We aim to compare the results after subtotal parathyroidectomies (sPtx) and total parathyroidectomies with autotransplant (tPtx + AT) performed for sHPT at a single referral centre. MATERIAL AND METHODS: This prospective study comparatively analysed sPtx and tPtx + AT performed in our department between February 2010 and December 2014. We followed-up both surgical techniques, with respect to the main clinical symptoms, laboratory data, mortality, and recurrent disease. RESULTS: Forty-three patients on whom we performed 26 sPtx and 19 tPtx + AT were entered in the study. There were no statistically significant differences between groups as far as demographic and preoperative clinical data are concerned. We did not encounter postoperative mortality in either of the groups. The follow-up period was significantly longer for the sPtx group (p = 0.04). The immediate postoperative serum calcium levels were significantly lower in the tPtx + AT group (p = 0.009). Definitive hypoparathyroidism was encountered in two patients in the sPtx group (8.3%) and in one from the tPtx + AT group (5.26%). Four patients from the sPtx group (16.6%) and three from the tPtx + AT group (15.78%) died during the follow-up due to causes unrelated to parathyroidectomy. Overall we had two recurrences in the sPtx group and none in the tPtx + AT group (p = 0.57). CONCLUSIONS: In our opinion both techniques have comparable results concerning the clinical and laboratory outcomes and rates of postoperative hypoparathyroidism, at least in short- and medium-term follow-up.

Outcomes after transhiatal esophagectomies in an eastern-European low-volume center.

BACKGROUND: The present study proposes to analyze the results obtained after transhiatal esophagectomies (THE), from the perspective of an Eastern European surgical center with low esophageal resection volume (LV). AIMS: Our analysis, which to the authors' knowledge is the first of its kind in Romania, has the purpose of comparing our results with those obtained in higher or similar volume centers, in order to derive conclusions regarding the quality of therapeutic management for patients diagnosed with esophageal cancer in Romania. STUDY DESIGN: Retrospective observational study. METHODS: In total, 70 patients were included, in whom THE was performed during the period 1997-2013 by six senior surgeons. The majority of our patients had esophageal cancers (n=66; 94.3%); we also performed 4 THE procedures for benign conditions (n=3; 4.27%) and esophageal perforation (n=1; 1.42%). RESULTS: The majority of cancer-group patients had T3/N+ tumors. The nodal involvement in the T2, T3 and T4 categories was 9.9%, 21.6% and 35.1%, respectively. Complications were identified in 45 patients (68.2%), with the majority being represented by pulmonary complications (16 patients; 24.3%) and cervical leaks (15 cases; 22.7%). In-hospital mortality was 9.09%. We found a one-year overall survival rate of 58.7% (95%CI: 51.7-65.7%), 27.2% at 2 years (95%CI: 21.2-36.2%) and 10.5% at 3 years (95%CI: 6.5-14.5%). The median survival rate was estimated to be 16 months. CONCLUSION: Morbidity and in-hospital mortality after THE was performed in low-volume centers, despite being significantly higher than reported in HV centers, could be kept at reasonable rates. In our opinion, the measures which have the potential to raise the standard of care for patients diagnosed with esophageal cancer in Romania are represented by the standardization of therapeutic and diagnostic protocols for esophageal cancer and the centralization of these major oncologic interventions in surgical excellence centers.

Clinicopathologic and therapeutic aspects of giant parathyroid adenomas - three case reports and short review of the literature.

In the last decade, the clinical picture of primary hyperparathyroidism has changed, with the majority of patients being diagnosed while asymptomatic and the "classical" clinical pattern characterized by bone disease, recurrent nephrolithiasis, peptic ulcer disease, neurological or psychiatric disorders being rarely encountered. In this context, most patients have minimal hypercalcemia and small parathyroid adenomas. Not surprisingly, giant parathyroid adenomas have seldom been described in the literature. We herein report three cases of giant parathyroid adenomas weighing more than 30 g and discuss their clinicopathological and therapeutic particularities. We also review the relevant literature, with the principal aim of outlining the rarity of these giant parathyroid adenomas and the issues concerning their diagnosis and treatment.