Determining changes in bone metabolism after bariatric surgery in postmenopausal women.

BACKGROUND: Accelerated bone loss is a known complication after bariatric surgery. Bone mineral density has been shown to decrease significantly after Laparoscopic Roux-en-Y gastric bypass (RYGB). Laparoscopic sleeve gastrectomy (SG) effects on bone density are largely unknown. This should be considered for those with increased preoperative risk for bone loss, such as postmenopausal females. METHODS: This prospective clinical trial included postmenopausal patients, with BMI ≥ 35 k/m2, being evaluated for either RYGB or SG. Patients with history of osteoporosis, estrogen hormone replacement therapy, active smoking, glucocorticoid use, or weight > 295 lb were excluded. Patients underwent DEXA scans preoperatively and 1 year postoperatively with measurement of total body bone mineral density (BMD) and bone mineral content (BMC) as well as regional site-specific BMD and BMC. RESULTS: A total of 28 patients were enrolled. 16 (57.1%) patients underwent RYGB and 12 (42.9%) patients underwent SG. Median preoperative BMI was 44.2 k/m2 (IQR 39.9, 46.6). Median change in BMI at 12 months was - 11.3 k/m2 (IQR - 12.8, - 7.9). A significant reduction in total body BMC was seen when comparing preoperative measurements to postoperative measurements (2358.32 vs 2280.68 grams; p = 0.002). Regional site BMC and BMD significantly decreased in the ribs and spine postoperatively (p = < 0.02) representing the greatest loss in the axial skeleton. Comparing those who underwent RYGB to SG there was no significant difference between the two groups when evaluating changes in total or regional site BMD. CONCLUSION: Postmenopausal women were found to have decreased BMD and BMC after RYGB and SG, suggesting that high-risk women may benefit from postoperative DEXA screening. Further study is needed to determine the clinical significance of these findings. It is unknown if these changes in BMD are due to modifiable factors (Vitamin D level, activity level, hormone status, etc.), and whether BMD and BMC is recovered beyond 1 year.

[Endoscopy after bariatric surgery: what the endoscopist must know]. / Endoscopía luego de cirugía bariátrica: Lo que debe saber el endoscopista.

Endoscopy is essential in the assessment and treatment of the bariatric patient, especially in the postoperative state. Since bariatric surgery is increasing exponentially, endoscopists should be familiar with the anatomy and how to manage possible complications. New less invasive therapeutic tools will have a major impact on the prognosis of these patients. Dreaded complications such as leaks, stenosis or weight regain can be successfully assessed and treated by endoscopy. Postoperative evaluation of symptoms requires the precise search of details that can change patient's management.

Use of magnets in gastrointestinal surgery.

BACKGROUND: Laparoscopic and endoscopic surgery has undergone vast progress during the last 2 decades, translating into improved patient outcomes. A prime example of this development is the use of magnetic devices in gastrointestinal surgery. Magnetic devices have been developed and implemented for both laparoscopic and endoscopic surgery, providing alternatives for retraction, anchoring, and compression among other critical surgical steps. The purpose of this review is to explore the use of magnetic devices in gastrointestinal surgery, and describe different magnetic technologies, current applications, and future directions. METHODS: IRB approval and written consent were not required. In this review of the existing literature, we offer a critical examination at the use of magnets for gastrointestinal surgery currently described. We show the experiences done to date, the benefits in laparoscopic and endoscopic surgery, and additional future implications. RESULTS: Magnetic devices have been tested in the field of gastrointestinal surgery, both in the contexts of animal and human experimentation. Magnets have been mainly used for retraction, anchoring, mobilization, and anastomosis. CONCLUSION: Research into the use of magnets in gastrointestinal surgery offers promising results. The integration of these technologies in minimally invasive surgery provides benefits in various procedures. However, more research is needed to continually evaluate their impact and implementation into surgical practice.

Asthma medication usage is significantly reduced following bariatric surgery.

INTRODUCTION: Asthma is an important healthcare problem affecting millions in the United States. Additionally, a large proportion of patients with asthma suffer from obesity. These patients exhibit poor asthma control and reduced therapy response, increasing utilization of healthcare resources. Pulmonary symptoms improve after bariatric surgery (BS), and we hypothesized that asthma medication usage would decrease following BS. METHODS: A retrospective data analysis was performed in adult patients from a single institution's database. Patients with obesity using at least one asthma medication pre-operatively who underwent BS were studied for up to 3-years post-operation. Poisson generalized linear mixed models for repeated measures were used to evaluate the effects of time and procedure type on the number of asthma medication. RESULTS: Bariatric patients with at least one prescribed asthma medication (mean 1.4 ± 0.6) were included (n = 751). The mean age at time of operation was 46.8 ± 11.6 years, mean weight was 295.9 ± 57 lbs, and mean body mass index (BMI) was 49 ± 8.2 kg/m2; 87.7% were female, 33.4% had diabetes, 44.2% used gastroesophageal reflux disease (GERD) medication, and 64.4% used hypertension medication. The most common procedure was Roux-en-Y gastric bypass (79%), followed by sleeve gastrectomy (10.7%), adjustable gastric banding (8.1%), and duodenal switch (2.3%). The mean number of prescribed asthma medications among all procedures decreased by 27% at 30 days post-operation (p < 0.0001), 37% at 6 months (p < 0.0001), 44% at 1 year (p < 0.0001), and 46% at 3 years (p < 0.0001) after adjusting for risk factors. No significant differences in medication use over time between procedure types were observed. In the adjusted analysis, the mean number of asthma medications was 12% higher in patients using at least one GERD medication (p = 0.015) and 8% higher with 10-unit increase in pre-operative BMI (p = 0.006). CONCLUSION: BS significantly decreases asthma medication use starting 30 days post-operation with a sustained reduction for up to 3 years.

Mediastinal Myxoid Liposarcoma with Intrapericardial Involvement and Large Pericardial Effusion.

Liposarcoma is the name given to a group of soft tissue sarcomas (STSs) with adipocytic differentiation. As a group, liposarcomas are the second most common STSs in adults. In 1951 Kozonis et al published that in the English language only four cases of liposarcomas originating in the mediastinum had been described. Primary mediastinal liposarcoma is an uncommon neoplasm of intrathoracic origin. We present the case of a 47-year-old woman diagnosed with a large mediastinal mass with intrapericardial invasion and massive pericardial effusion; biopsies showed a mediastinal liposarcoma.

Dysphagia lusoria in a young patient with a concomitant aortic arch anomaly, successfully treated with surgery: a case report.

Dysphagia is a common condition in clinical practice; however, an unusual type of dysphagia due to compression of the esophagus by an abnormal right subclavian artery may be discovered in a rare subset of patients. The prognosis and treatment will depend on the severity of the symptoms and the compromise of surrounding structures. We present the case of an 18-year-old female who presented with gradually progressive dysphagia. At first, it was treated as gastroesophageal reflux disease; nonetheless, the dysphagia became severe, and after a thorough evaluation, an aberrant right subclavian artery that compressed the esophagus was discovered along with a truncus bicaroticus. She was successfully treated with surgery without any complications. On follow-ups, she's doing well.

Incidental finding of an ectopic b2 thymoma attached to the pericardium.

Ectopic thymoma is a rare tumor that arises from the abnormal migration of thymus tissue. They are extremely rare and have a broad spectrum of clinical symptoms. Therefore, preoperative diagnosis is complex and can be easily misdiagnosed. Complete resection is the treatment of choice to avoid recurrence, radiotherapy and enhanced survival. Regretfully, many patients arrive at a late stage, limiting our therapeutic options; therefore, pre-operative diagnosis is vital. We present the case of an otherwise healthy 32-year-old woman; after a chest X-ray was done for a routine medical evaluation, a mass was discovered in her mediastinum. After surgery, a B2 thymoma attached to the pericardium was discovered and successfully treated.

Young females affected with hydatidosis, case report.

Hydatidosis is a zoonosis, caused by a cestode (Echinococcus). Management will depend on the organs affected by the infection and the response to medical treatment. Therapy may be clinical in early stages, but in case of poor response to drug therapy, surgery is the preferred choice. We present two cases in young females, the first case is with Hydatid cysts in both lungs and liver, she received initial medical treatment with lack of response, and surgery was indicated to resect the pulmonary and hepatic lesions. The second case is of a female with Hydatid cysts in the right lung. She was misdiagnosed at the beginning thinking of pneumonia and pulmonary abscess but after further investigation, hydatid cysts were the diagnosis, due to symptoms consistent with thoracic pain and persistent cough and the size of the cyst, surgery was indicated.

'Chest gossypiboma after spinal surgery, not so easy to forget'.

During any surgical procedure, complications may arise, some of which are fortuitous, whereas others, unfortunately, occur because of errors of the surgical team. Fortunately, most are minor and do not affect the patient's recovery, but others can cause severe morbidity and even mortality. A retained cotton or gauze surgical sponge inadvertently left in the body during an operation is known as a gossypiboma. This dreadful oversight is a marked complication that can cause serious postoperative complications, a severe economic burden on the healthcare system, and many medicolegal implications. We report the case of a 30-year-old male, who suffered a spinal fracture which was repaired through an anterior fixation approach 12 years ago in a local state hospital without complications. Suddenly, he presented with chest pain and cough, and sought medical attention. An 8 × 5 × 8 cm low-density heterogeneous mass was discovered on his chest; after successful surgery, a gossypiboma formed by several gauzes without radiopaque markers was discovered.

Intravascular leiomyomatosis with cardiac extension, a case report.

BACKGROUND: Intravascular leiomyomatosis (IVL) is a histologically benign smooth muscle tumor arising from the uterus that can spread through the pelvic veins and, on rare occasions, extend as far as the heart via the inferior vena cava. Despite its benign characteristics, it can behave like a malignant tumor leading to significant morbidity and even mortality if left untreated. CASE PRESENTATION: The patient is a 42-year-old woman with a past medical history of uterine leiomyomas. She presented with heavy bleeding and frequent spotting; therefore, she went to her gynecologist. After further evaluation, a mass within the uterus that expanded into the pelvic veins, inferior vena cava, and right atrium was discovered. After the complete removal of the mass, the patient underwent full recovery. IVL with cardiac extension was the final diagnosis. CONCLUSION: Although IVL is rare, it must be considered in women who underwent previous hysterectomies or myomectomies and present with symptoms of right heart failure. The ideal therapy will need the aid of a multidisciplinary team and will depend on the patient's symptoms, previous operative history, the tumor's extension, and resectability.

Paget-Schroetter syndrome in an active young female after unsupervised exercise.

INTRODUCTION AND IMPORTANCE: Thoracic outlet syndrome (TOS) is a rare syndrome caused by compression of one of the three neurovascular structures in their passage from the cervical area toward the axilla and proximal arm either at the interscalene triangle, the costoclavicular triangle, or the sub coracoid space. The mainstay of management is nonsurgical; however, surgery may be needed when patients persist with symptoms despite conservative management and when vascular structures are involved. Symptoms are non-specific and require high clinical awareness since this pathology tends to affect otherwise healthy young patients. CASE PRESENTATION: We present the case of a 45-year-old female without any past medical history. She was active and did plenty of exercises. After a high-intensity routine without any guidance, she presented with acute upper limb swelling with pain. After further examination, a venous thoracic outlet syndrome was identified and treated without complications. CLINICAL DISCUSSION & CONCLUSION: Venous TOS is a rare pathology associated with high long-term morbidity and disability if left untreated; heightened clinical awareness of the possibility of acute thrombosis obstructing venous return and producing these rare symptoms should lead the medical team to assess the patient further and lead to the appropriate medical and surgical intervention.

Case Report: Desmoid fibromatosis in the mediastinum of a 6-month-old toddler, what to do?

Desmoid fibromatosis is a rare, aggressive borderline lesion arising from soft tissues. Treatment will depend on the structures that the tumor has involved. Surgery with negative margins is the recommended strategy as it can usually achieve disease control; however, the tumor's location sometimes does not allow it. Therefore, a combination of medical therapies along with strict surveillance is crucial. We present the case of a 6-month-old boy with a chest mass. After further evaluation, a rapidly growing mediastinal mass involving the sternum and costal cartilage was detected. Desmoid fibromatosis was the final diagnosis.

COVID-19 infection and cardiac angiosarcoma: a dangerous combination-a case report.

Background: The COVID-19 pandemic has strained all medical systems, especially in countries like Ecuador, where health services were already limited. These conditions, combined with a deadly and unusual disease, like primary heart angiosarcoma, can lead to severe outcomes. Angiosarcomas represent the most common and aggressive primary malignant heart tumor; regretfully, its clinical manifestations are vague and can be easily missed. Most patients become symptomatic when there is local invasion, embolization, or metastases, leading to late diagnosis and poor survival. High clinical awareness, adequate diagnosis, and prompt treatment are vital in these rare diseases, in which time is of paramount importance. Case presentation: We report the case of a 28-year-old female who had cough, hemoptysis, and ground-glass opacities in the CT (computed tomography). Since Ecuador is in the middle of this pandemic, she was misdiagnosed and mistreated. Primary heart angiosarcoma was diagnosed, and regretfully, the patient suffered multiple complications due to diagnosis and died. Conclusion: To this day, most cardiac angiosarcomas are found in a late-stage with distal metastasis and advanced local invasion. Sadly, this tumor is frequently missed due to its incidence and broad-spectrum of clinical symptoms. Considering that its manifestations can be misleading, misdiagnosis can occur, especially in pandemic times. Therefore, knowledge of other pathologies prevents COVID-19 from overshadowing other diagnoses, hence preventing delayed diagnosis or even misdiagnosis and consequent adverse outcomes for patients. Supplementary Information: The online version contains supplementary material available at 10.1186/s43057-021-00042-7.

Magnetic Liver Retraction Decreases Postoperative Pain and Length of Stay in Bariatric Surgery Compared to Nathanson Device.

Objective: Retrospective case-matched comparison of magnetic liver retraction to a bedrail-mounted liver retractor in bariatric surgery specifically targeting short-term postoperative outcomes, including pain and resource utilization. Background: Retraction of the liver is essential to ensure appropriate visualization of the hiatus in bariatric surgery. Externally mounted retractors require a dedicated port or an additional incision. Magnetic devices provide effective liver retraction without the need of an incision. Methods: The sample consisted of primary and revisional bariatric surgery patients, including Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and biliopancreatic diversion with duodenal switch (BPD-DS) operations. Propensity score analysis was used to match patients with magnetic retraction to patients with a bedrail-mounted retractor with a 1:2 ratio using preoperative characteristics. Baseline characteristics and postprocedure outcomes were compared using two-sample t-tests or Wilcoxon rank sum tests and chi-square or Fisher's exact test as appropriate. Results: One hundred patients met inclusion criteria for the use of magnetic liver retraction (45 RYGB, 35 SG, 20 BPD-DS) with 196 suitable matched external retractor patients identified. Patients were matched and comparable for all preoperative characteristics except for transversus abdominus plane block (27% versus 47%). Patients in the magnet cohort had significantly decreased mean 12-hour postoperative pain scores (2.9 versus 4.2, P = .004) and decreased hospital length of stay (LOS) (1.5 versus 1.9 days, P = .005) while operating room supply were higher in the magnet cohort ($4600 versus $4213, P = .0001). Conclusions: Magnetic liver retraction in bariatric surgery is associated with decreased postoperative pain scores, decreased hospital LOS, and increased operating supply costs.

Endoscopic septotomy as a treatment for leaks after sleeve gastrectomy: Meeting presentations: Digestive Disease Week 2019.

Background and study aims Sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world. Leaks are the most feared complications after this procedure. Endoscopic septotomy has been described as a resolution technique that could be useful in the setting of late and chronic leaks. We present our experience in the management of gastric leaks with this advanced endoscopic technique. Patients and methods Retrospective review of patients who have been admitted to our hospital from January 2016 to December 2018. Results Five patients were found. All had their index surgery in outside hospitals. The average age was 51 years (range 40 - 69), and four patients were female. Mean time from LSG to leak presentation was 15 days (range 7 - 25). Mean time from leak presentation to septotomy procedure was 61 days (range 21 - 110). All patients were treated with sleeve dilatation before septotomy using endoscopic achalasia balloons. Mean procedure time was 79 minutes (range 55 - 125). Success was achieved in 80 % of patients, and no complications related to the procedure were identified. One patient underwent total gastrectomy for definitive management. Mean follow-up time was 14.25 months (range 6 - 26), and the average time for fistula closure was 60.25 days. Conclusion Endoscopic septotomy is safe and effective for management of chronic leaks after LSG. Associated non-selective dilatation may be a crucial step to allow distal patency and axis rectification for appropriate leak closure.

Antiphospholipid syndrome and valvular heart disease, a complex scenario of thrombotic events, a case report.

BACKGROUND: Antiphospholipid syndrome (APS) is a rare coagulation disorder associated with thrombotic events, myocardial infarction, and valvular heart disease. During valvular replacement surgery, the high risk of thrombosis combined with the operative risks in these specific groups of patients poses a challenge to the medical team. CASE PRESENTATION: We present a case of a female patient with APS and mixed aortic valve disease. During surgery, she suddenly developed complete cardiac arrest. Three months later, after she recovered, and while she was still on close follow up, a thrombotic event caused myocardial infarction. After prompt and precise treatment, the patient successfully recovered; one year after surgery patient is doing well. CONCLUSION: Adequate surgical technique along with optimal anticoagulation strategies and long term follow up are of paramount importance to ensure an uneventful recovery. A multidisciplinary team is required to manage these complex scenarios and high-risk patients.

Robotic Assisted Prostatectomy with Magnetic Retraction.

INTRODUCTION: In prostate surgery retraction of the prostate is essential to ensure appropriate visualization of the surgical field. In the past improvement in exposure would require the dedicated use of a port or an additional incision. Magnetic retraction provides a novel solution by allowing shaftless retraction during robotic assisted prostatectomy that does not require a dedicated port or extra incision. METHODS: We conducted a retrospective review of consecutive patients who underwent robotic assisted prostatectomy using magnetic retraction at a single center (Duke Regional Hospital) between April 2017 and November 2018. RESULTS: The 39 cases were all robotic assisted total prostatectomies for adenocarcinoma. All cases were successfully completed without conversion to open. Mean age was 63 years (range 44-75) and preoperative body mass index was 30.4 kg/m2 (range 20.1-43.9). Mean operative time was 184 minutes (range 129-304). Four patients experienced minor 30-day complications that were not directly attributed to the device and did not require further interventions. One patient suffered a myocardial infarction 5 days after surgery and recovered without major sequelae. There were no 30-day mortalities. Surgeons described subjective overall surgical exposure as adequate and device use as technically simple. CONCLUSIONS: Magnetic assisted retraction is a novel approach that allows a safe and reproducible technique for unconstrained tissue retraction, and manipulation does not require another port. The device successfully permitted optimal prostate retraction during robotic assisted prostate surgery, enhancing surgical exposure while not requiring additional abdominal incisions.

Racial Disparities in Bariatric Surgery Complications and Mortality Using the MBSAQIP Data Registry.

BACKGROUND: Racial disparities in postoperative complications have been demonstrated in bariatric surgery, yet the relationship of race to complication severity is unknown. STUDY DESIGN: Adult laparoscopic primary bariatric procedures were queried from the 2015 and 2016 MBSAQIP registry. Adjusted logistic and multinomial regressions were used to examine the relationships between race and 30-day complications categorized by the Clavien-Dindo grading system. RESULTS: A total of 212,970 patients were included in the regression analyses. For Black patients, readmissions were higher (OR = 1.39, p < 0.0001) and the odds of a Grade 1, 3, 4, or 5 complication were increased compared with White patients (OR = 1.21, p < 0.0001; OR = 1.21, p < 0.0001; OR = 1.22, p = 0.01; and OR = 1.43, p = 0.04) respectively. The odds of a Grade 3 complication for Hispanic patients were higher compared with White patients (OR = 1.59, p < 0.0001). CONCLUSION: Black patients have higher odds of readmission and multiple grades of complications (including death) compared with White patients. Hispanic patients have higher odds of a Grade 3 complication compared with White patients. No significant differences were found with other races. Specific causes of these disparities are beyond the limitations of the dataset and stand as a topic for future inquiry.

Scars Matter: The Importance of Incision Decisions in Bariatric Patients.

This study aims to determine if cosmetic outcomes play an important role for patients undergoing bariatric surgery, when considering a surgical approach. A video-animation describing open, conventional laparoscopic, and reduced incision magnetic assisted surgery was shown. The patient's perceptions of the surgical approaches were recorded using an anonymous survey. Fifty-one patients completed the survey. The median age was 45 (IQR: 36-51), and 38 (74.5%) were women. Cosmesis was found to be an important factor (77%) for selecting a surgical approach. Ninety percent of the patients believe that reduced incision magnet-assisted surgery provides superior cosmesis. Cosmetic results may play a determinant role when choosing a surgical approach.

Abnormal development of the inferior vena cava and its implications on distal venous drainage during cardiac surgery and other clinical entities.

Congenital anomalies of the inferior vena cava (IVC) are caused by an abnormal persistence or regression of embryonic precursor veins; they are usually incidental findings on imaging studies. These rare conditions have a 0.6% prevalence in individuals with congenital heart diseases and 0.3% in healthy patients. The purpose of this paper was to report two cases of interruption of IVC with hemiazygos continuation and its implications during surgery, highlighting that after recognizing this anomalous drainage the surgeon should be prepared to change the surgical strategies, especially in cardiovascular surgery, in order to obtain adequate circulatory flows or surgical exposure where venous cannulation could be difficult. We have also reported two cases of healthy patients with the same isolated IVC anomaly with no clinical repercussions, which can develop in the future.