Robotic double-loop reconstruction method following total gastrectomy

Minimally invasive surgery for gastric cancer is a challenge. The reconstructive time is a particular issue and researchers have adopted a large variety of solutions and produced heterogeneous data. The reconstructive phase can be divided into two major categories based on the approach adopted: the execution of extracorporeal versus intracorporeal anastomosis. In turn, the surgical team can perform the latter with laparoscopic or robotic assistance. However, the question is, how should a robotic esophagojejunal anastomosis be performed after total gastrectomy? Most articles in the literature have reported the execution of mechanical anastomoses [1] [2] [3] [4] [5] [6], especially with circular staplers via the creation of a manual purse-string around the anvil. Other solutions have described the use of the Orvil or the overlap technique. Only three authors have reported intracorporeal sutures with a completely robotic-sewn anastomosis [7] [8] [9]. A new robotic technique (the Parisi technique) was developed and adopted at St. Mary’s Hospital, Terni, Italy. A double-loop reconstruction method with an intracorporeal robot-sewn anastomosis is performe

Metabolic Comparison of One-Anastomosis Gastric Bypass, Single-Anastomosis Duodenal-Switch, Roux-en-Y Gastric Bypass, and Vertical Sleeve Gastrectomy in Rat

Background One-anastomosis gastric bypass (OAGB) and single-anastomosis duodenal switch (SADS) have become increasingly popular weight loss strategies. However, data directly comparing the effectiveness of these procedures with Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (SG) are limited. Objectives To examine the metabolic outcomes of OAGB, SADS, RYGB, and SG in a controlled rodent model. Setting Academic research laboratory, United States. Methods Surgeries were performed in diet-induced obese Long-Evans rats, and metabolic outcomes were monitored before and for 15 weeks after surgery. Results All bariatric procedures induced weight loss compared with sham that lasted throughout the course of the study. The highest percent fat loss occurred after OAGB and RYGB. All bariatric procedures had improved glucose dynamics associated with an increase in insulin (notably OAGB and SADS) and/or glucagon-like protein-1 secretion. Circulating cholesterol was reduced in OAGB, SG, and RYGB. OAGB and SG additionally decreased circulating triglycerides. Liver triglycerides were most profoundly reduced after OAGB and RYGB. Circulating iron levels were decreased in all surgical groups, associated with a decreased hematocrit value and increased reticulocyte count. The fecal microbiome communities of OAGB, SADS, and RYGB were significantly altered; however, SG exhibited no change in microbiome diversity or composition. Conclusions These data support the use of the rat for modeling bariatric surgical procedures and highlight the ability of the OAGB to meet or exceed the metabolic improvements of RYGB. These data point to the likelihood that each surgery accomplishes metabolic improvements through both overlapping and distinct mechanisms and warrants further research

Reducing gastrointestinal anastomotic leak rates: Review of challenges and solutions

Various techniques and interventions have been developed in an effort to obviate gastrointestinal anastomotic leaks. This review is intended to delineate potential modifications that can be made to reduce the risk of anastomotic leaks following gastrointestinal surgery. It may also serve to aid in identifying patients who are at increased risk of anastomotic leak. Modifiable risk factors for leak discussed include malnutrition, smoking, steroid use, bowel preparation, chemotherapy, duration of surgery, use of pressors, intravenous fluid administration, blood transfusion, and surgical anastomotic technique. Based upon literature review, operative techniques should include minimizing operative time, reducing ischemia, and utilizing stapled anastomoses. Buttressing of anastomoses with omentum has proven utility for esophageal surgery. Further recommendations include 5-7 days of immune-modifying nutritional supplementation for malnourished patients, discontinuation of smoking in the perioperative period, limiting steroid use, utilization of oral antibiotic preparation for colorectal surgery, avoidance of early operations (,4 weeks) following chemotherapy, limiting pressor use, and the utilization of goal-directed fluid management. © 2016 Phillips

Hepatic artery thrombosis after pediatric liver transplantation a medical or surgical event

Hepatic artery thrombosis (HAT) is one of the most serious complications after orthotopic liver transplan¬tation, and is associated with a high morbidity and mor¬tality. This study retrospectively reviewed 66 liver transplants in children under the age of 10 years during1 a year-long period at a single institution.;A, total of 28 perioperative variables were analyzed to identify responsible factors of HAT. Of the 66 children, 18 (26%) developed HAT within 15 days after the transplant (HAT group); 29 (42%) had an uneventful postoperative course (control group). To avoid the possible influence of other complications 19 patients were excluded. Of the variables compared between the 2 study groups, three surgical factors (diameter of the hepatic artery-- greater or less than 3 mm; type of arterial anastomosis—end-to-end versus the use of an iliac graft or aortic conduit; and number of times the anastomosis was redone--one versus more than one), were found to be significantly different (P<.05) between HAT and control groups. Two medical factors also were significantly different: the use of intraoperative transfusion of fresh frozen plasma (FFP) and the administration of postoperative prophylactic anticoagulant treatment. A heparin and dextran-40 protocol appeared to be effective in preventing HAT (P<.02). Moreover, after multivariate analysis, anticoagulation therapy was demonstrated to with poor hepatic artery flow. © 1989 by The Williams and Wilkins Co

Worsening of cerebral hyperemia by the administration of terlipressin in acute liver failure with severe hepatic encephalopathy

There is increasing evidence that terlipressin is useful in patients with cirrhosis and hepatorenal syndrome, but there are no data of its use in patients with acute liver failure (ALF) in whom hepatorenal syndrome is common. Although terlipressin produces systemic vasoconstriction, it produces cerebral vasodilatation and may increase cerebral blood flow (CBF). Increased CBF contributes to intracranial hypertension in patients with ALF. The aim of this study was to evaluate the safety of terlipressin in patients with ALF with respect to cerebral haemodynamics. Six successive patients with ALF were electively ventilated for grade IV hepatic encephalopathy. Patients were monitored invasively and CBF was measured (Kety- Schmidt technique). Measurements were made before, at 1, 3 hour and 5 hours after intravenous (single bolus) administration of terlipressin (0.005 mg/kg) )intravenously (single bolus), median 0.25mg (range 0.2-0.3). There was no significant change in heart rate, mean arterial pressure or cardiac output. CBF and jugular venous oxygen saturation both increased significantly at 1 hour (p<0.0=0.016) respectively. Intracranial pressure increased significantly at 21 hours (p<0=.0.031), returning back to baseline values at 42 hours. This study shows that administration of terlipressin, at a dose that did not alter systemic haemodynamicshemodynamics, resulted in worsening of cerebral hyperemia and intracranial hypertension in patients with ALF and severe hepatic encephalopathy. These data suggest the need to exercise extreme caution in the use of terlipressin in these patients in view of its potentially deleterious consequences on cerebral haemodynamics

Computational simulations demonstrate altered wall shear stress in aortic coarctation patients previously treated by resection with end-to-end anastomosis

Background.  Atherosclerotic plaque in the descending thoracic aorta (dAo) is related to altered wall shear stress (WSS) for normal patients. Resection with end-to-end anastomosis (RWEA) is the gold standard for coarctation of the aorta (CoA) repair, but may lead to altered WSS indices that contribute to morbidity. Methods.  Computational fluid dynamics (CFD) models were created from imaging and blood pressure data for control subjects and age- and gender-matched CoA patients treated by RWEA (four males, two females, 15 ± 8 years). CFD analysis incorporated downstream vascular resistance and compliance to generate blood flow velocity, time-averaged WSS (TAWSS), and oscillatory shear index (OSI) results. These indices were quantified longitudinally and circumferentially in the dAo, and several visualization methods were used to highlight regions of potential hemodynamic susceptibility. Results.  The total dAo area exposed to subnormal TAWSS and OSI was similar between groups, but several statistically significant local differences were revealed. Control subjects experienced left-handed rotating patterns of TAWSS and OSI down the dAo. TAWSS was elevated in CoA patients near the site of residual narrowings and OSI was elevated distally, particularly along the left dAo wall. Differences in WSS indices between groups were negligible more than 5 dAo diameters distal to the aortic arch. Conclusions.  Localized differences in WSS indices within the dAo of CoA patients treated by RWEA suggest that plaque may form in unique locations influenced by the surgical repair. These regions can be visualized in familiar and intuitive ways allowing clinicians to track their contribution to morbidity in longitudinal studies

Surgical complications in human orthotopic liver transplantation.

Between March 1, 1980 and December 31, 1984, 393 orthotopic liver transplantations (OLT) were performed in 313 consecutive recipients. Technical complications were responsible for a substantial morbidity (41/393 allograft loss--10.4%) and mortality (26/313 patient loss--8.3%). Failure of the biliary tract reconstruction, mainly expressed as leakage and obstruction, is the most frequent complication of OLT (52/393 grafts--13.2%). Biliary tract complication (BTC) was directly responsible for 5 deaths (9.6%). Reliance upon standardized methods of direct duct-to duct repair with T-tube (CC-T) and Roux-Y choledocho-jejunostomy (RYCH-J), appropriate postoperative investigation and treatment will reduce morbidity and mortality of BTC. A complicated CC-T will be conversed to a RYCH-J; a complicated RYCH-J needs surgical correction. Hepatic artery thrombosis (HAT) has become the "Achilles heel" of OLT. HAT is expressed by three different patterns: fulminant hepatic necrosis, delayed bile leakage and relapsing bacteremia. Diagnosed in 27 grafts (6.8%), HAT was responsible for 16 deaths (16/25 pat: 64%). The only chance to rescue patients presenting HAT is an early diagnosis and prompt retransplantation before occurrence of septic complications. Aneurysm of the hepatic arterial supply (4/393 grafts--1%) also needs aggressive surgery because of the high rate of fatal rupture (3/4 pat--75%). The incidence of thrombosis of the reconstructed portal vein (PVT) was only 2.2% (7 pat.), three inferior vena caval thromboses (0.9%) (CVT) were diagnosed after OLT. Four of the 7 patients whose portal veins clotted are alive. Three have their original graft. One patient, presenting both PVT and CVT, was rescued by prompt retransplantation. PVT was responsible for 3 patient (3/7 pat--42.8%) and 4 graft losses (4/7 pat--57%). The rate of graft (3/3) and patient loss (2/3) was even higher after CVT