Laparoscopic resection of tailgut cysts: the size is not the issue

INTRODUCTION: Tailgut cysts are rare retrorectal cystic lesions usually treated by surgical resection, even where asymptomatic, due to the risk of malignancy and recurrence. In the last 20 years, the laparoscopic abdominal approach has been gaining consensus for its better visualization of pelvic structures and minimal invasiveness. CASE REPORT: We present the case of the biggest tailgut cysts managed laparoscopically reported so far. DISCUSSION: Mostly asymptomatic, diagnosis of tailgut cysts is often fortuitous during routine examination. Their malignant transformation is estimated being 14.1% of cases. MRI is particularly indicated to lead the surgical approach, given its superior resolution in soft tissues and assessment of local invasion. Surgical resection is the therapy of choice, performed with different approaches: the laparoscopic abdominal technique, performed by surgeons with expertise in pelvic laparoscopic surgery, allows the best visualization of pelvic viscera with lesser morbidity. Due to rupture and seeding risks, the laparoscopic approach should not be performed if there is any suspicion of malignancy. CONCLUSION: Our case substantiates safety and feasibility of laparoscopic tailgut cysts management, even of large-size cysts. Preoperative imaging is crucial to assess the possible malignancy of the lesion and, in that case, to perform a laparotomic approach

Prepectoral breast reconstruction using the Braxon® porcine acellular dermal matrix: a retrospective study

none6Background: Breast cancer is the leading cause of death attributable to cancer among women worldwide. Breast reconstruction has become an integrated part of breast cancer treatment due to long-term psychosexual health factors and its importance to breast cancer survivors. Muscle-sparing techniques using an acellular dermal matrix (ADM) (Braxon; DECO med s.r.l., Venice, Italy) can be considered a possible alternative to immediate reconstruction or two-step reconstruction for patients with medium breasts who want to preserve their natural breast shape. Methods: We performed a retrospective analysis of reconstructions using a Braxon porcine-derived ADM at the Breast Unit of the University Hospital of Parma and the Breast Unit of Piacenza Hospital from January 2015 to September 2017. The objective was to evaluate the benefits and complications resulting from this technique. Results: We treated 42 patients and performed a total of 51 muscle-sparing reconstructions using the Braxon porcine-derived ADM. The incidence of cutaneous necrosis was 4% (n = 2); the incidence of seroma was 4% (n = 2). We had to remove the implants in two cases. Natural and symmetrical breasts with good form, ptosis, and softness were achieved for most patients. Conclusions: Good results were obtained with a high degree of esthetic and functional satisfaction for the majority of patients. A low rate of early complications compared to that reported in the international literature data was observed. Level of Evidence: Level IV, therapeutic study.noneGardani, Marco; Simonacci, Francesco; De Sario, Giuseppina; Cattadori, Francesca; Raposio, Edoardo; Palli, DanteGardani, Marco; Simonacci, Francesco; De Sario, Giuseppina; Cattadori, Francesca; Raposio, Edoardo; Palli, Dant

Laparoscopic subtotal gastrectomy for the treatment of advanced gastric cancer: A comparison with open procedure at the beginning of the learning curve

Background: In the last decades, after some initial concern, laparoscopic subtotal gastrectomy (LSG) is gaining popularity also for the treatment of advanced gastric cancer (AGC). The aim of this study is to compare a single surgeon initial experience on LSG and open subtotal gastrectomy in terms of surgical safety and radicality, postoperative recovery and midterm oncological outcomes. Methods: a case control study was conducted matching the first 13 LSG for AGC with 13 open procedures performed by the same surgeon. Operative and pathological data, postoperative parameters and midterm oncological outcomes were analyzed. Results: There was no significant difference in mortality (0%) and morbidity, while the laparoscopic approach allowed lower analgesic consumption and faster bowel movement recovery. Operation time was significantly higher in LSG patients (301.5 vs 232 min, p: 0.023), with an evident learning curve effect. Both groups had a high rate of adequate lymph node harvest, but the number was significantly higher in LSG group (p: 0.033). No significant difference in survival was registered. Multivariate analysis identified age at diagnosis, diffusetype tumor, pN and LODDS as independent predictors of worse prognosis. Conclusions: LSG can be safely performed for the treatment of AGC, allowing faster postoperative recovery. (www.actabiomedica.it)

Abdominal Pain After Roux-en-Y Gastric Bypass: Semiotic Aspects Suggestive of Internal Hernias

Introduction: Abdominal pain is the most frequent cause of hospital admission after Roux en y gastric bypass (RYGB) Among numerous possible underlying causes, internal hernia represents one of the most peculiar and insidious circumstances, setting challenging diagnostic and therapeutic problems for the surgeon. Objectives: The aim of this study is to analyze abdominal pain incidence and characteristics after RYGB, discriminating peculiar aspects suggestive of internal hernias. Methods: 9 patients submitted to internal hernia repair after RYGB and a group of 49 controls (non complicated RYGB) were evaluated using 2 types of abdominal pain questionnaires (Roma III and Roma III modified). Overall abdominal pain incidence (controls) and specific characteristics of internal hernias (cases) were analyzed. Results: 32% of controls presented aspecific (no diagnosed cause) abdominal pain after RYGB - mainly deep, remittent, colic, located in the upper left abdomen, postprandial. 78% of the cases presented prodromic algic episodes similar to those of the controls, differing from the acute episode only in pain intensity. Excess weight loss, mainly at 3 months and after one year, showed the most significant correlation with internal hernia (p: 0.043 and p: 0,026, respectively). Conclusion: Based on abdominal pain characteristics (angina abdominis-like) we can reasonably postulate the presence of remittent bowel torsions (remittent internal hernias) in many patients, occasionally complicating. Therapeutic management of such cases remains controversial, laparoscopic exploration being a good option when symptomatology is suggestive

The Sleeping Remnant. Effect of Roux-En-Y Gastric Bypass on Plasma Levels of Gastric Biomarkers in Morbidly Obese Women: A Prospective Longitudinal Study

Background: Morpho-functional modifications of the gastric remnant after Roux-en-Y gastric bypass (RYGB) have not been completely defined, due to its inaccessibility for bioptic mapping. The aim of the study is to evaluate such modifications using Gastropanel®, a non-invasive blood test cross-checking four gastric biomarkers, able to provide a snapshot of mucosa conditions. Subjects and Methods: Twenty-four women undergoing RYGB were prospectively enrolled. Gastropanel® parameters (pepsinogens, Gastrin-17 and immunoglobulins against Helicobacter pylori), biometrical/clinical data were collected preoperatively and at 6-months follow-up. Results: All parameters showed significant reduction (p < 0.05). Pepsinogen I reduction correlated with BMI percent decrease. Conclusions: The exclusion of food transit is responsible for significant drop in gastric output, hardly representing a risk factor in the remnant carcinogenesis, being unexposed to alimentary carcinogenic agents

Road Racing After Gastric Bypass for Morbid Obesity: Final Results of a New Protocol

Introduction: In recent years, the pandemic explosion of obesity has led to the definition of a pre-eminent therapeutic role for bariatric surgery, confining physical activity to a success parameter of surgery rather than a primary prevention measure. Objectives: The aim of this study was to re-define a role for aerobic physical activity (road running) in strengthening the metabolic and psycho-social effects of bariatric surgery. Methods: 10 patients who underwent gastric bypass (RYGB) for morbid obesity were submitted to an intensive program of road running training. After a preparatory trimester, a six-month intensive training program started, aimed at completing a 10.5 km competition in September 2013. Inclusion criteria included age (<50), BMI (<35), suitability for sporting activity and good compliance. A cohort of 10 patients excluded for logistical issues were enrolled as a control group. During the training period patients were submitted to biometrical measurements, sport performance tests (Cooper), and cardio-pulmonary, metabolic and psychiatric evaluations. Results: Protocol compliance was 70%. Completing the protocol resulted in an impressive increase in cardiopulmonary and athletic performance (from 1050 to 1800 m at Cooper test). Weight loss was higher in the cases, with a variation in waist circumference and body fat percentage significantly higher than in the control group. Psychiatric evaluation attested to an improvement in mood, drive and volition for the runners. Conclusion: Road running appears to have an important supporting role in boosting bariatric surgery results. The utilization of monitorized and regulated training programs represents a fundamental prerequisite to achieving satisfactory results and adequate patient complianc

Road Running After Gastric Bypass For Morbid Obesity: Rationale And Preliminary Results Of A New Protocol

Introduction: In recent years, the pandemic explosion of obesity has led to the definition of a pre-eminent therapeutic role for bariatric surgery, confining physical activity to a success parameter of surgery rather than a primary prevention measure. The aim of this study is to re-define a role for aerobic physical activity (road running) in strengthening the metabolic and psycho-social effects of bariatric surgery. Methods: 10 patients who underwent gastric bypass (RYGB) for morbid obesity were submitted to an intensive program of road running training. After a preparatory trimester, a six-month intensive training program started, aimed at completing a 10 km competition in September 2013. Inclusion criteria included age (<50), BMI (<35), suitability for sport activity and good compliance. A cohort of 10 patients excluded for logistical issues were enrolled as a control group. During the training period patients were submitted to biometrical measurements, sport performance tests (Cooper), and cardio-pulmonary, metabolic, nutritional and psychiatric evaluations. Results: Protocol compliance was 80%. After the preparatory phase mean weight significantly decreased (78.6 vs 86.8 kg, p: 0.03), slightly more than in the control group. Cooper test performance significantly increased for all the patients. Glycemic values remained normal during the entire period. All the participants (100%) expressed satisfaction at participating in the program. Conclusions: Road running seems to have an important supporting role in boosting bariatric surgery results. The utilization of monitorized and regulated training programs represents a fundamental prerequisite to achieving satisfactory results and adequate patient compliance

Road Running After Gastric Bypass for Morbid Obesity: Rationale and Results of a New Protocol

Background: In recent years, the pandemic explosion of obesity has led to the definition of a pre-eminent therapeutic role for bariatric surgery, confining physical activity to a success parameter of surgery rather than a primary prevention measure. The aim of this study is to evaluate the role for aerobic physical activity (road running) in strengthening the metabolic and psychosocial effects of bariatric surgery. Methods: Ten patients who underwent gastric bypass for morbid obesity were submitted to an intensive program of road running training, aimed at completing a 10.5-km competition in September 2013. Inclusion criteria included age (<50), BMI (<35), suitability for sport activity, and good compliance. A cohort of 10 patients excluded for logistical issues were enrolled as a control group. During the training period, patients were submitted to biometrical, sport performance, cardiopulmonary, metabolic, and psychiatric evaluations. Results: Protocol adherence was 70 %; no physical injury was registered among participants. More than weight loss (BMI 29.3 to 27.1), the runners experienced a redistribution of body mass with significant differences in fat percentage and waist/hip ratio. Participants had a significant running performance improvement and, differently from the controls, a significant amelioration of echocardiographic and cardiopulmonary parameters, predicting a reduction in cardiovascular risk. Psychiatric evaluation underlined a tendency to a reduction in anxiety, depression, and general psychopathology symptoms. Conclusions: Road running seems to have an important supporting role in boosting bariatric surgery results. The utilization of monitored and regulated training programs represents a fundamental prerequisite to achieving satisfactory results and patient compliance

Morphological Changes in the Carotid Artery Intima after Gastric Bypass for Morbid Obesity

Background: Carotid intima-media thickness (C-IMT) can be considered as an early marker of atherosclerosis, thus representing a reliable cardiovascular risk predictor. Bariatric surgery decreases the burden of cardiovascular disease in obese patients through complex mechanisms, of which weight loss is merely the most evident epiphenomenon. The aim of this study is to evaluate C-IMT variations in patients undergoing Roux-en-Y gastric bypass (RYGB) and possible correlations with biometric parameters and cardiovascular risk factors. Methods: Thirty patients undergoing RYGB for morbid obesity were enrolled for carotid artery B-mode ultrasound evaluation before surgery and at 1-, 3-, 6-, and 12-month follow-up; C-IMT was recorded at three levels (bulb, common, and internal carotid). At each one of the follow-ups, biometric and serohematic parameters were also collected. Results: The 22 patients who completed the follow-up and were included in the study showed significant C-IMT reduction at all three levels at 12-month follow-up (p < 0.001). Along with a significant BMI reduction and diabetes/hypertension remission, we found a considerable decrease in total cholesterol (219 vs 164 mg/dl; p < 0.001) and uric acid (5.6 vs 4.5 mg/dl; p < 0.01) and a significant increase in HDL cholesterol (43.9vs59.2 mg/dl; p < 0.001). The data imply that the mean 10-year cardiovascular risk score drops by nearly 50 % (5.7 ± 5.6 vs. 2.9 ± 2.7 %, p < 0.001) according to Framingham cardiovascular risk stratification. Conclusions: RYGB is associated with significant decrease in C-IMT at 1 year. Pathophysiologic processes underlying such a variation, probably involving lipid and urate metabolism and their correlation with cardiovascular risk reduction should be confirmed by long-term prospective trials