Massive choleperitoneum three months after mini-gastric bypass for morbid obesity: what every emergency surgeon should be prepared to face. A case report.

Background: Surgery for morbid obesity has spread worldwide, to the point that more than half a million people are operated on each year. As a result, significant numbers of people are living with a new anatomical condition. A mini-gastric bypass is a relatively new bariatric procedure that has gained popularity because of its simplicity and efficacy. Leak rate after this procedure is relatively low (on the order of 1.6%), but marginal ulcer of gastrojejunal anastomosis, if undetected, may lead to leak development. No cases of delayed massive choleperitoneum caused by an almost complete disruption of gastrojejunal anastomosis after mini-gastric bypass have yet been described. Case presentation: We describe here the case of a 51-year-old woman who presented at the emergency department three months after a mini-gastric bypass with acute abdomen caused by massive choleperitoneum due to an almost complete disruption of gastrojejunal anastomosis. The patient underwent an emergency conversion to a Roux-en-Y laparoscopic gastric bypass with associated re-gastrectomy. The postoperative period was characterized by fever due to an infected left pleural effusion, which required treatment with chest tube placement. The patient was discharged three weeks after the operation, in good condition. Six-month follow-up was regular. Conclusions: If suspected, the possibility of marginal ulcer should be investigated as soon as possible. When possible, every obese patient who has complications should be referred to a bariatric surgery department, but each emergency surgeon must be aware of these conditions to be able to treat them optimally

Low-pressure versus standard-pressure pneumoperitoneum in laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials

Introduction: It has been previously demonstrated that the rise of intra-abdominal pressures and prolonged exposure to such pressures can produce changes in the cardiovascular and pulmonary dynamic which, though potentially well tolerated in the majority of healthy patients with adequate cardiopulmonary reserve, may be less well tolerated when cardiopulmonary reserve is poor. Nevertheless, theoretically lowering intra-abdominal pressure could reduce the impact of pneumoperitoneum on the blood circulation of intra-abdominal organs as well as cardiopulmonary function. However, the evidence remains weak, and as such, the debate remains unresolved. The aim of this systematic review and meta-analysis was to demonstrate the current knowledge around the effect of pneumoperitoneum at different pressures levels during laparoscopic cholecystectomy. Materials and methods: This systematic review and meta-analysis were reported according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, and the Cochrane handbook for systematic reviews of interventions. Results: This systematic review and meta-analysis included 44 randomized controlled trials that compared different pressures of pneumoperitoneum in the setting of elective laparoscopic cholecystectomy. Length of hospital, conversion rate, and complications rate were not significantly different, whereas statistically significant differences were observed in post-operative pain and analgesic consumption. According to the GRADE criteria, overall quality of evidence was high for intra-operative bile spillage (critical outcome), overall complications (critical outcome), shoulder pain (critical outcome), and overall post-operative pain (critical outcome). Overall quality of evidence was moderate for conversion to open surgery (critical outcome), post-operative pain at 1 day (critical outcome), post-operative pain at 3 days (important outcome), and bleeding (critical outcome). Overall quality of evidence was low for operative time (important outcome), length of hospital stay (important outcome), post-operative pain at 12 h (critical outcome), and was very low for post-operative pain at 1 h (critical outcome), post-operative pain at 4 h (critical outcome), post-operative pain at 8 h (critical outcome), and post-operative pain at 2 days (critical outcome). Conclusions: This review allowed us to draw conclusive results from the use of low-pressure pneumoperitoneum with an adequate quality of evidence

Choices in surgical treatment of diverticulitis

Complications after surgical treatment of diverticulitis are not very frequent, in view of the total number of patients affected by this pathology, but they do become significant in absolute terms because of the high prevalence of the disease itself. Surgeons continue to debate which option is better: Hartmann re- section or combined resection and anastomosis. Since age is a crucial factor when surgery is being considered, we evaluated the outcome of surgical treatment for di- verticulitis in patients treated in our unit over a six- month period, in view of the number of elderly patients generally admitted. Between January 2001 and June 2012, 77 patients underwent surgery for diverticular disease in the Geriatric Surgery Unit of the Department of Surgical and Gastroenterological Sciences, Univer- sity of Padova Hospital. Gastrointestinal resection and anastomosis were performed in 75 patients (97%), re- sulting in an overall complication rate of 37% and a mortality rate of 1%. This surgical strategy was chosen because, when it is performed by experienced sur- geons, it offers the same results in terms of mortality and morbidity as Hartmann resection, while presenting significant advantages as regards the patient's quality of life. Various factors such as the timing of surgery, severity of the disease defined according to the Hinchey classification, patient’s clinical condition, and sur- geon's experience and expertise can all influence the surgical choice. Several studies in the literature confirm that combined resection and anastomosis is safe and ef- ficacious, but more research is needed to confirm these data

N0 Stage colon cancer: prognostic role of age in relation to tumor site.

This work investigates the prognostic role of advanced age as a risk factor for recurrence in a population of patients undergoing surgery for N0 stage colon cancer, and also evaluates whether that role is affected by tumor location. A population of 129 con- secutive patients who underwent radical surgery for N0 stage colon cancer was selected. Patients were subdi- vided into three age groups: 80. The only correlation found in the examined population between age and clinical-pathological features was be- tween advanced age (>80) and tumor location in the right side of the colon. Overall survival (OS) and dis- ease-free survival (DFS) were significantly lower in pa- tients over 80 than in the other two classes. Two mul- tivariate analyses were carried out: when tumor loca- tion was not considered, age >80 represented a neg- ative prognostic factor for risk of recurrence, regardless of the other factors examined. This role was also con- firmed when tumor location was considered. As hy- pothesized by several authors, the role of advanced age which emerges from this study is mainly due to the in- creased fragility of elderly patients caused by multiple pathophysiological factors, but it does not necessarily represent an absolute contraindication to surgery. The role played by tumor location remains contro- versial, as more and more studies show that right colon cancer (RCC) is a biological entity distinct from left colon cancer (LCC). Further studies are required to examine right and left colon cancers as two separate diseases

Using protamine can significantly reduce the incidence of bleeding complications after carotid endarterectomy without increasing the risk of ischemic cerebral events

Abstract Background Controversy persists regarding the use of protamine sulfate (PS) during carotid endarterectomy (CEA), chiefly because of conflicting experiences reporting both less bleeding and a higher stroke risk. The goal of the present study was to test the hypothesis that reversing heparin with PS after CEA significantly reduces the incidence of bleeding complications without increasing the risk of postoperative stroke. Methods From January 2010 to December 2012 all consecutive patients undergoing CEA under general anesthesia at our institution received 5,000 U of heparin prior to carotid clamping, which was partially (half-dose) reversed with PS 25 mg immediately after declamping (group I). Heparinization had never been reversed with PS in earlier CEAs performed from 1998 to 2009 at the same institution (group II). All patients were assessed preoperatively and postoperatively by a neurologist, and cerebral magnetic resonance imaging was performed in all group I patients to exclude any silent cerebral infarction. End points of the study were bleeding complications, perioperative (30-day) stroke, and death. Results Overall, 219 CEAs (201 patients) were performed in group I, and 1,458 CEAs (1,294 patients) in group II. Demographics, risk factors, and preoperative antiplatelet medication were comparable in the two groups. The incidence of adverse events (group I vs group II) was as follows: stroke (0 vs 0.5 % [8/1,458], p = 0.27); death (0 vs 0 %); neck bleeding (0 vs 8.2 % [120/1,458], p\0.001). Conclusions The results of the present study demonstrate that (1) partially neutralizing heparin with PS after CEA can significantly reduce the risk of bleeding complications, and (2) there is no association between the administration of PS and the incidence of postoperative stroke

Carotid endarterectomy for asymptomatic carotid stenosis in the very elderly

none6BACKGROUND: The indication for carotid endarterectomy (CEA) is uncertain in patients with asymptomatic severe (≥60% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria) carotid stenosis (ASCS), especially in the very elderly, because current evidence suggests that the risk of future stroke has been dropping in the past two decades owing to the recent advances in medical therapy. The aim of this observational study was to compare early and late outcomes in patients ≥80 years old with ASCS treated with CEA plus best medical treatment (BMT) or with BMT alone. METHODS: From 2005 to 2012, 69 octogenarians with ASCS underwent CEA plus BMT (group 1), and another 54 received BMT alone (group 2). All operations were eversion CEAs. BMT included lipid-lowering drugs, new antiplatelet and antihypertensive agents, avoidance of smoking, careful blood pressure and glycemic control, and lifestyle changes. Follow-up with serial ultrasonographic examination was obtained in 118 patients for a median 4.4-year period. RESULTS:There were no perioperative (30-day) strokes or deaths and one transient ischemic attack (1.4%). One late minor stroke developed in a CEA patient (1.5%). No late restenoses or occlusions were detected. Five patients in group 2 (9.6%) became symptomatic (one transient ischemic attack and four minor strokes) and subsequently underwent successful CEA; all their carotid plaques were complicated by ulceration and intraplaque hemorrhage (with plaque progression in four cases), confirmed by computed tomography images. The rate of freedom from cerebral ischemic events at 5 years showed a significant benefit for elderly patients who had CEA vis-à-vis those who did not (98% vs 84%; P = .04), and so did the 5-year rate of freedom from ipsilateral carotid disease progression (100% vs 91%; P = .01). At 5 years, the mortality rate was comparable for elderly patients whether they had CEA or not (66% vs 68%; P = .65). CONCLUSIONS: CEA is a safe, effective, and durable treatment for ASCS in patients aged 80 years or more, carrying an insignificant perioperative stroke/death risk. CEA associated with BMT seems preferable to BMT alone in preventing the risk of ipsilateral ischemic events, without translating into a longer survival.mixedBallotta E; Toniato A; Da Roit A; Lorenzetti R; Piatto G; Baracchini CBallotta, Enzo; Toniato, Antonio; DA ROIT, Anna; Lorenzetti, Renata; Piatto, Giacomo; Baracchini, Claudi

Reconstructive surgery for complex aortoiliac occlusive disease in young adults

BackgroundAlthough aortoiliofemoral bypass grafting is the optimal revascularization method for patients with severe aortoiliac occlusive disease (AIOD), previous studies have documented poor patency rates in young adults. This study investigated whether young patients with AIOD have worse outcomes in patency, limb salvage, and long-term survival rates after reconstructive surgery than their older counterparts.MethodsPatients aged ≤50 years undergoing reconstructive surgery at our institution for AIOD between 1995 and 2010 were compared with a cohort of randomly selected patients aged ≥60 years (two for each of the young patients, matched for year of operation), analyzing demographics, risk factors, indications for surgery, operative details, and outcomes.ResultsAmong 927 consecutive patients undergoing primary surgery for AIOD, 78 (8.4%) aged ≤50 years (mean age, 48.4 years) and 156 older control patients (mean age, 71.2 years) were identified. The younger patients were mainly men (81%) and 59% had surgery for limb salvage and 41% for disabling claudication (P = .02). Compared with older patients, they were significantly more likely to be smokers (90% vs 72%; P = .002) and had previously needed significantly more inflow procedures (28% vs 16%; P = .03). Only one death occurred perioperatively (30-day) among the control patients, and no major amputations or graft infections occurred in either group. The need for subsequent infrainguinal reconstructions was greater in the younger patients (18% vs 7%; P = .01). The primary patency rates were inferior in the younger patients at 5 years (82% and 75%) and 10 years (95% and 90%; P = .01), whereas assisted secondary patency (89% and 82% vs 96% and 91%; P = .08), secondary patency (93% and 86% vs 98% and 92%; P = .19), limb salvage (88% and 83% vs 95% and 91%; P = .13), and survival rates (87% and 76% vs 91% and 84%; P = .32) were comparable in the two groups.ConclusionsThis study shows that despite a higher primary graft failure rate than that in older patients, aortoiliofemoral revascularization for complex AIOD is a safe procedure for younger patients with disabling claudication or limb-threatening ischemia, providing they are willing to follow a regular protocol to complete their postoperative surveillance and to undergo graft revision as necessary

Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass

background In case of insufficient weight loss or weight regain or relapse of weight-related comorbidities after roux-en-Y gastric bypass (RYGB), other procedures such as reduction of a large gastric pouch and stoma, lengthening of the roux limb, conversion to sleeve gastrectomy and/or bilio-pancreatic diversion with duodenal switch have been advocated. Single anastomosis jejuno-ileal (SAJI) is a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass. methods SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250-300 cm proximal to the ileo-caecal valve and the jejunum 30 cm below the gastro-jejunal anastomosis on the roux limb of the previous RYGB. thirty-one patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB. the percent total weight loss (%TWL) after RYGB and before SAJI was 21.8 +/- 7.8. All SAJI operations were performed laparoscopically. the SAJI mean operating time was 145 min. results regarding weight loss after SAJI, %TWL is 27.2 +/- 7.4, 31.2 +/- 6.4, 33.7 +/- 5.9 and 32.9 +/- 5.2 at 12, 24, 36 and 48 months, respectively. our series recorded a low rate of peri-operative and medium-term complications with a low grade of severity (clavien-dindo classification grade). one patient required reoperation 36 days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. mortality was 0. comorbidity reduction/resolution after SAJI is 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidemia and 45.3% for OSA. conclusions treatment of failed RYGB is challenging. SAJI is a less complicated, purely low invasive malabsorptive operation that should reach satisfactory %TWL and comorbidity reduction/resolution

Use of High Energy Devices (HEDs) versus electrocautery for laparoscopic cholecystectomy: a systematic review and meta-analysis of randomised controlled trials

IntroductionAccording to the literature, there is no clear definition of a High Energy Devices (HEDs), and their proper indications for use are also unclear. Nevertheless, the flourishing market of HEDs could make their choice in daily clinical practice arduous, possibly increasing the risk of improper use for a lack of specific training. At the same time, the diffusion of HEDs impacts the economic asset of the healthcare systems. This study aims to assess the efficacy and safety of HEDs compared to electrocautery devices while performing laparoscopic cholecystectomy (LC).Materials and methodsOn behalf of the Italian Society of Endoscopic Surgery and New Technologies, experts performed a systematic review and meta-analysis and synthesised the evidence assessing the efficacy and safety of HEDs compared to electrocautery devices while performing laparoscopic cholecystectomy (LC). Only randomised controlled trials (RCTs) and comparative observational studies were included. Outcomes were: operating time, bleeding, intra-operative and post-operative complications, length of hospital stay, costs, and exposition to surgical smoke. The review was registered on PROSPERO (CRD42021250447).ResultsTwenty-six studies were included: 21 RCTs, one prospective parallel arm comparative non-RCT, and one retrospective cohort study, while three were prospective comparative studies. Most of the studies included laparoscopic cholecystectomy performed in an elective setting. All the studies but three analysed the outcomes deriving from the utilisation of US sources of energy compared to electrocautery. Operative time was significantly shorter in the HED group compared to the electrocautery group (15 studies, 1938 patients; SMD - 1.33; 95% CI - 1.89 to 0.78; I2 = 97%, Random-effect). No other statistically significant differences were found in the other examined variables.ConclusionsHEDs seem to have a superiority over Electrocautery while performing LC in terms of operative time, while no difference was observed in terms of length of hospitalisation and blood loss. No concerns about safety were raised