Utility of Routine Versus Selective Upper Gastrointestinal Series to Detect Anastomotic Leaks After Laparoscopic Gastric Bypass

Background: In up to 4% of laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures, anastomotic leaks occur. Early detection of gastrointestinal leakage is important for successful treatment. Consequently, many centers advocate routine postoperative upper gastrointestinal (UGI) series. The aim of this study was to determine the utility of this practice after LRYGB. Methods: Eight hundred four consecutive patients undergoing LRYGB from June 2000 to April 2010 were analyzed prospectively. The first 382 patients received routine UGI series between the third and fifth postoperative days (group A). Thereafter, the test was only performed when clinical findings (tachycardia, fever, and drainage content) were suspicious for a leak of the gastrointestinal anastomosis (group B; n = 422). Results: Overall, nine of 804 (1.1%) patients suffered from leaks at the gastroenterostomy. In group A, four of 382 (1%) patients had a leak, but only two were detected by the routine UGI series. This corresponds to a sensitivity of 50%. In group B, the sensitivity was higher with 80%. Specificities were comparable with 97% and 91%, respectively. Routine UGI series cost only 1.6% of the overall costs of a non-complicated gastric bypass procedure. With this leak rate and sensitivity, US $86,800 would have to be spent on 200 routine UGI series to find one leak which is not justified. Conclusions: This study shows that routine UGI series have a low sensitivity for the detection of anastomotic leaks after LRYGB. In most cases, the diagnosis is initiated by clinical findings. Therefore, routine upper gastrointestinal series are of limited value for the diagnosis of a lea

Reproducibility of straylight measurement by C-Quant for assessment of retinal straylight using the compensation comparison method

Background: Straylight gives the appearance of a veil of light thrown over a person's retinal image when there is a strong light source present. We examined the reproducibility of the measurements by C-Quant, and assessed its correlation to characteristics of the eye and subjects' age. Participants and Methods: Five repeated straylight measurements were taken using the dominant eye of 45 healthy subjects (age 21-59) with a BCVA of 20/20: 14 emmetropic, 16 myopic, eight hyperopic and seven with astigmatism. We assessed the extent of reproducibility of straylight measures using the intraclass correlation coefficient. Results: The mean straylight value of all measurements was 1.01 (SD 0.23, median 0.97, interquartile range 0.85-1.1). Per 10years of age, straylight increased in average by 0.10 (95%CI 0.04 to 0.16, p < 0.01]. We found no independent association of refraction (range −5.25 dpt to +2 dpt) on straylight values (0.001; 95%CI −0.022 to 0.024, p = 0.92). Compared to emmetropic subjects, myopia reduced straylight (−.011; −0.024 to 0.02, p = 0.11), whereas higher straylight values (0.09; −0.01 to 0.20, p = 0.09) were observed in subjects with blue irises as compared to dark-colored irises when correcting for age. The intraclass correlation coefficient (ICC) of repeated measurements was 0.83 (95%CI 0.76 to 0.90). Conclusions: Our study showed that straylight measurements with the C-Quant had a high reproducibility, i.e. a lack of large intra-observer variability, making it appropriate to be applied in long-term follow-up studies assessing the long-term effect of surgical procedures on the quality of visio

Three-Year Follow-Up Study of Retrocolic versus Antecolic Laparoscopic Roux-en-Y Gastric Bypass

Background: Since 1994, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has gained popularity for the treatment of morbid obesity. In analogy to open surgery, the operation was initially performed in a retrocolic fashion. Later, an antecolic procedure was introduced. According to short-term studies, the antecolic technique is favorable. In this study, we compared the retrocolic vs the antecolic technique with 3 years of follow-up. We hypothesized that the antecolic technique is superior to the retrocolic in terms of operation time and morbidity. Methods: 33 consecutive patients with retrocolic technique and 33 patients with antecolic technique of LRYGBP were compared, using a matched-pair analysis. Data were extracted from a prospectively collected database. The matching criteria were: BMI, age, gender and type of bypass (proximal or distal). The end-points of the study were: operation time, length of hospital stay, incidence of early and late complications, reoperation rates and weight loss in the followup over 36 months. Results: In the retrocolic group, operation time was 219 min compared to 188 min in the antecolic group (P = 0.036). In the retrocolic group, 3 patients (9.1%) developed an internal hernia and 4 patients (12.1%) suffered from anastomotic strictures. In the antecolic group, 2 patients (6.1%) developed internal hernias and in 3 patients (9.1%) anastomotic strictures occurred. Median hospital stay in the retrocolic group was 8 days compared to 7 days in the antecolic group. In the antecolic group, the mean BMI dropped from 46kg/m2 to 32kg/m2 postoperatively after 36 months. This corresponds to an excess BMI loss of 66%. In the retrocolic group, we found a similar decrease in BMI from preoperative 45kg/m2 to 34kg/m2 after 36 months (P = 0.276). Conclusion: The results of our study demonstrate a reduction of operation time and hospital stay in the antecolic group compared to the retrocolic group. No differences between the two groups were found regarding morbidity and weight loss. Taken together, the antecolic seems to be superior to the retrocolic techniqu

Development of Myeloid Dendritic Cells under the Influence of Sexual Hormones Visualized using Scanning and Transmission Electron Microscopy

Dendritic cells (DCs) are antigen-presenting cells, which are mediated by MHC-class II molecules reacting with T-helper cells, eliciting a broad spectrum of immune reactions at cellular and humoral levels depending on their subtypes. DCs are also able to cross-present peptides from intracellular proteins as well as from intracellular pathogens via MHC-class I molecules by inducing MHC-class I–restricted cytotoxic T cells, which are also able to destroy cells undergoing malignant transformation. DCs originate from CD34+ hematopoietic stem cells but can also develop from monocytes. The local or systemic milieu of cytokines and steroid hormones significantly influences the generation of particular DC subtypes such as the classical myeloid DCs such as cDC1 and cDC2 as well as the plasmacytoid DCs. These subtypes are able to induce specific Th1- and Th17-dependent, Th2-dependent, or regulatory immune responses, respectively. Immature DCs take up extracellular pathogens that are presented by MHC molecules that are upregulated during maturation. Immature and mature DCs can be characterized by morphological and biochemical features that are outlined in this article. In addition, DCs are under control of sexual hormones. Estrogen receptor ligands are potent modulators of hemopoiesis and immune function in health and disease, influencing key cytokines promoting the maturation of DCs. DC differentiation is mainly regulated by binding of estradiol to ERα. Estrogen promotes the differentiation of immature DC subsets derived from bone marrow precursors or from myeloid progenitors. In contrast to estrogen, progesterone inhibits DC maturation, causing a decreased immunity in pregnancy or in postmenopausal women, where elevated levels of progesterone result in the production of Th2 cytokines. The influence of estrogen and progesterone on DC maturation has been demonstrated in own in vitro experiments using fluorescence microscopy and cell sorting and, above all, by visualization using SEM and TEM. At the end of this article, pits and falls concerning the treatment of malignancies with living DC vaccines are discussed

Outcomes after Epiretinal Membrane Surgery with or Without Internal Limiting Membrane Peeling

The aim of this study was to assess the incidence of persistent postoperative cystoid macular edema (pCME) in patients undergoing pars plana vitrectomy with epiretinal membrane peel (ERM) only versus those with ERM peel combined with internal limiting membrane peel (ILM). Secondary endpoints of the study were to review both the central macular thickness (CMT) and visual acuity

Predictive risk factors for retinal redetachment following uncomplicated pars plana vitrectomy for primary rhegmatogenous retinal detachment

Purpose: To investigate clinical and surgical factors influencing the outcome after primary rhegmatogenous retinal detachment surgery. Methods: A retrospective, single-centre, case-control study of 1017 eyes of 1017 consecutive patients with primary rhegmatogenous retinal detachment (RRD) who underwent pars plana vitrectomy (PPV), were included in the study. Analysed surgical factors were: combined procedure with phacoemulsification, type of retinopexy (cryocoagulation, endolaser, combined), type of tamponade (gas, silicone oil), and anatomical factors: primary proliferative vitreoretinopathy (PVR) and macular detachment at the time of surgery. Results: Overall retinal re-detachment rate was 10.1%. The main reason for re-detachment was an insufficient retinopexy in 53.6%, followed by PVR (37.3%), and retinal detachment occurred at a different location caused by another break in 9.1%. No significant difference in the rate of re-detachment was found if a phacoemulsification with simultaneous IOL implantation was performed (p = 0.641). No significant difference between the various retinopexy techniques was found (p = 0.309). Risk factors re-detachment were primary PVR (p = 0.0003), silicone oil as initial tamponade (p = 0.0001) as well as macula off detachments (p = 0.034). Conclusions: The present study showed no significant difference between the types of retinopexy and if additional phacoemulsification was performed or not. Factors associated with a higher risk for re-detachment were detached macula at surgery, primary PVR and primary oil-filling

Successful treatment of peripheral proliferative vitreoretinopathy with cryocoagulation during retinal detachment repair – a new surgical technique

Purpose: To evaluate the effect of extrascleral cryocoagulation for the treatment of proliferative vitreoretinopathy (PVR) during retinal detachment repair. Methods: Patients with a rhegmatogenous retinal detachment associated with peripheral PVR Grade C star-folds were included in this study and analysed retrospectively. In all patients, PVR star-folds were treated by extrascleral cryocoagulation. Results: A total of six patients with a rhegmatogenous retinal detachment associated with at least one peripheral PVR star-fold were included in this study. Reattachment of the retina was successfully achieved in all patients. Conclusion: This novel and simple technique for the treatment of localized PVR using extrascleral cryocoagulation appears to be a safe and effective approach with favourable surgical success rates

Indications and outcomes for intravitreal injection of C₃F₈ gas for symptomatic vitreomacular traction

To evaluate the indications and outcomes of perfluoropropane (C3F8) gas injection for symptomatic vitreomacular traction (VMT). A retrospective analysis of eyes with VMT treated with 0.3 mL of C3F8 gas was performed. Patients were not asked to posture after gas injection. In phakic patients, cataract surgery was performed simultaneously. Patients were examined after one week and one month postoperatively. Twenty-nine consecutive eyes of 26 patients with symptomatic VMT who underwent pneumatic vitreolysis were included. A complete posterior vitreous detachment was achieved in 18 eyes (62.1%) after a single gas injection at the final visit. The rate of posterior vitreous detachment was reduced significantly with the presence of epiretinal membrane (ERM) (p = 0.003). Three eyes formed a macular hole (MH) postoperatively and another eye developed a retinal detachment. Mean visual acuity increased significantly after one month (p < 0.008). Pneumatic vitreolysis is a viable option for treating VMT with few adverse events. Patient with concomitant ERM had a significantly lower success rate

Long-term outcome of macular shift after retinal detachment repair

Background This study aimed to evaluate the long-term change of postoperative retinal shift after pars plana vitrectomy for macular off retinal detachment. Methods In this retrospective study, patients with retinal shift after pars plana vitrectomy for macula-off rhegmatogenous retinal detachment (RRD) were examined at 3 weeks and 12 months postoperatively. Fundus autofluorescence images were obtained to visualize retinal rotation. Best-corrected visual acuity was measured and metamorphopsia assessed using the Amsler grid. Results Nine patients with postoperative retinal shift were included in the study. Retinal shift decreased significantly in these patients, on average by 1.07 degrees (range 0.52-1.62, p = 0.002) after 12 months. However, more patients complained of distorted vision after 12 months (odds ratio for change = 3.0, 95% CI: 0.24 to 157.49). The main reason was the new formation of an epiretinal membrane (odds ratio for change = infinity, 95% CI: 0.41 to infinity). There was no change in visual acuity observed (p = 0.16). Conclusion Postoperative retinal shift after RRD repair decreases over a 1-year span. While retinal shift is the main cause for metamorphopsia in the early postoperative period, formation of an ERM is the main reason for distorted vision long term