Laparoscopic harvesting of small bowel graft for small bowel transplantation

Background: Small bowel transplantation represents a valid therapeutic option for patients with intestinal failure, obviating the need for long-term total parenteral nutrition. Recently, reports have shown the feasibility of performing living related intestinal transplantation using segmental small bowel grafts. The limitations of this technique include inadequate harvested small bowel lengths, as compared with the lengths obtained in cadaveric small bowel harvests, and large incisions for the donor. In this pilot study, we evaluated the feasibility of laparoscopically harvesting long segments of proximal jejunum for small bowel transplantation using a porcine model. The results can be used to evaluate the potential for applying this technique in human cases.Methods: For this study 10 yorkshire pigs were used. Under general anesthesia, each pig underwent laparoscopic segmental resection of 200 cm of proximal jejunum on a vascular pedicle. The harvested graft then was autoreimplanted using an open technique by anastomosing the vascular pedicle to the superior mesenteric vessels. Success was determined 2 hours after anastomosis by visually identifying a pink graft with viable-appearing mucosa, an artery with a strong thrill, and palpable venous flow. The animals were then sacrificed.Results: The mean operation time required to laparoscopically harvest the small bowel graft was 80 min (range, 35-120 min), and the mean length of harvested graft was 220 cm (range, 200-260 cm). The mean length of the graft's vascular pedicle was 4.5 cm (range, 4 5 cm). All 10 grafts were successfully harvested laparoscopically and then reimplanted using an open technique. All the grafts maintained good vascular flow, and showed no evidence of mucosal necrosis at necropsy. Obviously, further studies would be required to examine the long-term results of reimplanting a laparoscopically harvested small bowel graft, but proposals for such studies is beyond the scope of this report.Conclusion.-Minimally invasive techniques can be used to harvest proximal small bowel grafts for living related small bowel transplantation

Neuroanatomical changes in white and grey matter after sleeve gastrectomy

International audienceBACKGROUND: MRI studies show that obese adults have reduced grey matter (GM) and white matter (WM) tissue density as well as altered WM integrity. Bariatric surgery can lead to substantial weight loss and improvements in metabolic parameters, but it remains to be examined if it induces structural brain changes. The aim of this study was to characterize GM and WM density changes measured with MRI in a longitudinal setting following sleeve gastrectomy, and to determine whether any changes are related to inflammation and cardiometabolic blood markers. METHODS: 29 participants with obesity (age: 45.9 ​± ​7.8 years) scheduled to undergo sleeve gastrectomy were recruited. High-resolution T1-weighted anatomical images were acquired 1 month prior to as well as 4 and 12 months after surgery. GM and WM densities were quantified using voxel-based morphometry (VBM). Circulating lipid profile, glucose, insulin and inflammatory markers (interleukin-6, C-reactive protein and lipopolysaccharide-binding protein) were measured at each time point. A linear mixed effect model was used to compare brain changes before and after SG, controlling for age, sex, initial BMI and diabetic status. To assess the associations between changes in adiposity, metabolism and inflammation and changes in GM or WM density, the mean GM and WM densities were extracted across all the participants using atlas-derived regions of interest, and linear mixed-effect models were used. RESULTS: As expected, weight, BMI, waist circumference and neck circumference significantly decreased after SG compared with baseline (p ​\textless ​0.001 for all). A widespread increase in WM density was observed after surgery, particularly in the cerebellum, brain stem, cerebellar peduncle, cingulum, corpus callosum and corona radiata (p ​\textless ​0.05, after FDR correction). Significant increases in GM density were observed 4 months after SG compared to baseline in several brain regions such as the bilateral occipital cortex, temporal cortex, postcentral gyrus, cerebellum, hippocampus and insula as well as right fusiform gyrus, right parahippocampal gyrus, right lingual gyrus and right amygdala. These GM and WM increases were more pronounced and widespread after 12 months and were significantly associated with post-operative weight loss and the improvement of metabolic alterations. A linear mixed-effect model also showed associations between post-operative reductions in lipopolysaccharide-binding protein, a marker of inflammation, and increased WM density. To confirm our results, we tested whether the peak of each significant region showed BMI-related differences in an independent dataset (Human Connectome Project). We matched a group of individuals who were severely obese with a group of individuals who were lean for age, sex and ethnicity. Severe obesity was associated with reduced WM density in the brain stem and cerebellar peduncle as well as reduced GM density in cerebellum, regions that significantly changed after surgery (p ​\textless ​0.01 for all clusters). CONCLUSIONS: Bariatric surgery-induced weight loss and improvement in metabolic alterations is associated with widespread increases in WM and GM densities. These post-operative changes overlapped with baseline brain differences between participants who were severely obese and those who were normal-weight in a separate dataset, which may suggest a recovery of WM and GM alterations after bariatric surgery

Hepatectomia direita por videolaparoscopia

The first application of laparoscopic liver surgery consisted of wedge liver biopsies or resection of peripheral lesions, mostly benign. More recently, reports of anatomic left and right hepatectomy have been seen in the literature. Expertise in some centers has evolved to such an extent that even living related donor hepatectomy has been performed. The aim of this paper is to report a laparoscopic right hepatectomy and describe in detail the surgical technique employed. To our knowledge this is the first case performed in Brazil totally laparoscopically. The surgery followed four distinct phases: complete mobilization of the liver; hilum dissection with encircling of right portal vein and right hepatic artery, caval dissection using linear vascular stapler to divide right hepatic vein and parenchymal transection with harmonic shears and firings of linear staplers are used to divide segmental 5 and 8 branches of middle hepatic vein. The liver specimen was removed by Pfannenstiel incision. Intraoperative blood loss was estimated in 120 ml with no need for blood transfusion. Hospital stay was 5 days. Laparoscopic right hepatectomy is feasible, technically demanding but can be safely accomplished by surgeons who have experience in advanced laparoscopic procedures and open hepatic surgery. In Brazil laparoscopic liver surgery is still in its first years and there is a lack of technical description of this complex procedure