Laparoscopic-assisted resection of jejunal GIST with Acute Gastrointestinal Bleed

Small intestinal bleeding accounts for about 5-10% of gastrointestinal bleed. Jejunal GIST’s though can be a cause but rarely present with acute bleed. The diagnosis of such cases can be quite challenging and requires a multidisciplinary approach. We present a case of acute bleed from jejunal GIST that was managed by laparoscopic-assisted resection. The postoperative period was uneventful and the patient was discharged on day four. Histopathological examination of the specimen was suggestive of GIST that was confirmed further with immunohistochemical staining

Suaeda maritima-based herbal coils and green nanoparticles as potential biopesticides against the dengue vector Aedes aegypti and the tobacco cutworm Spodoptera litura

The overuse of synthetic pesticides to control insect pests leads to physiological resistance and adverse environmental effects, in addition to high operational cost. Insecticides of botanical origin have been reported as useful for control of agricultural and public health insect pests. This research proposed a novel method of mangrove-mediated synthesis of insecticidal silver nanoparticles (AgNP) using Suaeda maritima, acting as a reducing and stabilizing agent. AgNP were characterized by UV–vis spectroscopy, Fourier transform infrared (FTIR) spectroscopy, scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDX), and X-ray diffraction (XRD) analysis. S. maritima aqueous extract and mangrove-synthesized AgNP showed larvicidal and pupicidal toxicity against the dengue vector Aedes aegypti and the tobacco cutworm Spodoptera litura. In particular, LC50 of AgNP ranged from 8.668 (larva I) to 17.975 ppm (pupa) for A. aegypti, and from 20.937 (larva I) to 46.896 ppm (pupa) for S. litura. In the field, the application of S. maritima extract and AgNP (10 × LC50) led to 100% mosquito larval reduction after 72 h. Smoke toxicity experiments conducted on A. aegypti adults showed that S. maritima leaf-, stem- and root-based coils evoked mortality rates comparable or higher if compared to permethrin-based positive control (62%, 52%, 42%, and 50.2 respectively). In ovicidal experiments, egg hatchability was reduced by 100% after treatment with 20 ppm of AgNP and 250 ppm of S. maritima extract. Furthermore, low doses of the AgNP inhibited the growth of Bacillus subtilis, Klebsiella pneumoniae and Salmonella typhi. Overall, our results highlighted the potential of S. maritima-based herbal coils and green nanoparticles as biopesticides in the fight against the dengue vector A. aegypti and the tobacco cutworm S. litura

Laparoscopic Undo of Fundoplication with Roux-en-Y Gastric Bypass in a Morbidly Obese Patient with Prior Nissen's Fundoplication: A Video Report

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Role of routine pre-operative screening venous duplex ultrasound in morbidly obese patients undergoing bariatric surgery

Background/Aims: It is well established that obesity is a strongly associated risk factor for post-operative deep vein thrombosis (DVT). Physical effects and pro-thrombotic, pro-inflammatory and hypofibrinolytic effects of severe obesity may predispose to idiopathic DVT (pre-operatively) because of which bariatric patients are routinely screened before surgery. The aim of this study was to audit the use of routine screening venous duplex ultrasound in morbidly obese patients before undergoing bariatric surgery. Methods: We retrospectively reviewed 180 patients who underwent bariatric surgery from August 2013 to August 2014 who had undergone pre-operative screening bilateral lower-extremity venous duplex ultrasound for DVT. Data were collected on patient's demographics, history of venous thromboembolism, prior surgeries and duplex ultrasound details of the status of the deep veins and superficial veins of the lower limbs. Results: No patients had symptoms or signs of DVT pre-operatively. No patient gave history of DVT. No patient was found to have iliac, femoral or popliteal vein thrombosis. Superficial venous disease was found in 17 (8%). One patient had a right lower limb venous ulcer. Conclusion: Thromboembolic problems in the morbidly obese before bariatric surgery are infrequent, and screening venous duplex ultrasound can be done in high-risk patients only

Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorithm

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed 'standalone' bariatric procedure in India. Staple line gastric leaks occur infrequently but cause significant and prolonged morbidity. The aim of this retrospective study was to analyse the management of patients with a gastric leak after LSG for morbid obesity at our institution. Patients and Methods: From February 2008 to 2014, 650 patients with different degrees of morbid obesity underwent LSG. Among these, all those diagnosed with a gastric leak were included in the study. Patients referred to our institution with gastric leak after LSG were also included. The time of presentation, site of leak, investigations performed, treatment given and time of closure of all leaks were analysed. Results: Among the 650 patients who underwent LSG, 3 (0.46%) developed a gastric leak. Two patients were referred after LSG was performed at another institution. The mean age was 45.60 ± 15.43 years. Mean body mass index (BMI) was 44.79 ± 5.35. Gastric leak was diagnosed 24 h to 7 months after surgery. One was early, two were intermediate and two were late leaks. Two were type I and three were type II gastric leaks. Endoscopic oesophageal stenting was used variably before or after re-surgery. Re-surgery was performed in all and included stapled fistula excision (re-sleeve), suture repair only or with conversion to roux-en-Y gastric bypass or fistula jujenostomy. There was no mortality. Conclusion: Leakage closure time may be shorter with intervention than expectant management. Sequence and choice of endoscopic oesophageal stenting and/or surgical re-intervention should be individualized according to clinical presentation

Single incision multiport versus conventional laparoscopic inguinal hernia repair: A matched comparison

Background: The popularity of single-incision procedures is on the rise as wound cosmesis is increasingly being seen as an important body image-related outcome. In this study, we assess the potential benefits of single-incision multiport laparoscopic totally extra-peritoneal (S-TEP) without using specialised ports or instruments and compare the same with the conventional laparoscopic TEP (C-TEP) surgery in terms of operative time, post-operative pain, complications, cost and cosmesis. Materials and Methods: This is a prospective case-matched study of the patients undergoing S-TEP versus C-TEP from June 2014 to December 2015. Results: Each group had 36 patients. The two groups were comparable in the clinical characteristics. The mean duration of surgery for a unilateral hernia in C-TEP and S-TEP was 45.13 ± 10.58 min and 72.63 ± 15.23 min, respectively. The mean visual analogue scale (VAS) score for pain was significantly higher in S-TEP group at post-operative day (POD) 0 and 1. However, at POD 7, there was no significant difference between the groups. At 1st and 6-week post-surgery, the cosmetic results were significantly better in S-TEP group as compared to C-TEP, however, at 6 months, the scar was highly acceptable in both treatment groups. Conclusion: S-TEP, using conventional laparoscopic instruments, is safe and feasible even in resource challenged setting. However, there is a need to review the indications and advantages of single-incision laparoscopic surgery, as no difference in cosmetic outcome by VAS score in S-TEP versus conventional laparoscopic arm seen by the end of 1 month

Comparison of weight loss outcomes 1 year after sleeve gastrectomy and Roux-en-Y gastric bypass in patients aged above 50 years

Introduction: Safe, effective weight loss with resolution of comorbidities has been convincingly demonstrated with bariatric surgery in the aged obese. They, however, lose less weight than younger individuals. It is not known if degree of weight loss is influenced by the choice of bariatric procedure. The aim of this study was to compare the degree of weight loss between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients above the age of 50 years at 1 year after surgery. Materials and Methods: A retrospective analysis was performed of all patients more than 50 years of age who underwent LSG or LRYGB between February 2012 and July 2013 with at least 1 year of follow-up. Data evaluated at 1 year included age, sex, weight, body mass index (BMI), mean operative time, percentage of weight loss and excess weight loss, resolution/remission of diabetes, morbidity and mortality. Results: Of a total of 86 patients, 54 underwent LSG and 32 underwent LRYGB. The mean percentage of excess weight loss at the end of 1 year was 60.19 ± 17.45 % after LSG and 82.76 ± 34.26 % after LRYGB (P = 0.021). One patient developed a sleeve leak after LSG, and 2 developed iron deficiency anaemia after LRYGB. The remission/improvement in diabetes mellitus and biochemistry was similar. Conclusion: LRYGB may offer better results than LSG in terms of weight loss in patients over 50 years of age

Thoraco-laparoscopic Ivor-Lewis esophagectomy: the most extensive Indian experience

Aim: The overall incidence of adenocarcinoma is on the rise, mainly in the western population. Minimally invasive thoracolaparoscopic esophagectomy for adenocarcinoma of gastroesophageal junction tumors is being adopted worldwide, albeit with a slower pace. This study is to share our experience and technical modifications over two decades.Methods: This a retrospective data from 2009-2018 at a single center, including all the 143 cases of thora-colaparoscopic Ivor Lewis esophagectomies performed. There were no exclusions. The study objectives were to evaluate postoperative recovery, complications, and pathological completeness.Results: In 11 years, we have performed 532 cases of minimally invasive esophagectomies for both malignant and benign etiologies. Out of which 143 cases were of Ivor Lewis esophagectomy. The mean age of patients was 64.4 ± 10.86 years, and male to female ratio is 3:1. Out of these cases, 139 (97.20%) were performed for malignancy and 4 (2.79%) for benign cases, which include peptic stricture, sigmoid esophagus. The mean operative time is 457.97 ± 79.35 min. The mean blood loss was 138.08 ± 29.3mL. Out of these cases, the hand-sewn anastomosis was performed in 72 (50.34%), circular stapler anastomosis in 46 (32.16%) and, linear stapled anastomosis in 25 (17.48%). The mean lymph node retrieval rate was 22.68 ± 9.49 nodes. The average ICU stay in the postoperative period was 4.68 ± 3.95 days, and overall hospital stay was 13.48 ± 7.43 days. Among malignant cases (139), adenocarcinoma in 121 (87.05%), squamous cell carcinoma in 18 (12.94%). Among these cases T2, lesions in 56 (40.28%), T3 lesions in 77 (55.39%), T4 lesions in 6 (4.31%) The overall complication rate was 12.58% (pneumonia- 8.39%, RLN injury in 1.39%, anastomotic leak in 2.09%, chyle leak in 0.69%, anastomotic stricture in 12.58%). 3 (2.09%) cases had re-intervention in the form of combined endoscopic procedures (stenting) and re-thoracoscopic lavage in 3. Overall 30-day mortality in 1 case (0.69%).Conclusion: Thoracolaparoscopic esophagectomy with intrathoracic Ivor Lewis anastomosis is an excellent option for selected patients, in experienced hands