Laparoscopic approach in the management of diaphragmatic eventration in adults: gastrointestinal surgical perspective.

The current literature is poor with studies handling the role of laparoscopy in managing diaphragmatic eventration (DE). Herein, we describe our experience regarding the role of laparoscopy in managing DE patients presenting mainly with gastrointestinal symptoms. We retrospectively reviewed the data of 20 patients who underwent laparoscopic diaphragmatic plication between January 2010 and December 2018. Postoperative outcomes and quality of life were assessed. Most DEs were left sided (95%). Laparoscopic diaphragmatic plication was possible in all patients, along with correcting all associated gastrointestinal and diaphragmatic problems. The former included gastric volvulus (60%), reflux esophagitis (25%), cholelithiasis (5%), and pyloric obstruction (5%), while the latter included diaphragmatic and hiatus hernia (10% and 15%, respectively).The average operative time was 142 min. All patients had a regular (reviewer #1) postoperative course except for one who developed hydro-pneumothorax. At a median follow-up of 48 months, midterm outcomes were satisfactory, with an improvement (reviewer #1) in gastrointestinal symptoms. Three patients (reviewer #1) developed radiological recurrence without significant clinical symptoms. Patient's quality of life, including all parameters, significantly improved after the laparoscopic procedure compared to the preoperative values. Laparoscopic approach is safe and effective for managing adult diaphragmatic eventration (reviewer #1).

Pre-operative endoscopic balloon dilatation and its impact on outcome of laparoscopic Heller cardiomyotomy for patients with achalasia: does the frequency and interval matter?

BACKGROUND: Many surgeons believe that pre-operative balloon dilatation makes laparoscopic myotomy more difficult in achalasia patients. Herein, we wanted to see if prior pneumatic balloon dilatation led to worse outcomes after laparoscopic myotomy. We also assessed if the frequency of dilatations and the time interval between the last one and the surgical myotomy could affect these outcomes. METHODS: The data of 460 patients was reviewed. They were divided into two groups: the balloon dilation (BD) group (102 patients) and the non-balloon dilatation (non-BD) group (358 patients). RESULTS: Although pre-operative parameters and surgical experience were comparable between the two groups, the incidence of mucosal perforation, operative time, and intraoperative blood loss significantly increased in the BD group. The same group also showed a significant delay in oral intake and an increased hospitalization period. At a median follow-up of 4 years, the incidence of post-operative reflux increased in the BD group, while patient satisfaction decreased. Patients with multiple previous dilatations showed a significant increase in operative time, blood loss, perforation incidence, hospitalization period, delayed oral intake, and reflux esophogitis compared to single-dilatation patients. When compared to long-interval cases, patients with short intervals had a higher incidence of mucosal perforation and a longer hospitalization period. CONCLUSION: Pre-operative balloon dilatation has a significant negative impact on laparoscopic myotomy short and long term outcomes. It is associated with a significant increase in operative time, blood loss, mucosal injury, hospitalization period, and incidence of reflux symptoms. More poor outcomes are encountered in patients with multiple previous dilatations and who have a short time interval between the last dilatation and the myotomy.

Clinicopathological features and management of biliary cystic tumors of the liver: a single-center experience.

BACKGROUND: Biliary cystic neoplasms (BCNs) of the liver are rare pathologies encountered in hepatobiliary surgeries. Till now, there is a lack of definitive criteria used to differentiate biliary cystadenoma (BCA) from biliary cystadenocarcinoma (BCAC). METHODS: In the period between 2005 and 2018, the data of consecutive patients diagnosed with BCA and BCAC were retrospectively reviewed. RESULTS: A total of 62 patients underwent surgical management for BCNs. BCA was diagnosed in 50 patients while 12 patients had BCAC. Old age, male gender, smoking, and abdominal pain were strongly associated with BCAC. Left lobe location, small size, with the presence of mural nodule, and solid component were significantly noticed with BCAC. A novel pre-operative score was developed to predict the susceptibility for BCAC and help us to identify the optimal surgical strategy. Blood loss, operative time, and complications were comparable between the two study groups. CONCLUSION: Mural nodules or solid components are suggestive of BCAC. Complete surgical resection of cystic tumors of the liver is mandatory due to malignant potential of the lesion and for prolonged survival.

Mucosal injury during laparoscopic Heller cardiomyotomy: risk factors and impact on surgical outcomes.

PURPOSE: To investigate the risk factors and outcomes of mucosal perforation (MP) during laparoscopic Heller myotomy (LHM) in patients with achalasia. METHODS: We conducted a retrospective analysis of patients who underwent LHM for achalasia at a single facility. RESULTS: Among 412 patients who underwent LHM for achalasia, MP was identified in 52 (12.6%). Old age, long disease duration, low albumin level, an esophageal transverse diameter > 6 cm, and a sigmoid-shaped esophagus were found to be independent predictors of MP. These factors were assigned a pre-operative score to predict the perforation risk. MP had a significant impact on intra and post-operative outcomes. Gastric side perforation was associated with a higher incidence of reflux symptoms, whereas esophageal-side perforation had a higher incidence of residual dysphagia. CONCLUSIONS: Many risk factors for MP have been identified. Correctable parameters like low serum albumin should be resolved prior to surgery, while uncorrectable parameters like old age and a sigmoid-shaped esophagus should be managed by experienced surgeons in high-volume centers. Implementing these recommendations will help decrease the incidence and consequences of this serious complication.

Gastrointestinal stromal tumors of the small intestine: the challenge of diagnosis and the outcome of management.

PURPOSES: Gastrointestinal stromal tumor (GIST) is a rare small intestinal tumor. Most patients usually report long-period complaints due to difficult diagnoses. A high grade of suspicion is required for early diagnosis and initiation of the proper management. METHODS: A retrospective study of all patients with small intestinal GIST who were operated in the period between January 2008 and May 2021 at Mansoura University Gastrointestinal Surgical Center (GIST). RESULTS: Thirty-four patients were included in the study with a mean age of 58.15 years (± 12.65) with a male to female ratio of 1.3:1. The mean duration between onset of symptoms and diagnosis was 4.62 years (± 2.34). Diagnosis of a small intestinal lesion was accomplished through abdominal computed tomography (CT) in 19 patients (55.9%). The mean size of the tumor was 8.76 cm (± 7.76) ranging from 1.5 to 35 cm. The lesion was of ileal origin in 20 cases (58.8%) and jejunal in 14 cases (41.2%). During the scheduled follow-up period, tumor recurrence occurred in one patient (2.9%). No mortality was encountered. CONCLUSION: Diagnosis of a small bowel GISTs requires a high grade of suspicion. Implementing new diagnostic techniques like angiography, capsule endoscopy, and enteroscopy should be encouraged when suspecting these lesions. Surgical resection is always associated with an excellent postoperative recovery profile and very low recurrence rates.

Types, Safety, and Efficacy of Limb Distalization for Inadequate Weight Loss After Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis With a Call for Standardized Terminology.

OBJECTIVE: Comprehensive classification and evaluation of the outcome of limb distalization (LD) for inadequate weight loss after roux-en-y gastric bypass (RYGB). BACKGROUND: Limb distalization is a revisional malabsorptive procedure for the management of inadequate weight loss after RYGB. Multiple studies with small sample sizes reported the outcome of LD. This meta-analysis aims to reach a higher level of evidence regarding the safety and efficacy of the procedure. METHODS: A systematic search, including all studies on LD for management of inadequate weight loss after RYGB. The search engines included were PubMed, Embase, Web of Science, Cochrane Library, Scopus, and EBSCOhost. RESULTS: Fourteen studies were included. The pooled estimates of the mid-term percentage of excess weight loss (%EWL), diabetic, and hypertension remission were 50.8%, 69.9%, and 59.8%, respectively. The rate of surgical revision for the management of protein-energy malnutrition (PEM) was 17.1%. The %EWL was significantly higher with older age and good response to index surgery (P = 0.01, 0.04, respectively). Less total alimentary limb length was not associated with better %EWL (P = 0.9), but it was significantly associated with severe PEM (P = 0.01). CONCLUSIONS: LD has an encouraging rate of resolution of comorbidities. A judicious patient selection is essential for better weight loss after LD. Type I LD with total alimentary limb length ≥350 cm was associated with less risk of malnutrition. PEM is a life-threatening complication that may require revisional surgery years after LD. Future studies on LD, adopting standardized surgical practice and terminology, will allow a more conclusive assessment of the outcome of the procedure.

Insulin-Like Growth Factor-1 and Vascular Endothelial Growth Factor in Malignant and Benign Biliary Obstructions.

BACKGROUND: Despite the presence of various diagnostic tools, the differential diagnosis between malignant and benign biliary obstructions is so difficult. This study aimed to evaluate the role of serum and biliary insulin-like growth factor-1 (IGF-1) and vascular endothelial growth factor (VEGF) in this differential diagnosis. MATERIALS AND METHODS: Patients (n = 109, 61 men and 48 women) with diagnosis of benign (n = 62) or malignant (n = 47) biliary obstruction were included. Serum and biliary IGF-1 and VEGF markers were analyzed by the chemiluminescent immunometric method. RESULTS: Mean age was 62.7 ± 8.1 years for the malignant group and 58.5 ± 15.4 years for the benign group (P = 0.092). Choledocholithiasis (79%), cancer head of the pancreas (53.2%) and cholangiocarcinoma (38.3%) were the most common etiologies. No statistical difference was detected regarding serum IGF-1 and VEGF levels between 2 groups. At a cutoff value of 308.55 and 0.5ng/mL, biliary IGF-1 and VEGF had (91.4% and 90.3%) sensitivity and (89.5% and 84.9%) specificity differential diagnosis between malignant and benign biliary obstructions (area under the curve: 0.943, 0.915), respectively. CONCLUSIONS: Biliary levels of IGF-1 and VEGF significantly increase in malignant than benign obstructive lesions. Measurement of these markers in the bile of these patients may aid in the detection of biliary tumors.

A novel model using mean platelet volume and neutrophil to lymphocyte ratio as a marker of nonalcoholic steatohepatitis in NAFLD patients: multicentric study.

BACKGROUND AND AIM: Nonalcoholic fatty liver disease (NAFLD) is a leading cause of progressive and chronic liver injury. Mean platelet volume (MPV) and the neutrophil-lymphocyte ratio (N/L ratio) may be considered cheap and simple markers of inflammation in many disorders. We aimed to investigate the clinical utility of MPV and the N/L ratio to predict fibrosis in NAFLD patients and the presence of nonalcoholic steatohepatitis (NASH). MATERIALS AND METHODS: A total of 873 patients with biopsy-proven NAFLD and 150 healthy controls were included. Patients were divided into two groups: non-NASH group (n=753) and NASH group (n=120). Liver biopsy, MPV, lymphocyte, and neutrophil counts were registered; the N/L ratio was calculated. Proinflammatory cytokines (tumor necrosis factor-α and interleukin-6) were measured by an ELISA. RESULTS: NASH patients had higher MPV compared with non-NASH patients (10.9±1.8 and 9.5±1.6 fl, respectively, P<0.001). MPV correlated positively with the NAFLD activity score, proinflammatory cytokines, and C-reactive protein (CRP) (P<0.001). Patients with advanced fibrosis (F3-4) had increased MPV (11.3±0.9 fl) compared with patients with early fibrosis (F1-2) (10.2±0.8 fl, P<0.001). NASH patients had an increased N/L ratio compared with non-NASH cases (2.6±1.1 and 1.9±0.7 fl, respectively, P<0.001). The N/L ratio correlated positively with NAFLD activity score, proinflammatory cytokines, and CRP (P<0.001). In addition, patients with advanced fibrosis (F3-4) had an N/L ratio (2.5±1.1) comparable with that of patients with early fibrosis (F1-2) (1.8±0.9) (P<0.001). CONCLUSION: MPV and the N/L ratio were elevated in NASH patients versus non-NASH cases, and in patients with advanced fibrosis (F3-4) versus early fibrosis (F1-2). They can be used as noninvasive novel markers to predict advanced disease.