Single-incision sleeve gastrectomy versus conventional laparoscopic sleeve gastrectomy--a randomised pilot study.

BACKGROUND: This is a prospective pilot study done to evaluate the feasibility and to assess the outcomes and complication rates of the single-incision sleeve gastrectomy versus the conventional five-port laparoscopic sleeve gastrectomy. METHODS: A prospective comparative analysis was done of 50 patients in each arm who underwent laparoscopic sleeve gastrectomy and single-incision sleeve gastrectomy from September 2009 until April 2010. Both groups were matched for age, gender and BMI and were then randomly assigned to either group. Postoperative pain scoring was done using the visual analogue scale. Postoperative outcomes in terms of pain scores, excess weight loss, resolution of comorbidities and complication rates were compared in both groups, at the end of 6 months. RESULTS: Operating times in both groups were comparable with experience. Intraoperative blood loss was similar in both groups. VAS scoring revealed lesser postoperative pain after the first 8 h in the single-incision group as compared to the laparoscopy group-P < 0.0001. At 6 months, excess weight loss and resolution of comorbidities were comparable in both groups. There were no major complications or mortalities in either group. CONCLUSIONS: Single-incision laparoscopic sleeve gastrectomy is a feasible surgical procedure for morbid obesity in selected individuals. When compared to conventional laparoscopic sleeve gastrectomy, it has equally effective weight loss and resolution of comorbidities. It also has the added benefits of little or no visible scarring and reduced postoperative pain.

Comparison between the results of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass in the Indian population: a retrospective 1 year study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a procedure for the treatment of morbid obesity. Its indications and long-term results are currently under evaluation. Initially started as a first-stage procedure for superobese patients, it is now emerging as a standalone procedure in Asia and other parts of the world. Early results suggest that, at the end of 1 year, weight loss and resolution of comorbidities with LSG is comparable to laparoscopic Roux-en-Y gastric bypass (LRYGB). Whether LSG alone can replace LRYGB as a standard bariatric procedure is questionable. The aim of this study is to compare the results, resolution of comorbidities, and complications between LSG and LRYGB. METHODS: A retrospective comparative analysis was done of 50 patients in each arm who underwent LSG and LRYGB from October 2007 to March 2008. Both groups were matched for age, sex, and body mass index. The resolution of comorbidities, percentage of excess weight loss (EWL), and complications were studied at 6 months and 1 year in our study. RESULTS: It was seen that resolution of most comorbidities such as type 2 diabetes, hypertension, dyslipidemia, sleep apnea, joint pains, and percentage of EWL in both groups was comparable at the end of 6 months and 1 year. Though early resolution of type 2 diabetes was seen to be better in the LRYGB group, the results matched up at 1 year. There was increased incidence of gastroesophageal reflux disease in LSG patients. On comparison, it was also observed that the Asian studies have shown better results with LSG when compared to studies done in a largely Caucasian population. CONCLUSIONS: Long-term studies are needed to evaluate the efficacy of LSG alone as a procedure for the treatment of morbid obesity and its comorbidities.

Parotid area sign: a clinical test for the diagnosis of fluid overload in hysteroscopic surgery.

STUDY OBJECTIVE: To describe the clinical test parotid area sign, which is used to assess fluid absorption during resectoscopic surgery and to compare the test with volumetric fluid balance method with respect to its ability to detect fluid overload. DESIGN: Historical cohort study (Canadian Task Force classification II-1). SETTING: Tertiary endoscopy center. PATIENTS: Eighty-six women who underwent resectoscopic surgery between 1999 and 2004 at our center. INTERVENTION: The volumetric fluid balance method was used to evaluate glycine absorption (glycine deficit) during the surgery. A flexometallic ruler was placed on the left cheek of the patient between 2 fixed points: the midpoint of the philtrum and a point on the mastoid prominence, and this distance (philtrum-mastoid prominence distance) was measured at the beginning of every 3 minutes during, and at the end of the procedure. MEASUREMENTS AND MAIN RESULTS: Eighty-six patients were divided into 2 groups: Group A, which included patients with absorption less than 1000 mL as measured by the volumetric method; and Group B, which included patients with absorption of 1000 mL or more. The results of the parotid area sign test in the 2 groups were compared. The 2 groups were comparable with respect to the age, weight, preoperative measured philtrum-mastoid prominence distance, and hospital stay. The median (and average absolute deviation) operating time in group A (15 minutes [and 6.79]; range 8-60 minutes; 95% CI of the median, 15-20 minutes) was significantly lower than the median (and average absolute deviation) operating time in group B (25 minutes [and 8.96]; range 9-60 minutes; 95% CI of the median, 20-25 minutes; p <.001). The mean postoperative philtrum-mastoid prominence distance measured in patients of group A (14.23 +/- 0.396 cm [range 14-16 cm, 95% CI 14.10-14.36 cm]) was significantly lower than that in group B [14.76 +/- 0.622 cm (range 14-17 cm, 95% CI 14.58-15.12 cm]; p <.001). By paired t test, the change in the philtrum-mastoid prominence distance after surgery as compared with the value before surgery in each patient was found to be insignificant in group A (p =.86). However, it was found to be significant in group B (p <.001). The increase in the measured philtrum-mastoid prominence distance (i.e., postoperative measurement minus the preoperative measurement) in each patient after surgery was significantly more in group B (mean +/- SD, 0.54 +/- 0.362 cm [range 0-2 cm, 95% CI 0.43-0.65 cm]) than that in group A (mean +/- SD, 0.03 +/- 0.091 cm [range 0-0.4 cm, 95% CI 0.008-0.06 cm]; p <.001). The correlation coefficient for the increase in the philtrum-mastoid prominence distance as the glycine deficit increased in the 2 groups considered together was significant (r = 0.937, p <.01). The partial regression coefficient b value for the effect of duration of surgery while controlling for the effect of fluid deficit was 0.008 (p <.001), and the b value for the effect of fluid deficit while controlling for the effect of duration of surgery was 0.437 (p <.001). The regression coefficient r value (0.727) for the goodness of the fit of the regression line to the data sets was also significant (p <.001). The sensitivity of the test with respect to the volumetric fluid balance is 97.8% (95% CI, 87.28%-99.88%) and specificity is 92.3% (95% CI, 78.03%-97.99%). The negative predictive value is 97.30% (95% CI, 84.19%-99.85%) and positive predictive value is 93.87 (95% CI, 82.13%-98.40%). The conventional positive likelihood ratio for the test is 12.72 (95% CI 4.28-37.77). The conventional negative likelihood ratio is 0.023 (95% CI 0.003-0.16). CONCLUSION: The parotid area sign is a simple, effective, and easy-to-perform test (in real time continuously) that requires minimal equipment or training. It supplements the volumetric fluid balance method in the detection of fluid overload (1.5% glycine) during resectoscopic surgery. It may also enable us to detect fluid overload when volumetric fluid balance method fails to detect extraneous losses caused by spillage.

The intubation depth marker: the confusion of the black line.

BACKGROUND: Estimation of the correct depth of insertion of a tracheal tube (TT) in children is extremely important. Insertion of an excessive length may result in endobronchial intubation while an inadequate length of insertion may lead to accidental extubation. METHODS: We reviewed TTs commonly used in paediatric practice and also reviewed recommended guidelines for correct depth of insertion. RESULTS: Amongst the different brands of TTs used, there was a wide discrepancy in the placement of the intubation depth marker. This is important as the intubation depth marker is often used as a guideline for intubation. CONCLUSIONS: For optimal placement we can rely on various formulae and manufacturers' markings on the TTs. Clinical judgement, however, remains the cornerstone of optimal placement.

Difficult paediatric intubation when fibreoptic laryngoscopy fails.

We report an unusual problem with fibreoptic bronchoscopy in an 8-year-old girl with Negar syndrome. She had a history of difficult airway since birth, and had undergone mandibular distraction for severe obstructive sleep apnoea when she was aged 2 years. Nagar syndrome is a Treacher-Collins like syndrome with normal intelligence, conductive bone deafness and problems with articulation. The patients have malar hypoplasia with down slanting palpebral fissures, high nasal bridge, micrognathia, absence of lower eyelashes, low set posteriorly rotated ears, preauricular tags, atresia of external ear canal, cleft palate, hypoplasia of thumb, with or without radius, and limited elbow extension. Protracted attempts with a fibreoptic bronchoscope failed to visualize the glottis, and this was only possible when the tube was guided to the larynx by blind nasal intubation. Apparently, the healing of the wounds for the mandibular distraction in the mandibular space on the inside of the rami of the mandible had caused differential fibrosis on either side of the hyoid, leading to a triplane distortion of the larynx with a left shift, clockwise rotation to a 2-8 o'clock direction and a slight tilt towards the left pharyngeal wall. The large epiglottis overlying this had precluded a view of the larynx. Finally, the older technique of breathguided intubation facilitated fibreoptic bronchoscopy to achieve tracheal intubation.