The Effect of Different Staple Sizes on Leak Pressure Among Patients Undergoing Sleeve Gastrectomy: a Pilot Study.

Gastric leak after LSG is a devastating complication, reported in less than 1% of cases. Consensus is lacking regarding the best approach to construct the sleeve, staple sizes, and reinforcement methods on potential leak development. In this study, we have compared the leak pressure of two different staple sizes in the resected portion of the stomach, immediately after its removal. Fifteen patients were enrolled. Leak pressure of a vascular, small-size stapler was significantly higher than that of a medium-size one. All leaks appeared in the proximal third of the resected stomach. These results may have clinical implication. Since other factors may play a role in the risk for leaks following sleeve gastrectomy, a large, prospective clinical trial should be performed comparing the two staple sizes in laparoscopic sleeve gastrectomy.

Considerations for Improved Technique Survival Following Insertion of a Peritoneal Dialysis Catheter.

BACKGROUND: Peritoneal dialysis (PD) is a treatment option for patients with end-stage renal disease (ESRD) and cardiorenal syndrome (CRS). OBJECTIVES: To evaluate the outcome of this patient population. METHODS: A retrospective study was conducted of patients who underwent an open or laparoscopic insertion of a PD catheter at our institution between 2009 and 2017. Data included demographics, peri-operative parameters, and long-term outcome. Patient and technique survival curves are presented, including subgroup analysis by method of catheter insertion and techniques for infection prevention. RESULTS: The study population included 95 men and 42 women, aged 65.7 ± 12.4 years. Mean follow-up was 34.6 ± 27.3 months. Open insertion was performed in 113 cases, while 24 underwent laparoscopic insertion. There was no difference in technique survival between these groups (P = 0.943). Removal of the catheter was required in 66% of patients. Median technique survival was 12.1 months. Two-year technique survival was 37% and 5-year technique survival was 12%. The leading cause for catheter removal was infection (69%). Application of measures for prevention of infections were significantly associated with prolonged technique survival (P = 0.001). Technique survival after 2 years was 38% with the application of a single measure and 57% with the application of two measures (P = 0.001). CRS patients (n=24) had a significantly lower overall survival rate (2-year survival 20% vs. 74%, P = 0.001). CONCLUSIONS: The method of catheter insertion has no effect on technique survival. Prevention of infections is the most significant factor for improving the technique survival rates.

The effect of bariatric surgery on hypothyroidism: Sleeve gastrectomy versus gastric bypass.

BACKGROUND: Hypothyroidism is prevalent in morbidly obese patients and may improve after a weight reduction surgery. OBJECTIVES: Laboratory and clinical changes in hypothyroid patients undergoing laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) were compared and evaluated. SETTINGS: Data were retrieved from a prospectively collected database of 2 public bariatric units. METHODS: Patients with hypothyroidism prior to bariatric procedure were evaluated for changes in thyroid stimulating hormone (TSH) and changes or cessation of hormone replacement therapy after surgery. Correlation between changes in TSH levels and percentage of excess weight loss and comparison between effects of LSG and LRYGB were evaluated. RESULTS: Ninety patients were included. Mean follow-up was 11 ± 9 .73 months. Mean body mass index decreased from 43.8 to 33.2 kg/m2. Forty patients had deranged elevated TSH levels prior to surgery that decreased significantly after surgery (mean 6.6 ± 1.9 to 2.9 ± 1.5 mU/L, P < .01). Of patients receiving hormone replacement therapy prior to surgery, 42% required lower doses, with a 61% mean decrease in doses, while 10% stopped hormone replacement therapy completely. No correlation was found between the improvement in TSH and percentage of excess weight loss. A significant advantage to one of the bariatric procedures (LSG [61] and LRYGB [29]) could not be established. CONCLUSIONS: LSG and LRYGB both proved to improve thyroid function in hypothyroid obese patients. No procedure was found to be superior. No correlation was found between percentage of excess weight loss and TSH reduction. This implies that the effect of bariatric surgery on the improvement of thyroid functions is mediated by mechanisms other than weight loss, probably hormonal.

Ileo-ileal intussusception of a sutured enterotomy site, 6days after laparotomy due to fetobezoar: A case report.

INTRODUCTION: Postoperative small bowel obstruction due to intussusception is a rare entity but can lead to severe morbidity and even mortality. We present a case of this rare complication produced by an unusual cause. CASE REPORT: A 22year old male, who is a fruitarian, presented to the E.R on day 6 after laparotomy due to obstructing fetobezors that were removed via gastrotomy and enterotomy. In his readmission, he had severe, diffuse abdominal pain, distended abdomen and diffuse peritonitis. Abdominal computed tomography (CT) showed a large amount of fluid in the abdomen, distended small bowel loops, a small amount of free air around the stomach and a suspected ileo-ileal intussusception. The patient underwent emergent laparotomy which revealed an ileo-ileal intussusception with the sutured enterotomy site from the previous operation as the lead point. In addition, a minor dehiscence of the gastrotomy site was identified. A reduction of the intussusception was performed with resection of the enterotomy site and side to side anastomosis. The gastrotomy site was debrided and re-sutured. Recovery was uneventful. CONCLUSION: Postoperative intussusception, although rare, is potentially a dangerous complication, often not involving the site of the primary operation. To our knowledge this is the first report of an intussusception with a sutured enterotomy site as the lead point. Clinicians should be aware of this entity when assessing a patient with abdominal pain and distention after surgery with enterotomy or resection of bowel.

Correlation of CO2 pneumoperitoneal pressures between rodents and humans.

INTRODUCTION: Many studies have reported on the effects of pneumoperitoneum in a rat model, using a wide range of intra-abdominal pressures. The correlation between pneumoperitoneal pressures in rodents to pressures in humans has not been established. This study evaluates changes in various physiological parameters in different pneumoperitoneum pressures in the rat model with a comparison to known data in humans. MATERIALS AND METHODS: Three groups of eight Wistar rats each were anesthetized, tracheostomized, and mechanically ventilated with fixed tidal volume and respiratory rate. After a stabilization phase, CO(2) pneumoperitoneum was established to 12, 8, and 5 mmHg in the different groups. Changes in blood pressure, heart rate, peak ventilatory pressure, and end-tidal CO(2) (ETCO(2)) were recorded throughout the experiment. RESULTS: There were no significant changes in blood pressure and heart rate in all groups. No increase in ETCO(2) was demonstrated following induction of pneumoperitoneum in the 12 and 8 mmHg groups. A statistical significant increase in ETCO(2) occurred only in the 5 mmHg group (39.4 to 41.3 mmHg, p = 0.023). Ventilatory pressures increased after induction of pneumoperitoneum in all groups. The increase reached a maximal level in the 8 and 12 mmHg groups (from 3 to 12 mmHg) and was lower in the 5 mmHg group (from 3 to 7 mmHg) CONCLUSIONS: The neglected increase in ETCO(2) in pressures > or =8 mmHg, in the rat correlates to high pressures in humans (above 14-20 mmHg) when CO(2) diffusion through the peritoneum declines due to pressure occlusion of peritoneal capillaries. The maximal ventilatory pressures generated in the rat in intra-abdominal pressures > or =8 mmHg correlate to pressures, which are higher than the standard working pressures in humans. Thus, pneumoperitoneal pressures >8 mmHg in the rat do not simulate routine working pressures employed in humans. A pressure of 5 mmHg is optimal in a rat model to simulate laparoscopy in humans.

Effect of small bowel perforation during laparoscopy on end-tidal carbon dioxide: observation in a small animal model.

INTRODUCTION: There are currently no reports in the literature regarding changes in end-tidal carbon dioxide (ETCO(2)) when the small bowel is deliberately or inadvertently perforated during laparoscopic surgery. The aim of this study was to assess the influence of small bowel perforation during laparoscopy on ETCO(2) in a rat model. MATERIALS AND METHODS: Two groups of Wistar rats (n = 8/group) were anesthetized, tracheostomized, and mechanically ventilated at a fixed tidal volume and respiratory rate. After a stabilization phase of 30 min, CO(2) pneumoperitoneum was established to 5 mmHg in one group and 12 mmHg in the other group, and maintained for 30 min. A small bowel perforation was then created and pneumoperitoneum was reestablished for another 30 min. Blood pressure, heart rate, peak ventilatory pressure, and ETCO(2) were recorded throughout the experiment. RESULTS: No significant changes in blood pressure throughout the experiment were noted in either group. The ventilatory pressure increased in both groups after the induction of pneumoperitoneum. In the 5 mmHg group, there was a modest increase in ETCO(2) following the induction of pneumoperitoneum (from 39.4 +/- 1.9 to 41.1 +/- 1.4, P = 0.014), and a further increase following the small bowel perforation (from 41.1 +/- 1.4 to 42 +/- 0.8, P = 0.007). In the 12 mmHg group, there was no change in ETCO(2) after the induction of pneumoperitoneum; however, there was a substantial increase in ETCO(2) following bowel perforation (35.0 +/- 2.0 to 49.8 +/- 7.1, P = 0.002). CONCLUSIONS: ETCO(2) increases when the small bowel is perforated during CO(2) pneumoperitoneum. This increase seems more substantial under higher pneumoperitoneal pressures. Small bowel injury may enable the diffusion of CO(2) through the bowel mucosa, causing ETCO(2) elevation. Therefore, an abrupt increase in ETCO(2) observed during laparoscopy may indicate small bowel injury.