Management of suspected anastomotic leak after bariatric laparoscopic Roux-en-y gastric bypass.

BACKGROUND: Anastomotic leak is one of the most serious complications following bariatric laparoscopic Roux-en-Y gastric bypass (LRYGB), and associated with high morbidity rates and prolonged hospital stay. Timely management is of utmost importance for the clinical outcome. This study evaluated the approach to suspected leakage in a high-volume bariatric surgery unit. METHODS: All consecutive patients who underwent LRYGB performed by the same team of surgeons were registered prospectively in a clinical database from September 2005 to June 2012. Suspected leaks were identified based on either clinical suspicion and/or associated laboratory values, or by a complication severity grade of at least II using the Clavien-Dindo score. RESULTS: A total of 6030 patients underwent LRYGB during the study period. The leakage rate was 1·1 per cent (64 patients). Forty-five leaks (70 per cent) were treated surgically and 19 (30 per cent) conservatively. Eight (13 per cent) of 64 patients needed intensive care and the mortality rate was 3 per cent (2 of 64). Early leaks (developing in 5 days or fewer after LRYGB) were treated by suture of the defect in 20 of 22 patients and/or operative drainage in 13. Late leaks (after 5 days) were managed with operative drainage in 19 of 23 patients and insertion of a gastrostomy tube in 15. Patients who underwent surgical treatment early after the symptoms of leakage developed had a shorter hospital stay than those who had symptoms for more than 24 h before reoperation (12·5 versus 24·4 days respectively; P < 0·001). CONCLUSION: Clinical suspicion of an anastomotic leak should prompt an aggressive surgical approach without undue delay. Early operative treatment was associated with shorter hospital stay. Delays in treatment, including patient delay, after symptom development were associated with adverse outcomes.

Splenic rupture following ESWL for a pancreatic duct calculus.

Extracorporeal shock wave lithotripsy (ESWL) is an established and extensively used treatment alternative for urinary calculi. It is also an established method of dealing with pancreatic duct calculi complementing endoscopic techniques in selected cases. Three reports of splenic injury following and probably caused by ESWL for urinary calculi have previously been published. We report a case of splenic rupture presenting with life-threatening hemorrhage 6 days after a single ESWL therapy session for pancreatic duct calculi.

Serum calcium and survival in a large health screening program.

There is evidence that hyperparathyroidism is associated with increased morbidity and mortality. It is not known, however, whether elevated serum calcium (S-Ca) by itself is associated with those risks. We, therefore, examined mortality rate in relation to a single S-Ca value obtained at screening of a large population (n = 33,346) during a mean follow-up period of 10.8 yr. A survival analysis was performed, comparing groups with S-Ca values above different defined limits with those below these limits, adjusting for age and date of screening. We found that men less than 50 yr of age at screening (n = 21,131) with S-Ca greater than 2.45 mmol/L exhibited a 20% increased mortality rate compared with those with lower S-Ca values (odds ratio = 1.2; P < 0.005), whereas those with S-Ca greater than 2.60 mmol/L had a doubled rate (odds ratio = 2.0; P < 0.0002). Men less than 50 yr of age with S-Ca levels between 2.51-2.55 mmol/L exhibited a 50% increased risk of death from all causes compared with those with S-Ca between 2.31-2.45 (P < 0.0001). The excess mortality in those with S-Ca above 2.5 mmol/L was largely attributable to cardiovascular diseases (58%), although a significant excess mortality was also evident for malignant disorders (28%). In contrast, the risk of obtaining a diagnosis of malignant disease was not found to increase with rising S-Ca levels. These results indicate that the risk of premature death in men less than 50 yr of age increases with rising S-Ca, even within the normal range, and this increase may be largely due to cardiovascular diseases.

Embryonal rhabdomyosarcoma with 100 chromosomes but no structural aberrations.

An embryonal rhabdomyosarcoma was analyzed cytogenetically after short-term culturing. The tumor was located in the scrotum of an 18-year-old man who, at the age of 4, had been treated for a rhabdomyosarcoma in the orbita. The chromosome number was 100. No structural aberrations were present. There were 2-7 copies of each chromosome type with particular excess of chromosomes 8, 12, and 22, and a relative deficit of chromosome 15.