Knowledge of Jordanian women of reproductive age who underwent bariatric surgery and its effect on birth outcomes: A cross-sectional study.

Objectives: This study aims at exploring the knowledge of women of reproductive age who underwent bariatric surgery in Jordan regarding its effect on birth outcomes. Methods: A cross-sectional study was conducted on 183 women (aged 15-49) who had undergone bariatric surgery at the Jordan University Hospital in Amman, Jordan, between 2016 and 2019, using telephone interviews with conveniently selected participants' samples. The survey tool obtained data on women's knowledge and other sociodemographic, obstetric health, and bariatric surgery information. Unfavorable birth outcomes include preterm delivery, small for gestational age, congenital abnormalities, low birth weight, and admission to the neonatal critical care unit. Results: More than half of the participants did not know about the possible unfavorable birth outcomes after bariatric surgery and related practice guidelines. This is shown in their median score of 3 (interquartile range: 2-4) out of a maximum possible score of 8. Women who had a good score (>4) had received counseling about unfavorable bariatric surgery outcomes from their surgeon (p < 0.013); those who had educational qualifications higher than secondary school (p < 0.001) as well as those who were employed (p < 0.008) and believed that the surgery would affect the newborn (p < 0.001). The median score was also unfavorably associated with the parity of the participants (p < 0.003). Conclusion: The extent of knowledge regarding the unfavorable birth outcome of bariatric surgery is low among women who underwent bariatric surgery at Jordan University Hospital in Jordan. Improving health literacy and information on bariatric surgery implications on pregnancy and birth outcomes amongst women of reproductive age is a recommendation from this study.

Preoperative Dexamethasone for Airway-Related "Calibration Tube" Complications After Sleeve Gastrectomy: a Randomised Clinical Trial.

BACKGROUND: Bariatric surgeries utilise Bougie device to guide stomach resection. The device implementation is associated with many underreported complications. This study aims to compare nebulised vs. intravenous preoperative dexamethasone in mitigating airway-related Bougie complications after sleeve gastrectomy. METHODOLOGY: This is a prospective double-blinded interventional study conducted by a tertiary hospital. The study involved 105 patients allocated to 3 groups: Group (I) received 8 mg dexamethasone intravenously (IV) preoperatively, group (N) received 8 mg dexamethasone from a nebulizer mask preoperatively, and Group (S) received nebulised normal saline. Outcomes evaluated were postoperative sore throat, odynophagia, change of voice, and nausea and vomiting. RESULTS: Nebulized dexamethasone was found to be significantly superior to IV dexamethasone in terms of postoperative sore throat at zero-hour (p = 0.001) and 1-h intervals (p = 0.011). No significant difference was found at 6- and 24-h intervals. For odynophagia, post hoc analysis showed there was no significant difference between (I), (N), and (S) groups. Incidence of change of voice was significantly lower in (N) and (I) groups compared to (S) group, with p values of 0.0067 and 0.00014, respectively. The incidence of post-operative sore-throat (PONV) in (I) group was significantly lower than incidences in (S) group (p = 0.00002) and (N) group (p = 0.0004). CONCLUSION: Preoperative nebulized and IV dexamethasone are effective strategies in mitigating complications related to mechanical effects of Bougie insertion. IV dexamethasone was as effective as nebulized dexamethasone in terms of late postoperative sore throat, and was superior in postoperative nausea and vomiting.

Role of Preoperative Dexamethasone Nebulization in Reducing Bougie Complications Encountered After Sleeve Gastrectomy: a Prospective Double-Blind Control Interventional Study.

INTRODUCTION: The usage of bougie devices in guiding the extent of sleeve gastrectomies has been associated with several laryngeal and pharyngeal complications. Despite these being distressing for patients, they draw little attention in current literature. OBJECTIVES: To study the role of preoperative nebulized dexamethasone in relieving the symptoms related to bougie insertion during laparoscopic sleeve gastrectomy postoperatively. MATERIALS AND METHODS: A prospective interventional study that included 80 patients. The patients were assigned to two groups, 40 patients in each group: the dexamethasone group (D) which received nebulized dexamethasone 8 mg 1 h before surgery and the control group (S) which received saline nebulizer instead. Assessment of postoperative sore throat, nausea and vomiting, odynophagia, and change of voice was used as an outcome comparative tool. RESULTS: The patient's age ranged from 17 to 61 years, and the mean age of patients was 34.51 (± 9.5) years. Patients were composed of 13 (16.3%) males and 67 (83.8%) females. The study found a significant preference of outcome values in the dexamethasone group. Sore throat mean and medians were less at all-time intervals: 0 h (p < 0.001), 1 h (p < 0.001), 6 h (p < 0.004), and 24 h (p < 0.001). Nineteen patients of the saline group suffered from a change of voice (p < 0.001), compared to only 4 patients in the dexamethasone group. On the contrary, no significant differences are noted in the incidences of PONV and odynophagia. CONCLUSION: Preoperative nebulized dexamethasone was found to be an effective measure in reducing bougie insertion complications in laparoscopic sleeve gastrectomy.

Bifid appendix: a case report and a review of literature.

Anomalies of the appendix are extremely rare, with a reported incidence of 0.004 to 0.009. Due to the wide range of variations, failing to recognize these anomalies may lead to failure of treatment and complications. We report a case of a 21-year-old female patient who presented to the Emergency Department with a clinical picture of acute appendicitis. After performing the proper laboratory and radiological tests, a decision was made to do a laparoscopic appendectomy which revealed a partially duplicated 'bifid' vermiform appendix with features of acute appendicitis.

Portomesenteric Venous Thrombosis Post-Laparoscopic Sleeve Gastrectomy: Do Energy Systems Pose as Instigating Factor to This Infrequent Complication?

BACKGROUND: Portomesenteric venous thrombosis (PMVT), a rare complication after laparoscopic sleeve gastrectomy (LSG). Severe consequences are owed to a high risk of bowel ischemia. Our aim is to present a series of patients who developed PMVT after LSG, highlighting the potential role of the vessel sealer and divider as a risk factor. METHODS: Medical records of seven patients who underwent LSG and developed PMVT from April 2010 to January 2019, at King Abdullah University Hospital and Jordan University Hospital, Jordan were reviewed. Our findings were studied, audited, and compared with published data. RESULTS: A sum of 4900 patients underwent LSG, 7 (0.14%) developed PMVT. The mean age and body mass index (BMI) were 36.8 years and 45 kg/m2, respectively. Four were women. Epigastric pain radiating to the back was the presenting symptom at a median time of 9 days after surgery. Computed tomography (CT) of the abdomen confirmed the diagnosis. Five patients presented with a total portal vein thrombosis (PVT), one with splenic vein thrombosis and one with dual portal and mesenteric vein thrombosis. CONCLUSION: Portomesenteric venous thrombosis is a relatively uncommon complication following LSG. Early recognition is required to avoid catastrophic outcomes. The role of energy systems in the development of PMVT remains unknown and requires further elaboration.

Wound infiltration with bupivacaine 0.5% with or without adrenaline does not decrease pain after thyroidectomy. A randomized controlled study.

OBJECTIVES: To study the effect of local wound infiltration with and without adrenaline on pain perception after thyroidectomy using the visual analog score (VAS).  Methods: A prospective randomized controlled double-blinded study was conducted between May 2015 and June 2016 at The University of Jordan Hospital, Amman, Jordan. Eighty-nine patients undergoing planned thyroidectomy were included in the study. Patients were divided randomly into 3 groups: Group A, local wound infiltration with bupivacaine 0.5% was administered; Group B, bupivacaine 0.5% with adrenaline was administered; Group C (control), no infiltration was performed. Standardized thyroidectomies were performed in the 3 groups. Pain perception was measured using VAS at 2, 4, 6, 12, and 24 hours after surgery. A comparison between the 3 groups was carried out. Results: No significant differences among the 3 groups were observed at all time points (p=0.246). Visual analog scores were significantly lower at 12 and 24 hours after operations.  Conclusion: Local wound infiltration with bupivacaine 0.5% does not decrease pain perception after thyroidectomy performed under general anesthesia, and adding adrenaline does not enhance its effect.

Helicobacter pylori Does not Affect Postoperative Outcomes After Sleeve Gastrectomy.

BACKGROUND: The effect of Helicobacter pylori (HP) colonization of the stomach of patients undergoing laparoscopic sleeve gastrectomy (LSG) is unclear. OBJECTIVE: The objective of this study is to evaluate the effect of HP colonization on postoperative outcomes of LSG. SETTING: The setting of this study is in University Hospital. METHODS: This study was a retrospective cohort study of prospectively maintained database of all patients who underwent LSG at Jordan University Hospital from 2008 to 2015. RESULTS: Five hundred patients were included (362 females and 138 males). The mean preoperative weight was 124.5 ± 23.8 kg. The mean preoperative body mass index (BMI) was 45.5 ± 6.9 kg/m2. Two hundred sixteen (43.2%) patients were found to be HP positive. The differences between the HP positive and negative groups in respect of sex, baseline weight, and BMI were not statistically significant. However, patients who were HP positive were significantly older. All patients were followed for at least 3 months. We had an overall complication rate of 2.6%. Differences in the complication rate between the two groups were not statistically significant. Follow-up was 61% at 1 year. The mean percent total weight loss (%TWL) was 32.9 ± 7.9, and the mean percent excess weight loss (%EWL) was 76.9 ± 21.1. The decrease in BMI was 15.2 ± 5.2. The difference between the two groups was not statistically significant. CONCLUSION: There is no clear association between HP infection at the time of surgery and postoperative complications, especially leaks.

The impact of family members on weight loss after sleeve gastrectomy.

BACKGROUND: Weight loss after laparoscopic sleeve gastrectomy (LSG) is multifactorial. Postoperative compliance with appropriate dietary guidance may be affected by psychosocial factors and may influence the success of surgery. OBJECTIVE: To evaluate the effect of LSG in siblings compared to case-matched controls. SETTING: University hospital. METHODS: Siblings who had undergone LSG were compared with controls case-matched by age, sex, and body mass index. The percentage excess weight loss (%EWL) was calculated at 3, 6, and 12 months postoperatively. RESULTS: We had 32 siblings, of which 4 were lost to follow-up. Thus, 28 (87.5%) siblings completed 1 year of follow-up and were included in the study. In the family group, the %EWL was 72.7±15.0% at 1 year while in the control group the mean %EWL was 62.1±21.4%. Patients in the family group had significantly greater weight loss. Within the family group, the outcomes of family order had no statistically significant difference in weight loss between the first family member who had undergone LSG and subsequent family members. In addition, family members who had resided together in the same home had no advantage over those who resided separately. CONCLUSION: Genetic and environmental factors may have great influence on outcomes after bariatric surgery.

Dexmedetomidine versus morphine infusion following laparoscopic bariatric surgery: effect on supplemental narcotic requirement during the first 24 h.

INTRODUCTION: The primary aim of this pilot study was to determine whether the dexmedetomidine infusion initiated immediately after laparoscopic bariatric surgery, offers an advantage over a morphine infusion with respect to rescue morphine and paracetamol requirements over the first 24 post-operative hours. METHODS: Sixty morbidly obese adult patients scheduled for laparoscopic bariatric surgery were randomly assigned to receive an infusion of either 0.3 mcg/kg/h dexmedetomidine (Group D) or 3 mg/h Morphine (Group M) for 24 h immediately post-operatively. All patients received standardized general anesthesia and were evaluated and treated for pain in the intensive care unit by providers who were blinded to their treatment group. The primary outcome was the need for supplemental, "rescue" paracetamol (Dolargan. Hikma, Jordan) and morphine titrated to achieve visual analog scales (VAS) of <40 and <70, respectively. RESULTS: A total of 60 patients (77 % female, mean age 33.5 years ± 9.5 and body mass index (BMI) 43.0 ± 4.5) were randomized to Group M and 30 to Group D. There were no significant differences in mean rescue paracetamol and morphine requirements. Mean total morphine requirements in Group D were 6.1 ± 3.1 mg, whereas 72.9 ± 2.2 mg in Group M (p < 0.0001). CONCLUSIONS: An intravenous infusion of dexmedetomidine, initiated and continued for 24 h following laparoscopic bariatric surgery, can decrease the overall morphine requirements during this period. This pilot study demonstrated that the post-operative initiation of dexmedetomidine can be morphine sparing following laparoscopic bariatric surgery.

Early Weight Loss as a Predictor of 2-Year Weight Loss and Resolution of Comorbidities After Sleeve Gastrectomy.

BACKGROUND: The objective of this study was to investigate whether early postoperative weight loss predicts weight loss 1 and 2 years after laparoscopic sleeve gastrectomy (LSG) and to determine its effect on the resolution of comorbidities. METHODS: This was a prospective study of patients who underwent LSG at Jordan University Hospital from February 2009 to January 2014. RESULTS: One hundred ninety patients (mean age 34.0 ± 10.8 years; mean preoperative body mass index 46.2 ± 7.7 kg/m(2)) were included in the study. Of these, 146 were followed for 1 year and 73 were followed for 2 years. Thirty patients (20.5 %) had hypertension, 23 (15.8 %) had diabetes, 78 (53.4 %) had hyperlipidemia, 30 (20.5 %) had obstructive sleep apnea, and 50 (34.2 %) had more than one comorbidity. The percentage of excess weight loss (%EWL) was 22.7 ± 8.1, 75.1 ± 22.8, and 72.6 ± 17.5 at 1, 12, and 24 months, respectively. Fifty-five patients (37.7 %) had a 1-year %EWL of ≥80 %, and 29 (39.7 %) had a 2-year %EWL of ≥80 %. Linear regression analysis showed a strong correlation between 1-month %EWL and %EWL at 1 year (r (2) = 0.23, p < 0.001) and 2 years (r (2) = 0.28, p < 0.001). Resolution of comorbidities was associated with higher %EWL achieved at 1 year, but early postoperative weight loss did not have a significant effect on comorbidity resolution. CONCLUSIONS: Early postoperative weight loss can be used to identify and target poor responders.

The Magnitude of Antral Resection in Laparoscopic Sleeve Gastrectomy and its Relationship to Excess Weight Loss.

BACKGROUND: The objective of this study was to evaluate the effect of antral resection on weight loss and complications after laparoscopic sleeve gastrectomy (LSG). METHODS: This was a retrospective study of the prospectively collected data of patients who underwent LSG at Jordan University Hospital from February 2011 to February 2012. Patients were divided into two groups based on antral resection: group A underwent a 6-cm antral resection, and group B underwent a 2-cm antral resection. The percentage of excess weight loss (%EWL) was calculated at 3, 6, 12, and 24 months postoperatively. RESULTS: One hundred and ten patients were included in the study, all of whom completed at least 24 months of follow-up (mean follow-up, 33 months). Their mean body mass index was 46.1 ± 7.9 kg/m(2). In group A, the mean %EWL was 38.1 ± 14.1, 54.9 ± 19.9, 65.6 ± 22.8, and 66.8 ± 28.4% at 3, 6, 12, and 24 months, respectively. However, in group B, the mean %EWL was 42.1 ± 13.4, 63.8 ± 19.8, 80.0 ± 22.1, and 81.5 ± 22.9% at 3, 6, 12, and 24 months, respectively. Patients in group B experienced statistically significant greater weight loss than patients in group A. Statistically significant greater weight regain was seen in group A. Group A had a higher incidence of reflux symptoms (six patients; 11%) than group B (four patients; 7.1%). CONCLUSIONS: Radical antral resection in association with LSG safely potentiates the restrictive effect achieved and may result in greater and better maintained weight loss.

Volume of resected stomach as a predictor of excess weight loss after sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity for the treatment of obesity. The objective of this study was to evaluate the volume of the resected stomach (VRS) as a predictor of the percentage of excess weight loss (%EWL) 1 year after LSG. METHODS: This was a single-surgeon study of prospectively collected data of patients who underwent LSG at Jordan University Hospital (February 2009 to February 2012). The VRS was measured using a standardized technique. The %EWL was calculated at 3, 6, and 12 months postoperatively. The correlation between the VRS and %EWL was statistically evaluated. RESULTS: Ninety patients underwent LSG during the study period. Of these, 73 patients (57 female) completed at least 1 year of follow-up and were analyzed; their body mass index was 45 ± 7.6 kg/m(2) (33-81). The VRS was 1,337.4 ± 435.2 ml (600-2,800). The %EWL was 33.6 ± 11.1 % at 3 months, 48.6 ± 15.5 % at 6 months, and 56.8 ± 18.9 % at 12 months. A significant correlation was observed between the VRS and %EWL at 1 year (p = 0.003). Patients with a VRS of >1,100 ml (n = 43) achieved significantly greater %EWL at 12 months than did those with a VRS of ≤ 1,100 (n = 30). Removal of >1,100 ml of gastric volume was associated with a sensitivity and specificity of 75.5 and 46.2 %, respectively, for achieving a %EWL of ≥ 50 %. CONCLUSION: The VRS can be used as an indicator of excess weight loss 1 year after LSG.

Gastric perforation secondary to metastasis from ovarian cancer: Case report.

INTRODUCTION: Metastasis from ovarian cancer occurs frequently through the peritoneal cavity in the form of peritoneal carcinomatosis; isolated gastric metastasis is rarely reported in literature. PRESENTATION OF CASE: We present a case of 43-year-old infertile lady, who developed a picture of acute abdomen four days post total abdominal hysterectomy and salpingoopherectomy for ovarian cancer. Further contrast-enhanced CT scan demonstrated massive free gas and fluid in the abdomen. She underwent antrectomy with truncal vagotomy due to 3cm×4cm prepyloric gastric ulcer. Final pathology proved the presence of metastatic serous cystadenocarcinoma of ovarian origin. DISCUSSION: Our patient had a gastric perforation secondary to ovarian metastasis. Being isolated, the absence of ascites and the transmural nature of the gastric metastasis suggest haematogenous spread .To the best of our knowledge perforated gastric metastasis secondary to ovarian cancer was not reported in literature before. CONCLUSION: Gastric metastasis should be kept in mind in patients with a well-known ovarian cancer who present with gastric lesions, ulcers, bleeding or perforation.

Laparoscopic anterior hemifundoplication and hiatoplasty for the treatment of upside-down stomach: mid- and long-term results after 40 patients.

BACKGROUND: Treatment of type 4 hiatal hernia using a minimally invasive approach is challenging and requires good familiarity with this technique. METHODS: From October 1992 to August 2010, 40 patients with a median age of 68 years underwent laparoscopic anterior hemifundoplication surgery for upside-down stomach and were included in our prospective study. The median symptoms duration was 5 years. The leading clinical symptoms were postprandial, epigastric, or retrosternal pain (80%), heartburn (78%), regurgitation (80%), dysphagia (53%), and anemia (48%). Preoperative evaluation included blood test, chest X-ray, upper endoscopy, and barium swallow. In some patients an esophageal 24-h pH study and esophageal manometry were performed. The median follow-up was 46 months using a standardized questionnaire, including Smiley score, modified Visick score, gastrointestinal quality-of-life index (GQLI), and specific reflux symptoms score. RESULTS: Surgery was finished laparoscopically in 39 patients (97%). One patient had to be converted to an open procedure because of severe adhesions. Mesh hiatoplasty had to be performed in one patient due to a large hiatal defect. Median operative time was 160 min (range=90-275) and median blood loss was 5 ml (range=0-300). Seven patients (18%) presented with acute symptoms. Intraoperative technical complications occurred in four patients (10%) and nontechnical complications in two cases (5%). Median postoperative hospital stay was 5 days (range=2-17). Postoperative complications occurred in two patients (5%): one pleural effusion and one surgical emphysema. There was no mortality or symptomatic recurrence. All scores showed significant improvement and patient satisfaction. CONCLUSION: Laparoscopic treatment of type 4 hiatal hernia is safe. With respect to the quality of life, anterior hemifundoplication is highly effective.

Primary extensive pyomyositis in an immunocompetent patient: case report and literature review.

Pyomyositis is a suppurative infection of the skeletal muscle; it mainly occurs in immunocompromised patients or, exceptionally, in immunocompetent patients in tropical or other areas. We present a 24-year-old immunocompetent lady with bilateral thigh myalgia and fever. Upon investigation, extensive multifocal bilateral fluid collections involving the extensor muscles of both thighs were demonstrated. Pus aspirate from the involved muscles proved the presence of Staphylococcus aureus. Incision and drainage of the involved muscles were performed with successful and complete recovery.

Esophageal leiomyomatosis combined with intrathoracic stomach and gastric volvulus.

CASE REPORT: A 42-year-old female presented with long-standing symptoms suggestive of gastroesophageal reflux disease improved after proton pump inhibitor treatment. An upper endoscopy revealed an intrathoracic position of the stomach (type 4 hiatal hernia) with no mucosal abnormality. Barium swallow demonstrated gastric herniation with gastric volvulus without stenosis. A computed tomographic scan confirmed the intrathoracic location of the stomach associated with thickening and edema of the gastric wall due to gastric volvulus, but no evidence of malignancy. The patient was scheduled for laparoscopic gastric repositioning with anterior hemifundoplication. Due to the incidental intraoperative finding of a large distal esophageal tumor (frozen section: esophageal leiomyomatosis), the operation was converted to conventional distal esophagectomy and proximal gastrectomy with reconstruction using a Merendino procedure. Final histology revealed extensive circumferential leiomyomatosis of the distal esophagus with a diameter of 10 cm. Esophageal leiomyomatosis is an extremely rare pathological finding with <100 cases reported in the literature. CONCLUSION: Any surgeon performing laparoscopic fundoplication has to be ready to deal with such unexpected findings, ie, converting the procedure and doing reconstruction with minimal morbidity. The Merendino procedure is a well-established reconstructive surgical option in cases of tumor formation at the gastroesophageal region with fewer postoperative morbidities like reflux symptoms.

The challenge of pancreatic anastomosis.

BACKGROUND AND AIMS: Significant progress in surgical technique and perioperative management has substantially reduced the mortality rate of pancreatic surgery. However, morbidity remains considerably high, even in expert hands and leakage from the pancreatic stump still accounts for the majority of surgical complications after pancreatic head resection. For that reason, management of the pancreatic remnant after partial pancreatoduodenectomy remains a challenge. This review will focus on technique, pitfalls, and complication management of pancreaticoenteric anastomoses. MATERIALS AND METHODS: A medline search for surgical guidelines, prospective randomized controlled trials, systematic metaanalysis, and clinical reports was performed with regard to surgical technique and complication management of pancreatic anastomoses. RESULTS: Pancreaticojejunostomy appears to be most widely performed, but pancreaticogastrostomy is a reasonable alternative. Postoperative treatment with octreotide can be recommended only for patients with soft pancreatic tissue, and neither stents of the pancreatic duct nor drainages have proven to effectively reduce anastomotic complications. Gastroparesis remains the most common complication after pancreatic surgery and should be treated conservatively. However, it may be a symptom of other local complications, such as anastomotic leakage, pancreatic fistula or abscess. All septic complications may finally result in late postoperative hemorrhage, which requires immediate diagnostic workup and therapy. Today, interventional radiology has emerged as a standard tool in the management of local septic complications and bleeding. Therefore, relaparotomy has become less frequent and salvage pancreatectomy is now a rare procedure in case of local complications. CONCLUSION: The surgeon's experience with one or the other technique of pancreatic anastomosis appears to be more important than the technique itself.