Unreported rare but serious complication: Major vascular injuries during bariatric surgery.

BACKGROUND: The aim of this study was to investigate the incidence, risk factors, clinical presentation, and management of major vascular injuries during bariatric surgery, with a specific focus on the role of different access methods in abdominal cavity entry. METHODS: A nationwide survey was conducted among bariatric surgeons to assess the prevalence of major vascular injuries. A questionnaire was distributed to 365 surgeons through WhatsApp groups of two national bariatric surgery societies, with 76 surgeons completing the survey. The study population included general surgeons practicing bariatric surgery, and the questionnaire consisted of 12 questions. RESULTS: Among the participants, 16.9% reported experiencing a major vascular injury during bariatric surgery. The majority of injuries (75%) occurred at the trocar entrance, with the remaining cases during the dissection phase. Notably, 66.7% of surgeons used optical trocars for access, while 27.8% employed the Veress needle technique. Early detection varied, with 45% identifying the injury immediately and 30% recognizing it within three minutes. Most injuries (52.4%) were repaired laparoscopically, and only three surgeons sought assistance from cardiovascular surgeons. CONCLUSION: Vascular injuries are infrequent but potentially serious complications in laparoscopic bariatric surgery. Understand-ing their incidence, timely recognition, and proper management are crucial to minimize adverse effects. The findings of this study shed light on the patterns of vascular injuries and the potential role of specific access methods, providing valuable insights for enhancing patient safety in bariatric surgery.

Panniculectomy with bariatric surgery in super morbid obesity patients.

OBJECTIVE: Panniculitis is an inflammation of the subcutaneous fat common in patients defined as super-super obese (>60 kg/m2). Poor hygiene and skin infections are common in the super morbidly obese group due to impaired metabolism of subcutaneous fat tissue, especially at abdominal folding. In our study, we will discuss the short-term results of panniculitis that develops as a result of these, simultaneously with bariatric surgery. MATERIAL AND METHODS: In our study, six super morbid obese patients with Body Mass Index (BMI) of 80 kg/m2, 77 kg/m2, 74 kg/m2, 72 kg/m2, 68 kg/m2, 65 kg/m2, respectively, and sub umbilical skin tissue panniculitis were evaluated. These patients underwent bariatric surgery as a result of the obesity council decision. In the preoperative evaluation of the patients, it was observed that the blood supply to the subcutaneous fat tissues under the umbilicus was impaired, and the dermis/epidermis was hypertrophied. RESULTS: Mean BMI of patients 73 kg/m2. Sleeve Gastrectomy (SG) was performed in 4 patients, Mini Gastric Bypass (MGB) was performed in 1 patient, and modified transit bipartition was performed in 1 patient. Infected erythematous lesions were detected on the skin secondary to ischemia, especially in some areas. After the patients performed the operations, a panniculectomy of approximately 70x30x20 cm was performed from under the umbilicus to the transverse line and up to the fascia. CONCLUSION: Panniculectomy and bariatric surgery are recommended in the appropriate patient group. Extensive prospective studies are required to define further the burden of infectious morbidity and mortality conferred by obesity. KEY WORDS: Bariatric surgery, Obesity, Panniculectomy.

Bridged one-anastomosis gastric bypass: technique and preliminary results.

PURPOSE: One-anastomosis gastric bypass (OAGB) is an established bariatric procedure performed worldwide. We developed a modification of OAGB leaving a bridge at the cranial 2 cm of the fundus as a gastro-gastric fistula to allow for endoscopic access to the bypassed stomach. We present the preliminary results of 44 patients who underwent this technique in our hospital. METHODS: We analyzed, retrospectively, data collected prospectively on 44 patients who underwent our bridged one-anastomosis gastric bypass (BOAGB) procedure between September, 2018 and November, 2020. RESULTS: The mean age of the patients was 45.2 ± 9.3 years (range 20-66 years). The mean preoperative body mass index (BMI), weight, and HbA1c values were 41.5 ± 6.4 kg/m2 (range 35-59), 116 ± 22.7 kg, and 8.2 ± 2.1%, respectively. After a median follow-up period of 18 months (11-26 months), the mean postoperative BMI was 28.4 ± 3.2 kg/m2 (range 21-38), the mean total weight loss was 35.8 ± 13.5 kg (range 20-80 kg), and the mean percentage of excess weight loss (%EWL) and the percentage of total weight loss (%TWL) were 79.8 ± 16.1% (range 47-109) and 30.6 ± 6.9% (range 19-48), respectively. The mean postoperative HbA1c level was 6.3 ± 0.9%. There were two early complications (stenosis and bleeding) and one late complication (marginal ulcer). CONCLUSION: Patients who underwent BOAGB lost weight similarly to those who underwent OABG as reported in the literature, without an apparent increase in complications related to the technique. Randomized studies with longer term follow-up are needed.

A new approach in bariatric operations: bridged mini gastric by-pass. Is rabbit model suitable for an experimental study?

OBJECTIVES: Obesity is a global health epidemic with considerable co-morbidities. The increasing demand for bariatric surgery has led to the emergence of new techniques. We modified previously described Mini Gastric By-pass(MGB) technique via leaving a bridge at the most cranial 2 cm of the fundus of the human stomach to the follow-up and treatment of the remnant stomach and duodenum. We would like to entitle this new technique as Bridged MGB and aimed to apply on rabbits as an experimental study. MATERIAL AND METHODS: The study was performed in the experimental animal laboratory of university after ethical approval was taken from the local ethics committee. Described new technique was applied to 2.1 and 3.2 kg 2 New Zealand rabbits. RESULTS: As a result of the operations, one of the rabbits died on the day of the operation; the other rabbit was exitus postoperatively on the third day. In autopsies, although no problem was detected at the anastomoses, necrosis was detected in the large curvature of both rabbits. CONCLUSION: Rabbit, one of the popular experimental animals, has been shown to be different from the human gastrointestinal system in both arterial and topographic aspects and it has been emphasized that it varies according to the species and even the diet and the climate. We believe that our study failed as a result of these differences and that animals more similar to humans should be used in gastrointestinal experimental studies.

Recommendations for bariatric and metabolic surgical operations during the COVID-19 pandemic in Turkey.

The world has been struggling with the COVID-19 virus since December 2019. Turkey has also been battling with the virus since March 2019. While struggling with this unknown virus, we have postponed our new bariatric surgeries like most elective surgery. However, curfew and quarantine period (increase in food intake and decreased physical activity) increases risks for morbidity and mortality because of obesity and diabetes. When the pandemic decreases and disappears, many obesity patients will seek treatment for obesity and the workload of surgeons will increase. Before bariatric and metabolic surgery operations, which is the most effective treatment of obesity and related comorbidities, necessary precautions must be determined and implemented to protect patients and healthcare workers before and during surgery. In this review, it was aimed to determine the pre-peri and postoperative periods of bariatric surgical requirements. This review has been written on behalf of the Turkish Society for Metabolic and Bariatric Surgery as an initiative in order to answer some questions about bariatric and metabolic surgery during the COVID-19 pandemic.

Comparison of Magenstrasse and Mill gastroplasty and sleeve gastrectomy techniques as an experimental study on rabbits.

AIM: Bariatric surgery is an important option when life-style modification, diet, and medical treatment are inadequate in lose weight. Bariatric surgical methods have gained popularity in recent years. In this paper, we compared the Magenstrasse and Mill(M&M) technique, with performing a simpler and more physiological type of gastroplasty without implanted foreign material such as band and reservoir, to the Sleeve Gastrectomy (SG) technique. This study aimed to determine the effects of the M&M for obesity on the rabbits in comparison with the SG, which is accepted as a standard bariatric technique with creating a gastric tube. MATERIAL AND METHODS: The study was approved by the University of Van Yuzuncu Yil Regional Committee of Ethics (Institutional Animal Care and Use Committee). 20New Zealand Rabbits underwent operations. After prestudy with 2 rabbits, the remaining 18 rabbits were divided into 2 groups; Group 1 (SG) and Group 2 (M&M). RESULTS: Group 1 rabbits were observed to lose weight in all, while Group 2 rabbits; 2 of them died, 5 of them lost weight, 2 of them gained weight. When the pre and post-operative weight of the rabbits were compared; preoperative median weight values of 9 rabbits in Group 1 were significantly higher than postoperative values. On the other hand, there was no significant change in the mean weight of Group 2 of 7 rabbits (living up to 8weeks). The mean weight of rabbits undergoing standard SG was significantly lower than the M&M technique. CONCLUSION: We believe that this animal experimental study, which we conducted intending to compare M&M and SG techniques, will contribute to the literature as a pilot study and determine the survey of M&M technique as a pioneer in other studies. KEY WORDS: Bariatric surgery, Magenstrasse and Mill gastroplasty, Sleeve gastrectomy.

Retrospective analysis of the first 50 emergency/elective surgical cases in terms of mortality and morbidity in CoVid-19 Pandemic Hospital in Istanbul.

2019-nCoV currently named SARS-CoV-2 is a highly pathogenic Coronavirus identified in Wuhan China in December 2019. Turkey declared the first case relatively late compared to Asian and European countries on March 11, as the first SARS-CoV-2 infection in Turkey. In this study, we aimed to determine patients' outcomes in 50 surgeries done in the incubation period of SARS-CoV-2 in our hospital. METHODS: We retrospectively analyzed the clinical data of 50 patients who underwent surgeries during the incubation period of CoVid-19 at Istinye University Gaziosmanpasa Medical Park Hospital in Istanbul, from March 2 to April 11, 2020. RESULTS: The age of 50 patients range was 21 to 73, and the median age was 43.32 (64%) patients were women. The median length of hospital stay is 2.6 days (1-21). Operations at various difficulty levels were also performed on patients with co-morbidities. No complication or mortality was observed except for 1 patient, and the ICU requirement of that patient was also due to high energy trauma. CONCLUSION: Although contrary claims have been made in various studies; it is the primary duty of us surgeons to operate CoVid-19 positive/suspicious patients safely and without any contamination, and on the other hand, to continue their operations without victimizing negative patients. In this pilot study, we would like to emphasize with necessary and adequate measures these can be achieved. KEY WORDS: CoVid-19, SARS-CoV-2, Surgery.

Minimally invasive distal pancreatectomy A retrospective review of 30 cases.

OBJECTIVES: Pancreatic surgery has been greatly influenced by the advent of laparoscopic surgery and increasing experience in its performance and by advances in techniques and surgical devices. This study aimed to represent two centers' initial experiences in laparoscopic distal pancreatic surgery. METHODS: This study was a bi-centric study including 30 patients undergoing distal pancreatectomy for pancreatic disorders. All the patients were operated on from November 2006 to November 2013 in Turkey and Spain. RESULTS: Laparoscopic spleen-preserving distal pancreatectomy was performed in 9 patients, laparoscopic distal pancreatectomy was performed in 14 patients, laparoscopic enucleation was performed in 4 patients, and single-incision laparoscopic distal pancreatosplenectomy with splenectomy was performed in 3 patients. CONCLUSIONS: Laparoscopic distal pancreatectomies for pancreatic disorders are feasible and safe procedures if performed by experienced laparoscopic surgeons. KEY WORDS: Laparoscopy, Pancreas, Multi-port, Tumor, SILS.

Desmoid tumor in puerperium period: a case report.

Desmoid tumors (DTs) are rare tumors classified as deep fibromatoses taking origin from fascial or musculoaponeurotic structures. With pregnancy and surgical scars considered in the etiology, most anterior abdominal wall DTs occur in women in their reproductive years, especially during a pregnancy or post-partum. Herein, we present development of DT in a female patient in the post-partum period following cesarean delivery, which manifested itself with a growing mass in anterior abdominal wall. In our case, possibility of hematoma most probably located beneath the fascia was considered initially as a complication of cesarean section based on ultrasonographic examination and location of the lesion, while upon lack of either spontaneous regression with eventual diminish in size or resolve of symptoms within six weeks, further investigation via MRI and tru-cut biopsy revealed the diagnosis of abdominal DT. Radical tumor extirpation with resection of an adequate margin of surrounding normal tissue was applied, and the post-operative period was uneventful.

Matrix metalloproteinases in pathogenesis of hemorrhoidal disease.

The aim of this study is to investigate the accuracy of serum matrix metalloproteinase (MMP) levels in an effort to find a reliable factor that may play an important role in pathogenesis of hemorrhoidal disease. Twenty control subjects and 21 Grade I, 19 Grade II, 20 Grade III, and 21 Grade IV patients with internal hemorrhoid were included in this prospective study. The mean ages of control subjects were 47.65 ± 6.71 standard deviation (SD) years (range, 37 to 60 years). The mean age of internal Grade I, Grade II, Grade III, and Grade IV patients with internal hemorrhoid were 48.85 ± 6.44, 47.20 ± 6.75, 44.90 ± 6.13, and 42.95 ± 3.49 SD years (ranges, 38 to 58, 38 to 60, 34 to 55, and 38 to 50 years), respectively. Ten milliliters of blood was taken from all subjects. Enzyme-linked immunosorbent assay (ELISA) for MMP-1, -2, -7, and -9 levels were performed using an ELISA kit (R&D Systems) following the manufacturer's instructions. There was an important difference between Grade I and Grade II groups in the serum levels of MMP-9 (P < 0.01). Patients with Grade III hemorrhoidal disease had significantly higher serum levels of all MMP than patients with Grade I and Grade II hemorrhoidal disease (P < 0.001). Also, patients with Grade 4 hemorrhoidal disease had higher serum levels of MMP-7 and -9 according to Grade I, II, and III groups (P < 0.01, 0.001). High serum levels of MMP are present in patients with hemorrhoids, suggesting the possible mechanism in the pathogenesis of hemorrhoids.

Single-port transumbilical laparoscopic cholecystectomy: A prospective randomised comparison of clinical results of 140 cases.

INTRODUCTION: A novel single port access (SPA) cholecystectomy approach is described in this study. We have designed a randomised comparative study in order to elucidate any possible differences between the standard treatment and this novel technique. MATERIALS AND METHODS: Between July 2009 and March 2010, 140 adult patients with gallbladder pathologies were enrolled in this multicentre study. Two surgeons (RV and UB) randomised patients to either a standard laparoscopic (SL) approach group or to an SPA cholecystectomy group. Two types of trocars were used for this study: the TriPort™ and the SILS™ Port. Outcomes including blood loss, operative time, complications, length of stay and pain were recorded. RESULTS: There were 69 patients in the SPA group and 71 patients in the SL group. The mean age of the patients was 43.2 (17-77) for the SPA group and 42.6 (19-70) for the SL group. The mean operative time was 63.9 min in the SPA group and 58.4 min in the SL group. For one patient, the SPA procedure was converted to a standard laparoscopic technique and to open approach in the SL group. Complications occurred in eight patients: Five seromas (two in the SPA group) and three hernias (one in the SPA group).The mean hospital stay was 38.5 h in the SPA group and 24.1 h in the SL group. Pain was evaluated and was 2 in the SPA and 2.9 in the SL group, according to the visual analogue scale (VAS) after 24 h (P<0.001). The degree of satisfaction was higher in the SPA group (8.3 versus 6.7). Similar results were found for the aesthetic result (8.8 versus 7.5). (P<0.001). CONCLUSION: Single-port transumbilical laparoscopic cholecystectomy can be feasible and safe. When technical difficulties arise, early conversion to a standard laparoscopic technique is advised to avoid serious complications. The SPA approach can be undertaken without the expense of additional operative time and provides patients with minimal scarring. The cosmetic results and the degree of satisfaction appear to be significant for the SPA approach.

Preoperative serum placenta growth factor level as a new marker for stage II or III colorectal cancer patients.

BACKGROUND/AIMS: We first reported in this study that serum placenta growth factor and carcinoembryonic antigen in combination were useful markers for selecting early-stage colorectal cancer patients. The aim of the present study was to determine whether serum placenta growth factor could provide carcinoembryonic antigen-independent prognostic information on patients undergoing curative surgery. METHODS: Serum and tissue samples were collected from 158 patients with colorectal cancer and from 50 controls. Serum and tissue levels of placenta growth factor were measured by enzyme-linked immunosorbent assay. The serum placenta growth factor levels in colorectal cancer patients were compared with those in healthy controls, and we retrospectively assessed the association between serum placenta growth factor levels and clinicopathological findings and survival. RESULTS: Expression of placenta growth factor was significantly higher in colorectal cancer tissues compared with non-tumor tissues. The mean serum placenta growth factor level in patients was significantly higher than that in controls and significantly higher in patients with large tumor, lymph-node involvement and distant metastasis. CONCLUSIONS: Elevated serum placenta growth factor levels are significantly associated with colorectal cancer development, lymph or distant invasive phenotypes and survival, especially in stage II or III patients.

Single-port transumbilical laparoscopic appendectomy: a preliminary multicentric comparative study in 87 patients with acute appendicitis.

Introduction. Laparoscopic appendectomy (LA) has been performed in many approaches such as open, laparoscopic and recently Single Port Access (SPAA). In order to elucidate its potential advantages, we compared the two laparoscopic approaches. Methods. 87 patients were included in a multicentric study for suspected appendicitis in order to perform (SPAA) appendectomy or laparoscopic appendectomy (LA). All outcomes, including blood loss, operative time, complications, and length of stay and pain were recorded prospectively. Results. There were 46 patients in the SPAA group and 41 in the LAG with a mean operative time of 40,4 minutes in the SPAA group and 35,0 minutes in the LA group. Only one patient was converted to an open approach. We described only 2 complications. Pain was graded 2,8 in the SPAA group and 2,9 in the LA group, according to the AVS after 24 hours. Patients in the SPAA Group were more satisfied (7,5 versus 6,9) (P < 0.05). Same results were found for the cosmetic result (8,6 versus 7,4) (P < 0.05). Conclusion. Using the single port approach feasible and safe. The true benefit of the technique should be assessed by new randomised controlled trials.

Serum procarboxypeptidase A and carboxypeptidase A levels in pancreatic disease.

BACKGROUND AND OBJECTIVES: To determine the serum levels of procarboxypeptidase A (pro-CPA) and carboxypeptidase A (CPA) in patients with acute and chronic pancreatitis and pancreatic cancer. MATERIALS AND METHODS: Serum samples obtained from 96 patients with acute pancreatitis, 101 patients with chronic pancreatitis, 98 patients with pancreatic cancer and 96 control groups were assayed for biochemical parameters and serum pro-CPA and CPA. RESULTS: Serum pro-CPA and CPA levels were significantly higher in acute and in chronic pancreatic cancer patients compared to control group (p < 0.001). Pancreatic cancer patients had significantly higher serum pro-CPA and CPA levels when compared with acute and chronic pancreatitis cases (p < 0.001). CONCLUSION: These data prove for increased pro-CPA and CPA levels as a biomarker for the diagnosis of pancreatitis and pancreatic cancer.

Prevention of adhesion to prosthetic mesh: comparison of oxidized generated cellulose, polyethylene glycol and hylan G-F 20.

BACKGROUND: The aim of this study was to investigate the impact of oxidized generated cellulose, polyethylene glycol and hylan G-F 20 on adhesion formation, fibrosis and inflammation after repair of abdominal wall defect with polypropylene mesh in an animal model. METHODS: Forty rats were divided into four groups and abdominal wall defect was established. The defect was repaired with polypropylene mesh alone (control group), polypropylene mesh and hylan G-F 20 as adhesion barrier, polypropylene mesh and oxidized generated cellulose as adhesion barrier, or polypropylene mesh and polyethylene glycol as adhesion barrier in Groups I, II, III, and IV, respectively. Rats were sacrificed on the 14th day in all groups. RESULTS: A comparison of the groups in terms of macroscopic adhesion scores revealed statistically significant differences between the groups using an adhesion barrier and the control group. Severe fibroblast proliferation was seen in the control group and mild fibroblast proliferation was seen in polyethylene glycol group. CONCLUSION: Polyethylene glycol is an effective adhesion prevention barrier. Laparoscopic surgery has become the standard method in most of the surgical field. With its laparoscopic apparatus, polyethylene glycol allows easy application on the damaged surface.

Pure SILS Floppy Nissen Fundoplication with Hiatal Repair: A Case Report.

Background. Single-incision laparoscopic surgery has recently became popular on behalf of inventing less invasive procedures. In this paper, we present a case of Pure SILS Nissen Fundoplication. Patient and Methods. In February 2010 a 29-year old male patient with a 4 cm sliding hiatus hernia presenting with reflux symptoms had undergone a standard floppy Nissen Fundoplication with a hiatus repair via single 2 cm incision in umbilicus. Results. The procedure had obeyed the standard natural orifice surgery rules, and no needlescopic assistance for any stage of the operation was used so to be a pure single-incision procedure. The operation lasted for 120 minutes without any need of conversion, and the patient was discharged the following day of operation. Conclusion. In the recent time, hybrid single incision laparoscopy techniques have been defined with the use of extra-abdominal supplements for retraction of liver or stomach for Nissen procedure. In addition the main issue in single-incision upper GI and/or hiatus surgery is still the retraction of liver. We succeeded to retract the left lobe of liver through the incision and completed the operation without any need for supplemental access besides the umbilical incision till the end. SILS Hiatus Surgery can be safely and effectively done but the issue needs further clinical studies to state the efficacy when compared to standard laparoscopy.

SILS Incisional Hernia Repair: Is It Feasible in Giant Hernias? A Report of Three Cases.

Aim. Three incisional ventral abdominal wall hernias were repaired by placing a 20 × 30 cm composite mesh via single incision of 2 cm. Methods. All three cases had previous operations and presented with giant incisional defects clinically. The defects were repaired laparoscopically via single incision with the placement of a composite mesh of 20 × 30 cm. Nonabsorbable sutures were needed to hang and fix the mesh only in the first case. Double-crown technique was used in all of the cases to secure the mesh to the anterior abdominal wall. Results. The mean operation time was 120 minutes. The patients were mobilized and led for oral intake at the first postoperative day. No morbidity occurred. Conclusion. Abdominal incisional hernias can be repaired via single incision with a mesh application in experienced centers.

Relationship between clinicopathologic variables and serum and tissue levels of dickkopf-1 in patients with rectal cancer.

The major biomarker for rectal cancer is the pathologic development of the tumor. In our study, we identified Dikkopf-1 (DKK1) as a novel biomarker and a therapeutic target for rectal cancer. To emphasize the biological and clinicopathologic significance, we performed tumor tissue and serum analysis of 150 rectal cancer samples with enzyme-linked immunosorbent assay. Serum DKK-1 levels are found significantly higher in controls, in poor differentiation, and depth of invasion (in pT3 and pT4), present lymph node metastasis, and TNM stage (in pT3 and pT4) according to good differentiation, depth of invasion (in pT1 and pT2), absent lymph node metastasis, and TNM stage (in pT1 and pT2; P < 0.001 and P < 0.0001, respectively). Tissue DKK-1 levels are found in patients with rectal cancer than in control tissues (P < 0.0001). Dikkopf-1 correlated significantly with depth of invasion (P = 0.009), lymph node metastasis (P = 0.028), venous involvement (P = 0.019), and advanced pTNM stage (P = 0.001). There was no correlation between DKK-1 and age or sex (P > 0.05). This marker is also a potential candidate for development of rectal cancer cells and cancer progression.

Levels of matrix metalloproteinase-1 and tissue inhibitors of metalloproteinase-1 in gastric cancer.

AIM: To evaluate the levels of preoperative serum matrix metalloproteinase-1 (MMP-1) and tissue inhibitor of metalloproteinase-1 (TIMP-1) in gastric cancer. METHODS: One hundred gastric cancer patients who underwent gastrectomy were enrolled in this study. The serum concentrations of MMP-1 and TIMP-1 in these patients and in fifty healthy controls were determined using an enzyme-linked immunosorbent assay. RESULTS: Higher serum MMP-1 and TIMP-1 levels were observed in patients than in controls (P < 0.001). Serum MMP-1 and TIMP-1 levels were positively associated with morphological appearance, tumor size, depth of wall invasion, lymph node metastasis, liver metastasis, perineural invasion, and pathological stage. They were not significantly associated with age, gender, tumor location, or histological type. CONCLUSION: Increased MMP-1 and TIMP-1 were associated with gastric cancer. Although these markers are not good markers for diagnosis, these markers show in advanced gastric cancer.

A New Era in Minimally Invasive Liver Resection (MILR) Single-Incision Laparoscopic Liver Resection (SIL-LR): The First Two Cases.

Laparoscopy has gained a place in everyday surgical routine as an alternative surgical approach that decreases morbidity and postoperative hospitalization. Single port laparoscopic surgery has been introduced as a further development of laparoscopy. The feasibility and safety of single port laparoscopy is under extensive evaluation in specialized laparoscopic centers. Nevertheless, wide acceptance of the technique requires adequate documentation of the advantages of the approach over conventional laparoscopy and further refinement of surgical instrumentation to overcome intraoperative ergonomic problems.