Roux-en-Y Gastric Bypass after Laparoscopic Sleeve Gastrectomy Failure: Could the Number of Previous Operations Influence the Outcome?

After a failed laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG) has been proposed as revisional surgery. Those patients that receive a second restrictive procedure fall into a small subgroup of patients with more than one restrictive procedure (MRP). If also the second restrictive procedure fails, the correct surgical strategy is a challenge for the surgeon. Roux-en-Y gastric bypass (RYGB) may be an option but there is no evidence in the literature on whether the procedure is effective in treating failures after MRP. This study aims to evaluate the influence of the previous number of restrictive interventions (MRP vs single LSG) in the results of RYGB as revisional surgery. We have retrospectively analyzed patients who underwent conversion from laparoscopic sleeve gastrectomy (LSG), or from multiple restrictive procedures (MRP), to RYGB for weight regain (WR) or insufficient weight loss (IWL) between 2009 and 2019. The number of patients analyzed was 69 with conversion to RYGB after LSG and 44 after MRP. The reduction of excess weight (%TWL) at 3, 6, 12, 24 RYGB postoperative months was respectively of 11.03%, 16.39%, 21.43%, and 24.22% in the MRP group, and of 10.97%, 16.4%, 21.22%, and 22.71% in the LSG group. No significant difference was found in %TWL terms after RYGB for the MRP group and the LSG group with an overall %TWL, which was 11.00 ± 6.03, 16.40 ± 8.08, 21.30 ± 9.43, and 23.30 ± 9.91 respectively at 3, 6, 12, and 24 months. The linear regression model highlighted a positive relationship between the %EWL post-bypass at 24 months and the time elapsed only between the LSG and RYGB in the MRP group patients (p < 0.001). RYGB has proved to be a reliable technique with good results in terms of weight loss after failed bariatric surgery both in patients who previously underwent MRP and in those who underwent exclusively LSG. RYGB showed better results in patients who experienced WR than in those who had IWL from previous techniques.

Conversion of one-anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB) for gastroesophageal reflux disease (GERD): who is more at risk? A multicenter study.

BACKGROUND: Although gastroesophageal reflux disease (GERD) affects 0.6% to 10% of patients operated on for one-anastomosis gastric bypass (OAGB), only about 1% require surgery to convert to Roux-en-Y gastric bypass (RYGB) [3-5]. The aim of the present study was to analyze the characteristics of OAGB patients converted to RYGB for GERD not responding to medical treatment. METHODS: This retrospective multicenter study included patients who underwent conversion from OAGB to RYGB for severe GERD. The conversion was performed with resection of the previous gastro-jejunal anastomosis and the use of the afferent loop as a new biliary loop. RESULTS: A total of 126 patients were included in the study. Of these patients, 66 (52.6%) had a past medical history of bariatric restrictive surgery (gastric banding, sleeve gastrectomy). A hiatal hernia (HH) was present in 56 patients (44.7%). The association between previous restrictive surgery and HH was recorded in 33 (26.2%) patients. Three-dimensional gastric computed tomography showed an average gastric pouch volume of 242.4 ± 55.1 cm3. Conversion to RYGB was performed on average 60 ± 35.6 months after OAGB. Seven patients (5.5%) experienced an early postoperative complication (4 patients grade IIIb and 3 grade IIb), and 3 (2.4%) a late complication. Patients showed further weight loss after RYGB conversion and an average of 24.8 ± 21.7 months after surgery, with a mean % of total weight loss (%TWL) of 6.9 ± 13.6 kg. From a clinical point of view, the problem of GERD was definitively solved in more than 90% of patients. CONCLUSIONS: Situations that weaken the esogastric junction appear to be highly frequent in patients operated on for OAGB and converted to RYGB for severe reflux. Similarly, the correct creation of the gastric pouch could play an important role in reducing the risk of conversion to RYGB for GERD.

Colostomy Reversal following Hartmann's Procedure: The Importance of Timing in Short- and Long-Term Complications: A Retrospective Multicentric Study.

The restoration of bowel continuity following Hartmann's Procedure (HP) has been reported hitherto with high morbidity and mortality rates. No clear guidelines exist about timing in Hartmann's Reversal (HR), the literature data being conflicting. We have sought to investigate the effect of the interval time between HP and HR in short- and long-term HR outcomes through a retrospective study based on consecutive patients undergoing HR between 2009 and 2017 in two regional hospitals in Italy. Demographic characteristics, comorbidities, intra- and post-operative data, as well as early complications, were recorded. Long-term data were collected on the surgical site occurrences of Incisional Ventral Hernia (IVH). One hundred and five patients were recruited for the study. Late HR, female gender, and long operating time were related to the highest incidence of peri-operative complications. Patients who developed IVH had undergone HR at significantly shorter times and had a higher Body Mass Index (BMI). The timing of HR seems to be an important variable linked to the onset of early and late post-operative complications. The patients submitted to early HR show a significantly lower complication rate but, at the same time, a higher rate of IVH incidence after restorative surgery. These data, in our opinion, reflect the need for planning, where possible, an early restoration of bowel continuity after HP.

Combined approach with negative pressure wound therapy and biological mesh for treatment of enterocutaneous fistula after synthetic mesh repair of incisional hernia. A case report.

AIM: Enterocutaneous fistula is a rare but severe complication of prosthetic incisional hernia repair. Management requires re-exploration with intestinal repair/resection and mesh removal. Repair of the parietal defect in this contaminated field is challenging. MATERIAL OF STUDY: A 58-years male patient presented to our department one year after synthetic mesh repair of large incisional hernia with mesh infection and enterocutaneous fistula. The diagnosis was confirmed by ultrasound guided drainage and CT scans with oral contrast. A multiple-step surgical approach has been adopted: first, the mesh was removed, intestinal resection performed and posterior fascial closure obtained by bilateral transversus abdominis release (TAR) and supra-fascial NPWT (negative pressure wound therapy) was positioned and maintained for one week; second, a definitive repair was obtained by a biological prothesis fixed to posterior fascia and covered by anterior fascia closure. Then, new NPWT was positioned and maintained for 6 days on the skin closure. At 18-months follow-up, the patient showed no clinical or radiological signs of recurrence or reinfection. DISCUSSION: Surgical strategies to face enterocutaneous fistula after prosthesis ventral hernia repair are not standardized. After bowel fistula treatment and mesh removal, the challenge of abdominal wall closure stay unsolved because of the high rate of complication and failure of a new prosthetic repair. A case-by-case management plan, often with the use of a multi-step strategy, may be an option. CONCLUSION: This is a single recovery multiple-step strategy combined approach using NPWT and biological prothesis to manage a case of mesh infection by an enterocutaneous fistula. This unique approach has revealed safe and effective for the treatment of parietal defect in infected field resulting from a mesh removing procedure. KEY WORDS: Biological prosthesis, Bowel mesh erosion, Enterocutaneous fistula, Negative Pressure Wound Therapy, Open incisional hernia repair.

Surgical management of rectal GIST. A case report and a review of literature.

AIM: Rectal GIST is a rare tumor of the gastrointestinal tract. The few literature cases didn't show significant evidence about diagnostic and therapeutic management. We present a rare case of rectal GIST treated with laparoscopic anterior rectal resection (RARLs) preceded by neoadjuvant therapy with Imatinib Mesylate (IM). CASE REPORT: A 68-year-old woman with abdominal pain, rectal bleeding and palpable mass on rectal exam has been subjected to computerized tomography (CT) of the abdomen and pelvis and magnetic resonance imaging (MRI) that revealed a rectal GIST of 5x4x2 cm at 3 cm from anal verge. The diagnosis was confirmed with colonoscopy. After 3- mounts neoadjuvant therapy with IM, which allowed to down-stage the neoformation, the patient underwent RARLs without intraoperative or postoperative complications. Immunohistochemistry revealed cluster of differentiation CD 117 positive, HPF 5/50, Ki 67overexpressed. PDGF mutation was detected. The patient was therefore taken in charge by the oncologist. DISCUSSION AND CONCLUSION: Resection appear curative for rectal GIST. Extensive resections aren't necessary because of downstaging after IM therapy. However, the appropriate surgical technique is still debated. Further studies are necessary for a correct surgical standardization. KEY WORDS: Rectal GIST, Cajal cell, Laparoscopic rectal resection, Imatinib.

Primary malignant melanoma of the bowel diagnosed following a bowel intussusception in an adult patient. A case report and review of the literatureport.

AIM: Primary small bowel melanoma is a very rare clinical entity with a paucity of publications in literature. Most cases of gastrointestinal melanomas are metastatic lesions arising generally from primary lesion of the skin, eyes, or anus. We present a case of a small bowel intussusception with primary malignant melanoma as lead point and a gluteal melanoma metastasis after four years free from disease. CASE REPORT: A 77-year-old female has come to our attention with signs and symptoms of intestinal occlusion. She was subjected to a computerized tomography (CT) of the abdomen and pelvis that revealed small bowel intussusception caused by intestinal polypoid lesion. She was treated with a bowel resection. The histological exam has shown the presence of an amelanocytic malignant melanoma. The examination of skin, eyes, esophagus, colon and anus, a tot al body contrast- enhanced CT and a bone scintigraphy were negative for primary melanoma. So, the final diagnosis was primary melanoma of the ileum. After four-years disease-free survival, the patient came back to our attention for a gluteal melanoma metastasis, that was surgically removed. Afterwards she started immunotherapy, that is still ongoing. DISCUSSION AND CONCLUSION: The diagnosis and the treatment of primary intestinal melanoma is a challenging due to the lack of scientific indications. Our case shows how an early diagnosis, although accidental, can offer a good survival free from disease. Moreover, a careful follow-up of our patients allows us to promptly identify neoplasm recurrence or distant metastasis that can be treated with surgery and systematic therapy. KEY WORDS: Intussusception, Primary bowel melanoma.

Laparoscopic sleeve gastrectomy follow-up: use of connected devices in the postoperative period.

BACKGROUND: During the last decade, laparoscopic sleeve gastrectomy (LSG) has become the most performed bariatric procedure worldwide. OBJECTIVES: To evaluate the feasibility of the use of connected devices in monitoring patients operated on by LSG and discharged 24 hours after surgery under the enhanced recovery after surgery protocol. SETTING: Private hospital, France. METHODS: This is a prospective pilot study designed to assess the risk and benefit of using connected devices in the postoperative follow-up of patients operated on by LSG. Patients operated on with LSG were discharged 24 hours after surgery, and vital signs such as blood pressure, heart rate, peripheral capillary oxygen saturation, and temperature were monitored via connected devices with data sent to an internet platform to make them immediately viewable by the surgeon. RESULTS: The study population consisted of 82 women and 18 men. The mean body mass index was 43.4 kg/m2, and the mean age was 39.6 years. Two patients were reoperated on for bleeding and, consequently, were excluded from the study. At postoperative day 8, 1 patient presented with tachycardia, fever, and mild abdominal discomfort. After the alert was received from the internet platform, the patient was immediately contacted, admitted to the ward, and promptly reoperated on. At 1 year after the surgery, the mean percentage of excess weight loss and total weight loss were 68.1 ± 18.1% and 36 ± 9.8 kg, respectively. For the patients not available for follow-up at the 1-year control, weight loss data were extrapolated from the internet platform. Globally, 92% of patients felt safe when they returned home, and 92% of patients would recommend this way of managing the postoperative period. CONCLUSIONS: In conclusion, this study shows that the early postoperative follow-up to an intervention such as LSG can be done at the patient's home under the monitoring of connected devices without a risk of increase in the rate of complications and rehospitalization. The role of the connected devices in the long-term postoperative follow-up seems promising.

Which is the correlation between carcinoid tumor and Laparoscopic Sleeve Gastrectomy? A case series and literature review.

INTRODUCTION: Gastric Carcinoid Tumors (GCT) are very rare in general population, but some studies evidenced a higher incidence among bariatric surgery patients. Laparoscopic Sleeve Gastrectomy (LSG) is a widely accepted procedure for the surgical treatment of morbid obesity. LSG acts both in reducing food intake and interfering with hormonal balance in the gut-brain axis. In these patients, incidental GCT diagnosis can occur both during pre-bariatric surgery investigation and during post-operative follow-up. METHODS: We retrospectively analyzed the database of obesity patients submitted to LSG in two different centers to find out incidence of GCT in patients treated by surgery from May 2013 to March 2018. RESULTS: From the 560 obese consecutive patients underwent LSG, we recorded two cases of patients with GCT (0.36%): the case 1 was a patient who had a pre-operative diagnosis of GTC receiving a curative LSG which totally included the carcinoid in the resected portion; the case 2 was a patient that received a curative endoscopic resection 42 months after LSG. DISCUSSION: the predisposing factors that can correlate GCT with obesity and LSG and in particular the hormonal changes have been discussed. We illustrated our experience about the management of these tumors in obese patients. CONCLUSION: there are neither certain data which evidence a correlation between obesity and GCT, nor data to support the hypothesis of a higher incidence of GCT after bariatric surgery. Based on our experience in obese patients the finding of GCT in the pre-operatory phase is not an absolute contraindication for bariatric surgery.

High Resected Gastric Volume and poorly controlled DM2 in laparoscopic sleeve gastrectomy.

BACKGROUND: Our aim is to evaluate the effects of High Resected Gastric Volume(HRGV) on poorly Type 2 Diabetes Mellitus(DM2) after Laparoscopic Sleeve Gastrectomy(LSG). METHODS: 256 patients were divided into two groups according to the RGV: < 1500 mL(Group A: 131 pts) and > 1500 mL(Group B: 147 pts). % excess body mass index loss (%EBMIL), Fasting Blood Glucose (FBG), HbA1c, C peptide were assessed before surgery and at the 3rd day, 6th,12th,24th,36th month after LSG. RESULTS: A significant difference in %EBMIL between the two groups at 24 and 36 months was found. RGV was not significantly associated with DM2 in the multivariate logistic regression. FBG levels showed no differences between the two groups. A significant decrease of Hb1Ac at 6 and 12 months was found in group B. The C-peptide level showed a significant reduction at 6 and 12 months in group B. CONCLUSION: The HRGV may play a role in the regulation of the glucose metabolism in the first year after LSG without influence in poorly DM2 control. Further studies are needed to confirm these findings.

Advantage of laparoscopic resection for pelvic Schwannoma: Case report and review of the literature.

INTRODUCTION: Single pelvic schwannomas are rare tumor arising from the retrorectal, lateral or obturatory space. Laparoscopic approach to schwannoma located in lateral pelvic space has been previously described only in one case report. We present a case of a successful laparoscopic resection of pelvic schwannoma emphasizing the advantages of such a minimal invasive approach. PRESENTATION OF CASE: A 54-years-old, obese, male patient was admitted to our hospital referring dysuria and strangury. Abdominal CT scan showed a lateral pelvic well-circumscribed mass with smooth regular margins. A CT-guided fine needle biopsy resulted non-diagnostic. An elective laparoscopic resection was performed. The patient had a short, uneventful post-operative course. Pathological examination revealed a benign schwannoma. DISCUSSION: Using PubMed database, we reviewed the English language international literature using the MeSH terms "laparoscopic," "minimally invasive" and "schwannoma". We identified quite 20 previous cases of pelvic schwannomas removed by laparoscopy or robotic surgery. We found out that a preoperative diagnosis of these rare neoplasms is difficult to be obtained; in most cases, laparoscopic approach was successfully performed. CONCLUSION: Despite it could not be proven yet, due to the rarity of this tumor, we agree with literature that laparoscopic removal of pelvic benign tumor may offer several advantages. The direct high-definition vision deeply into this narrow anatomical space, especially in obese patients, provides a detailed view that makes easier to isolate and spear the anatomical structures surrounding the tumor. Furthermore, the pneumoperitoneum may create the right plane of dissection, minimizing the risk of tumor rupture and bleeding.

Resolution of type 2 diabetes after sleeve gastrectomy: a 2-step hypothesis.

BACKGROUND: Weight loss (WL) and altered gut hormonal levels are involved in glucose homeostasis after laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: The aim of this study was to evaluate the time-related effects of WL, ghrelin, and glucacon-like peptide-1 (GLP-1) plasma concentrations on type 2 diabetes resolution after LSG. SETTING: University hospital, Italy. METHODS: Ninety-one patients who underwent LSG were investigated. Insulin secretion (insulinogenic index [IGI]), insulin resistance, plasma glucose level and percentage glycated hemoglobin using the oral glucose tolerance test were assessed before surgery, on postoperative day 3, and then at 6, 12, 24, and 36 months after LSG. At the same time points, WL, ghrelin, and GLP-1 levels were determined. RESULTS: During follow-up, the resolution rate of type 2 diabetes was 9.4%, 42.3%, 71.8%, 81.2%, and 91.8%, respectively. Ghrelin plasma concentrations decreased significantly after LSG (271.5 ± 24.5 pg/mL versus 122.4 ± 23.4 pg/mL, P = .04). GLP-1 plasma concentrations increased significantly after LSG (1.7 ± 2.6 pg/mL versus 2.5 ± 3.4 pg/mL, P = .04). The percentage of excess weight loss and IGI presented a positive linear correlation (r) at all follow-up time points with a strong positive correlation at 12 and 24 months. A strong negative correlation between ghrelin and IGI was recorded during the first 3 days after LSG (r = -.9). GLP-1 and IGI presented a strong positive correlation at day 3 and 6 months (i.e., .8 and .8, respectively). CONCLUSION: LSG may affect glucose homeostasis by 2 different time-related modes: a first step in which the hormonal changes play a predominant role in glucose homeostasis and a second step in which the percentage excess weight loss determines the metabolic results.

Intraluminal ileal tumour after right hemicolectomy for cancer: An implantation recurrence or a new cancer? A case report.

INTRODUCTION: Extra-anastomotic intraluminal recurrence of the colon cancer after curative surgery was rarely reported but intraluminal ileal relapse has not been described to date.We report a case of intraluminal ileal tumor arising after curative right hemicolectomy that could be ascribed to an implantation of exfoliated cancer cells. CASE REPORT: A 71-years old man was admitted with no metastatic stenotic adenocarcinoma of the hepatic flexure and submitted, without preoperative bowel preparation, to right hemicolectomy using a "no-touch" technique. Histology showed moderately differentiated adenocarcinoma without lymph nodes involvement (pT3N0). No adjuvant therapy was prescribed. First colonoscopy three months after surgery was negative but a second endoscopic examination nine months later revealed an ileal neoplasia, presenting like an ulcer 10 cm proximally to ileocolic anastomosis. A new ileo-colic resection including past anastomosis was performed with curative intent. Pathological examination showed moderately differentiated adenocarcinoma extended to peri-visceral fat tissue with 10 tumor-free lymph nodes. (pT3N0). Six courses of Capecitabine adjuvant chemotherapy was prescribed and 32 months after second surgery, the patient is alive without disease. DISCUSSION: In the present case, the relatively short time from the primary surgery and the fact that recurrence occurred outside the anastomosis suggest that implantation of exfoliated malignant cells seems to be the main pathogenetic mechanism. We suppose that the high grade of primary cancer and the occlusive condition could have promoted the cancer cells reflux through the ileocecal orifice and in the transverse colon. CONCLUSION: This case seems to confirm the intraluminal implanting capacity of exfoliated carcinoma cells.

Short- and Long-Term, 11-22 Years, Results after Laparoscopic Nissen Fundoplication in Obese versus Nonobese Patients.

BACKGROUND: Some studies suggest that obesity is associated with a poor outcome after Laparoscopic Nissen Fundoplication (LNF), whereas others have not replicated these findings. The effect of body mass index (BMI) on the short- and long-term results of LNF is investigated. METHODS: Inclusion criteria were only patients who undergone a LNF with at least 11-year follow-up data available, patients with preoperative weight and height data available for calculation of BMI (Kg/m2), and patients with a BMI up to a maximum of 34.9. RESULTS: 201 patients met the inclusion criteria: 43 (21.4%) had a normal BMI, 89 (44.2%) were overweight, and 69 (34.4%) were obese. The operation was significantly longer in obese patients; the use of drains and graft was less in the normal BMI group (p < 0.0001). The hospital stay, conversion (6,4%), and intraoperative and early postoperative complications were not influenced by BMI. CONCLUSIONS: BMI does not influence short-term outcomes following LNF, but long-term control of reflux in obese patients is worse than in normal weight subjects.

Spontaneous liver rupture associated with anticoagulant therapy A case report.

Spontaneous hepatic rupture without underlying liver diseases is uncommon entity. We report a rare case of spontaneous rupture of liver hematoma in patient treated with warfarin end enoxaparin sodium because of pulmonary embolism. Two day after admission the patient complained generalized abdominal pain and hemodynamic instability. The abdominal US and TC scan revealed free fluid and lesion at right liver lobe. The patient, despite intravenous fluid support and blood transfusion, was hemodinamically instable and urgent laparotomy was needed. At laparotomy, it was found that a subcapsular haematoma, involving the diaphragmatic face of the right liver, had ruptured into peritoneum. Hepatic bleeding was stopped using a conservative approach by Pringle manoeuvre, parenchymal suture and fibrin sealant. There was no complication related to hepatic surgery but the patient died because of new massive pulmonary embolism 10 days after surgery. The absence of underlying liver pathology was confirmed by autopsy examination. This case report suggests that the possibility of spontaneous liver rupture should be considered in patients being treated with oral anticoagulants. Early diagnosis are critically important given the high morbidity and mortality. Aggressive resuscitation and immediate exploratory laparotomy is needed when hemodynamic instability occurs. In our case a quick, safe and effective control of bleeding was provided by partial vascular occlusion, parenchymal suture and topical haemostatic agent. KEY WORD: Anticoagulant therapy, Araumatic hemoperitoneum, Liver hematoma.

The effect of sleeve gastrectomy on GLP-1 secretion and gastric emptying: a prospective study.

BACKGROUND: Rapid gastric emptying has been proposed to justify the increase in glucagon-like polypeptide-1 (GLP-1) after laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: To assess gastric emptying changes after LSG and their relationship with GLP-1 secretion. SETTING: San Salvatore Hospital general surgery unit, University of L'Aquila, Italy. METHODS: 52 patients underwent gastric emptying scintigraphy for liquid and solid foods, before and 3 months after LSG. Twenty-six patients were in the liquid group (L group) and the remaining in the solid group (S group). We evaluated the half time of gastric emptying (T1/2) and percentage of gastric retention (%GR) at 15, 30, and 60 minutes for liquids and at 30, 60, 90, and 120 minutes for solids. GLP-1 plasma concentrations were measured in each group before and after LSG and related to %GR. Statistical analysis was performed by Χ2 test and Pearson correlation(r). RESULTS: After surgery, T1/2 was significantly accelerated: 15.2±13 min and 33.5±18 min in the L group and S group, respectively (P<.05). In both groups, GLP-1 plasma concentrations were increased at each blood sampling time: 2.91±2.9 pg/mL, 3.06±3.1 pg/mL and 3.21±2.6 pg/mL at 15, 30, and 60 minutes, respectively, (P<.05) for L group and 2.72±1.5 pg/mL, 2.89±2.1 pg/mL, 2.93±1.8 pg/mL, and 2.95±1.9 pg/mL at 30, 60, 90, and 120 minutes, respectively, (P< .05) for the S group. After LSG, GLP-1 and %GR presented a negative linear correlation (r) at each blood sampling time in both groups. CONCLUSION: The rapid gastric emptying 3 months after LSG upregulates the production of GLP-1 in the distal bowel. Further studies are needed to confirm these findings.

Effect of Resected Gastric Volume on Ghrelin and GLP-1 Plasma Levels: a Prospective Study.

BACKGROUND: The correlation between resected gastric volume (RGV) and neuro-humoral changes (ghrelin and GLP-1) after laparoscopic sleeve gastrectomy (LSG) and their effects on type 2 diabetes mellitus (T2DM) has been evaluated. MATERIALS: Ninety-eight patients were divided in two groups: RGV <1200 mL (group A: 53 pts) and RGV >1200 mL (group B: 45 pts). Insulin secretion (insulin area under the curve (AUC)), insulinogenic index (IGI) and insulin-resistance (homeostasis model assessment, HOMAIR) were assessed before and after surgery (at the 3rd day and 6, 12 and 24 months after LSG) using the oral glucose tolerance test (OGTT). At the same time, ghrelin and GLP-1 levels were determined. RESULTS: A significant difference in T2DM resolution rate was observed after 6, 12 and 24 months in favour of RGV >1200 mL. Group B performed better than group A at the 3rd day and at the 6th, 12th and 24th months with regard to AUC, IGI and HOMAIR. In both groups, OGTT resulted in decreased ghrelin values and a significant increase in GLP-1 values for group B at the 3rd day and at the 6th and 12th months with no difference at the 24th month. CONCLUSION: Ghrelin and GLP-1 changes play a role in the regulation of glucose metabolism during the 1st year after LSG. RGV influences ghrelin and GLP-1 plasma levels after LSG, with a significant improvement in the T2DM control.

Intestinal permeability and systemic endotoxemia in patients with acute pancreatitis.

BACKGROUND: The bacterial contamination of pancreatic necrosis in acute pancreatitis is supposed to occur through translocation of intestinal bacteria. The aim of this clinical study was to evaluate intestinal mucosa permeability and endotoxemia in patients with acute pancreatitis. METHODS: Sixtythree patients with acute pancreatitis were studied. Classification 42 patients had mild and 21 patients severe pancreatitis. Intestinal permeability was assessed at day 0, 1, 3, 7, 9 and 11 using the lactulose/mannitol differential absorption test. Serial venous blood samples were taken at 0, 30, 60, 90, 120, and 180 minutes, at 12, 24 hours, and at days 3, 7, 9 and 11 for endotoxin measurement RESULTS: Patients with severe pancreatitis had higher intestinal barrier dysfunction compared with patients with mild pancreatitis, the L:M ratio being 0.36 ± 0.15 and 0.051 ± 0.013 respectively (p< 0.05). The systemic endotoxin concentration were higher in patients with severe pancreatitis as regards mild pancreatitis (p < 0.05). A significant correlation was observed between the maximum systemic endotoxin concentration and intestinal permeability measured at day 7 in patients with mild (rs = 0.721; p = 0.001) and severe (rs = 0.956; p= 0.001) pancreatitis. CONCLUSION: Gut permeability is increased in patients with acute pancreatitis. Patients with severe pancreatitis may be more exposed to impaired gut barrier function. Moreover the pancreatits (especially severe) can lead to systemic endotoxemia. This agrees with the hypothesis that the splanchnic hypoperfusion, during the pancreatitis, may impair intestinal mucosal barrier function and contribute to the systemic inflammatory response and multiorgan failure. KEY WORDS: Acute pacreatitis, Endotoxemia, Intestinal permeability.

Twelve years of gastric GIST A retrospective study of laparoscopic and open approach.

PURPOSE: The authors wanted to evaluate the outcome of laparoscopic and open resection for gastric GISTs, in the long and short run with a retrospective study based on 63 consecutive patients. METHODS: Two surgical groups were compared according to age, sex, ASA group and Surgical procedure: a laparoscopic resection was performed on 30 patients (47,7%) while the open approach was preferred for 33 patients (52,3%). Duration of surgery, blood loss, positive resection margins, postoperative morbidity, postoperative ileus, hospital stay, tumor's mean dimensions, degree of malignancy and recurrences rate and 5-years mortality were compared in subgroups. RESULTS: Significant differences between Open Gastrectomy group and Laparoscopic Gastrectomy group were found in blood loss 425 ml (180-610) vs 137 ml (110-320), postoperative ileus 4,1D (3-6) vs 2,3D (1-7), hospital stay 15D (8-25) vs 10D (8-17), neoplasia mean dimensions in patients who underwent total gastrectomy ( 7,1±0,9 cm vs 5,3±0,5 cm) and atypical gastrectomy (4,3±0,8 cm vs 2,2±0,3 cm), high degree of malignancy in patients who underwent subtotal gastrectomy (4 vs 0 pz) and 5-years mortality in patients who underwent total gastrectomy (36.6% vs 12.5%). CONCLUSIONS: Poor blood loss, shorter postoperative ileus and shorter hospital stay in the LG group show that laparoscopy can be performed safely and efficiently in gastric GISTs.

Reconstruction of Scrotal Sac and Penis with Biological Prosthesis and Vacuum Therapy.

Fournier's gangrene is a rapidly progressing necrotizing fasciitis, involving perineal, perianal, or genital regions, and it constitutes a true surgical emergency. Surgical excision of all necrotic tissue is required, and multiple debridements may be necessary to remove all nonviable tissue. After surgical intervention for debridement, reconstruction may be necessary. We present our experience in the treatment of tissue loss after Fournier's gangrene of genital and perianal regions with the use of biological mesh (derma porcine mesh) in association with vacuum-assisted closure therapy.