Projection of Gut Microbiome Pre- and Post-Bariatric Surgery To Predict Surgery Outcome.

Bariatric surgery is often the preferred method to resolve obesity and diabetes, with ∼800,000 cases worldwide yearly and high outcome variability. The ability to predict the long-term body mass index (BMI) change following surgery has important implications for individuals and the health care system in general. Given the tight connection between eating habits, sugar consumption, BMI, and the gut microbiome, we tested whether the microbiome before any treatment is associated with different treatment outcomes, as well as other intakes (high-density lipoproteins [HDL], triglycerides, etc.). A projection of the gut microbiome composition of obese (sampled before and after bariatric surgery) and lean patients into principal components was performed, and the relation between this projection and surgery outcome was studied. The projection revealed three different microbiome profiles belonging to lean, obese, and obese individuals who underwent bariatric surgery, with the postsurgery microbiome more different from the lean microbiome than the obese microbiome. The same projection allowed for a prediction of BMI loss following bariatric surgery, using only the presurgery microbiome. The microbial changes following surgery were an increase in the relative abundance of Proteobacteria and Fusobacteria and a decrease in Firmicutes. The gut microbiome can be decomposed into main components depicting the patient's development and predicting in advance the outcome. Those may be translated into the better clinical management of obese individuals planning to undergo metabolic surgery. IMPORTANCE BMI and diabetes can affect the gut microbiome composition. Bariatric surgery has large variabilities in the outcome. The microbiome was previously shown to be a good predictor for multiple diseases. We analyzed here the gut microbiome before and after bariatric surgery and showed the following. (i) The microbiome before surgery can be used to predict surgery outcomes. (ii) The postsurgery microbiome drifts further away from the lean microbiome than the microbiome of the presurgery obese patients. These results can lead to a microbiome-based presurgery decision whether to perform surgery.

Pilonidal Sinus Management; Bascom Flap Versus Pilonidal Pits Excision: A Single-Center Experience.

PURPOSE: This study aimed to evaluate the outcomes of the Bascom cleft lift (flap) and the pilonidal pits excision (Gips procedure). METHODS: The records of all the patients who underwent pilonidal sinus excision between November 2013 and August 2017 were reviewed. Inclusion criteria included either pilonidal pits excision or the Bascom cleft lift procedure. All procedures were performed by a single surgeon. Perioperative complications and recurrence rates were reviewed. RESULTS: Fifty-three patients met the inclusion criteria. Male/female ratio was 36/17, with a mean age of 23.4 ± 7 years. In this study, 21 patients underwent the Bascom cleft lift (skin flap) procedure and 32 underwent the Gips-style operation. The mean follow-up was 3.5 months. Twenty-eight patients (52.8%) underwent prior drainage of pilonidal abscess. Eleven patients had a previous wide local excision with recurrent disease. A higher rate of recurrence was observed among patients who underwent pits picking following failure of a previous wide local excision (80% vs. 0%, P = 0.02). Minor wound dehiscence developed in 8 patients; all of which were in the Bascom flap group (40% vs. 0%, P < 0.005). All of these wounds healed completely between 3 and 6 weeks. CONCLUSION: The Gips procedure is the recommended treatment for simple pilonidal disease. For recurrent pilonidal disease, the Bascom cleft lift (flap) procedure is an excellent option since it demonstrates a short wound healing time and a good success rate. This calls into question the continued use of the wide excision technique used by most surgeons in this country and abroad.

SYMPTOMATIC AND ASYMPTOMATIC HYPOGLYCEMIA POST THREE DIFFERENT BARIATRIC PROCEDURES: A COMMON AND SEVERE COMPLICATION.

Background: The prevalence of post-bariatric surgery hypoglycemia (PBH) remains unclear due to diagnostic criteria variability, types of bariatric procedures and possible unawareness. Objective: To determine the frequency, pattern and severity of symptomatic and asymptomatic hypoglycemia in subjects post three different bariatric procedures performed >1 year before evaluation and a group of obese subjects before surgery. Design and Setting: Observational cohort study. Fifty-one consecutive patients participated: post Roux-en-Y gastric-bypass (RYGB) (n=16), post omega-loop gastric-bypass (OLGB) (n=12), post sleeve-gastrectomy (SG) (n=15), obese subjects before surgery (controls) (n=8). Hypoglycemic events (glucose ≤54 mg/dL) and severe hypoglycemia (glucose ≤40 mg/dL) were evaluated by symptoms' questionnaire, mixed-meal tolerance test (MMTT) and continuous glucose monitoring (CGM). Results: According to questionnaires, meal-related complaints were reported in 11 (26%) of the surgical group and in one control subject. During MMTT, 88%, 82% and 67% experienced hypoglycemia in RYGB, OMGB and SG groups, respectively, vs. none of the controls (P<0.001). Severe hypoglycemia occurred in 38%, 45% and 7% in RYGB, OMGB and SG groups, respectively (P=0.025), but only 10 of the total operated patients (24%) reported any symptoms. During CGM, fasting hypoglycemic events occurred more in RYGB and OLGB vs. SG group: 55%, 63% and 17% respectively (P=0.036). Conclusions: PBH is very common after RYGB, OMGB and SG and can be severe especially following bypass procedures. Our results show that hypoglycemia occurs not only postprandially but also in the fasting state, especially following bypass procedures. In most cases, there were no specific complaints, possibly leading to its underestimation.

Anal canal adenocarcinoma with a late brain metastatic lesion - a case report / Adenocarcinoma de canal anal com lesão cerebral metastática tardia - um relato de caso

ABSTRACT Herein we present a rare case of anal canal adenocarcinoma manifesting as non-healing perianal abscess that subsequently underwent radiochemotherapy followed by abdominoperineal resection for residual disease. The patient recovered, and a year later presented with a single brain metastasis. The lesion was successfully resected, and the patient is now disease free.

RESUMO Apresentamos aqui um caso raro de adenocarcinoma de canal anal que se manifesta como abscesso perianal não cicatrizado que subsequentemente foi submetido à radioquimioterapia seguida de ressecção abdominoperineal por detecção de doença residual. O paciente recuperou-se e um ano depois apresentou uma única metástase cerebral. A lesão foi ressecada com sucesso e o paciente agora está livre da doença.

Comparison between laparoscopic and open Hartmann's reversal: results of a decade-long multicenter retrospective study.

BACKGROUND: Hartmann's reversal is a challenging surgical procedure with significant postoperative morbidity rates. Various surgical methods have been suggested to lower the risk of postoperative complications. In this study, we aimed to compare the postoperative results between open and laparoscopic techniques for Hartmann's reversal. METHODS: A retrospective study of all patients who underwent Hartmann's reversal in five centers in central Israel between January 2004 and June 2015 was conducted. Medical charts were reviewed, analyzing preoperative and operative parameters and short-term postoperative outcomes. RESULTS: 260 patients were included in the study. 76 patients were operated laparoscopically with a conversion rate of 26.3% (20 patients). No differences were found between patients operated laparoscopically and those operated in an open technique regarding gender (p = 0.785), age (61.34 vs. 62.64, p = 0.521), body mass index (26.6 vs. 26.2, p = 0.948), Charlson index score (1.79 vs. 1.95, p = 0.667), and cause for Hartmann's procedure (neoplastic vs. non-neoplastic, p = 0.644). No differences were seen in average time from the Hartmann's procedure to reversal (204.89 vs. 213.60 days, p = 0.688) and in overall complication rate (46.4 vs. 46.5%, p = 1). The Clavien-Dindo score for distinguishing between minor (0-2 score, p = 1) and major complications (3-5 score, p = 0.675) failed to demonstrate an advantage to laparoscopy, as well as to average length of stay (10.91 days in the laparoscopic group vs. 11.72 days in the open group, p = 0.529). An analysis based on the intention-to-treat with laparoscopy, including converted cases in the laparoscopic group, showed similar results, including overall complication rate (48.6 vs. 45.6%, p = 0.68) and Clavien-Dindo score in both minor (p = 0.24) and major complications (p = 0.44). Length of stay (10.92 vs. 11.81 days, p = 0.45) was also similar between the two groups. CONCLUSION: In this series, a laparoscopic approach to Hartmann's reversal did not offer any short-term advantage when compared to an open surgical approach.

Anastomotic Stricture Rates Following Roux-en-Y Gastric Bypass for Morbid Obesity: A Comparison Between Linear and Circular-Stapled Anastomosis.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective procedure in the management of morbid obesity with variations in outcome, which are technique dependent. Anastomotic stricture remains an important complication. The aim of this study was to assess the long-term outcome of patients undergoing either a linear-stapled anastomosis (LSA) or circular-stapled anastomosis (CSA) with an emphasis on postoperative stricture formation and excess body weight loss (EBWL). METHODS: Medical records of all patients who underwent bariatric surgery between 2008 and 2013 at a single bariatric surgical center were reviewed. All patients who had a LRYGB were included in the study. Patients were divided in two groups based on stapling technique-LSA and CSA. Patient groups were compared with regard to perioperative complication, EBWL. RESULTS: A total of 114 patients were included in the study. There were 51 patients in the LSA group and 63 in the CSA group. No differences were found between the two groups with regard to operative time, hospital stay, or in the EBWL over a 12-month follow-up period. Anastomotic stricture developed in 4 patients, all occurring in the LSA group (7.8%). Three of these patients had undergone successful endoscopic dilatation. CONCLUSIONS: Both stapling techniques resulted in a similar EBWL during the follow-up period and an acceptable safety profile. Anastomotic stricture rate was slightly higher in the LSA, but this did not affect EBWL.

Considerations for Hartmann's reversal and Hartmann's reversal outcomes-a multicenter study.

PURPOSE: Hartmann's procedure is commonly practiced in emergent cases with the restoration of bowel continuity planned at a second stage. This study assessed the rate of restorations following Hartmann's procedure and evaluated factors affecting decision-making. METHODS: Data on patient demographics, comorbidities, causes for Hartmann's procedure, reversal rate, and complications were collected in a multicenter retrospective cohort study of patients who underwent Hartmann's procedure in five medical centers. RESULTS: Six hundred forty patients underwent Hartmann's procedure for diverticular disease (36.1%), obstructing malignancy (31.8%), benign obstruction (5%), and other reasons (23.1%). Overall, 260 (40.6%) patients underwent subsequent restoration of bowel continuity. One hundred twenty-one (46.5%) patients had post-reversal complications, with an average Clavien-Dindo score of 1.4 and a mortality rate of 0.77%. Decision to avoid reversal was mostly related to comorbidities (49.7%) and metastatic disease (21.6%). Factors associated with the decision to restore bowel continuity included male gender (P = 0.02), patient age (62.3 years in Hartmann's reversal patients vs 73.5 years in non-reversal patients; P < 0.0001), number of comorbidities (1.1 vs 1.58; P < 0.001), average Charlson score (1.93 vs 3.44; P < 0.001), and a neoplastic etiology (P < 0.0001). A sub-analysis excluding all patients who died in the 30 days following Hartmann's procedure showed similar factors associated with ostomy closure. CONCLUSION: Many patients do not have restoration of bowel continuity after undergoing Hartmann's procedure. Hartmann's reversal is associated with a significant postoperative morbidity. Surgeons and patients should be aware of the possibility that the colostomy might become permanent.

Percutaneous cholecystostomy in the management of high-risk patients presenting with acute cholecystitis: Timing and outcome at a single institution.

BACKGROUND: Cholecystectomy is the standard of care in acute cholecystitis (AC). Percutaneous cholecystostomy (PC) is an effective alternative for high-risk surgical cases. METHODS: A retrospective analysis is presented of AC patients treated with PC drainage at a single tertiary institution over a 21 month period, assessing outcome and complications. RESULTS: Of 119 patients, 103 had clinical improvement after PC insertion. There were 7 peri-procedural deaths (5.9%), all in elderly high-risk cases. Overall, 56/103 cases (54%) were definitively managed with PC drainage with 41 patients (40%) undergoing an elective cholecystectomy (75% performed laparoscopically). The timing of PC insertion did not affect AC resolution or drain-related complications, although more patients underwent an elective cholecystectomy if PC placement was delayed (>24 h after admission). CONCLUSIONS: In AC, drainage by a PC catheter is a safe and effective procedure. It may be used either as a bridge to elective cholecystectomy or in selected cases as definitive therapy.

The Charlson Comorbidity Index (CCI) as a Mortality Predictor after Surgery in Elderly Patients.

The increasing range of surgery in elderly patients reflects the changing demography where in the next 10 years one quarter of the population will be 65 years of age or older. There is presently no consensus concerning the optimal predictive markers for postoperative morbidity and mortality after surgery in older patients with an appreciation that physical frailty is more important than chronological age. In this retrospective analysis, we have compared the impact of age and the calculated preoperative Charlson Comorbidity Index (CCI) on early (30-day) and late (one-year) mortality in a group of patients >75 years of age dividing them into an "older old" cohort (75-84 years of age, Group A) and an "oldest old" group (≥85 years of age, Group B). Increased age was associated with a higher death rate after emergency surgery, with late deaths after elective surgery exceeding those after emergency operations. A higher mean CCI was noted in both age groups in early nonsurvivors after both elective and emergency surgery with a more significant effect of the preoperative CCI than chronological age for the prediction of late postoperative death for both groups after elective and emergency operations. Although the CCI was not designed to predict perioperative mortality in surgical cohorts, it correlates with a greater risk than age for perioperative death in the elderly.

Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations.

BACKGROUND: Perforation after endoscopic retrograde cholangiopancreatography (ERCP) is uncommon, and its management is dependent on the mechanism and the graded classification of injury. METHODS: Records of patients undergoing ERCP were analyzed over a 16-year period, patterning the types of injuries, diagnosis, management, and patient outcome. Type I injuries damage the medial or lateral duodenal wall before sphincter cannulation. Type II injuries are periampullary and occur as a result of a precut or a papillotomy. Type III injuries occur secondary to guidewire insertion or stone extraction from the common bile duct. Type IV injuries are probably microperforations that are noted on excessive insufflation during and after ERCP withdrawal. RESULTS: Between 1995 and 2011, 27 perforations were identified from 1,638 ERCP procedures (1.6%). Nearly half of the procedures were regarded as difficult by the endoscopist, with 70% of the ERCPs (19 of 27) being for therapeutic indications. There were 5 type I, 12 type II, 5 type III, and 5 type IV perforations, of which 18 cases were diagnosed at the time of ERCP. Delayed diagnosis of type I perforations that were associated with free intraperitoneal air and contrast leakage proved fatal. Most type II perforations required immediate surgery with pyloric exclusion; delayed surgery with simple drainage had a high mortality rate. Most type III and type IV injuries can successfully be managed conservatively without delayed sepsis. CONCLUSIONS: In perforation, the mechanism of injury during ERCP predicts the need for surgical management. Type I and type II injuries require early diagnosis and aggressive surgery, whereas type III and type IV injuries may be managed conservatively.

Selective utilization of pre-operative endoscopic ultrasound to exclude choledocholithiasis prior to laparoscopic cholecystectomy: a retrospective study.

BACKGROUND/AIMS: The objective of this study was to define the clinical, biochemical and ultrasonographic criteria correlating with a likelihood of a positive preoperative endoscopic ultrasound (EUS) in patients presenting with acute gallstone-related pancreatobiliary disease. METHODOLOGY: All patients who underwent EUS prior to elective laparoscopic cholecystectomy were analyzed at the Gastroenterology Unit, Kaplan Medical Center, following acute admission with cholecystitis, cholelithiasis, cholangitis, acute pancreatitis and obstructive jaundice. RESULTS: One hundred and seventy four patients met the inclusion criteria. EUS showed choledocholithiasis in 37 (21.3%) with 35/37 undergoing a preoperative ERCP (24/35 cases - 64.9% positive yield). Twenty seven of the positive EUS studies (73%) were performed during the acute illness, with 50 of the 137 negative studies (36.4%) performed during the acute phase of the illness (p=0.0001). On multivariate analysis, a positive EUS was more commonly found during the acute phase of the illness [OR: 3.445; 95% CI: 1.48-8.008, p=0.004] or if there was transient jaundice [OR: 1.167; 95% CI: 1.002-1.36, p=0.047]. CONCLUSIONS: The timing of the examination influences the detection rate of CBD stones by EUS prior to surgery although it may be appropriate to more selectively use EUS in those patients with hyperbilirubinaemia and/or where the CBD is dilated.

Improving the diagnostic accuracy of ultrasonography in suspected acute appendicitis by the combined transabdominal and transvaginal approach.

Transabdominal ultrasound has a lower diagnostic yield in acute appendicitis than computed tomography (CT) scanning. The addition of transvaginal sonography in women with suspected appendicitis has shown improvement in the efficacy of diagnosis, potentially providing the option of selective CT use and reducing overall investigative cost and surgical delay. Two hundred ninety-two women who underwent combined transabdominal and transvaginal ultrasound for suspected acute appendicitis were evaluated. Patients were divided into two groups; Group 1 including patients with a positive sonographic diagnosis of appendicitis who underwent operation and Group 2 including patients with a negative sonographic diagnosis. Of the 157 women in Group 1, the diagnosis of appendicitis was histologically confirmed in 144 patients with five cases having a normal appendix in whom eight other pathologies were found. Of the 135 women with negative ultrasound examinations, 14 underwent surgery in which four cases of appendicitis were found. The sensitivity of the combined approach was 97.3 per cent, the specificity 91 per cent, the positive predictive value 91.7 per cent, and the negative predictive value 97 per cent. Combined ultrasound has a high predictive value for the diagnosis of appendicitis and may assist in reduction of the use of CT scanning for diagnosis and in the negative appendectomy rate.

Phase II study of UFT with leucovorin plus hepatic arterial infusion with irinotecan, 5-fluorouracil and leucovorin for non-resectable liver metastases of colorectal cancer.

BACKGROUND: Compared with systemic therapy, hepatic arterial infusion (HAI) increases the response to fluoropyrimidines. METHODS: Thirty-one patients with non-resectable, colorectal cancer (CRC) liver metastases received irinotecan 120 mg/m(2), followed by leucovorin (LV) 20 mg/m(2) and 5-fluorouracil (5-FU) 500 mg/m(2) administered by HAI every 2 weeks, plus UFT (tegafur-uracil) 200 mg/m(2)/day with LV 30 mg/day on days 1-22, followed by a 6-day rest. RESULTS: The objective response rate was 65% (all 20 patients achieving a partial response). Ten patients (32%) had stable disease. The median time to progression (TTP) and overall survival (OS) were 12 and 36 months. OS was similar in patients with low versus high expression of thymidylate synthase (TS) and/or dihydropyrimidine dehydrogenase (DPD). The regimen was well tolerated. CONCLUSIONS: UFT with LV plus HAI irinotecan and 5-FU/LV was a feasible and effective treatment for non-resectable CRC liver metastases, increasing response, TTP and OS. TS and DPD levels in liver metastases did not predict outcome.

Small bowel obstruction caused by secondary tumors.

Small bowel obstruction in an oncology patient is a common and serious medical problem which is associated with diagnostic as well as therapeutic dilemmas. While the condition is most commonly caused by postoperative adhesions and peritoneal carcinomatosis, other causes have been reported [Cormier WJ, Gaffey TA, Welch JM, et al. Linitis plastica caused by metastatic lobular carcinoma of the breast. Mayo Clinical Proceedings 1980;55:747-53; Clavien P-A, Laffer U, Torhos J, et al. Gastrointestinal metastases as first clinical manifestation of the dissemination of a breast cancer. European Journal of Surgical Oncology 1990;16:121-6; Bender GN, Maglinte DD, McLarney JH, et al. Malignant melanoma: patterns of metastasis to the small bowel, reliability of imaging studies, and clinical relevance. American Journal of Gastroenterology 2001;96:2392-400; Gatsoulis N, Roukounakis N, Kafetzis I, et al. Small bowel intussusception due to metastatic malignant melanoma. A case report. Technical Coloproctology 2004;8:141-3; Hung GY, Chiou T, Hsieh YL, et al. Intestinal metastasis causing intussusception in a patient treated for osteosarcoma with history of multiple metastases: a case report. Japanese Journal of Clinical Oncology 2001;31(4):165-7; Chen TF, Eardley I, Doyle PT, Bullock KN. Rectal obstruction secondary to carcinoma of the prostate treated by transanal resection of the prostate. British Journal of Urology 1992;70(6):643-7; Kamal HS, Farah RE, Hamzi HA, et al. Unusual presentation of rectal adenocarcinoma. Roman Journal of Gastroenterology 2003;12(1):47-50; Hofflander R, Beckes D, Kapre S, et al. A case of jejunal intussusception with gastrointestinal bleeding caused by metastatic testicular germ cell cancer. Digestive Surgery 1999;16(5):439-40]. One of these, reported thus far in only very few patients, is obstruction caused by secondary tumors, i.e. metastases from other organs to the small bowel wall. As cancer patients live longer with improved therapy, physicians are more likely to cope with rare phenomena of neoplasms, such as small bowel obstruction caused by secondary tumors. We hereby present a review of the relevant medical literature. The goal of this article is to define current knowledge on this phenomenon, with emphasis on its epidemiology and clinical characteristics, and to increase the awareness of the clinician treating cancer patients of such possibility.

Pelvic actinomycosis masquerading as malignancy: report of two cases and review of the literature.

Pelvic actinomycosis is uncommon, presenting most frequently as an abdominal mass and simulating advanced malignancy in female patients with a past history of intrauterine contraceptive use. It responds favourably to prolonged antibiotic therapy with occasional need for abscess drainage and débridement or ureteric stenting. Incorrect diagnosis may result in overly invasive investigations and unnecessarily radical extirpative surgery.