Systematic Review and Meta-analysis of the Effects of Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy on Dyslipidemia.

The aim of this meta-analysis was to compare the effects of LRYGB and LSG on dyslipidemia. Studies comparing the effects of LRYGB and LSG on dyslipidemia with follow-up of 12 months or more were included. Twenty-four studies comprising seven RCTs and 17 comparative observational studies were included. Meta-analysis of RCTs (n=487) showed that improvement/resolution of dyslipidemia was better after LRYGB (68.5%, n=161/235) compared to LSG (48.4%, n=122/252). Patients undergoing LRYGB were more than twice as likely to experience improvement/resolution in dyslipidemia compared to those undergoing LSG (OR 2.28, 95% CI 1.21-4.29, p=0.010). Both LRGYB and LSG appears effective in improving dyslipidemia at >12 months after surgery; however, this improvement is more than twice higher after LRYGB compared to LSG.

Critical number of lymph node involvement in esophageal and gastric cancer and its impact on long-term survival-A single-center 8-year study.

BACKGROUND: Nodal disease in esophageal and gastric cancer is associated with poor survival. OBJECTIVES: To determine the critical level of lymph node involvement where survival becomes significantly compromised. METHODS: Survival analyses using multivariable Cox regression and receiver operator characteristics (ROC) were undertaken to determine what number of positive lymph nodes were most sensitive and specific in predicting survival. RESULTS: A total of 317 patients underwent esophagectomy (n = 190, 59.9%) and gastrectomy (n = 127, 40.1%) for adenocarcinoma. At multivariable analyses, four nodes positivity (irrespective of T-category) was associated with nearly a fivefold increased risk of mortality when compared to node-negative patients (hazard ratio [HR], 4.9; interquartile range 2.0-11.5; P < .001). A positive ratio of up to 50.0% was not associated with worse survival than having four nodes positive (HR, 4.6; 95% confidence interval, 2.6-8.1; P < .001). ROC analysis demonstrated four lymph nodes positive to have a sensitivity of 80.5%, a specificity of 60.1%, and an accuracy of 77.8 (P < .001). CONCLUSION: The absolute number of nodes positive for cancer is more important than the proportion of positive nodes in predicting survival in esophageal/gastric cancer. Four positive lymph nodes are associated with a fivefold increase in mortality. Beyond this, increasing numbers of positive lymph nodes make no appreciable difference to survival.

A Safe and Effective Technique of Paraesophageal Hernia Reduction Using Combined Laparoscopy and Nonsutured PEG Gastropexy in High-Risk Patients.

BACKGROUND: Paraesophageal hernias (PHs) can cause significant morbidity and even mortality in untreated patients. While formal surgical repair remains the ideal treatment option, patients who are elderly and/or frail and who have with multiple comorbidities may be unsuitable candidates for a surgical repair. We present a case series of 5 patients treated with a combined laparoscopic reduction of PH and 2-point percutaneous endoscopic gastropexy (PEG). METHODS: Data on the 5 patients were collated, and a review of the literature was performed to determine similar cases and outcomes. RESULTS: Five elderly patients (mean age 80 y, range 71-89 y) with significant existing comorbidities (average ASA 3) presented acutely with large PH at our institution. All had abdominal pain, nausea/vomiting, symptoms of gastric outlet obstruction, and an element of hypoxia. Computed tomography examination results confirmed the diagnosis. Because the patients were elderly and frail, a formal surgical repair of the PHs was not feasible. A combined laparoscopy/PEG gastropexy was undertaken to reduce the PH, and a 2-point PEG fixation was performed. Four of the 5 patients returned to normal oral intake before discharge. A fifth patient was successfully fed via the PEG. There were no complications, and all were discharged to their usual place of residence. CONCLUSION: A combination of laparoscopic reduction and nonsutured PEG gastropexy is a safe and effective alternative treatment for high-risk patients (with significant morbidity and mortality) with symptomatic PHs. Most patients (80%) returned to normal oral intake postprocedure and were discharged home within 3 d.

Distinct sonographic features of acute appendicitis in sickle cell disease.

BACKGROUND AND OBJECTIVES: The purpose of this study was to report sonographic findings of appendicitis in patients with positive screening tests for sickle cell compared to normal control patients. DESIGN AND SETTING: A retrospective study of the medical records of 396 patients who underwent appendectomy during a 3-year period from March 2005-2008. PATIENTS AND METHODS: The study included 216 males and 180 females, whose ages ranged from 7 to 55 years. Four patients (0.9%) had sickle cell disease (SCD), 101 had sickle cell trait (SCT) (25%) and 291 (74%) patients were without sickle cell anemia (control group). RESULTS: Positive sonographic findings of appendicitis were identified in 95 (90%) SCT patients and in 253 (87%) control patients. The mean maximal mural thickness was higher in sickle cell patients (4.5 [1.4] mm) in comparison with the control group (3.0 [2.2] mm) (P < .0001). Appendicolith was significantly detected in 53% of the control group and in 8.5% of the sickle cell group (P < .0001). Color Doppler showed hypervascularity in 72% of patients with appendicitis in the control group with a significant difference compared to only 12 cases (11%) of SC patients (P < .05). Ultrasonography findings suggesting perforation were found in 35 sickle cell patients and in 75% (3 of the 4 patients) with SCD. Findings suggesting perforation were found only in 49 patients (17%) of the control group. Perforated appendix was significantly higher in sickle cell patients in preoperative US and intraoperatively (P < .05) CONCLUSION: Positive sonographic findings of appendicitis in sickle cell patients are different from the general population. These findings include mural thickening with a low incidence of appendicolith and wall hypervascularity. Also sonographic features of perforation in sickle cell patients are more common suggesting a need for more urgent operative intervention.

Submucosal lipoma acting as a leading point for colo-colic intussusception in an adult.

Intussusception in adults is a rare condition, in contrast to paediatric intussusception where the majority of cases are idiopathic, ∼90% of adult cases have identifiable aetiology. The clinical presentation is often non-specific abdominal pain. We report the case of a 49-year-old gentleman who presented to our emergency department with a 10-day history of colicky abdominal pain. Computed tomography imaging revealed a lipomatous mass lesion in the transverse colon leading to intussusception. An extended right hemicolectomy was performed with a good result. Histology confirmed that the leading point of the intussusception was a large submucosal lipoma. Gastrointestinal lipomas are rare and largely asymptomatic. However, they may cause abdominal pain, bleeding per rectum, obstruction or intussusception. Since adult colonic intussusception is frequently associated with malignant organic lesions, the differential diagnosis is important, and timely surgical intervention paramount.

Unusual cause of a painful right testicle in a 16-year-old man: a case report.

INTRODUCTION: Urgent surgical exploration of the scrotum of a child or teenager who presents with a painful and swollen testicle is paramount if testicular torsion is not to be missed. It is extremely rare for a non-scrotal pathology to present with acute scrotal signs. Here we present such a rare case and emphasize the importance of being aware of this potential clinical pitfall. CASE PRESENTATION: A 16-year-old Caucasian man presented as a surgical emergency with a five to six hour history of a painful, red, and swollen right hemiscrotum. He also complained of vague lower abdominal pain, vomiting, and watery diarrhea. He had a temperature of 38.5°C and a tender, red, and swollen right hemiscrotum. The right testicle appeared elevated. He was mildly tender in his central and upper abdomen and less so in the lower abdomen. No convincing localizing abdominal signs were noted. He had an increased white cell count (15 × 109/L) and C-reactive protein (CRP; 300 mg/L). Urgent right hemiscrotal exploration revealed about 5 ml of pus in the tunica vaginalis and a normal testicle. A right iliac fossa incision identified the cause: a perforated retrocecal appendix. Appendectomy was performed, and both the abdomen and scrotum washed copiously with saline before closure. The patient made an uneventful recovery. CONCLUSION: Acute appendicitis presenting with scrotal signs due to a patent processus vaginalis is an extremely rare clinical entity. To date, fewer than five such cases have been reported in the medical literature. It is, therefore, extremely important to be aware of this unusual clinical scenario, as only a high index of suspicion will enable prompt, successful management of both the appendicitis and the scrotal abscess.

Use of hand held Doppler to identify venous tributaries in in situ vein arterial bypass.

BACKGROUND: It very important to reduce the morbidity associated with arterial bypass surgery by minimizing the length of incision used in infrainguinal bypass surgery using in situ vein as a conduit. This paper describes a quick and less invasive method of identifying the location of vein tributaries using Hand Held Doppler in arterial bypass surgery with local cut down instead of extensive exposure. METHODS: The technique was used in 19 consecutive procedures. Fourteen grafts were subsequently evaluated for completeness of tributary ligation using duplex scanning. RESULTS: A mean of 2.5 tributaries were identified per limb. Thus, there were 35 patent tributaries in our cohort of 14 patients. None was of clinical significance. Four occluded spontaneously during the period of study. Wound length was reduced by 30-60% depending on the total length of the incision. CONCLUSION: This technique is an effective, cheap and simple means of performing bypass surgery in high-risk patients (with significant comorbidity and a high ASA score) and also reducing inherent complications associated with the length of the incision.

Bleeding prolapsed hemorrhoids as a presentation of ruptured internal iliac artery aneurysm: report of a case.

Internal iliac artery aneurysms (IIAAs) are rare and their concealed location in the pelvis presents a diagnostic challenge. We report a case of a 79-year-old man who presented 12 years after an abdominal aortic aneurysm repair, with signs of prolapse, bleeding, hemorrhoids, and a deep vein thrombosis. His condition rapidly deteriorated, with the development of acute renal failure and obvious perianal and perineal ecchymoses, within a few days. Abdominal ultrasound and computed tomography showed a ruptured IIAA. His renal function returned to normal after surgical decompression of the aneurysm.

Radiation enteropathy and leucocyte-endothelial cell reactions in a refined small bowel model.

BACKGROUND: Leucocyte recruitment and inflammation are key features of high dose radiation-induced tissue injury. The inflammatory response in the gut may be more pronounced following radiotherapy due to its high bacterial load in comparison to the response in other organs. We designed a model to enable us to study the effects of radiation on leucocyte-endothelium interactions and on intestinal microflora in the murine ileum. This model enables us to study specifically the local effects of radiation therapy. METHOD: A midline laparotomy was performed in male C57/Bl6 mice and a five-centimetre segment of ileum is irradiated using the chamber. Leucocyte responses (rolling and adhesion) were then analysed in ileal venules 2 - 48 hours after high dose irradiation, made possible by an inverted approach using intravital fluorescence microscopy. Furthermore, intestinal microflora, myeloperoxidase (MPO) and cell histology were analysed. RESULTS: The highest and most reproducible increase in leucocyte rolling was exhibited 2 hours after high dose irradiation whereas leucocyte adhesion was greatest after 16 hours. Radiation reduced the intestinal microflora count compared to sham animals with a significant decrease in the aerobic count after 2 hours of radiation. Further, the total aerobic counts, Enterobacteriaceae and Lactobacillus decreased significantly after 16 hours. In the radiation groups, the bacterial count showed a progressive increase from 2 to 24 hours after radiation. CONCLUSION: This study presents a refinement of a previous method of examining mechanisms of radiation enteropathy, and a new approach at investigating radiation induced leucocyte responses in the ileal microcirculation. Radiation induced maximum leucocyte rolling at 2 hours and adhesion peaked at 16 hours. It also reduces the microflora count, which then starts to increase steadily afterwards. This model may be instrumental in developing strategies against pathological recruitment of leucocytes and changes in intestinal microflora in the small bowel after radiotherapy.

Role of angiotensin II in ischemia/reperfusion-induced leukocyte-endothelium interactions in the colon.

The aims of the present study were to determine the effects and mechanisms of angiotensin II (Ang II) on leukocyte-endothelium interactions and the role of Ang II in a novel model of ischemia/reperfusion (I/R) in the mouse colon. Ang II dose-dependently increased leukocyte rolling and adhesion in colonic venules. Importantly, Ang II-induced leukocyte rolling was completely inhibited by immunoneutralization of P-selectin, and leukocyte adhesion was abolished in lymphocyte function antigen-1 (LFA-1)-deficient mice. The P-selectin-dependent rolling was found to be a precondition for the subsequent LFA-1-dependent leukocyte adhesion. Moreover, Ang II-induced leukocyte responses involved generation of reactive oxygen species and up-regulation of CXC chemokines. Notably, CXC chemokines, but not Ang II, stimulated leukocyte chemotaxis in vitro. I/R increased gene expression of angiotensin converting enzyme (ACE) in the colon and plasma concentrations of Ang II. Inhibition of ACE and the type 1 angiotensin (AT1) receptor significantly decreased the I/R-induced leukocyte adhesion. Taken together, these novel findings demonstrate that Ang II exerts potent pro-inflammatory effects in the colonic microcirculation and that inhibition of Ang II expression or function protects against I/R-induced leukocyte responses in the colon. Thus, it is suggested that Ang II is a major target to control pathological inflammation in the colon.

Fundamental and distinct roles of P-selectin and LFA-1 in ischemia/reperfusion-induced leukocyte-endothelium interactions in the mouse colon.

OBJECTIVE: To study the adhesive mechanisms underlying ischemia/reperfusion (I/R)-induced leukocyte-endothelium interactions in the colon. SUMMARY BACKGROUND DATA: Leukocyte recruitment is a key feature in I/R-induced tissue injury, but the mechanisms regulating leukocyte rolling and adhesion in the colon are not known. The authors recently developed a new model to study the molecular mechanisms of I/R-provoked leukocyte-endothelium interactions in the colon microcirculation using inverted intravital fluorescence microscopy. METHODS: The superior mesenteric artery was occluded for 30 minutes and leukocyte responses were analyzed after 120 minutes of reperfusion in colonic venules in mice. The adhesive mechanisms underlying I/R-induced leukocyte rolling and adhesion were investigated using monoclonal antibodies against L-, E- and P-selectin, and CD11a gene-targeted mice were used to examine the role of lymphocyte function antigen-1 (LFA-1, CD11a/CD18). RESULTS: Reperfusion provoked a clear-cut increase in leukocyte rolling and adhesion in colonic venules compared to negative controls. Both P- and E-selectin mRNA were expressed in the colon after this I/R insult. Pretreatment with an anti-P-selectin antibody reduced leukocyte rolling and adhesion by 88% and 85%, respectively, whereas antibodies against L- and E-selectin had no effect. Moreover, I/R-induced leukocyte adhesion in LFA-1-deficient mice was reduced by more than 95%. CONCLUSIONS: This study provides evidence that leukocyte rolling is exclusively and nonredundantly mediated by P-selectin and that firm adhesion is supported by LFA-1 in I/R-induced leukocyte recruitment in the colon. Taken together, both P-selectin and LFA-1 may be important targets to control pathologic inflammation in I/R-induced tissue injury in the colon.

Leukocyte rolling is exclusively mediated by P-selectinin colonic venules.

1. The objective of the present study was to examine the role of the endothelial selectins (i.e. P- and E-selectin) in leukocyte-endothelium interactions in colonic venules by use of intravital microscopy. 2. Balb/c mice were exposed to dextran sodium sulphate (DSS) in the drinking water for 5 days or treated intraperitoneally (i.p.) with tumour necrosis factor-alpha (TNF-alpha) for 3 h. 3. In DSS-treated mice, mRNA of both P- and E-selectin were expressed and leukocyte rolling and adhesion was increased to 27+/-3 cells min(-1) and 36+/-8 cells mm(-1), respectively. An anti-P-selectin antibody abolished DSS-induced leukocyte rolling, whereas an antibody against E-selectin had no effect. Established leukocyte adhesion was insensitive to inhibition of the selectins. 4. DSS markedly increased production of TNF-alpha in the colon. TNF-alpha increased leukocyte rolling to 22+/-3 cells min(-1) and adhesion to 45+/-4 cells mm(-1). Only inhibition of P-selectin significantly reduced (>94%) leukocyte rolling provoked by TNF-alpha. Leukocyte adhesion was not changed by late anti-P-selectin antibody treatment. In contrast, pretreatment with the anti-P-selectin antibody not only abolished leukocyte rolling but also completely inhibited firm adhesion in response to TNF-alpha. 5. This study demonstrates that P-selectin plays an important role in leukocyte rolling in colonic venules, both in experimental colitis and when stimulated with TNF-alpha. Moreover, P-selectin-dependent leukocyte rolling was found to be a precondition for TNF-alpha-induced firm adhesion. Thus, these findings suggest that P-selectin may be a key target to reduce pathological recruitment of inflammatory cells in the colon.