Treatment of postoperative jejunal intussusception in adult with oral gastrografin after laparoscopic low rectal resection. A case report.

INTRODUCTION: Postoperative intussusception is a rare cause of intestinal obstruction in adults. Intussusception refers to a condition in which a segment of the intestine invaginates into the lumen of an adjacent segment of the intestine. PRESENTATION OF CASE: We report a case of postoperative jejunojejunal intussusception in a 42-year-old male following a laparoscopic low anterior resection for rectal cancer. In post-operative day (POD) 2 the patient showed intermittent bowel obstruction and fever. Diagnosis was established with abdominal computed tomography (CT) and enteroclysis, which led to a spontaneous reduction of the invagination. DISCUSSION: The incidence of intussusception in adults is rare condition. It represents less than 5% of all cases. In adults, transient asymptomatic enteric intussusception often resolves spontaneously without any treatment. When bowel obstruction is complete and persistent, surgery is need. Intussusception as cause of intestinal obstruction should be kept in mind in a post operative patient who develops obstructive symptoms. Early diagnosis makes the difference between surgical and others treatment. The pathogenesis and diagnosis of postoperative intussusception in the adult is discussed in the case report. CONCLUSION: The authors presented a rare cause of postoperative small bowel obstruction treated without surgery. The peculiarity of this case report is that the authors have successfully used, in an adult, conservative treatment with gastrografin, which is the treatment of choice used in children. The use of gastrografin was decisive and there were no recurrences in the follow up.

Omentopexy with Glubran®2 for reducing complications after laparoscopic sleeve gastrectomy: results of a randomized controlled study.

BACKGROUND: Gastric fistulas, bleeding, and strictures are commonly reported after laparoscopic sleeve gastrectomy (LSG), that increase morbidity and hospital stay and may put the patient's life at risk. We report our prospective evaluation of application of synthetic sealant, a modified cyanoacrylate (Glubran®2), on suture rime, associated with omentopexy, to identify results on LSG-related complications. METHODS: Patients were enrolled for LSG by two Bariatric Centers, with high-level activity volume. Intraoperative recorded parameters were: operative time, estimated intraoperative bleeding, conversion rate. We prospectively evaluated the presence of early complications after LSG during the follow up period. Overall complications were analyzed. Perioperative data and weight loss were also evaluated. A control group was identified for the study. RESULTS: Group A (treated with omentopexy with Glubran®2) included 96 cases. Control group included 90 consecutive patients. There were no differences among group in terms of age, sex and Body Mass Index (BMI). No patient was lost to follow-up for both groups. Overall complication rate was significantly reduced in Group A. Mean operative time and estimated bleeding did not differ from control group. We observed three postoperative leaks in Group B, while no case in Group A (not statistical significancy). We did not observe any mortality, neither reoperation. Weight loss of the cohort was similar among groups. In our series, no leaks occurred applying omentopexy with Glubran®2. CONCLUSION: Our experience of omentopexy with a modified cyanoacrylate sealant may lead to a standardized and reproducible approach that can be safeguard for long LSG-suture rime. TRIAL REGISTRATION: Retrospective registration on clinicaltrials.gov PRS, with TRN NCT03833232 (14/02/2019).

Small bowel obstruction after gastric by-pass: Diagnostic limits and percutaneous drain. A paradigmatic case.

BACKGROUND: Obesity is showing a constant increase worldwide, making it the major public health problem. Bariatric surgery seems to be the best treatment for these to achieve a good excess weight loss. Gastric by-pass (GBP) is one the most important bariatric procedure, but there are a lot of complications as bowel obstruction for internal hernia, fistula and intussusception. CASE REPORT: We present a peculiar case report of a 53-years old woman that underwent to GBP. On the fourth postoperative day, she presented a bowel obstruction and underwent a second surgical intervention for incisional hernia. Another surgical revision was necessary because of dilatation of excluded stomach. Subsequent external drain of excluded stomach solved the paralytic ileum post bowel obstruction. CONCLUSION: Postoperative occlusion is more complex in bariatric patients, either for variety of etiology, either for choosing best approach to the new anatomy. In addition, post-surgery course may be different, because GBP may determine many modifications on gastrointestinal motility and clinical symptoms. An accurate knowledge of bariatric surgery is mandatory in these situations, obtaining the best management.

Correcting micronutrient deficiencies before sleeve gastrectomy may be useful in preventing early postoperative micronutrient deficiencies.

Micronutrient deficiencies (MD) shortly after sleeve gastrectomy (SG) are frequent and patients with obesity often show MD preoperatively. Our aim was to assess whether the correction of MD before SG could play a role in preventing early postoperative MD. Eighty patients (58 females, 22 males) who underwent SG were evaluated retrospectively. Patients were divided according to whether they had received preoperative MD correction (Group A, n = 42; 30 females, 12 males) or not (Group B, n = 38; 28 females, 10 males). Micronutrient status was assessed preoperatively, at 3 and 12-months after SG in both groups. After SG, Group A and Group B patients received the same multivitamin supplement and followed the same diet. Nutrient intake of all patients was evaluated by food frequency questionnaires. Before SG, patients of Group A had no MD, whereas patients of Group B were mostly deficient in vitamin B12 (10.5%, 3 women, 1 man), folate (15.8%, 5 women, 1 man), 25-vitamin D (39.5%, 10 women, 5 men), iron (26.3%, 8 women, 2 men), and zinc (7.9%, 2 women, 1 men). At 3- and 12-month follow-up, no patient in group A had developed new MD, whereas all patients of Group B continued to be deficient in one or more micronutrient, despite systematic postoperative supplementation. No statistical differences (p<0.05) in estimated nutrient intake were observed in either group. Based on our findings, we are able to support the hypothesis that pre-SG correction of MD may be useful in preventing early post-SG MD.

Evaluation of anti-Müller hormone AMH levels in obese women after sleeve gastrectomy.

INTRODUCTION: The link between obesity epidemic in fertile age and fertility reduction, in relation with BMI increase, has been demonstrated. An inverse proportionality between BMI and anti-Müller hormone (AMH) has been investigated. This hormone is strictly related to ovarian function. It has been demonstrated that it is significantly decreased in obese women. SCOPE: The aim of this study was evaluation of AMH levels in 53 obesity women with BMI >35, at 3 and 6 months after laparoscopic sleeve gastrectomy (LSG). Specific evaluation of comorbidities and of gynecological effects of weight loss was also evaluated. RESULTS: Cohort of 53 women was considered, treated with LSG. A progressive increase of AMH levels after LSG was confirmed, with statistically significant results at followup of 6 months. In these patients, we also observed an improvement in the menstrual cycle and resolution of dysmenorrhea. All considered comorbidities were ameliorated at both followup. CONCLUSION: LSG determined a significant increase of AMH level in women, at early followup, with a comprehensive amelioration of gynecological status. Larger cohorts and a better evaluation of ovarian function after LSG will lead to more powerful results of the effect of weight loss on women.

Giant mucinous ovarian borderline tumor. A good lesson from an asymptomatic case.

INTRODUCTION: Cases of giant mucinous ovarian tumors are rarely described in literature, with different clinical manifestations. Compressive symptoms or visible abdominal mass are the most frequent observations, with higher surgical risks and life-threatening complications. PRESENTATION OF CASE: We report a case of a 69-year-old female with a giant borderline ovarian mucinous tumor, with peculiarity of absence of clinical manifestation, in front of a mass of over 6500 g. The patient underwent exploratory laparotomy where a giant cystic mass with solid lesions measuring more than 50 cm was found. It originated from the left ovary and extended up to mesocolon. Excision of the tumor intact wall, without fluid aspiration, abdominal hysterectomy with bilateral ooforectomy was performed. No hemodynamic and cardiac intraoperative modifications were observed. There were no significant early or late postoperative complications. Patient was well 12 months after surgery. The pathological examination showed a giant cystic neoplasm measuring 60 × 50 × 40 cm, weighing 6500 g. This histological study showed a mucinous neoplasm of borderline malignancy, with epithelial cells mainly of endocervical type with focal development of intestinal epithelium with goblet cells. DISCUSSION: Giant ovarian lesions are often related with compressive symptoms and need resection with high-risk of mortality. Although optimal imaging evolution, rarely rapid growth and abnormal mucina production can determine giant evolution. CONCLUSION: Our case report is paradigmatic for absence of symptoms at diagnosis, although dimension of lesion, for borderline mucinous histotype, that determined a good prognosis in this patient, and for safe operative treatment.

Metabolic effects, safety, and acceptability of very low-calorie ketogenic dietetic scheme on candidates for bariatric surgery.

BACKGROUND: Previous studies have demonstrated significant advantages from a preoperative dietetic regimen for candidates to bariatric procedure. OBJECTIVES: Evaluation of safety, efficacy, and acceptability of a very low-calorie ketogenic diet in patients before bariatric surgery. SETTING: University Hospital. METHODS: A standardized 30-day sequential preoperative diet regimen has been analyzed, optimizing metabolic response with gradual carbohydrate reintroduction. Patients were given a dedicated KetoStationkit, for use during the first 10 days of the scheme, followed by a hypocaloric scheme for 20 days. The study group underwent routine laboratory tests and anthropometric measurements (percent weight loss, body mass index, waist circumference) at enrollment (T0), after 10 days (T1), and after 30 days (T2). Ketone body levels were measured in the plasma and urine. RESULTS: Between January 2015 and September 2015, 119 patients were included in the study. Mean body mass index was 41.5 ± 7.6 kg/m2. Weight, body mass index, and waist circumference at T0 and T1, T0 and T2, and T1 and T2 decreased significantly (P<.05). A bioelectrical impedance assay determined a significant reduction in visceral fat at T1 and T2. We observed a significant (P<.05) improvement in several clinical parameters, including glycemic and lipid profile parameters. We also observed a mean 30% reduction in liver volume. The majority of patients declared satisfied or very satisfied. The adverse effects were mild, of short duration, and not clinically relevant. CONCLUSION: Our results confirm the acceptability, safety, and significant advantage of a very low-calorie ketogenic diet for reducing weight and liver volume of patients in preparation for bariatric surgery.

ABSI (A Body Shape Index) and ARI (Anthropometric Risk Indicator) in Bariatric Surgery. First Application on a Bariatric Cohort and Possible Clinical Use.

BACKGROUND: BMI (body mass index) is used to identify candidates for bariatric surgery, with a criterion of BMI ≥ 40. For lesser degrees of obesity, BMI 35-39.9, comorbidities are also considered. A Body Shape Index (ABSI) was derived to correct WC (waist circumference) for BMI and height. ABSI has been shown to be a linear predictor of long-term mortality across the range of BMI. Anthropometric risk indicator (ARI) combines the complementary contributions of BMI and ABSI and further improves mortality hazard prediction. We report for the first time ABSI and ARI for a bariatric surgical cohort at baseline and with 3-year follow-up. METHODS: ABSI and BMI were calculated for 101 subjects from our bariatric surgery center database at baseline and after 3 years of follow-up. Raw values for BMI and ABSI were converted to Z scores and ARI values based on sex- and age-specific normals and risk associations from the National Health and Nutrition Examination Survey (NHANES) III sample of the US general population. RESULTS: Baseline scores for the anthropometric variables BMI and ABSI and the corresponding ARI were all higher than for the NHANES population sample. At 3-year post surgery, all three measures decreased significantly. While baseline BMI did not predict the change in mortality risk by ARI, baseline ABSI did (r = - 0.73), as did baseline ARI (r = - 0.94). CONCLUSION: Sleeve gastrectomy lowers ABSI and the associated mortality risk estimated from population studies after 3 years of follow-up. Considering our results, bariatric surgical candidates with BMI in the range of 35 to 39.9 with an increased ABSI-related mortality risk may have considerable survival benefit from bariatric surgery, even in the absence of qualifying comorbidities. TRIAL REGISTRATION NUMBER: 2814.

Follicular adenoma in ectopic thyroid. A case-report.

INTRODUCTION: The term ectopic thyroid refers to the presence of thyroid tissue located far from its usual anatomic placement and with no vascular connection to the main gland. The presence of swelling in atypical locations is diagnostically differentiated from other pathologies like pleomorphic adenoma or carcinoma, inflammatory lesions like sialadenitis, neurogenic tumors, paraganglioma, fibrolipoma and lymphadenopaties of diverse etiologies. PRESENTATION OF CASE: Here we present the case of a submandibular ectopic thyroid in a 67year old woman. She came to our attention for a left submandibular swelling. The anamnesis did not show related pathologies, as well as blood tests. Diagnostic image studies and a FNAC were performed. The mass was surgically removed and histopatology showed a follicular adenoma in the contest of the capsulated lesion. DISCUSSION: It is important to not underestimate these types of lesions and procede with hematochemical, instrumental tests and above all surgery that can eliminate any diagnostic uncertainty and on the whole be therapeutic. CONCLUSION: It should not be forgotten that ectopic thyroid tissue can be a site for adenoma or papillary carcinoma and thus any watch and wait strategy should be avoided.