Clinical, functional and radiological outcome after osteosynthesis of ankle fractures using a specific provocation test.

BACKGROUND: Ankle fractures are frequent, and despite numerous publications on their treatment and outcome, there is a lack of precise data on the functional results in young, healthy and physically active patients. We hypothesized that patients who underwent open reduction and internal fixation (ORIF) for simple ankle fractures would have similar function compared to a healthy control group, whereas patients with complex fractures will have significant functional deficits. Furthermore, we postulate that there is a discrepancy between the radiological and the functional outcomes. METHODS: A set of specific provocation tests was developed to evaluate the postoperative possibility of weight bearing, stop-and-go activities and range of motion. In combination with three questionnaires and a radiographic evaluation, the true functional outcome and the possibility of participating in sporting activities were investigated and compared with those of an age- and sex-matched control group. RESULTS: A significant impairment was found in unilateral and simple ankle fractures. This impairment increased in tests including stop-and-go activities in combination with load bearing and with the complexity of the fractures. Concerning the subjective outcome, there was a significant adverse effect for daily activities without any difference in preoperative or postoperative sporting activity between the groups. No difference was found in the radiological assessment. CONCLUSIONS: Both simple and complex ankle fractures treated with ORIF have a significant and long-lasting impact on functional outcome in young and active patients. The radiological result is not associated with a good functional outcome. TRIAL REGISTRATION: BASEC-Nr. 2018 - 01124.

Laparoscopic Roux-Y-gastric bypass versus laparoscopic one-anastomosis gastric bypass for obesity: clinical & metabolic results of a prospective randomized controlled trial.

BACKGROUND: One anastomosis gastric bypass (OAGB) has been proposed as an effective alternative to the current standard procedure in Switzerland, Roux-en-Y gastric bypass (RYGB). Prospective data comparing both procedures are scarce. Therefore, we performed a non-inferiority randomized controlled trial assessing the effectiveness and safety of these 2 operative techniques. METHOD: Eighty patients were randomized 1:1. OAGB consisted of a very long gastric pouch with a 200 cm biliopancreatic limb, RYGB of a 150 cm ante-colic alimentary and a 60 cm biliopancreatic limb, respectively. Primary endpoint was the percent excess weight loss (%EWL) at 12 months after surgery. RESULTS: Mean %EWL at 12 months was 87.9% (SD24.4) in the RYGB group and 104.1% (SD24.6) in the OAGB group (p = 0.006). There was no mortality. The rate of marginal ulcers was higher in patients with OAGB compared to those with RYGB (p = 0.011), while the total number of late complications did not statistically differ between the two groups. Except for the remission of GERD, which was higher in the RYGB group compared to OAGB, there was no difference between the groups regarding the remission of comorbidities. OAGB showed improved glucose control compared to the RYGB after 1 year (p = 0.001). Furthermore, glucagon-like peptide-1 increase was significantly higher in OAGB at 6 weeks (p = 0.041) and 1 year after surgery (p = 0.029). Quality of life improved after both surgeries, without differences between the groups. CONCLUSIONS: %EWL 1 year after surgery was higher in OAGB than in RYGB. A better glycemic control with a higher increase in GLP-1 was observed after OAGB compared to RYGB. TRIAL REGISTRATION: This trial is registered on ClinicalTrials.gov under the identifier NCT02601092.

Evaluation of the Introduction of a Colorectal Bundle in Left Sided Colorectal Resections (EvaCol): Study Protocol of a Multicentre, Observational Trial.

Purpose: Overall complication and leak rates in colorectal surgery showed only minor improvements over the last years and remain still high. While the introduction of the WHO Safer Surgery Checklist has shown a reduction of overall operative mortality and morbidity in general surgery, only minor attempts have been made to improve outcomes by standardizing perioperative processes in colorectal surgery. Nevertheless, a number of singular interventions have been found reducing postoperative complications in colorectal surgery. The aim of the present study is to combine nine of these measures to a catalogue called colorectal bundle (CB). This will help to standardize pre-, intra-, and post-operative processes and therefore eventually reduce complication rates after colorectal surgery. Methods: The study will be performed among nine contributing hospitals in the extended north-western part of Switzerland. In the 6-month lasting control period the patients will be treated according to the local standard of each contributing hospital. After a short implementation phase all patients will be treated according to the CB for another 6 months. Afterwards complication rates before and after the implementation of the CB will be compared. Discussion: The overall complication rate in colorectal surgery is still high. The fact that only little progress has been made in recent years underlines the relevance of the current project. It has been shown for other areas of surgery that standardization is an effective measure of reducing postoperative complication rates. We hypothesize that the combination of effective, individual components into the CB can reduce the complication rate. Trial registration: Registered in ClinicalTrials.gov on 11/03/2020; NCT04550156. Highlights: Purpose: Overall complications in colorectal surgery remain still highStandardizing can reduce overall operative mortality and morbidityOnly minor attempts have been made to standardize perioperative processes in colorectal surgerySingular interventions have been found reducing postoperative complicationsThe aim is to combine nine of these measures to a colorectal bundle (CB)The CB will help to reduce complication rates after colorectal surgery Methods: The observational study will be performed among nine hospitals in SwitzerlandSix month the patients will be treated according to the local standardsAfterwards patients will be treated according to the CB for another six monthsComplication rates before and after the implementation of the CB will be compared Discussion: Only little progress has been made to reduce complication rate in colorectal surgeryStandardization is an effective measure of reducing complication ratesThe combination of effective, individual components into the CB can reduce the complication rate.

Efficacy of intraoperative cholangiography versus preoperative magnetic resonance cholangiography in patients with intermediate risk for common bile duct stones.

BACKGROUND: This is the first randomized trial to evaluate the efficacy of intraoperative cholangiography (IOC) and magnetic resonance cholangiopancreatography (MRCP) in patients with suspected CBDS. METHODS: This unblinded, multicenter RCT was conducted at five swiss hospitals. Eligibility criteria were suspected CBDS. Patients were randomized to IOC and laparoscopic cholecystectomy (LC), followed by endoscopic retrograde cholangiopancreatography (ERCP) if needed, or MRCP followed by ERCP if needed, and LC. Primary outcome was length of stay (LOS), secondary outcomes were cost, stone detection, and complication rates. RESULTS: 122 Patients were randomised to the IOC Group (63) or the MRCP group (59). Median LOS for the IOC and the MRCP groups were 4 days IQR [3, 6] and [4, 6], with an estimated increase of LOS of 1.2 days in the MRCP group (p = 0.0799) in the linear model. Median cost in the IOC and MRCP groups were 10 473 Swiss Francs (CHF) and 10 801 CHF, respectively (p = 0.694). CBDS were found in 24 and 12 patients in the IOC and the MRCP groups, respectively (p = 0.0387). The complication rate did not differ between both groups. CONCLUSION: There is equipoise between both pathways. IOC has a significantly higher diagnostic yield than MRCP. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT02351492: Radiological Investigation of Bile Duct Obstruction (RIBO).

Risk of Reopening of the Mesenteric Defects After Routine Closure in Laparoscopic Roux-en-Y Gastric Bypass: a Single-Centre Experience.

PURPOSE: Small bowel obstruction (SBO) due to internal hernias (IH) is a well-recognised complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). Routine closure of the mesenteric defects (MDs) is recommended to reduce the risk of IH and subsequent SBO. However, data about the rates of reopening of the MDs after LRYGB is scarce. The main aim of this study was to evaluate the risk of reopening of the MDs after routine closure during LRYGB. The secondary objective was to determine any risk factors associated with the reopening of the MDs. METHODS: Data of all patients who underwent reoperations after LRYGB with closure of both MDs between January 2010 and December 2018 were retrospectively reviewed. RESULTS: A total of 162 patients were included. The median time between LRYGB and reoperation was 17 months. At the time of reoperation, both MDs were closed in 83 patients (51.2%); thus, 79 patients (48.8%) presented at least one open MD. The group of patients with preoperative diagnosis of SBO or with recurrent abdominal pain showed significantly higher rates of open Petersen's space compared to the group of patients with other preoperative diagnoses. Preoperative body mass index (BMI) less than 40 kg/m2 at time of LRYGB was associated with a higher risk for an open MD. CONCLUSION: At least one MD reopened in almost half of the patients despite routine closure during LRYGB. Therefore, the status of MDs should be routinely examined during every reoperation after LRYGB and closure of open MDs should be performed.

Revisional Adjustable Gastric Band in Roux-en-Y Gastric Bypass-Is It Worth It?

PURPOSE: A subset of patients undergoing Roux-en-Y gastric bypass (RYGB) presents with either insufficient weight loss or weight regain. Data on the revisional restrictive options including laparoscopic adjustable gastric band (LAGB) is scarce. This study analyzes the mid-term efficacy and safety of LAGB as a revisional procedure after RYGB. METHODS: Data of all patients with revisional LAGB after primary RYGB between January 2011 and May 2019 were retrospectively reviewed. Outcomes included assessment of weight changes, resolution of comorbidities, and early and late complications during the study period. RESULTS: Twenty patients were included. The median Body Mass Index (BMI) before revisional LAGB was 34.8 (interquartile range [IQR] 31.9-38.1) kg/m2. After a median follow-up of 33.5 (IQR 19.5-76.5) months, the median BMI was 28.7 (IQR 26.1-32.2) kg/m2. The median additional Excess Weight Loss (EWL) was 37.6% (IQR 23-44.4), leading to a median total EWL of 79.5% (IQR 54.4-94.6). BMI and EWL post-LAGB improved significantly compared to BMI and EWL pre-LAGB (p<0.001 and p<0.001, respectively). Obstructive sleep apnea syndrome resolved 6 months after LAGB in one patient. Three band deflations occurred during the follow-up. Six patients underwent band removal after a median time of 19 (IQR 15.8-26) months. Overall, thirteen patients underwent a reoperation. There was no loss of follow-up until 5 years. After that, two patients were lost to follow-up. CONCLUSION: LAGB may be a salvage option after failed RYGB. However, the high rate of revisions after secondary LAGB needs to be taken into consideration.

Incidence and Prognostic Factors for the Development of Symptomatic and Asymptomatic Marginal Ulcers After Roux-en-Y Gastric Bypass Procedures.

INTRODUCTION: Marginal ulcer (MU) is a serious complication after Roux-en-Y gastric bypass (RYGB) procedures. This study reports the incidence, risk factors, and treatment outcomes of symptomatic and incidentally, at routine endoscopy diagnosed, MU. METHODS: All patients undergoing RYGB procedures between 2013 and 2018 at a single center were included. Upper endoscopy was performed in case of symptoms and/or routinely 2 and 5 years postoperatively. RESULTS: In total, 568 patients (83.3% female) underwent RYGB procedure with a median age of 40 years and median initial body mass index of 41 kg/m2. The median time to follow-up was 2.99 years. Routine 2- and 5-year upper endoscopy was performed in 256 (55.3%) and 65 (38.0%) eligible patients, respectively. In 86 (15.1%) patients, MU was diagnosed at a median time of 14.2 months (4.58-26.2) postoperatively and 24.4% of patients with MU were asymptomatic. In total, 76.7% of MUs were located on the side of the Roux limb. 88.4% of MUs were treated conservatively; re-operation was necessary in 10 (11.6%) patients. Smoking and type 2 diabetes mellitus were the only independent risk factors for MU development in multivariate analysis with a hazard ratio of 2.65 and 1.18 (HbA1c per unit >6.0), respectively. CONCLUSION: MU is a common complication after gastric bypass surgery with 25% of patients being asymptomatic. Follow-up routine endoscopy is recommended for early MU detection and subsequent accurate therapy, especially in patients with the independent risk factors smoking and type 2 diabetes mellitus.

Long-Term Outcome of Proximal Versus Very-Very Long Limb Roux-en-Y Gastric Bypass: the Roux-Limb to Common Channel Ratio Determines the Long-Term Weight Loss.

BACKGROUND: The influence of the Roux limb (RL) length on weight loss in Roux-en-Y (RYGB)-type gastric bypass procedures is still unclear. This study analyzes the true impact of RL length by comparing the long-term outcomes of proximal RYGB (PRYGB) and very-very long limb RYGB (VVLL-RYGB). METHODS: RL length in PRYGB was 150 cm. In VVLL-RYGB, common channel length was 100 cm. In both groups, biliopancreatic limbs measured 50-60 cm, resulting in equal total alimentary limb lengths. To adjust for pre-operative differences between groups, and to predict the long-term outcome, a mixed model analysis was performed. RESULTS: Two hundred thirty-two patients with VVLL-RYGB (73.7% female, mean age 41.1 ± 10 years, initial BMI 45.8 ± 6.3 kg/m2) and 223 with PRYGB (83.9% female, mean age 38.5 ± 11 years, initial BMI 42.9 ± 4.9 kg/m2) were included. Mean follow-up was 9.4 ± 4 years in VVLL-RYGB and 5.3 ± 1.9 years in PRYGB. After 5 years, mean BMI reduction was 15.7 ± 5.9 kg/m2 in VVLL-RYGB and 11.9 ± 4.1 kg/m2 in PRYGB (p < 0.001), and mean %EWL was 78.3 ± 23.1% and 70.2 ± 23.7% (p = 0.002) with a follow-up rate of 78% and 75.9%, respectively. The mixed model analysis showed a significantly higher weight rebound after PRYGB. Frequency of revisional surgery (i.e., limb length alteration, pouch banding) was similar between VVLL-RYGB and PRYGB (25 vs. 29 revisions, p = 0.463). CONCLUSION: The VVLL-RYGB has a significantly higher long-term BMI reduction and a significantly lower weight rebound. The length of the Roux limb significantly influences long-term outcome.

Short or Long Biliopancreatic Limb Bypass as a Secondary Procedure After Failed Laparoscopic Sleeve Gastrectomy.

PURPOSE: Laparoscopic sleeve gastrectomy (SG) may be associated with long-term problems such as insufficient weight loss or weight regain, persistence or relapse of comorbidities, and gastroesophageal reflux disease (GERD). This study analyzes the outcome of patients that underwent conversion of SG to a gastric bypass procedure. MATERIALS AND METHODS: All patients that underwent conversion from SG to the following four different gastric bypass procedures were analyzed: short biliopancreatic limb (BPL) bypass types such as proximal Roux-en-Y gastric bypass (PRYGB) or type 2 distal Roux-en-Y gastric bypass (type 2 DRYGB) and long BPL types such as long BPL RYGB or one anastomosis gastric bypass (OAGB). RESULTS: Between 2012 and 2016, 52 patients received the following revisional procedures after primary SG: proximal RYGB (n = 12, 23.1%), type 2 DRYGB (n = 8, 15.4%), long BPL RYGB (n = 20, 38.5%), and OAGB (n = 12, 23.1%). The long BPL type procedures (long BPL RYGB, OAGB) resulted in a significant long-term additional %EWL (33.8%; 33.2%) at 3 years. In the PRYGB, the effect lasted only for 2 years. In all patients with GERD and dysphagia as the dominant post-SG symptoms, the conversion to a bypass procedure resulted in the complete resolution of these. CONCLUSION: In case of weight regain or insufficient weight loss after SG, revisional surgery with a long BPL should be considered. The OAGB provides effective additional weight loss, with low morbidity and malnutrition rates, respectively. Conversion to the malabsorptive long BPL RYGB with a total alimentary limb length below 400 cm should be avoided. Patients that suffer primarily from post-SG GERD or dysphagia should undergo conversion to PRYGB.

Mid-term results of minimally invasive deltoid-split versus standard open deltopectoral approach for PHILOS™ (proximal humeral internal locking system) osteosynthesis in proximal humeral fractures.

PURPOSE: Only a few reports compare the mid- and long-term outcome of the minimally invasive deltoid split (MIDS) with the classic anterior deltopectoral (DP) approach for osteosynthesis in proximal humeral fractures. This study compared the mid-term functional and the radiological results in patients with proximal humeral fractures undergoing osteosynthesis with the proximal humeral internal locking system (PHILOS™). METHODS: All patients undergoing osteosynthesis between 2008 and 2015 were clinically and radiologically examined with a minimal follow-up period of 1 year. Functional outcomes were analyzed using the DASH- and Constant Shoulder Scores (CSS). Radiological results were analyzed using a newly developed score. RESULTS: Thirty-nine patients underwent PHILOS™ osteosynthesis with the MIDS and twenty-three with the DP approach. Follow-up time was 41 months in the MIDS group and 62 months in the DP group, respectively. The median CSS was similar with 79 points in the MIDS group and 82 points in the DP group (p = 0.17). The MIDS group showed a significant lower power measurement in the CSS. In four-part fractures, a substantially lower CSS in absolute numbers in the MIDS group was detected. The median DASH score was 26.7 points in the MIDS group and 25.8 points in the DP group (p = 0.48). There was no difference in the radiological score. More patients with partial avascular necrosis (AVN) were found in the MIDS group, most with three- and four-part fractures. However, this was not statistically significant. Morbidity was similar between groups. CONCLUSION: The results of the two surgical approaches are statistically comparable. Some differences such as a lower power measurement in the MIDS group, a higher partial AVN frequency and more plate removals are observed. In four-part fractures, the CSS was lower in the MIDS compared to the DP cohort. The MIDS technique might not be a solution for all fracture types, and the surgeon should be careful to analyze the morphology of the fracture before deciding upon the approach. Four-part fractures might be better treated with a DP approach.

Revisional Surgery for Insufficient Loss or Regain of Weight After Roux-en-Y Gastric Bypass: Biliopancreatic Limb Length Matters.

INTRODUCTION: Weight regain after laparoscopic Roux-en-Y gastric bypass (RYGB) occurs in up to 35% of patients. Revisional surgery may be applied. Conversion from RYGB to a long biliopancreatic limb (BPL) RYGB is a potential option for revisional surgery and short-term results are promising. METHODS: All patients who underwent conversion to long BPL RYGB due to weight loss failure, defined as excess weight loss (EWL) < 50% or body mass index (BMI) > 35 kg/m2, were assessed. Proximal RYGB or very very long limb RYGB (VVLL RYGB) was modified by shortening of the total alimentary limb length (TALL) to create a long BPL. RESULTS: A total of 28 patients received revisional surgery from either PRYGB (n = 22) or VVLL RYGB (n = 6). Mean age at operation was 45.3 ± 10.4 years, with 78% females. Mean prerevisional BMI was 41.7 ± 4.4 kg/m2. Mean time to revision was 76.5 ± 38.5 months. Limb lengths were 150 cm (95% CI 133-156 cm) for RL and 100 cm (95% CI 97-113 cm) for CC, thus providing a total median alimentary limb length of 250 (95% CI 238-260 cm). Additional %EWL and TWL improved significantly in long-term. Five years postoperatively, all patients (n = 9) had an EWL% > 50%. Six patients (21.4%) required reoperation due to severe malnutrition during the postoperative course. CONCLUSION: Conversion from RYGB to BPL RYGB leads to significant additional weight loss in the long term. However, the morbidity is relevant, especially severe protein malnutrition and the frequency of revisional surgery. Therefore, this type of surgery should not be done routinely.

Computed tomography as primary postoperative follow-up after laparoscopic Roux-en-Y gastric bypass.

AIM: To evaluate upper abdominal computed tomography (CT) scan as primary follow-up after laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: This prospective study was approved by the Ethical Committee of the State of Zurich, and informed consent was obtained from all patients. Sixty-one patients who underwent LRYGB received upper abdominal CT on postoperative day 1, with the following scan parameters: 0.6 mm collimation, 1.2 mm pitch, CareKV with reference 120 mAs and 120 kV, and 0.5 s rotation time. Diluted water-soluble radiographic contrast-medium (50 mL) was administered to achieve gastric pouch distension without movement of the patient. 3D images were evaluated to assess postoperative complications and the radiation dose received was analysed. RESULTS: From the 70 patients initially enrolled in the study, 9 were excluded from analysis upon the intraoperative decision to perform a sleeve gastrectomy and not a LRYGB. In all of the 61 patients who were included in the analysis, CT was feasible and there were no instances of aspiration or vomiting. In 7 patients, two upper abdominal scans were necessary as the pouch was not distended by contrast medium in the first acquisition. Radiologically, no leak and no relevant stenosis were found on the first postoperative day. These early postoperative CT findings were consistent with the findings at clinical follow-up 6 wk postoperatively, with no leaks, stenosis or obstructions being diagnosed. The average total dose length product in CT was 536.6 mGycm resulting in an average effective dose of 7.8 mSv. The most common surgical complication, superficial surgical site infections (n = 4), always occurred at the upper left trocar site, where the circular stapler had been introduced. CONCLUSION: Early LRYGB postoperative multislice spiral CT scan is feasible, with low morbidity, and provides more accurate anatomical information than standard upper gastrointestinal contrast study.

Spiradenocarcinoma: A Comprehensive Data Review.

INTRODUCTION: Spiradenocarcinomas (SCs) are rare and potentially aggressive skin adnexal tumors. Optimal treatment has not yet been established. Experiences with this carcinoma are mostly presented in case reports and few case series. OBJECTIVE: To generate to a synopsis of published data on SC with regard to diagnostic procedures, treatment, and outcome. RESULTS: Median patient age was 60 years and sex distribution was balanced. Tumor manifestations were evenly distributed within the sweat gland carrying skin. The most commonly reported symptom was accelerated growth of a longstanding indolent lesion, typically present for more than 2 years. Metastatic spread to the lung, bone, lymph nodes, liver, kidney, and breast has been documented. For staging computed tomography (CT) and positron emission tomography-CT are recommended, especially for detection of hematogenic metastases and lymph node involvement. Clear resection margins and tumor free regional lymph nodes reduce recurrence and carcinoma related death. Although low-grade SCs were reported over 3 times more often, high-grade carcinomas show a greater likelihood for recurrence and lethal outcome. CONCLUSION: Suspicion of an SC should lead to performance of a magnetic resonance imaging for defining tumor extent, and a fludeoxyglucose positron emission tomography-CT for detection of metastases. Radical tumor excision and resection of tumor involved regional lymph nodes are essential for a curative approach. Histopathological evaluation should involve determination of tumor differentiation grade, because high-grade carcinomas seem to have a much more aggressive behavior. Excision of distant metastases has no therapeutic value. Follow-up needs to be carried out in short intervals with frequent imaging.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic mini gastric bypass in the treatment of obesity: study protocol for a randomized controlled trial.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the gold standard in bariatric surgery, achieving durable long-term weight loss with improvement of obesity-related comorbidities. Lately, the laparoscopic mini gastric bypass (LMGB) has gained worldwide popularity with similar results to LRYGB in terms of weight loss and comorbidity resolution. However, there is a lack of randomized controlled trials (RCT) comparing LMGB and LRYGB. This article describes the design and protocol of a randomized controlled trial comparing the outcomes of these two bariatric procedures. METHODS/DESIGN: The trial is designed as a single center, randomized, patient and observer blinded trial. The relevant ethics committee has approved the trial protocol. To demonstrate that LMGB is not inferior to LRYGB in terms of excess weight loss (EWL) the study is conducted as a non-inferiority trial with the sample-size calculations performed accordingly. EWL 12 months after surgery is the primary endpoint, whereas 3-year EWL, morbidity, mortality, remission of obesity related comorbidities, quality of life (QOL) and hormonal and lipid profile changes are secondary endpoints. Eighty patients, 18 years or older and with a body mass index (BMI) between 35 and 50 kg/m2 who meet the Swiss guidelines for the surgical treatment of morbid obesity will be randomized. The endpoints and baseline measurements will be assessed pre-surgery, peri-surgery and post-surgery (fixed follow up measurements are at discharge and at the time points 6 weeks and 12 and 36 months postoperatively). DISCUSSION: With its 3-year follow up time, this RCT will provide important data on the impact of LMGB and LRYGB on EWL, remission of comorbidities, QOL and hormonal and lipid profile changes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02601092 . Registered on 28 September 2015.

Intraoperative Patterns of Gastric Microperfusion During Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a very popular surgical treatment for the treatment of morbidly obese patients. Staple line leaks are the major cause of severe morbidity. Reasons for leaks might be hyperpressure (mechanical theory) or hypoperfusion (vascular theory) of the narrow gastric tube. This study assessed microperfusion patterns of the stomach during LSG using visible light spectroscopy (VLS), a method to measure tissue oxygenation (saturated O2 (StO2)). METHODS: The study population comprised 20 patients undergoing LSG. Real-time intraoperative microperfusion measurements were performed at nine different ventral stomach localizations in the antrum, body, and fundus at the beginning of the operation, after mobilization of the greater curve and after sleeve resection. RESULTS: There were 17 women and 3 men, mean age 42.9 years, mean BMI 45.6 kg/m2. There were no staple line leaks. StO2% values dropped substantially in the most cephalad area of measurement at the greater curve after mobilization (56 versus 49 %) and after resection (60 versus 49.5 %). The reduction in StO2 in the most cephalad area from before mobilization of the stomach to resection was 9.5 % (p < 0.01). CONCLUSION: Assessment of microperfusion patterns of the stomach during LSG using VLS is safe and efficacious to use allowing an accurate measurement of StO2%. The upper third of the stomach is the zone of reduced microperfusion with a significant drop of tissue oxygenation after sleeve resection of the stomach.

Alveolar echinococcosis of the right adrenal gland: a case report and review of the literature.

BACKGROUND: Extrahepatic manifestations of Echinococcus multilocularis are very rare, especially in the adrenal glands. To the best of our knowledge, only seven cases of adrenal alveolar echinococcosis have been reported, all from the Far East. All of these occurred exclusively in the right adrenal gland. CASE PRESENTATION: We report a rare case of an extrahepatic alveolar echinococcosis in an asymptomatic 78-year-old white man with an incidentaloma of his right adrenal gland. After surgical resection and medical treatment with albendazole no recurrence of the disease appeared at 1-year follow-up. CONCLUSIONS: As the occurrence of Echinococcus multilocularis in Europe increases, alveolar echinococcosis should be included in the differential diagnosis of cystic adrenal incidentalomas.

Primary non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: reoperations and intraoperative findings in 146 patients.

BACKGROUND: Internal hernias (IH) after laparoscopic Roux-en-Y gastric bypass (LRYGB) have been reported with an incidence of 11 %. IH can lead to bowel incarceration and potentially bowel necrosis. The aim of this study was to analyze reoperations and intraoperative findings in a cohort of patients with unclosed mesenteric defects. METHODS: From a prospective database of patients with LRYGB, we selected as primary cohort patients with non-closure of mesenteric defects and abdominal reoperation for analysis. The data included pre-, intra- and post-operative findings, computed tomogram results and laboratory test results. This group underwent a very very long limb LRYGB, at that time the institutional standard technique. Additionally, a more recently operated cohort with primary closure of mesenteric defects was also analyzed. RESULTS: We identified 146 patients with primary non-closure and reoperation, mean age of 43.8 years. The main indication for reoperation was unclear abdominal pain in 119 patients with 27 patients undergoing a reoperation for other reasons (weight regain, prophylactic surgical inspection of mesenteric defects). Median time and mean excess weight loss from RYGB to reoperation were 41.1 months and 62.7 %, respectively. The incidence of IH was 14.4 %, with all patients with an IH being symptomatic. Conversion rate from laparoscopic to open surgery was 5.5 %, mortality 0.7 % and morbidity 3.4 %. Thirty-one patients underwent a second re-look laparoscopy. Eleven patients had recurrent open mesenteric defects. Three hundred and sixteen patients who underwent primary closure of the mesenteric defects had a reoperation rate of 13.6 % and an IH rate of 0.6 %. CONCLUSION: The incidence of IH in patients without closure of mesenteric defects and reoperation is high and substantially higher compared to patients with primary closure of mesenteric defects. Patients with or without closure of mesenteric defects following LRYGB with acute, chronic or recurrent pain should be referred to a bariatric surgeon for diagnostic laparoscopy.

Outcome in body-contouring surgery after massive weight loss: A prospective matched single-blind study.

INTRODUCTION: Body-contouring (BC) procedures after massive weight loss (MWL) are extensive and numerous. Currently, inconsistent data exist regarding quality-of-life (QoL) scales, and long-term analysis is lacking. The aim of this study was to investigate the long-term outcome of patients who elect to have BC procedures after MWL. METHODS: Post-bariatric patients and patients who had dietary weight loss with no history of bariatric surgery (BS) (BC group) were included. Patients after BS with similar demographic characteristics but no BC procedures served as the control group (BS group). The results were compared with severely obese patients who have not yet undergone BS or BC surgery (obese group). Outcome measures include the type of BC surgery with the rates of the associated procedures and outcome satisfaction evaluated after the Moorehead-Ardelt questionnaire (range -3.0 to +3.0). RESULTS: Fifty-six female and 10 male Caucasian patients with a mean age of 50 years (14 years) who underwent BC procedures between February 1999 and October 2009 were included. Of those, 23 patients completed the survey in 2014 (20 female and three male patients, mean age of 53 years (14 years)) at a final follow-up of 8 years (3 years). Two years (range 1-3 years) after MWL, a total of 51 BC procedures were performed. The most frequent interventions were abdominoplasty (n = 20), followed by rectus plication and liposuction (n = 7 and n = 6, respectively). QoL scores revealed a high overall patient satisfaction in the BC group, which was comparable with the BS group (n = 23). The obese group (n = 17) had a significantly lower overall QoL and lower health-related QoL (HRQoL) subdomains compared with the BC and BS group. CONCLUSION: BC procedures lead to high and durable patient satisfaction. However, the appropriate management of expectations before surgery is mandatory.