David Goitein

Portomesenteric Thrombosis Following Laparoscopic Bariatric Surgery Incidence, Patterns of Clinical Presentation, and Etiology in a Bariatric Patient Population

OBJECTIVE To describe the incidence of, the patterns of clinical presentation of, and the reasons for portomesenteric vein thrombosis among patients who underwent laparoscopic bariatric surgery. DESIGN Retrospective, multicenter study. SETTING Six academic bariatric centers. PATIENTS Morbidly obese patients diagnosed with portomesenteric vein thrombosis following laparoscopic bariatric surgery between January 2007 and June 2012. MAIN OUTCOME MEASURES Clinical presentation, diagnostic measures used, treatments employed, outcome, and hematologic workup of patients. RESULTS Of 5706 patients who underwent laparoscopic bariatric surgery, 17 (0.3%) had portomesenteric vein thrombosis, 16 after sleeve gastrectomy and 1 following adjustable gastric banding. Seven patients were women, the mean age was 38 years, and the mean body mass index was 44.3. The median time to presentation was 10.1 days, and the median time to diagnosis was 11.7 days. New-onset epigastric pain was present in all patients, whereas other signs and symptoms were sporadically found. Computed tomography was performed and was diagnostic in 16 cases. Ultrasonography was used for 9 patients, and positive results were found for 8 of these patients. Patients were treated by anticoagulation with subcutaneous low-molecular-weight heparin (n = 15) or intravenous heparin (n = 2), followed by warfarin sodium. One patient underwent transhepatic portal infusion of streptokinase. Three patients required surgery: laparoscopic splenectomy due to infarct and abscess for 1 patient and laparotomy for 2 patients (with necrotic small-bowl resection for 1 of these patients). There were no deaths. CONCLUSIONS Portomesenteric vein thrombosis is rare after laparoscopic bariatric surgery. Familiarity with this dangerous entity is important. Prompt diagnosis and care, initiated by a high index of suspicion, is crucial.

Balloon dilatation for symptomatic gastric sleeve stricture

During recent years, laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients has been gaining popularity. Several studies have reported that it yields a percentage of weight loss similar to that of Roux-en-Y gastric bypass (RYGB). Moreover, LSG has demonstrated a good safety profile and is not as technically demanding as RYGB. In addition, LSG has fewer late adverse events, such as nutrient and vitamin deficiencies, marginal ulceration, and internal hernia. Last, it leaves the gut in continuity and allows future ERCP without difficulty. Nevertheless, because of a long staple line and altered intragastric pressures, sleeve gastrectomy is prone to some serious adverse events, such as staple line leakage in 1% to 20% of patients, bleeding, and sleeve stricture. The reported prevalence of sleeve stricture is between 0.7% and 4% in different studies. Early strictures are symptomatic in the first 6 weeks after surgery. Strictures may be caused by imbrications of the staple line, overretraction of the greater curvature during stapling, progressive rotation of the staple line, and scarring of the sleeve in a kinked rotation. Whether the size of the bougie is related to the incidence of strictures remains controversial. The incisura angularis is the site most prone to stricture development. Typical symptoms of sleeve stenosis include dysphagia, vomiting, and rapid weight loss. Different therapeutic approaches have been suggested including conservative

Gastrobronchial fistula as a complication of bariatric surgery: a series of 6 cases.

Objective: To present a multicenter series of 6 patients who developed gastrobronchial fistula (GBF). GBF is a rare subtype of gastric leaks following bariatric surgery, which is the mainstay of treatment for the obesity pandemic. Methods: We retrospectively identified 6 patients with GBF (out of 2,308 cases performed: 0.2%). One patient had undergone Roux-en-Y gastric bypass, and 5 had a sleeve gastrectomy. Demographics, previous surgeries, clinical presentation, timing of fistula diagnosis, diagnostic and treatment measures employed, and outcome were collected. Results: Four patients were female, the average age and BMI were 42 years and 42.5 kg/m2, respectively. Three patients had previous surgeries (Nissen fundoplication, adjustable gastric banding, and vertical banded gastroplasty). Median time to fistula diagnosis was 40 days (range 15–90 days). Clinical presentation included chronic cough, hemoptysis, dyspnea and fever as well as persistent left pleural effusion or pneumonia. Diagnosis was confirmed by computed tomography in all cases. Two patients were treated nonoperatively, while 4 eventually required surgery for resolution. Left lower lobectomy was necessary in 3 of 4 cases. Concomitant procedures were total gastrectomy in 2 cases and conversion of a sleeve to a gastric bypass in 1 case. Resolution occurred 30 days to 2 years after initial surgery. No mortalities were encountered. Conclusions: GBF is a rare but devastating complication following bariatric surgery. It may develop as a late complication of a chronic upper gastric leak. Surgery is curative although nonoperative management may be warranted in selected cases.

Gastric emptying is not prolonged in obese patients

BACKGROUND Obesity is associated with a poor anesthetic risk, in part because of the greater aspiration rates. A greater gastric residue and lower stomach pH have been implicated. The relationship of obesity to gastric emptying is ill-defined. with contradicting reports stating shorter, similar, and longer times compared with nonobese subjects. The aim of the present study was to compare gastric emptying in obese and nonobese subjects at a university hospital. METHODS A total of 19 obese (body mass index [BMI] >40 kg/m(2)) and 20 nonobese (BMI <30 kg/m(2)) subjects underwent a standardized scintigraphic gastric emptying study. The participants consumed a standard semisolid, technetium-99m-labeled meal. Images were acquired immediately and 1, 2, and 4 hours after meal completion. The interval to evacuate one half of the counts measured at meal completion) and retention (the percentage of counts in stomach at each measurement point) were recorded. RESULTS The mean age and BMI was 35 years and 45 kg/m(2) in the obese and 44 years and 26 kg/m(2) in the nonobese group, respectively. No differences were found between the 2 groups regarding gastric emptying. Regression analysis showed no statistical association between the BMI and gastric emptying, including multivariate analysis, considering BMI, age, and gender. CONCLUSION A scintigraphy test of a labeled meal was used to evaluate gastric emptying in obese and nonobese subjects. In accordance with other published data, no significant difference was found between the 2 groups. The anesthetic risks in the obese should be attributed to factors other than delayed gastric emptying (i.e., anatomic variation, increased rates of hiatal hernia and reflux).

Freehand Elastography for Determination of Breast Cancer Size Comparison With B-Mode Sonography and Histopathologic Measurement

Elastography assesses the strain of soft tissues and is used to enhance diagnostic accuracy in evaluating breast tumors, but minimal data exist on its ability to accurately assess tumor size. This study was performed to assess the preoperative accuracy of measuring the size of biopsyproven breast cancer lesions with elastography and conventional B‐mode sonography compared with the reference standard size measured by histopathologic examination.

Probiotics administration following sleeve gastrectomy surgery: A randomized double-blind trial

Background:Probiotics are commonly used after bariatric surgery; however, uncertainty remains regarding their efficacy. Our aim was to compare the effect of probiotics vs placebo on hepatic, inflammatory and clinical outcomes following laparoscopic sleeve gastrectomy (LSG).Methods:This randomized, double-blind, placebo-controlled, trial of 6-month treatment with probiotics (Bio-25; Supherb) vs placebo and 6 months of additional follow-up was conducted among 100 morbidly obese nonalcoholic fatty liver disease (NAFLD) patients who underwent LSG surgery. The primary outcome was a reduction in liver fat content, measured by abdominal ultrasound, and secondary outcomes were improvement of fibrosis, measured by shear-wave elastography, metabolic and inflammatory parameters, anthropometrics and quality of life (QOL). Fecal samples were collected and analyzed for microbial composition.Results:One hundred patients (60% women, mean age of 41.9±9.8 years and body mass index of 42.3±4.7 kg m−2) were randomized, 80% attended the 6-month visit and 77% completed the 12-month follow-up. Fat content and NAFLD remission rate were similarly reduced in the probiotics and placebo groups at 6 months postsurgery (−0.9±0.5 vs −0.7±0.4 score; P=0.059 and 52.5 vs 40%; P=0.262, respectively) and at 12 months postsurgery. Fibrosis, liver-enzymes, C-reactive protein (CRP), leptin and cytokeratin-18 levels were significantly reduced and QOL significantly improved within groups (P⩽0.014 for all), but not between groups (P⩾0.173 for all) at 6 and 12 months postsurgery. Within-sample microbiota diversity (alpha-diversity) increased at 6-month postsurgery compared with baseline in both study arms (P⩽0.008) and decreased again at 12 months postsurgery compared with 6 months postsurgery (P⩽0.004) but did not reach baseline values.Conclusions:Probiotics administration does not improve hepatic, inflammatory and clinical outcomes 6- and 12 months post-LSG.

Printed MDCT 3D models for prediction of left atrial appendage (LAA) occluder device size: a feasibility study

AIMS Transoesophageal echocardiography (TEE) and multidetector computed tomography (MDCT) currently serve as imaging modalities for left atrial appendage (LAA) occlusion preprocedural planning. We assessed the feasibility of MDCT-based models to predict the correct size of device for LAA occlusion procedures. METHODS AND RESULTS Patients planned for LAA occlusion underwent MDCT before implantation, which was used for creating and printing 3D LAA models. Three cardiologists evaluated the 3D models and predicted the correct size of the device by manual manipulation. These predictions were compared with the actual device implanted during the procedure. Twenty-nine patients were included in this study. AMPLATZER and WATCHMAN devices were deployed in 12 and 17 patients, respectively. Two procedures were aborted due to failure of occlusion; all three physicians predicted it. There was good correlation between the 3D models and the inserted device for AMPLATZER devices with a concordance correlation coefficient of 0.778 (p=0.001) and poor agreement for WATCHMAN devices - concordance correlation coefficient of 0.315 (p=0.203). Agreement among the three physicians for AMPLATZER and WATCHMAN devices was excellent, with a calculated average intra-class correlation of 0.915 and 0.816, respectively. CONCLUSIONS We found LAA printed 3D models to be accurate for prediction of LAA occluder device size for the AMPLATZER device but not for the WATCHMAN device.

Fetal liver T2* values: defining a standardized scale.

To define the normal T2* values of liver in the third trimester of pregnancy in normal fetuses.

Coronary CT angiography for acute chest pain triage: Techniques for radiation exposure reduction; 128 vs. 64 multidetector CT

Background Coronary CT angiography (CCTA) is used daily in acute chest pain triage, although exposing patients to significant radiation dosage. CCTA using prospective ECG gating (PG CCTA) enables significant radiation reduction Purpose To determine whether the routine use of 128 vs. 64 multidetector CT (MDCT) can increase the proportion of patients scanned using PG CCTA technique, lowering radiation exposure, without decreasing image quality. Material and Methods The study comprised 232 patients, 116 consecutive patients scanned using 128 MDCT (mean age 49 years, 79 men, BMI 28) and 116 consecutive patients (mean age 50 years, 75 men, BMI 28) which were scanned using 64 MDCT. PG CCTA was performed whenever technically permissible by each type of scanner: 64 MDCT = stable heart rate (HR) <60/min and weight <110 kg; 128 MDCT = stable HR < 70/min and weight <140 kg. All coronary segments were evaluated for image quality using a visual scale of 1–5. An estimated radiation dose was recorded. Results PC CCTA was performed in 84% and 49% of the 128 and 64 MDCT groups, respectively (P < 0.0001). Average image quality score were 4.6 ± 0.3 and 4.7 ± 0.1 for the 128 and 64 MDCT, respectively (P = 0.08). The mean radiation dose exposure was 6.2 ± 4.8 mSv and 10.4 ± 7.5 mSv for the 128 and 64 MDCT, respectively (P = 0.008). Conclusion The 128 MDCT scanner enables utilization of PG CCTA technique in a greater proportion of patients, thereby decreasing the related radiation significantly, without hampering image quality.

Melatonin premedication improves quality of recovery following bariatric surgery – a double blind placebo controlled prospective study

BACKGROUND Melatonin has hypnotic, sedative, analgesic, anti-inflammatory, and antioxidant properties, and is a widely used sleep agent. OBJECTIVES Our aim was to evaluate the effect of melatonin premedication on postoperative recovery in patients undergoing bariatric surgery. SETTING University Hospital, Israel. METHODS Patients undergoing bariatric surgery were randomized to receive either 5 mg melatonin (M group) or placebo (P group) once on the night before surgery and again 2 hours before surgery. Quality of recovery was assessed using the QoR-15, a 15 item questionnaire on quality of recovery after surgery and anesthesia, regarding emotional state, physical comfort, psychological support, pain, and physical independence. A maximal score of 140 suggested good recovery (1 question was omitted due to irrelevance). The patients answered the questionnaire in the preanesthesia clinic, on admission to the operating room, and on the first postoperative day. RESULTS A total of 44 patients completed the study. There was no statistical difference between M and P groups in the mean QoR-15 scores obtained before the surgery. Mean postoperative QoR-15 score was higher in the M group compared with the P group (118.3±12.9 versus 107.8±18.7, respectively; P<.01). Scores were also higher in the M group regarding pain (P<.05) and quality of sleep (P< .05). CONCLUSIONS Use of melatonin premedication improved the quality of recovery 1 day after bariatric surgery as measured by the QoR-15, specifically the quality of sleep and pain levels. Melatonin may serve as a premedication, especially when other options, like benzodiazepines are not recommended.