Dimitrios Tsamis

Thyroid surgery with the new harmonic scalpel: A prospective randomized study

BACKGROUND Despite their safety and effectiveness in thyroid surgery, the previous harmonic scalpel instruments are considered large and cumbersome by several surgeons. An innovative technical improvement of the device has been made available since 2008. The objective of this study was to compare the results of total thyroidectomy using the new harmonic scalpel (FOCUS) with that with the previously available device (HARMONIC ACE). METHODS A prospective randomized study of all total thyroidectomies between February and July 2008 was conducted. Patients (n = 90) were randomized to undergo total thyroidectomy with FOCUS (group A, n = 45) or HARMONIC ACE (group B, n = 45). RESULTS No significant differences were identified between the 2 groups in terms of demographics, reoperative thyroid surgery, thyroid gland weight and diameter, pathologic diagnosis, preoperative and postoperative serum PTH and calcium levels, postoperative complications, duration of hospital stay, and final outcome. The mean operative time was less in group A than group B (63 ± 7 min vs 76 ± 8 min, P = .009). CONCLUSION The new harmonic scalpel is a useful adjunct to the armamentarium of the thyroid surgeon. It is safe, effective, and hand friendly, offering great capabilities for delicate tissue grasping and dissection. Use of this device decreased operative time compared with the previously available instrument.

Impact of Laparoscopic Sleeve Gastrectomy on Weight Loss and Associated Comorbidities in Adolescents and Young Adults.

BACKGROUND Obesity is a common disease affecting young adults and adolescents worldwide. This study aims to delineate the role of laparoscopic sleeve gastrectomy (LSG) in weight loss and associated comorbidities to adolescents and young adults. PATIENTS AND METHODS This study is a retrospective analysis of a prospective cohort of all young adults 16-22 years old who underwent LSG for morbid obesity and were followed up for 24 months. Demographic data, weight loss, and the status of several comorbidities, such as diabetes mellitus, hypertension, and dyslipidemia, were assessed at postoperative Months 1, 3, 6, 12, 18, and 24. RESULTS Overall, at baseline and after 24 months of close follow-up of 37 adolescents and young adults who had undergone LSG, the body mass index of the patients was 46.93 ± 6.07 kg/m(2) versus 26.2 ± 3.6 kg/m(2) (P < .001), and the body weight was 143 ± 29 kg versus 78 ± 15 kg (P < .001). From the first follow-up visit after operation to the last one at the 24 months, there was also a significant difference in percentage excess weight loss (22.40 ± 6.58% versus 81 ± 17%; P < .001), body mass index difference (-5.47 ± 1.69 kg/m(2) versus -18.08 ± 4.38 kg/m(2); P < .001), and percentage excess body mass index loss (26.06 ± 7.56% versus 96 ± 21%; P < .001). The percentage of the adolescents and young adults with diabetes mellitus, hypertension, and dyslipidemia were diminished gradually at 6 months postoperatively (P < .001). CONCLUSIONS LSG represents a safe and attractive treatment strategy for morbidly obese adolescents and young adults with comorbidities. In this study group excellent resolution of excess weight and comorbid conditions is achieved 2 years after LSG.

Gastrobronchial fistula as a late complication of sleeve gastrectomy

Sleeve gastrectomy is currently one of the most popular operations for morbid obesity. However, staple line leaks occur in up to 4.3% of cases, depending on the experience of the center, and can lead to major morbidity [1,2]. Abdominal sepsis, abscesses, fistulas, and respiratory failure are some of the most common complications of a leak. Most of these complications occur soon after the appearance of a leak. However, a gastrobronchial fistula usually occurs late after the procedure. We report 2 cases in which gastrobronchial fistulas developed several months after sleeve gastrectomy.

Transgastric Band Removal. A Different Approach

In this video, a gastric band removal is presented in an obese 43-year-old patient. The patient had undergone placement of the gastric band approximately 2 years before. The patient during this period had problems with epigastric pain and weight regain. The band eroded and migrated inside the stomach of the patient. Two endoscopic attempts at band cutting and retrieval were unsuccessful. During laparoscopic exploration, multiple adhesions were seen in the upper abdomen around the band. The body of the band was entirely inside the stomach, as it is seen in the video, and it cannot be transected. Through the dilated stomach, a 10mm trocar was carried forward inside the stomach. The camera was placed through this trocar to facilitate view inside the dilated stomach. Two more trocars were inserted into the stomach, 5 mm each. Intraluminal band division and removal was facilitated through these two trocars. The gastrotomies were repaired and a leak test was performed with air insufflation inside the stomach. There were no intraoperative or postoperative complications. The patient began a soft diet and was discharged on the fifth postoperative day. Follow-up visits of the patient remarked complete resolution of her symptoms. Removal of a gastric band after gastric erosion by laparoscopic transgastric placement of trocars is feasible, safe and effective when standard endoscopic techniques fail. Conflict of Interest The authors have nothing to declare. Statement of Informed Consent Informed consent was obtained from the individual participant included in the video presentation. Electronic supplementary material The online version of this article (doi:10.1007/s11695-014-1565-7) contains supplementary material, which is available to authorized users. D. Tsamis (*) :K. Albanopoulos Endoscopic Surgery Department, A Propaideutic Surgical Clinic of University of Athens, Hippokration Hospital of Athens, Vas. Sofias 114, Athens 11527, Greece e-mail: tsamisdim@hotmail.com OBES SURG DOI 10.1007/s11695-014-1565-7

Efficacy of Vitamin D Supplementation After Bariatric Operation: Letter to the Editor

Dear Editor, I read the article “Vitamin D Supplementation Efficacy: Sleeve Gastrectomy Versus Gastric Bypass Surgery” [1]. I was concerned about the aim of the study trying to show any differences after two bariatric operations in a small group of patients (11 versus 12 patients). Three months after the bariatric procedures and after the intense supplementation with vitamin D, 26.1 % of patients had vitamin D deficiency in both groups. I think that this study is based in a very small population, without any power analysis data given. The authors do not also reveal the possible problems with unmasking subclinical parathyroid glands adenomas with intensive vitamin D supplementation [2]. The rate of these problems and the rate of preoperative secondary hyperparathyroidism could not possibly be revealed with such a small group of patients [3]. I think a study with more patients will enlighten us about the possible role of vitamin D supplementation after these two bariatric procedures. Assessment of vitamin D deficiency should also be performed after a longer period after the operation.

Glucose Tolerance Test Before and After Gastroplasty. Is It a Secure Measurement

Dear Editor, To date, many articles have focused on the impact of restrictive bariatric operations on diabetes mellitus control. In some of these studies, the authors used glucose tolerance tests before and after the bariatric operation to prove better postoperative glucose tolerance [1, 2]. However, while reviewing such studies, questions arise regarding the reliability of the glucose tolerance test after a bariatric operation as a measure of diabetes mellitus control. In our department, many morbidly obese patients undergo restrictive operations, such as sleeve gastrectomy and gastric bypass, and the glucose tolerance test is conducted preoperatively and occasionally postoperatively. After reducing the stomach volume of these patients, much less liquid and solid food can be safely tolerated than was preoperatively. Frequently, after the operation, patients are unable to tolerate and timely ingest the requisite amount of food assumed by the mixed meal glucose tolerance test or the simple glucose tolerance test. Furthermore, gastric bypass has a much more intense restrictive effect than sleeve gastrectomy with respect to the stomach volume of these morbidly obese patients. In our opinion, the glucose tolerance test is not a safe and efficacious test for measuring diabetes mellitus control post constrictive bariatric operation. Furthermore, this test is not appropriate for comparing a non-gastrectomy obese patient with a patient who underwent a restrictive gastric operation. We also believe that it is not prudent to compare the glucose metabolism by this way before and after the restrictive operation on the same morbidly obese patient. In the aforementioned cases, we submit that the glucose tolerance test is not reliable.

Laparoscopic excision of a lymphangioma of the cystic duct

Lymphangiomas are benign tumors that originate from malformations of the lymphatic vessels. They are rarely seen in adults and are extremely rare in the cystic duct. Herein, we report the case of a 48‐year‐old woman who presented with a cystic lymphangioma that originated in the cystic duct and was excised laparoscopically. Preoperative imaging revealed the cystic and benign nature of the lesion. Laparoscopic abdominal exploration and excision of the 10‐cm cystic lymphangioma were performed. Four trocar sites were used, and the excision was achieved using clips and electrocautery. The laparoscopic excision of these benign masses is safe and efficacious in experienced hands. This procedure requires preoperative planning and must be individualized.

Migratory sialocele after fine needle aspiration of the parotid gland.

Sialocele is a subcutaneous collection which contains saliva. This collection is mainly developing at the area of parotid gland and it is evolving after trauma in this region or after a surgical procedure. During these procedures, a disruption of a duct or injury of the parenchyma promotes extravasation of the saliva and the formation of this collection in glandular or periglandular tissues [1]. This condition usually is a self-limited phenomenon and conservative measures are efficient in most of the times. Rarely, interventional measures like drainage of the collection and botulinum toxin injection or surgical management are needed [2, 3]. In this report, a case of a patient who developed a migrating sialocele after fine needle aspiration (FNA) for a Warthin tumor of the parotid gland is presented. This male patient 60-year old had a progressive bulge in his both parotid glands for approximately the last 10 years. The patient presented in our department with a painful swelling of his left gland after a diagnostic FNA 48 h before. This bulge was movable and the parotid duct in the affected side was normal and salivary flow had normal physical aspects without debris or purulent discharge. Imaging studies were performed. Ultrasound of the region revealed lesions in both of the glands. In the left gland, the lesion seems to be collection or abscess (Fig. 1). Moreover, a computed tomography (CT) of the cervix revealed a 3-cm tumor in the right parotid gland and two tumors in the left parotid gland approximately 1.0 and 1.3 cm in diameter (Fig. 2). CT and FNA results both confirmed that these tumors were Warthin tumors of the parotid gland type 2B. The patient was hospitalized and antibiotic therapy was administered. The fourth day after the FNA, this reddish bulge of the patient which located in the preauricular region in the left side of the patient moved distally to the cervix. The migration of this red bulge was continued and in approximately 6 h the bulge was located in the left sternocostal space. After this position, the bulge was progressively diminished. The presumptive diagnosis of this bulge in the left parotid gland site was initially the abscess from the previously performed FNA. But the rapid migration and disappearing of the bulge with complete loss of the symptoms and signs of inflammation just in few hours made the diagnosis of a sialocele as the most appropriate one. It seems that FNA generated an injury in Warthin tumor or the healthy part of the parotid gland and produced the collection of the saliva.

Colonic metastasis of a renal cell carcinoma: Case report and brief review of the literature

IntroductionColonic metastasis following curative surgery for renal cell carcinoma has rarely been described in the literature.Case PresentationWe present a case of a 64-year-old man who previously had a left nephrectomy for renal cell carcinoma. Five months post-operatively the patient presented with microscopic intestinal bleeding and anemia. Colonoscopic surveillance revealed a metastatic lesion in the ascending colon, and a right hemicolectomy was subsequently performed.DiscussionColonic metastasis following resection for renal cell carcinoma is a rare entity, as evidenced by its lack of description in the literature. Imaging scans, such as computed tomography, have little diagnostic value and an increased medical suspicion is warranted for prompt diagnosis.

Sexual Behavior in an Intensive Care Unit

Sexuality is something which is intimately combined with the human life and behavior. But in cases in which the human body is severely ill, the sexual instincts are sidelined and subsided. Conversely, fears are raised about survival and condition of health. In intensive care units (ICU), sexuality is most of the times absent. But there are some cases where sexual desire is present and is intense (Kotronoulas, Papadopoulou, & Patiraki, 2009 ;W ilmoth,2007). We report two cases of patients who demonstrated intense sexual desire by masturbating in the area of an ICU. The first patient was a 26-year-old male, who after eight gunshots and two surgical interventions for massive bleeding from liver parenchyma was stabilized and withdrawn from mechanical ventilation. The patient about 3 days before leaving ICU performed masturbation, even if a urinary catheter was present. The overall stay of the patient in the ICU was approximately 3 months. The second patient was a 55-year-old female patient. This woman was a morbidly obese patient who underwent a sleeve gastrectomy. At the third postoperative day, sepsis was developed since a leak from the stapling line near the cardia of the stomach was present. The patient underwent surgical drainage of the region and cervical esophagostomy was performed. During the monitoring of the patient in the ICU, she underwent masturbation. The overall stay of the patient in the ICU was 40 days and the incident was performed 35 days approximately after the transfer of the patient at the ICU. This phenomenon is rare in patients who are critically ill and are hospitalized in an ICU. Nevertheless, both of these patients were in relatively good overall condition near their export from the unit. Thus, both of these patients had a long stay with nonexistent sexual activity. Their medication in the ICU had not diminished sexual desire as an adverse effect. Maybe this act and the return of the sexual desire were indicative of the good clinical condition of the patients and the overtaking of their medical problems. It is very interesting the fact that this instinct was greater than awkwardness which the patients may felt by the presence of the personnel of ICU.