Eran Sadot

Laparoscopic Sleeve Gastrectomy Using 42-French Versus 32-French Bougie: The First-Year Outcome

BackgroundThe optimal size of bougie in laparoscopic sleeve gastrectomy (LSG) remains controversial. The aim of this study was to evaluate the first-year outcome of LSG using two different sizes of bougies.MethodsThis study used a single institute retrospective case-control study of two groups of patients. Group A (Nu2009=u200966) underwent LSG using 42-Fr and group B (Nu2009=u200954) using 32-Fr bougies. A medication score was applied to assess the change in comorbid conditions.ResultsGroups A and Bs age (39.5u2009±u200912 vs. 43.6u2009±u200912.3xa0years), weight (119u2009±u200917 vs. 120u2009±u200920), and BMI (42.8u2009±u20093.8 vs. 43.6u2009±u20096.9xa0kg/m2), respectively, were comparable (pu2009=u2009NS). Comorbid conditions were type 2 diabetes (T2DM) in 19 (29xa0%) vs. 23 (43xa0%) patients, hypertension in 22 (33xa0%) vs. 18 (33xa0%) patients, and gastroesophageal reflux (GERD) in 28 (42xa0%) vs. 10 (19xa0%) patients, respectively. At 1xa0year, group A vs. B BMI was (29.4u2009±u20095 vs. 30u2009±u20095xa0kg/m2) and excess weight loss was 67 vs. 65xa0%, respectively (pu2009=u2009NS). Postoperatively, T2DM (79 vs. 83xa0%), hypertension (82 vs. 61xa0%), and GERD (82 vs. 60xa0%) (pu2009=u2009NS), respectively, in groups A vs. B did not require previous medications anymore. Complications were comparable.ConclusionsOur data suggest that using a 42-Fr or 32-Fr bougie does not influence LSG first-year weight loss or resolution of comorbid conditions. Long-term data is needed to conclude this issue.

The role of bariatric surgery in morbidly obese patients with inflammatory bowel disease.

BACKGROUNDnBariatric surgery is considered as being contraindicated for morbidly obese patients who also have inflammatory bowel disease (IBD). The aim of our study was to report the outcomes of bariatric surgery in morbidly obese IBD patients.nnnMETHODSnThe prospectively collected data of all the patients diagnosed as having IBD who underwent bariatric operations in 2 medical centers between October 2006 and January 2014 were retrieved and analyzed.nnnRESULTSnOne male and 9 female morbidly obese IBD patients (8 with Crohns disease and 2 with ulcerative colitis) underwent bariatric surgery. Their mean age was 40 years, and their mean body mass index was 42.6 kg/m2. Nine of them underwent a laparoscopic sleeve gastrectomy and 1 underwent a laparoscopic adjustable gastric band. Eight patients had obesity-related co-morbidities, including type 2 diabetes, hypertension, sleep apnea, osteoarthropathy, etc. After a median follow-up of 46 months (range 9-67), all of the patients lost weight, with an excess weight loss of 71%, and 10 out of 16 obesity-related co-morbidities were resolved. There was 1 complication not related to IBD, and no IBD exacerbation.nnnCONCLUSIONnBariatric surgery was safe and effective in our morbidly obese IBD patients. The surgical outcome in this selected patient group was similar to that of comparable non-IBD patients.

Acute Appendicitis in the Twenty-First Century: Should We Modify the Management Protocol?

BackgroundRecent data challenge the traditional management of acute appendicitis with early surgical intervention. This study evaluated the impact of timing of appendectomy and other potential risk factors on progression of acute appendicitis.Study DesignA search of the relevant databases of a tertiary medical center identified 1,604 patients with verified acute appendicitis who underwent appendectomy in 2004–2007. Demographic and clinical data and time from symptom onset to emergency room admission (“patient interval”) and from emergency room admission to surgery (“hospital interval”) and their combination were analyzed by pathological grade.ResultsOn multivariate analyses, independent risk factors for appendiceal perforation were age <20xa0years (ORu2009=u20091.58, 95xa0% CI 1.07–2.35) or >50xa0years (ORu2009=u20092.84, 95xa0% CI 1.82–4.45) (relative to 20–50xa0years), white cell count >10u2009×u2009103/mm3 (ORu2009=u20094.45, 95xa0% CI 2.05–9.67), body temperature >37.8xa0°C (ORu2009=u20092.23, 95xa0% CI 1.45–3.41), hospital interval >24xa0h (ORu2009=u20092.84, 95xa0% CI 1.49–5.4), patient interval >48xa0h (ORu2009=u20093.84, 95xa0% CI 2.35–6.29), and combined interval >48xa0h (ORu2009=u20094.29, 95xa0% CI 2.2–8.36). No association with perforation was found for the hour of emergency room arrival, hour of operation, surgical approach, or the performance of preoperative imaging.ConclusionsIn the general population, the risk of advanced pathological grade of appendicitis increases with time. Thus, prompt appendectomy is warranted. Prospective studies of subgroups of perforated and nonperforated appendicitis are needed.

Acute appendicitis in the elderly in the twenty-first century.

BackgroundThe incidence of appendicitis in the elderly has risen. Older age is an independent predictor of poor surgical outcome. Herein, we present the most comprehensive single institution study to describe the natural history and outcome of appendicitis in elderly patients.MethodsA review of 1898 consecutive patients who underwent appendectomy between 2004 and 2007 was performed. The elderly patients were defined as older than 68xa0years.ResultsThe median age of the entire cohort was 25xa0years, and 55xa0% were males. The elderly group included 68 patients (3.6xa0%). On comparison by age, the elderly group had a significantly longer delay from symptom onset to admission (50 vs 31xa0h, Pu2009=u20090.01) and from admission to surgery, a longer operative time and hospital stay, and higher rates of postoperative complications and complicated appendicitis.ConclusionThe current study demonstrated several unique characteristics of the elderly population with acute appendicitis, which include poor outcome and longer time intervals to diagnosis and treatment. In order to improve the poor outcome of the elderly population with appendicitis, prospective trials are necessary.

Laparoscopic accuracy in prediction of appendiceal pathology: oncologic and inflammatory aspects

BACKGROUNDnIn the prelaparoscopy era, macroscopically normal appendices were routinely resected. The aim of this study was to evaluate the accuracy of laparoscopy.nnnMETHODSnA review of 1,899 patients who underwent appendectomy with multivariate analysis was conducted.nnnRESULTSnLaparoscopic and open approaches had similar false-positive rates, false-negative rates, accuracy, and sensitivity. The study population included 17 false-negative cases (11% of all macroscopically normal appendices). Tumors were found in 1.1% of our study population. Female gender (1.9% vs. .5%; odds ratio, 4; 95% confidence interval, 1.5 to 11; P < .005) and appendiceal perforation were independent risk factors for harboring a tumor.nnnCONCLUSIONSnIt is suggested that laparoscopy has diagnostic quality similar to that of the open approach. Until randomized trials evaluate the fate of patients who receive false-negative diagnoses, routine appendectomy is recommended. Special attention should be paid to female patients and to patients with perforations, who have a 4-fold increased risk for harboring a tumor.

The diagnostic performance of ultrasound for acute appendicitis in pregnant and young nonpregnant women: A case-control study

BACKGROUNDnUltrasonography is frequently used to diagnose acute appendicitis in women of reproductive age, but its diagnostic value in pregnant patients remains unclear. This study sought to compare the diagnostic performance of ultrasound in pregnant and young nonpregnant women with suspected acute appendicitis.nnnMETHODSnThe database of a single tertiary medical center was reviewed for all women of reproductive age who underwent appendectomy either during pregnancy (2000-2014) or in the nonpregnant state (2004-2007) following ultrasound evaluation. The performance of ultrasound in terms of predicting the final pathologic diagnosis was compared between the pregnant and non pregnant groups using receiver operating characteristic curve analysis.nnnRESULTSnOf 586 young women treated for appendicitis during the study periods (92 pregnant, 494 non-pregnant), 200 underwent preoperative ultrasound [67 pregnant, and 133 nonpregnant young women]. The pregnant and nonpregnant groups were comparable in age and presenting symptoms. There was no significant difference in the predictive performance of ultrasound between the two groups (AUC 0.76 and 0.73 respectively, pxa0=xa00.78) or within the pregnant group, by trimester [first (nxa0=xa023), AUC 0.73; second (nxa0=xa032), AUC 0.67; third (nxa0=xa012), AUC 0.86; pxa0=xa00.4]. Ultrasound had a positive predictive value of 0.94 in the pregnant group and 0.91 in the nonpregnant group; corresponding negative predictive values were 0.40 and 0.43.nnnCONCLUSIONSnThere appears to be no difference in the ability of ultrasound to predict the diagnosis of acute appendicitis between pregnant women and nonpregnant women of reproductive age. Therefore, similar preoperative imaging algorithms may be used in both patient populations.

Weight Loss After Laparoscopic Band-to-Bypass Revision Compared With Primary Gastric Bypass: Long-term Outcomes.

Laparoscopic Roux-en-Y gastric bypass (RYGB) is frequently performed as a salvage operation after failed laparoscopic adjustable gastric banding (LAGB). Reports about long-term outcomes are lacking. We assessed the long-term outcomes of RYGB revision surgery after failed LAGB (study group, n=44) and compared these outcomes with a demographically matched group who underwent primary RYGB (control group, n=82). There were no between-group differences in sex distribution, age, or initial weight characteristics. At 2 years after RYGB, the mean &Dgr;BMI was 11.8±5.7 kg/m2 in the study group and 15.6±4.2 kg/m2 in the control group (P=0.01); the corresponding %EWL values were 57% and 78% (P=0.005). At 6 years after RYGB, the mean &Dgr;BMI was 10±4.5 kg/m2 in the study group and 13.6±5.7 kg/m2 in the control group (P=0.006); the corresponding %EWL values were 53% and 66% (P=0.04). In conclusion, this study supports the safety and favorable weight-loss outcome of LAGB revision to RYGB. However, the results are inferior to those of primary RYGB.

CD24 gene polymorphism--a novel prognostic factor in esophageal cancer.

Background The CD24 gene has been correlated with poor prognosis of various malignancies. The significance of CD24 in esophageal cancer remains unknown. Our aim was to evaluate the association between CD24 genetic polymorphism and esophageal cancer. Materials and Methods Between June 2011 and May 2012 patients with esophageal cancer and healthy controls were prospectively enrolled and clinicopathological data were collected. Genomic DNA was extracted and restriction fragment length polymorphism (RFLP) analysis was performed to determine CD24 polymorphism at the coding region of CD24, which results in a substitution of the amino acid Ala by Val. Statistical significance was determined by unpaired t-test, χ2-test, and Fishers exact test. Results A total of 102 patients were included, of whom 51 had esophageal cancer and the rest comprised a healthy control group. The incidence of the polymorphism variant (Val/Val) among the healthy subjects and the esophageal cancer cohort was 6% in both groups. The incidence of N3 (metastasis in 7 or more regional lymph nodes) was markedly higher in those esophageal cancer patients who carried the polymorphism variant compared with those who did not carry it (66% and 2%, respectively, p=0.007). No significant difference was found between the groups with regard to age, gender, histology type, tumor location, tumor stage, and other histological characteristics of the tumor. Conclusions This CD24 polymorphism may serve as a novel prognostic marker identifying esophageal cancer patients with poor prognosis. Further studies are warranted to evaluate CD24 function and to validate its predictive potential with regard to esophageal cancer.

Diagnosing colorectal medullary carcinoma: interobserver variability and clinicopathological implications ☆ ☆☆ ★

Colorectal medullary carcinoma, recognized by the World Health Organization as a distinct histologic subtype, is commonly regarded as a specific entity with an improved prognosis and unique molecular pathogenesis. A fundamental but as yet unaddressed question, however, is whether it can be diagnosed reproducibly. In this study, by analyzing 80 colorectal adenocarcinomas whose dominant growth pattern was solid (thus encompassing medullary carcinoma and its mimics), we provided a detailed description of the morphological spectrum from classic medullary histology to nonmedullary poorly differentiated histologies and demonstrated significant overlapping between categories. By assessing a selected subset (n=30) that represented the spectrum of histologies, we showed that the interobserver agreement for diagnosing medullary carcinoma by using 2010 World Health Organization criteria was poor; the κ value among 5 gastrointestinal pathologists was only 0.157 (95% confidence interval, 0.127-0.263; P=.001). When we arbitrarily classified the entire cohort into classic and indeterminate medullary tumors (group 1, n=19; group 2, n=26, respectively) and nonmedullary poorly differentiated tumors (group 3, n=35), groups 1 and 2 were more likely to exhibit mismatch repair protein deficiency than group 3 (P<.001); however, improved survival could not be detected in either group compared with group 3. Our findings suggest that the diagnosis of medullary carcinoma, as currently applied, may only serve as a morphological descriptor indicating an increased likelihood of mismatch-repair deficiency. Additional evidence including a more objective classification system is needed before medullary carcinoma can be regarded as a distinct entity with prognostic relevance. Until such evidence becomes available, caution should be exercised when making this diagnosis, as well as when comparing results across different studies.

An Unusual Presentation of Cholecystoduodenal Fistula: Massive Upper Gastrointestinal Bleeding

Background: Cholecystodoudenal fistula (CDF) as a cause of severe upper gastrointestinal bleeding (UGIB) is a rare event that has few reported cases. Methods: Here we discuss the case of an 86-year-old male who presented with UGIB due to a CDF. Results: The patient was diagnosed promptly and underwent successful emergent operation. Discussion and Conclusion: The following is a discussion of the case, accompanied by a brief review of enterobiliary fistulas. Physicians involved in the management of patients with UGIB should entertain the possibility of a biliary-enteric fistula as a possible cause, particularly in patients with risk factors for gallstone disease. Computed Tomography (CT) might enable prompt diagnosis.