Georgios Vasilikostas

Potent vasorelaxant activity of the TMEM16A inhibitor T16Ainh‐A01

T16Ainh‐A01 is a recently identified inhibitor of the calcium‐activated chloride channel TMEM16A. The aim of this study was to test the efficacy of T16Ainh‐A01 for inhibition of calcium‐activated chloride channels in vascular smooth muscle and consequent effects on vascular tone.

Staple line reinforcement during laparoscopic sleeve gastrectomy: Does it affect clinical outcomes?

Although laparoscopic sleeve gastrectomy (LSG) is safe and efficacious treatment for morbid obesity, this procedure is associated with major staple line complications including leakage and bleeding. Staple-line reinforcement (SLR) either through suturing or buttressing with biological or synthetic material has been suggested as a method to prevent these complications. A Best Evidence Topic was constructed to address the question of whether SLR reduced these and other complications. MEDLINE, EMBASE and CINAHL searches up to October 2012 returned 97 unique results, of which nine (one meta-analysis, two randomised controlled trials (RCTs), six prospective cohort studies) provided the best evidence to answer this clinical question. We conclude that current evidence suggests that staple-line reinforcement reduces the incidence of leakage and postoperative complications than non-reinforcement but does not significantly reduce bleeding complications. However, we cannot as yet recommend staple-line reinforcement as the strength of the presented evidence is limited by the variable quality of the published studies. The full-length publication of several abstracts of randomised, controlled trials presented at various recent conferences is awaited. This may provide more data on the effect of staple-line reinforcement on other outcomes largely neglected by currently available studies.

Sleeve gastrectomy for gastric band failures – A prospective study

BACKGROUND We prospectively evaluated the feasibility and efficacy of a strategy of performing concomitant laparoscopic band removal and sleeve gastrectomy on all-comers who had a failed laparoscopic adjustable gastric band (LABG) and analysed the impact of the reason for revision surgery on outcomes. METHODS Over a two-year period, 23 patients who previously had LAGB insertion were referred for revision surgery. Of this cohort, three patients elected to undergo band removal alone. Of the remaining 20 patients, 10 presented with weight regain and 10 presented with pathological symptoms secondary to band migration (band complication group). All patients were listed for simultaneous LABG removal and sleeve gastrectomy and the outcomes of the two groups analysed. RESULTS Simultaneous band removal and sleeve gastrectomy was achieved in all cases of weight regain and in 7 cases of band complications. There were no complications in the weight regain group and three major morbidities in the band complication group. At the time of revision, the mean body mass index was 40.3 ± 1.5; however at a mean follow-up period of 2.2 ± 0.28 years the mean BMI of the cohort had fallen to 35.9 ± 1.4. The mean BMI was significantly lower in the band complication group (p = 0.03). CONCLUSIONS Gastric band removal and revision sleeve gastrectomy following failed LABG is feasible as a single-stage procedure with good outcomes. The optimum peri-operative results of this approach are seen in patients with weight regain whilst the longer term outcomes are superior in those with band complications.

Resident phenotypically modulated vascular smooth muscle cells in healthy human arteries

Vascular interstitial cells (VICs) are non‐contractile cells with filopodia previously described in healthy blood vessels of rodents and their function remains unknown. The objective of this study was to identify VICs in human arteries and to ascertain their role. VICs were identified in the wall of human gastro‐omental arteries using transmission electron microscopy. Isolated VICs showed ability to form new and elongate existing filopodia and actively change body shape. Most importantly sprouting VICs were also observed in cell dispersal. RT‐PCR performed on separately collected contractile vascular smooth muscle cells (VSMCs) and VICs showed that both cell types expressed the gene for smooth muscle myosin heavy chain (SM‐MHC). Immunofluorescent labelling showed that both VSMCs and VICs had similar fluorescence for SM‐MHC and αSM‐actin, VICs, however, had significantly lower fluorescence for smoothelin, myosin light chain kinase, h‐calponin and SM22α. It was also found that VICs do not have cytoskeleton as rigid as in contractile VSMCs. VICs express number of VSMC‐specific proteins and display features of phenotypically modulated VSMCs with increased migratory abilities. VICs, therefore represent resident phenotypically modulated VSMCs that are present in human arteries under normal physiological conditions.

Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial

Although, minimally invasive oesophagectomy was first described in the early 1990s, there is a paucity of high quality data on the relative merits of minimally-invasive versus open oesophagectomy (1,2). This is contrast to colorectal surgery where a number of randomised control trials have conclusively demonstrated the efficacy of laparoscopic colorectal resections (3). The reason for this disparity in evidence base lies in the relative rarity of oesophageal cancers combined with the variety of potential surgical approaches for resection oesophageal cancers (e.g., transhiatal, 2 stage, 3 stage and hybrid laparoscopic approaches). The paper by Beire et al. (4) is therefore very significant addition to the literature on the topic of minimally invasive oesophagectomies.

Does closure of the mesenteric defects during antecolic laparoscopic gastric bypass for morbid obesity reduce the incidence of symptomatic internal herniation

A best evidence topic in surgery was written according to a structured protocol. The question asked was whether the closure of the mesenteric defects during laparoscopic gastric bypass via antecolic approach for morbid obesity reduces the incidence of symptomatic internal herniation. 251 papers were found using the reported search strategy of which three papers best represented the answer to the question. All three studies showed that by closuring the mesenteric defects, resulted in a reduction in the incidence of symptomatic internal hernias. One study showed there to be new complications arising from primary closure, but this was undetermined statistically. The evidence still however remains limited regarding the need for closure of mesenteric defects in gastric bypass operations. We recommend there is a need for large scale randomized control trials with suitable follow up for patients.

Laparoscopic repair of a spontaneous diaphragmatic hernia

BACKGROUND Spontaneous diaphragmatic hernia without a previously documented history of trauma is uncommon and clinical presentation can often be atypical ranging from an incidental radiological finding to patients presenting with complications. CASE PRESENTATION In this video we present the case of a patient presenting with gastric perforation within a large spontaneous diaphragmatic hernia in the central part of the left hemidiaphragm. CONCLUSIONS Management of a complicated diaphragmatic hernia could be achieved using laparoscopic approach. The rarity of these hernias means that the operative strategy necessary for safe dissection and repair has to be individualized for each patient.

An innovative endoluminal rendezvous technique to restore gastrogastric continuity following extensive gastrointestinal loss from internal herniation after gastric bypass.

One relatively rare but major complication after a laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity is internal herniation, which can lead to extensive small bowel infarction [1]. Through technical refinements and closure of potential anatomic defects, incidence of such complications is decreasing. However, this is often a fatal event and challenges any approach to management [2,3]. We present a novel combined endoscopic and interventional radiology rendezvous technique to restore proximal gastrointestinal continuity after salvage surgery for a gastric bypass complicated by extensive loss of the small intestine, including the majority of the Roux limb.

PTH-150 Giant hiatus hernias in the laparoscopic era

Introduction Laparoscopic repair of giant hiatal hernias (LRGHH) remains a major technical challenge in the successful management of this complex surgical pathology. The aim is to present herein our experience and highlight technical tips in ensuring a safe and efficient approach that improves outcome. Method A retrospective review of patients undergoing elective LRGHH for symptomatic disease was undertaken between January 2011 and September 2014. Size of hiatal defect, herniated contents, surgical variations were recorded and correlated with clinical outcomes. Results Sixteen LRGHH surgeries were performed by three consultant surgeons [A=8, B=4 and C=4, respectively]. There were six males and 10 females with a median age of 65 years (range 33–74). There were eleven Type 3 and five Type 4 hernias with hiatal defect ranging from 2.8 to 7 cm. Complete sac excision, meticulous crural dissection and repair and Nissen undoplication were performed in all cases. Collis gastroplasty for shortened oesophagus was fashioned in 4 cases, mesh applied in 1 case and Teflon pledgets in further 3 cases. Eight (50%) patients remained asymptomatic at 6 weeks, five (31%) reported minimal reflux that had settled at 4-month follow up. Complications occurred in 3 patients (18.7%) and included: immediate hernia recurrence with gastric necrosis requiring laparoscopic sleeve gastrectomy, recurrent vomiting that underwent laparoscopic adhesiolysis 18 months post initial procedure and post-operative dysphagia requiring endoscopic dilatation. All 3 patients remained symptom free at 24 months. Conclusion This report represents the largest reported series in the UK in the modern laparoscopic era. Extensive oesophageal mobilisation to ensure adequate intra-abdominal length and strong crural repair with minimal tension are key to a successful repair. Minimally invasive surgery for such complex major pathology allows perioperative morbidity to remain low with good early outcomes. Disclosure of interest None Declared. References Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases Luketich JD, Raja S, Fernando HC, Campbell W, Christie NA, Buenaventura PO, Weigel TL, Keenan RJ, Schauer PR. Ann Surg. 2000;232(4):608–18 Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients Pierre AF, Luketich JD, Fernando HC, Christie NA, Buenaventura PO, Litle VR, Schauer PR. Ann Thorac Surg. 2002;74(6):1909–15; discussion 1915–6

Esophageal Perforation After Transesophageal Echocardiography in a Malnourished Patient and Repair with an Esophageal Stent

1. D’Ancona G, Baillot R, Poirier B, et al: Determinants of gastrointestinal complications in cardiac surgery. Tex Heart Inst J 30: 280-285, 2003 2. Geissler HJ, Fischer UM, Grunert S, et al: Incidence and outcome of gastrointestinal complications after cardiopulmonary bypass. Interact Cardiovasc Thorac Surg 5:239-242, 2006 3. Lomivorotov VV, Efremov SM, Shmirev VA, et al: Glutamine is cardioprotective in patients with ischemic heart disease following cardiopulmonary bypass. Heart Surg Forum 14:E384-E388, 2011 4. Sufit A, Weitzel LB, Hamiel C, et al: Pharmacologically dosed oral glutamine reduces myocardial injury in patients undergoing cardiac surgery: a randomized pilot feasibility trial. JPEN J Parenter Nutr 36: 556-561, 2012 5. Ziegler TR, Bazargan N, Leader LM, et al: Glutamine and the gastrointestinal tract. Curr Opin Clin Nutr Metab Care 3:355-362, 2000 6. De-Souza DA, Greene LJ: Intestinal permeability and systemic infections in critically ill patients: Effect of glutamine. Crit Care Med 33:1125-1135, 2005