Marco Milone

Effect of bariatric surgery on obesity-related infertility

BACKGROUND There is a strong association between obesity and infertility, and weight loss can increase fecundity in obese women. In an attempt to determine the effect of bariatric surgery on obesity-related infertility, we reviewed the fertility outcomes after intragastric balloon placement, adjustable gastric banding, sleeve gastrectomy, and gastric bypass in childbearing women with a diagnosis of infertility at a university hospital in Italy. METHODS This was a retrospective study of 110 obese infertile women. We evaluated the effectiveness of bariatric surgery in improving fertility, assessing the influence of age, surgical technique, co-morbidities (hypertension and diabetes), weight loss, and body mass index before and after surgery. RESULTS Of these 110 women who had tried unsuccessfully to become pregnant before weight loss, 69 became pregnant afterward. The pregnancies proceeded without complications and ended with a live birth. Only the weight loss (odds ratio 20.2, P = .001) and the achieved body mass index (P = .001) after surgery were the predictors of pregnancy. CONCLUSION Bariatric surgery might be effective in young infertile obese women who wish to become pregnant. Weight loss appears to be independent from the surgical technique in determining the increase in the pregnancy rate as well as the body mass index achieved at pregnancy.

Safety and Efficacy of Barbed Suture for Gastrointestinal Suture: A Prospective and Randomized Study on Obese Patients Undergoing Gastric Bypass

BACKGROUND Laparoscopic intracorporeal suturing and knot tying for anastomosis are considered the most difficult laparoscopic skills to master. The aim of this study was to establish the safety and efficacy of barbed suture for intestinal sutures to close the gastrojejunal anastomosis in obese patients undergoing gastric bypass. STUDY DESIGN All consecutive patients undergoing gastric bypass were screened for enrollment in our study. Patients were randomly allocated to undergo knotless anastomosis with barbed suture (V-Loc™ 180; Covidien, Mansfield, MA) (case group) or knot-tying anastomosis with 3/0 polyglactin sutures (Polysorb(®); Covidien) (control group). The primary outcome was the time needed for the gastrojejunal anastomosis and the operative time. The secondary outcomes were the incidence of leak, bleeding, and stenosis and the evaluation of the cost of the different procedures evaluated. RESULTS Among the 60 consecutive patients enrolled in our study, 30 underwent knot-tying anastomosis, and 30 underwent knotless anastomosis. The time needed for the anastomosis was significantly less (P<.001) in the knotless group, whereas no significant differences were found between the two groups for operative time (P=.151). We recorded one leak in the control group and one leak in the case group (P=1.000). One bleeding in the case group (P=1.000) and no stenosis in either group was recorded. Finally, in our experience, the knotless anastomosis was cheaper than the knot-tying anastomosis (P<.001). CONCLUSIONS Our study appears to be encouraging to suggest the use of barbed suture for gastrointestinal anastomosis.

Late micronutrient deficiency and neurological dysfunction after laparoscopic sleeve gastrectomy: a case report

Although the micronutrient deficiencies and the related neurological manifestations are widely reported after malabsorbitive weight loss surgery, little is known about cerebral dysfunction secondary to micronutrient impairment in subjects undergoing restrictive interventions (that is, sleeve gastrectomy). We describe a case of a 27-year-old woman with a late development of a Wernickes encephalopathy (WE) and of severe polyneuropathy following a sleeve gastrectomy without any sleeve stenosis. The impact of WE after bariatric surgery is significantly underestimated. Such a risk should be taken into consideration also after restrictive weight loss surgery. Thus, surgeoun/clinicians involved in bariatric patients management must be aware of neurological sequelae related to this intervention.

Erratum to: Effectiveness of a drain in surgical treatment of sacrococcygeal pilonidal disease. Results of a randomized and controlled clinical trial on 803 consecutive patients

PurposeThe aim of this study was to evaluate the influence of cavity drainage in the surgical treatment of sacrococcygeal pilonidal sinuses.MethodsThe study was prospectively carried out in 803 patients randomized into two groups of respectively 401 and 402 patients. In the first group, primary excision and closure were associated with drainage of the wound; in the second group, the wound was not drained. We have analyzed time off work, time to walk without pain, time to sitting on the toilet without pain, recurrences, and wound infections. We have also evaluated the satisfaction rate and esthetic results.ResultsOn comparing time off work, time to walk without pain, and time to sitting on toilet without pain postoperatively, there were no significant differences between the two groups. A significant difference between the two groups with regard to wound infection rates (p = 0.5) and recurrence rates (p = 0.6) was not observed. In order to prevent prolonged inpatient stay and social intolerance, this study suggests that the post-operative period is tolerated by a few when a drain was used. The visual analog scale (VAS) in the drained group was 3.2 ± 0.9, and VAS in the non-drained group was 3.5 ± 0.9 with a significant statistical difference (p = 0.0001). As regards the cosmetic appearance of the scar after surgery, we achieved a high satisfaction rate among patients in either group with 82.9% good cosmetic results.ConclusionsThe use of a drain, in our experience, appears to be useless in achieving a quick healing of the sacral wound; in addition, it has a low satisfaction rate.PURPOSE The aim of this study was to evaluate the influence of cavity drainage in the surgical treatment of sacrococcygeal pilonidal sinuses. METHODS The study was prospectively carried out in 803 patients randomized into two groups of respectively 401 and 402 patients. In the first group, primary excision and closure were associated with drainage of the wound; in the second group, the wound was not drained. We have analyzed time off work, time to walk without pain, time to sitting on the toilet without pain, recurrences, and wound infections. We have also evaluated the satisfaction rate and esthetic results. RESULTS On comparing time off work, time to walk without pain, and time to sitting on toilet without pain postoperatively, there were no significant differences between the two groups. A significant difference between the two groups with regard to wound infection rates (p = 0.5) and recurrence rates (p = 0.6) was not observed. In order to prevent prolonged inpatient stay and social intolerance, this study suggests that the post-operative period is tolerated by a few when a drain was used. The visual analog scale (VAS) in the drained group was 3.2 ± 0.9, and VAS in the non-drained group was 3.5 ± 0.9 with a significant statistical difference (p = 0.0001). As regards the cosmetic appearance of the scar after surgery, we achieved a high satisfaction rate among patients in either group with 82.9% good cosmetic results. CONCLUSIONS The use of a drain, in our experience, appears to be useless in achieving a quick healing of the sacral wound; in addition, it has a low satisfaction rate.

A decade of bariatric surgery. What have we learned? Outcome in 520 patients from a single institution

BACKGROUND Today a variety of bariatric surgical procedures is available and, currently, it is difficult to identify the most effective option based on patient characteristics and comorbidities. Aim of this retrospective study is to evaluate the efficacy of four different techniques; Intragastric Balloon (IB), Laparoscopic Adjustable Gastric Banding (LAGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Mini Gastric Bypass (LMGB), performed in our unit along ten years. PATIENTS AND METHODS Starting from January 2005, 520 patients, 206 men (39.6%) and 314 women (60.4%) were treated at our institution. Among patients candidate to bariatric surgery 145 underwent IB, 120 underwent LAGB, 175 underwent LSG and 80 underwent LMGB. Follow up rate was 93.1% for IB at 6 months; 74.1% and 48% for LAGB at 36 and 60 months respectively; 72.8% and 58.1% for LSG at 36 and 60 months respectively; and 84.2% for LMGB at 36 months. RESULTS The period 2005-2014 has been considered. Mortality was 1/520 patients (0.19%). The excess weight loss rate (EWL%) has been 32.8 for IB at six months, 53.7 for LAGB and 68.1 for LSG, at 60 months respectively and 79.5 for LMGB at 36 months. Early major postoperative complications requiring surgery were 0.6% for IB and 1.1% for LSG whereas late major postoperative complications were 1.2% for IB, 4.1% for LAGB and 0.5% for LSG. Diabetes resolution rate was 0 for LAGB, 76.9% for LSG and 80% for LMGB at 36 months. CONCLUSIONS If more invasive procedures as LSG or LMGB may entail higher operative and peroperative risks, conversely, in skilled hands their efficacy remains undisputed, especially in the long term, presenting a very low rate of major complications. In general, the efficacy of a bariatric surgery unit seems improved by the capability to offer both different primary procedures and re-do surgery.

Video-assisted ablation of pilonidal sinus: A new minimally invasive treatment—A pilot study

BACKGROUND We hypothesized that video-assisted ablation of pilonidal sinus could be an effective, minimally invasive treatment of pilonidal sinus. This new, minimally invasive treatment allows the identification of the sinus cavity with its lateral tracks, destruction and the removal of all infected tissue, and the removal of any hair. STUDY DESIGN All consecutive patients with primary sacrococcygeal pilonidal sinus were screened for enrolment in our study. We analyzed time off work, time to walk without pain, time to sitting on the toilet without pain, recurrences, wound infections, and patient satisfaction (pain, health status, and aesthetic appearance). RESULTS We analyzed 27 patients. All procedures were successful, with complete ablation of the sinus cavity. No infection and only 1 recurrence were recorded during the follow-up (1 year) with an immediate return to work and normal activities. In addition, patient satisfaction and aesthetic appearance were high. CONCLUSION Our results are encouraging and suggest that this technique may offer a very effective way to treat pilonidal sinus. Further studies are necessary to validate its use in daily practice.

Wernicke Encephalopathy in Subjects Undergoing Restrictive Weight Loss Surgery: A Systematic Review of Literature Data

The use of weight loss surgery is progressively increasing, and in recent years, restrictive bariatric surgery procedures have been more often used. Although thought to be associated with a lower incidence of post-operative side effects than malabsorpitive surgery, some cases of micronutrients deficiency have been reported because of an acquired thiamine deficiency; in this clinical setting, some cases of Wernicke encephalopathy (WE) have been described. Major determinants and predictors of this major neurological complication are currently unknown. The aim of this systematic review was to analyse literature data in order to address this issue. The main result of our systematic review was that persistent vomiting is the major determinant of WE in patients undergoing restrictive weight loss surgery. In addition, early thiamine supplementation can rapidly improve the clinical conditions, avoiding permanent deficiencies. On the other hand, given the wide variability of clinical and demographic characteristics, definite prognostic factors of WE occurrence and of clinical outcome cannot be identified. In conclusion, although our results are suggestive, further ad hoc prospective studies evaluating changes in micronutrients levels according to different types of surgery are needed.

Endovascular Thrombolysis in Acute Mesenteric Vein Thrombosis: A 3-year follow-up with the rate of short and long-term sequaelae in 32 patients

Mesenteric vein thrombosis (MVT) is a rare, often lethal, entity that accounts for approximately 10-15% of all cases ofmesenteric ischemia. A variety of risk factors have been reported to be associatedwith acute MVT. However, no underlying cause is found in 25-50% of patients diagnosed with MVT [1,2]. Because of the slow onset of symptoms (vague abdominal discomfort thatworsens in 7-10 days in the absence of significant laboratory abnormalities), the clinical diagnosis is difficult. [1–3] In keeping with this, abdominal CT imaging for other indications, has increased awareness on the issue that mesenteric occlusions may be only mildly symptomatic or completely asymptomatic [3,4]. Current indications for surgery in patients with acute MVT include signs of peritonitis, bowel infarction, hemodynamic instability. In all other cases, long-lasting anticoagulation is the strategy of choice [5,6], patients with MVT having a fairly good prognosis and long-term outcomes once achieved appropriate anticoagulation [6,7]. Nevertheless, MVT is still a serious disease, with a highmortality rate (25%-35%), mostly related to transmural necrosis and bowel perforation due to the delay in diagnosis [1,4]. At variance with the slow onset of recanalization that takes place during anticoagulation, thrombolysis leads to a rapid re-opening of a vessel, with immediate tissue reperfusion [6]. Systemic thrombolysis has been used with success in MVT [8,9]. Encouraging results of endovascular thrombo-

Computed tomography findings of pneumatosis and portomesenteric venous gas in acute bowel ischemia

AIM To use more representative sample size to evaluate whether computed tomography (CT) scan evidence of the concomitant presence of pneumatosis and portomesenteric venous gas is a predictor of transmural bowel necrosis. METHODS Data from 208 patients who were referred for a diagnosis of bowel ischemia were retrospectively reviewed. Only patients who underwent a surgical intervention following a diagnosis of bowel ischemia who also had a post-operative histological confirmation of such a diagnosis were included. Patients were split into two groups according to the presence of histological evidence of transmural bowel ischemia (case group) or partial bowel ischemia (control group). CT images were reviewed for findings of ischemia, including mural thickening, pneumatosis, bowel distension, portomesenteric venous gas and arterial or venous thrombi. RESULTS A total of 248 subjects who underwent surgery for bowel ischemia were identified. Among the 208 subjects enrolled in our study, transmural bowel necrosis was identified in 121 subjects (case group), and partial bowel necrosis was identified in 87 subjects (control group). Based on CT findings, including mural thickening, bowel distension, pneumatosis, pneumatosis plus portomesenteric venous gas and presence of thrombi or emboli, there were no significant differences between the case and control groups. The concomitant presence of pneumatosis and porto-mesenteric venous gas showed an odds ratio of 1.95 (95%CI: 0.491-7.775, P = 0.342) for the presence of transmural necrosis. The presence of pneumatosis plus porto-mesenteric venous gas exhibited good specificity (83%) but low sensitivity (17%) in the identification of transmural bowel infarction. Accordingly, the positive and negative predictive values were 60% and 17%, respectively. CONCLUSION Although pneumatosis plus porto-mesenteric venous gas is associated with bowel ischemia, we have demonstrated that their co-occurrence cannot be used as diagnostic signs of transmural necrosis.

Preoperative workup in the assessment of adrenal incidentalomas: outcome from 282 consecutive laparoscopic adrenalectomies

BackgroundTo confirm the efficacy of preoperative workup, the authors analyse the results of a multicentre study in a surgical series of patients diagnosed with an adrenal incidentaloma.MethodsThe retrospective review of a prospectively collected database was conducted. The data was obtained by six surgical units operating in the Campania Region, Italy. Five-hundred and six (506) adrenalectomies performed between 1993 and 2011 on 498 patients were analysed. Final histology in patients with a preoperative diagnosis of incidentaloma and studied according to guidelines (230/282 patients group A) was compared with final histology coming from patients presenting the same preoperative diagnosis but studied not according to guidelines (52/282 patients group B).ResultsIn group A preoperative diagnosis was confirmed at final histology in 76/81 (93.8%) cases of subclinical functioning lesions presenting as an incidentaloma. The preoperative detection of pheochromocytoma and primary adrenocortical cancer (ACC) reached 91.6% and 84.6% respectively. In group B conversion rate to open surgery was higher than in group A (p = 0.02). One pheochromocytoma was missed at preoperative diagnosis whereas one ACC smaller than 4 centimetres (cm) and coming from an incidental lesion was discovered. In both groups a significant association between increasing dimensions of incidentaloma and cancer has been observed (p = 0.001).ConclusionsThis surgical series confirm the high efficacy of suggested guidelines. A significant preoperative detection rate of adrenal lesions presenting as incidentaloma is observed. The unnecessary number of adrenalectomies performed in understudied patients, causing higher morbidity, was not associated to a higher detection rate of primary adrenocortical cancer.