Rachel M. Gomes

The effect of surgically induced weight loss on nonalcoholic fatty liver disease in morbidly obese Indians: “NASHOST” prospective observational trial

BACKGROUNDnSurgically induced weight loss improves nonalcoholic fatty liver disease (NAFLD) in morbidly obese Caucasian patients. Similar data are lacking from India.nnnOBJECTIVEnTo compare the histologic features of NAFLD in morbidly obese Indian patients before and 6 months after bariatric surgery. Histologic changes were also separately assessed according to the type of bariatric intervention.nnnSETTINGnTeaching institution, India; private practice.nnnMETHODSnAll patients undergoing bariatric surgery from July 2012 to July 2013 underwent a routine liver biopsy at the time of bariatric surgery. If the biopsy specimen indicated NAFLD, patients were asked to undergo a second biopsy after 6 months. Baseline anthropometry, clinical data, biochemistry, and pathology were recorded and repeated at follow-up.nnnRESULTSnEighty-eight of 134 index biopsy specimens indicated NAFLD. Thirty patients had paired liver biopsies. Steatosis was present in all, 14 had lobular inflammation, 10 had ballooning degeneration, and 14 had fibrosis. Mean time between the biopsies was 7.1 months (range 6-8 months). At the second biopsy, steatosis had resolution in 19 and improvement in 11, lobular inflammation had resolution in 12 and improvement in 2, ballooning had resolution in 9 and improvement in 1 and fibrosis had resolution in 11 and improvement in 3 (P<0.05 for all). Improvement was greater among those who underwent a sleeve gastrectomy in comparison to a Roux-en-Y gastric bypass, although this difference was not statistically significant. None had worsening of liver histologic results.nnnCONCLUSIONSnSurgically induced weight loss significantly and rapidly improves liver histology in morbidly obese Indians with NAFLD.

Prevalence and Predictors of Non-Alcoholic Fatty Liver Disease in Morbidly Obese South Indian Patients Undergoing Bariatric Surgery

BackgroundNumerous studies worldwide have identified a high prevalence of non-alcoholic fatty liver disease (NAFLD) among morbidly obese subjects. Several predictors have been found to be associated with NAFLD and its histological high-risk components. Similar data from India is lacking. We aimed to determine the prevalence and the predictors of NAFLD and its histological high-risk components in a cohort of Indians with morbid obesity undergoing bariatric surgery. Safety of a routine intraoperative liver biopsy was also assessed.MethodsThere were 134 morbidly obese patients who underwent bariatric surgery with concomitant liver biopsy. These were assessed for NAFLD and its histological high-risk components. Clinical, biochemical, and histological features were evaluated, and predictors of NAFLD, non-alcoholic steatohepatitis (NASH), fibrosis, and advanced fibrosis were identified.ResultsMean BMI was 44.66u2009±u20099.81. Eighty-eight (65.7xa0%) showed NAFLD. Forty-five (33.6xa0%) showed NASH and 42 (31.3xa0%) showed fibrosis both not mutually exclusive. Nineteen (14.1xa0%) showed advanced fibrosis. Higher alanine aminotransferase (ALT) independently predicted NAFLD and was significantly associated with NASH and fibrosis. Type 2 diabetes mellitus (T2DM) and the metabolic syndrome were significantly associated with fibrosis. Systemic hypertension (HT) independently predicted NASH and fibrosis. There were no intraoperative or postoperative complications related to the liver biopsy.ConclusionsNAFLD has a high prevalence among morbidly obese patients. Elevated ALT, HT, T2DM, and the metabolic syndrome are predictors for NAFLD and its high-risk histological components. Routine intraoperative liver biopsy is safe in morbidly obese undergoing bariatric surgery for diagnosing NAFLD.

Unexpected benign histopathology after pancreatoduodenectomy for presumed malignancy: accepting the inevitable

BackgroundDifferentiating malignant and benign disease in the pancreatic head and periampullary region is difficult. The aim of this retrospective study was to analyze patients with unexpected “benign” disease after pancreatoduodenectomy (PD) to evaluate the incidence, possible discriminating factors, and outcome. The role of preoperative pathology interpretation in diagnosing malignancy was also assessed.MethodsPatients with unexpected benign disease were identified from a prospectively maintained database of 446 PDs for presumed malignancy from April 2006 to December 2013. Clinical, radiological, and pathological features were reviewed. Positive predictive values (PPVs) of preoperative pathology interpretation were analyzed. Short-term outcomes were compared.ResultsIncidence of unexpected benign disease was 6.5xa0% (29/446). Radiological diagnostic signs (except the double duct sign) suggestive of malignancy were seen in more than half of the benign cases. Preoperative pathology ‘positive’ or ‘suspicious for malignancy’ had a PPV of 97.6xa0% and ‘indeterminate disease’ and had a PPV of 90xa0% for malignancy. ‘Benign’ or ‘negative’ pathology had a PPV of 19xa0% for benignxa0disease in strongly suspected malignancy. There was no significant difference in outcomes in PD for benign versus malignant disease except for a decreased rate of POPFs and a higher trend toward mortality. However, both outcomes were not independently associated with benign disease.ConclusionsA small percentage of benign disease after PD for “strongly suspected malignancy” is inevitable. No radiological or pathological features can reliably discriminate benign from malignant in these patients. Trend toward higher mortality after PD for unexpected benign disease exists. Detailed preoperative pathological subclassifications are helpful in malignancy.

Laparoscopic Undo of Fundoplication with Roux-en-Y Gastric Bypass in a Morbidly Obese Patient with Prior Nissen’s Fundoplication: A Video Report

BackgroundRoux-en-Y gastric bypass (RYGB) may be a better option for morbidly obese patients with gastroesophageal reflux (GERD) for long-term reflux control. It is recommended after fundoplication if a patient is morbidly obese with GERD with failed fundoplication or if bariatric surgery is planned with a prior successful fundoplication (Kim et al., Am Surg 80(7):696–703, 2014; Kambiz Zainabadi, Surg Endosc. 22(12):2737–40, 2008). Complete takedown of the wrap to avoid stapling over the fundoplication creating an obstructed, septated pouch is needed (Kambiz Zainabadi, Surg Endosc. 22(12):2737–40, 2008). The aim of this video was to demonstrate the technical aspect of dissection and undo of Nissen’s fundoplication followed by performance of a RYGB in a morbidly obese patient with GERD with prior successful Nissen’s fundoplication opting for bariatric surgery after a year.MethodsWe present a case of a 50-year-old woman with a BMI of 36.14 with previous laparoscopic Nissen’s fundoplication for severe GERD (controlled after surgery) and a prior laparoscopic intraperitoneal onlay mesh repair who presented for bariatric surgery 1xa0year after fundoplication. She was successfully treated by laparoscopic undo of the fundoplication with RYGB.ResultsIn this multimedia high-definition video, we present step-by-step the laparoscopic undo of a Nissen’s fundoplication followed by RYGB. The procedure included lysis of all adhesions between the liver and the stomach, dissection of the diaphragmatic crura, complete takedown of the wrap, repair of the hiatal hernia, creation of a gastric pouch, creation of an antecolic Roux limb, gastrojejunal anastomosis, and jejuno-jejunal anastomosis.ConclusionLaparoscopic RYGB after fundoplication in morbidly obese patients with GERD is a technically difficult but feasible option.

Management of Type 1 Late Sleeve Leak with Gastrobronchial Fistula by Laparoscopic Suturing and Conversion to Roux-en-Y Gastric Bypass: Video Report

BackgroundGastrobronchial fistula (GBF) is a rare but serious complication after laparoscopic sleeve gastrectomy (LSG). It commonly appears sometime after the primary LSG. (Alharbi Ann Thorac Med. 8(3):179–80, 2013; Albanopoulos et al. Surg Obes Relat Dis. 9(6):e97–9, 2013). Surgical approach is an effective treatment. (Rebibo et al. Surg Obes Relat Dis. 10(3):460–67, 2014).The aim of this video was to demonstrate the operative management of a gastrobronchial fistula after LSG by laparoscopic suturing and conversion to a Roux-en-Y gastric bypass (RYGB).MethodsWe present the case of a 53-year-old woman, with a BMI of 50.2 who presented with a left lower lobe consolidation 7xa0months after LSG. Imaging revealed a gastrobronchial fistula with left lower lobe consolidation and small sub-diaphragmatic collections. Endoscopy done revealed a fistulous opening beyond the oesophago-gastric junction and a trial of endoscopic stenting failed.ResultsIn this multimedia high definition video, we present step-by-step the operative management of a late sleeve leak with gastrobronchial fistula by laparoscopic suturing and conversion to a RYGB. The procedure included mobilization of the gastric sleeve, identification and suturing of the fistulous opening, creation of a gastric pouch, creation of an ante-colic Roux limb, gastro-jejunal anastomosis and jejuno-jejunal anastomosis. Drainage of the fistula decreased with absence of a leak on imaging and pneumonia resolved in 15xa0days. This patient was diagnosed 7xa0months postoperatively with a gastric sleeve leak and the time to fistula closure from diagnosis was 2xa0months.ConclusionGBF is a severe complication of bariatric surgery that usually presents late in the postoperative period. GBF after LSG can be treated by surgical fistula repair and conversion of the sleeve into a RYGB.

Role of intraoperative frozen section for assessing distal resection margin after anterior resection

Background and aimsThe use of neoadjuvant long-course chemoradiotherapy (LCRT), shorter distal safety margins (DSMs) and stapled or intersphincteric resections has increased sphincter preservation rates. While intraoperative frozen section (IOFS) is not mandatory, it helps achieve negative distal resection margins (DRMs). Our aim was to audit the role of IOFS for DRM assessment while performing sphincter-saving rectal surgery and to identify those subgroups that would benefit the most from IOFS analysis.MethodsPatients who underwent rectal cancer surgery between 2009 and 2013 were identified from a prospectively maintained database. Patients who intraoperatively underwent an IOFS for DRM assessment were included in the study. Factors associated with a positive margin on IOFS were analysed. The sensitivity and specificity of IOFS were also assessed.ResultsOf 250 patients, who had an anterior resection with an IOFS, 12 had an involved DRM. Of these patients, eight were involved by adenocarcinoma, two by acellular mucin, one by moderate dysplasia and one by adenoma confirmed on paraffin section. Positive margins had a 100xa0% intervention rate. There were two false negative on IOFS. IOFS had a sensitivity of 85.17xa0% with a specificity of 100xa0% and a negative predictive value of 99.16xa0%. Specimens with a positive IOFS were lower rectal (Pu2009<u20090.05), poorly differentiated and post LCRT locally advanced tumours.ConclusionsIOFS to confirm negative DRM is recommended in lower rectal tumours irrespective of DSM. It can be considered for locally advanced post LCRT poorly differentiated mid rectal tumours and avoided for upper rectal tumours.

Sporadic Giant Mesenteric Fibromatosis

Mesenteric fibromatosis is an uncommon tumour which is locally aggressive without any metastatic potential and can occur as a sporadic event or in association with familial adenomatous polyposis syndrome. Giant mesenteric fibromatosis is very rare and is a diagnostic and therapeutic challenge. This is a case report of a rare presentation of deep fibromatosis as a sporadic giant intrabdominal mesenteric tumour in a 29xa0year old male managed by surgical excision and definitive diagnosis made on the basis of immunohistochemical findings.

Perforated colonic tubulovillous adenoma—a rare presentation

Dear Editor: A 25-year-old male sought evaluation in our emergency department with several hours of diffuse abdominal pain and distension. He gave a prior history of intermittent attacks of colicky pain which was present since a few months. On physical examination, his pulse rate was 120/ min, blood pressure was 110/70 mmHg and respiratory rate was 22 breaths/min. The abdominal examination revealed distension and generalized tenderness, especially over the right upper abdominal region with guarding. Laboratory testing detected a white blood cell count of 15,000/μL. An abdominal computed tomography (CT) scan identified a transverse colon tumour with surrounding fluid and few specks of air. The patient was subjected to an exploratory laparotomy. During surgery, gross faecal contamination with a perforated large transverse colon growth was seen. An inflammatory phlegmon was formed with the perforated tumour mass and the omentum which had adhered to the stomach. Intraoperative impression of the transverse colon mass was a perforated adenocarcinoma. An extended right hemicolectomy was performed. The histopathological examination of the surgical specimen identified an ulceroproliferative growth measuring 4×2×2 cm seen in the transverse colon involving the bowel circumferentially. The mass was centrally necrotic covered with exudates leading to a perforation on the serosal aspect. Histological examination showed a tubulovillous adenoma with moderate atypia in the mucosa with no evidence of invasion beyond mucosa. Adjacent was seen the perforation tract with transmural acute and chronic inflammation in the form of diverticulitis-like inflammatory pattern with serositis. The lining of the perforation tract showed acute fibrinopurulent inflammatory infiltrate. Few microabscesses were also seen with foreign body giant cells in the subserosal fat. No granulomas were seen. All 37 nodes isolated were negative for malignancy. Postoperatively the patient developed an intra-abdominal collection managed by pigtail drainage and antibiotics. The course of the patient was otherwise uneventful, and he was discharged in a stable condition. The major concern associated with colonic adenomatous polyps is the risk of malignant transformation. They are asymptomatic lesions usually diagnosed at investigation of unrelated abdominal complaints or at colonic screening of at risk patients. Rarely, they may be symptomatic in cases of extensive polyposis or in large villous adenomas. In some instances, colonic adenomas have been reported to cause obstructive appendicitis and subsequent perforation or have been found in the mouths of perforated diverticulitis [1, 2]. However, colonic adenomas are rarely ever reported to be associated with a spontaneous perforation as a clinical presentation. One case of a perforated villous adenoma of the caecum has been reported in literature [3]. We in this report have highlighted another case with this unexpected complication. While perforation may be easy to understand with transmural involvement and necrosis associated with invasive tumours or distended colons in stenosing growths, the exact reason is difficult to outline in the case of colonic adenomas. Erosion of a necrosed tumour by raised intraluminal pressure and inspissated stools may be a possibility in these juxtatumoural perforations. R. M. Gomes :A. Desouza :A. Saklani (*) Unit of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Dr. E. Borges Road, Parel, 400012 Mumbai, India e-mail: asaklani@hotmail.com

Primary epiploic appendagitis: Laparoscopic diagnosis and treatment

Sir, The diagnosis of primary epiploic appendagitis was rarely made preoperatively, but nowadays, with improved imaging, this is possible in many cases. We read with interest the article “Primary epiploic appendagitis: Reconciling CT and clinical challenges” published in your Journal [1]. The authors describe 15 cases of primary epiploic appendagitis which were diagnosed on CT scan, treated conservatively and advised for follow up. Only 10 patients completed the advised follow up schedule of a CT scan at 2 weeks, 3 months and 6 months to look for resolution. Complete resolution was noted in three patients at 2 weeks, in six patients at 3 months and in one patient at 6 months. We at our institution treat epiploic appendagitis surgically by the laparoscopic method. The optimum treatment for this condition is still a matter of controversy. Most authors state that if diagnosed preoperatively, it should be managed conservatively with antibiotics and analgesics. We wish to point out several issues in clinical practice with this approach. This condition is relatively rare with a possibility of misdiagnosis especially if there is significant colonic wall thickening on imaging in spite of its characteristic imaging features. Symptoms resolve slowly in 7–10 days with imaging resolution taking even up to 6 months as was also noted in this study. The latter adds to diagnostic confusion and makes it necessary that the patient be subjected to the anxiety and expense of several follow up imagings lest a more alarming diagnosis is missed out. Many patients are lost to follow up. On the other hand, laparoscopic diagnosis and treatment offers an excellent option. It confirms the diagnosis without the morbidity of open surgery and allows for surgical removal with subsequent rapid recovery. Histopathological confirmation is made, and there is no need for follow up. Laparoscopy should be strongly considered as a primary treatment option for primary epiploic appendagitis.

Prevention of migration of endotracheal tubes used for aided nasogastric tube placement in anaesthetized patients.

Sir, n nDuring bariatric surgery procedures, the anaesthesiologists help facilitate proper placement of nasogastric tubes (NGTs) and bougies to size the gastric pouch. They help perform leak tests with saline, methylene blue or air to ensure staple-line or anastomotic integrity. They ensure complete removal of all gastric tubes before gastric division to avoid unplanned stapling and transection of these tubes. After the surgery is performed, they re-insert the NGT tube under vision watching the monitor carefully while the tube is advanced to avoid disruption of the anastomosis. n nNGT insertion in an anaesthetised patient is however a very cumbersome procedure for the anaesthesiologist with the need to burrow under sterile drapes to approach the oral cavity and the need to use a laryngoscope and Magills forceps to advance the tube 1–2 cms at a time to avoid coiling in the oropharynx because of the flexibility and slippery nature of a lubricated NGT through the compromised lumen of the oesophagus secondary to the inflated endotracheal bulb.[1] Several techniques to simplify this procedure have been recommended in the literature.[2,3,4,5,6,7] Of these a quick and easy way often adopted intra-operatively by many anaesthesiologists is to pass a paediatric endotracheal tube (ETT) nasally and a NGT is passed down this tube directly to the oesophagus without coiling or trauma.[2,3,4] The ETT can be then be removed from around the NGT without displacement of the tube. Correct position of NGT is confirmed by injection of air and auscultation over the epigastrium, aspiration of gastric contents or direct visualisation/palpation at surgery. An ETT is preferred over a nasopharyngeal airway as guide for NGT insertion because of its length. n nWe would like to share our experience of a possible undesired event associated with this manoeuvre to create awareness and for adoption of necessary precautions. We recently encountered three patients undergoing bariatric procedures for treatment of their morbid obesity spread over three different centres that were complicated by intra-operative migration of the guiding nasal ETT into the oesophagus after dislodgement of the tube from its connector by this manoeuvre [Figure u200b[Figure1a1a and u200bandb].b]. In all three cases unaware of tube dislodgment (as the connector was the only visible portion), the NGT was threaded pushing the tube further downwards. In all three cases, the tube could not be readily accessed for removal through the mouth and were managed by endoscopic retrieval in two and retrieval through a gastrostomy in one [Figure u200b[Figure2a2a and u200bandbb]. n n n nFigure 1 n n(a) Endoscopic image of the proximal end of migrated nasal endotracheal tube in the oesophagus after displacement of the tube connector, (b) Endoscopic image of the body of the migrated nasal endotracheal tube in the oesophagus after displacement of the ... n n n n n nFigure 2 n n(a) Endoscopic image of the visualization and grasping of the migrated nasal endotracheal tube in the oesophagus, (b) Endoscopic image of the retrieval of the migrated nasal endotracheal tube from the oesophagus n n n nPortex® ETT connectors easily get separated from the tube if attached shallowly resulting in dislodgement of the tube. The simplest precaution to prevent dislodgement is to encircle a 1-cm wide tape at the proximal end of tube and secure it to the connector or use a one-size larger tracheal tube connector, which can be easily and snugly fit into the proximal end of the tube.[8] Furthermore, the Portex® ETTs used should be larger than the NGT as a snugly fitting NGT can easily carry the ETT also with it. Precautionary measures should always be implemented to avoid this unnecessary intra-operative complication.