Background: The band erosion (BE) is defined as the partial or complete movement towards the lumen of the stomach, is also known as migration, gastric incorporation and gastric inclusion. The presentation of this complication involves failure of bariatric procedures being ineffective and consequently requires the removal of the laparoscopic adjustable gastric banding (LAGB), usually through laparoscopic surgery.
The objective of this study is to describe the clinical presentation, diagnostic methods, surgical procedure, postoperative evolution in the integral treatment of BE. Material and Methods: We captured the data of patients with BE since January 2010 to October 2017. Database included the year of patient care, age, and sex, BMI before band placement, percentage of excess weight loss, number of device adjustments, clinical data and surgical procedure performed for resolution.
Results: A total 379 LAGB complications were diagnosed in our Institution; 210 patients with BE were diagnosed and treated, the average age was 39 years; range from 19 to 66 years, sex was 178 women and 32 men. The diagnosis was endoscopic in the 210 patients (100%). The surgical procedure to solve the problem was: to remove the LAGB, the fistulous orifice was closed and patch of omentum. The hospital stay was 3-5 days. The motility was zero. Complications were minor in 3% of the 210 patients (fever, atelectasis, wound infection). One patient was re-operated for evolving to residual abscess.
Conclusions: The BE is a serious failure in bariatric surgery. The resolution in this group of patients was to remove the band, direct closure of the fistulous orifice with patch of omentum. The surgical technique that was performed in this complication is safe, effective and easily reproducible.
Morbidity and mortality of HIV-infected patients have been improved over the last decades with the advent of combined antiretroviral therapy. As a result, other comorbidities such as chronic kidney and chronic liver diseases have emerged in the HIV population. A considerable percentage of end-stage liver disease (ESLD) in HIV population is attributed to hepatitis C co-infection and reactivation, and a growing need for solid organ transplantation has emerged among those patients. On the other hand, several studies on liver transplantations of patients co-infected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) have shown discouraging results both in patient and graft survival rates. As a result, HIV-HCV co-infection has been considered a relative contraindication for liver transplantation. Thankfully, new drugs for HCV treatment have been discovered, acting direct on viral replication of HCV and they have changed the whole clinical course of HCV/HIV co-infected liver transplant recipients. Our case illustrates the long-term efficacy and safety of the new combination of Sofosbuvir/Ledipasvir in HCV/HIV co-infected liver transplant recipients.
Background: To date, the scientific community has mainly focused on outcomes of obesity surgery such as weight loss and resolution of associated complications. Adverse post-operative events and reoperation rates have been poorly reported even if they are a marker of surgical safety and therefore of great importance in guiding patients and surgeons in the choice of the more suitable operation.
Methods: This retrospective multicenter observational study is based on the data extracted from the Italian Society of Bariatric Surgery and Metabolic Disorders (S.I.C.OB.) database, which covers almost all the bariatric operations performed in Italy. We analysed the 30 days post-operative complications occurring, in the period from 2009 to 2015, after Roux-en-Y Gastric Bypass (RYGB), Sleeve Gastrectomy (SG) and Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB) qualitatively, quantitatively and on the basis of the Clavien-Dindo classification of surgical complications. Complications following surgeries were tested using the 95% confidence interval. Statistical analysis was performed with Statistical Analysis System (SAS).
Results: In the 2009-2015 time frame, a total of 31,624 operations were performed of which 6,864 RYGB, 10,833 SG and 992 MGB/OAGB. The complication rate was 4.39 %, 4.04 % and 3.83% respectively. The most frequent complications were hemoperitoneum (0.9%) and perforation, fistula and dehiscence (1%) which were higher in SG when compared with RYGB (with a statistical significance) and when compared with MGB/OAGB (without a statistical significance). When dividing the complications by the different grades of the Clavien-Dindo classification, the only significant difference encountered, from a statistical standpoint, was between MGB/OAGB and SG. MGB/OAGB was associated with a lower grade I Clavien-Dindo complication rate (1.31% versus 2.34%).
Conclusions: This study supports a safe profile of obesity surgey in Italy, along with positive bariatric outcomes. The rate of 30 days post-operative complications is progressively lower after MGB/OAGB (3.83%), SG (4.04%) and RYGB (4.39%) respectively. In particular, MGB/OAGB records statistically less low-grade Clavien-Dindo complications compared to SG and RYGB.
The story of Nuremberg code in human experiments was evolved by a 70-year old historical link, aiming to provide an alert message for scientists in case of nonprovisional disaster caused by immoral human experiment. It played a safeguard role standing on the front line .
Introduction: Laparoscopic approach is emerging as a standard of care approach for management of masses amenable to partial nephrectomy. Laparoscopic partial nephrectomy is a challenging surgery and its successful performance depends on various factors. We aim to evaluate the influence of tumor characterestics on the operative performance for laparoscopic partial nephrectomy.
Methods: Patients undergoing laparoscopic partial nephrectomy in our institution were recruited for this study. The tumor profile was evaluated by a senior radiologist from cross sectional imaging (computed tomography or magnetic resonance imaging). Tumor characerestics was defined by assessing tumor size, tumor location and RENAL score. The operative performance was evaluated in terms of warm ischemia time, blood loss, operation duration and any significant operative complications. Statistical inference was drawn.
Results: 37 patients who underwent laparoscopic partial nephrectomy between January 2010 and June 2012 were included in this study. The mean tumor dimension was 3.81 cms. 21 tumors involved left kidney and 16 involved right kidney. 12 were located in upper pole, 8 were located in midpole and 17 were located in lower pole. The average RENAL score was 6.56. The mean warm ischemia time, blood loss and operation duration was 26.29 minutes (min), 256.76 millilitres (ml) and 208.11 min respectively. Statistically significant correlation was appreciated between tumor location (polar location, side, anterior/ posterior location) and RENAL score and operative parameters (warm ischemia time and operation duration). Tumor size did not have any correlation with the operative parameters.
Conclusion: The operative performance of laparoscopic partial nephrectomy is significantly influenced by the tumor location and RENAL score.
Introduction: Immediate postoperative gastrointestinal bleeding following bariatric bypass surgery is a major complication, and usually results from staple line hemorrhage or conventional gastro-esophageal causes. Dieulafoy`s lesion is a rare cause of gastrointestinal bleeding and is usually managed by endoscopic means. Herein we present a case of massive intraoperative bleeding resulting from gastric Dieulafoy`s lesion single anastomosis gastric bypass surgery necessitating resection of the gastric pouch. This is the first description of this complication, and the difference of such a lesion from the sporadic ones is discussed.
Discussion: Gastric bypass saurgery is an effective procedure for morbid obesity. The approach we have adopted for massive upper GI hemorrhage in the immediate postoperative period should be distinguished from delayed bleeding after gastric bypass. In these latter cases, marginal ulceration is more common than bleeding from the remnant gastric pouch. It is also likely that bleeding from a Dieulafoy`s lesion following gastric bypass surgery represents a different disease compared to other Dieulafoy's cases.
Conclusion: This is the first description of an intraoperative Dieulafoy's lesion bleeding during the conduct of a single anastomosis gastric bypass procedure which required gastric pouch resection. Such a lesion differs from sporadic Dieulafoy`s cases, and must be considered in every case of intraoperative bleeding during gastric bypass.
From the First case of primitive cardiac surgery (CS), treatment of stab wound of the heart (Dr. Daniel Hale Williams, 1893), to recent surgical procedures and device implantations for end-stage heart failure (HF), the CS has grown and emerged in the public health more and more .
The heart valve disease had interested immediately since the non-cardiopulmonary era because of the multitude of rheumatic patients and congenital valve disease. In the 1952, Hufnagel implanted the first valve in descending aorta and it was the sign of the first step of the CS evolution. New prosthesis and heart valve techniques were tested between 1970 and 2000 with optimal results in patients’ quality of life and survival, at the same time of CPB evolution.
In actual pharmacological therapy we can see that some drugs can be added to other medical instruments to improve their activity: in example we can see medicated stent for some coronary disease, or hormonal medical devices used in pregnancy prevention, but other example are known today. In example Carmustine wafer is delivered by delivery systems in some brain cancer and radioactive seed implants in prostatic cancer. Ocular intra vitreal implants for some macular degenerations (MABS or cortisones) other implants delivery systems drugs, naltrexone implant for opiate dependence. Other strategies imply carrier use to deliver the drugs in the site of action: In example MABS linked to radioactive isotopes in some relapse of severe Hodgkin disease but many other example we can see in therapy used today. So we can think that other chronic conditions can be treated using a combination of drugs with other instrument to improve the clinical outcomes. This to make possible that the ERLICH MUGIC BULLETS can act in the right site reducing the side effect. In example today we can see various medical interventional radiological strategy to treat in coronary and hearth disease with medicate stents positioning or to local use of contrast agents or other valvle surgery procedures with global good clinical results.
Chronic Hepatic deficiency due to the ingestion of alcohol remains as one of the main causes of morbidity and mortality in our country. From it a variety of complications arise, one of them is the Hepatopulmonary Syndrome, which usually goes unnoticed and undiagnosed; this syndrome is distinguished by the presence of hypoxemia and pulmonary vasodilation. The gold standard to establish a diagnostic is contrast-enhanced Echocardiogram. No pathognomonic sign is known for this syndrome, which leads the present elaboration to evaluate the use of orthodeoxia by pulse oximetry as a screening test in the detection of Hepatopulmonary Syndrome cases.
Acute pancreatitis forms a major bulk of our inpatient admission due to gall stone disease. Diagnosis of acute pancreatitis remains a challenge even now. Serum amylase remains the most commonly used biochemical marker for its diagnosis but its sensitivity can be reduced by late presentation, hyper-triglyceridemia and chronic alcoholism. We conducted a study to determine the levels of serum and urinary amylase in patients with acute pancreatitis and compared their sensitivity and correlation with CT findings vis-à-vis the severity of the disease. The study was taken as a post graduate research model in the Post graduate Department of General and Minimal Access Surgery, Govt. Medical College Srinagar, J&K, India 2014-2016 and submitted for the award of masters in General Surgery. A total number of 150 patients were enrolled in the studies which were admitted in our unit as acute pancreatitis. 73 (48.7%) belonged to the age group of 30-44 years, 15(10%) patients aged >60 years with 86 (57.3%) males and 64 (42.7%) females. We had 81 (54%) patients with biliary tract diseases, followed by 21 (14%) patients with worm induced, 20 (13.3%) had hyperlipidaemia and only 4 (2.7%) patients had post ERCP etiology. Tenderness in epigastrium was the presenting sign in 111 (74%), followed by chest signs in 25 (16.7%) patients, diffuse tenderness in 19 (12.7%), icterus in 11 (7.3%), low grade fever in 9 (6%) patients, shock in 5 (3.3%). Diabetes mellitus as a comorbidity was observed in 48 (32%) patients followed by hypothyroidism 37 (24.7%) patients. Hypertension was seen in 31 (20.7%) patients, COPD in 19 (12.7%) patients and obesity in 13 (8.7%) patients. Twenty two (14.7%) needed ICU admission; while as 128 (85.3%) were managed in the general ward. All the enrolled patients in our study were managed conservatively. Out of a total of 150 patients, 148 (98.7%) survived while as only 2 (1.3%) of our patients expired. At the time of admission in the hospital, 120 (80%) patients had serum amylase level of >450 U/L, 19 (12.7%) patients had 150-450 U/L levels while as 11 (7.3%) patients had <150 U/L serum amylase levels. CT has been shown to yield an early overall detection rate of 90% with close to 100% sensitivity after 4 days for pancreatic gland necrosis. The correlation of urinary amylase with the CECT Severity Scoring in a patient of acute pancreatitis is still ambiguous.
Morgagni hernia represents 2-4% of congenital diaphragmatic hernias. Only one-third of them are symptomatic, due to the hernia of abdominal viscera in the thoracic cavity, causing respiratory and digestive problems, some of them serious ones, such as intestinal obstruction. Acute presentation with incarceration of the contents is rare; there are only 7 cases described in the literature.
We are presenting a case of diaphragmatic hernia that began with obstruction of the colon and secondary ischemia, requiring emergency surgery in two phases: first surgery to control the damage, with an open right hemicolectomy, and then later surgery to repair the hernia and perform bowel transit reconstruction, with proper postoperative evolution and no evidence of relapse.
The treatment of Morgagni diaphragmatic hernia is surgical. Also in asymptomatic cases, due to the risk of incarceration, the most appropriate way to enter is abdominally, whether by way of laparotomy or laparoscopy, for the reduction of the contents of the hernia sac, the repair of the defect, as well as the performing of associated techniques on herniated viscera, as occurred in our case.
A complicated congenital hernia is an infrequent pathology, and there is little experience in handling it. Acute presentation requires a combined treatment of the abdominal symptoms and repair of the hernia defect. The carrying over of surgical techniques for damage control into non-traumatic surgery in the face of serious hemodynamic instability is a widespread, accepted practice with the benefits of reducing mortality in critical patients and at times allowing the avoidance of ostomies.
Introduction: A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Herein we present a case of an elderly woman with an impacted gallstone in duodenum and discuss its’ management.
Patient description: A 96-year-old woman was admitted to our department due to a gastric outlet obstruction. Initial gastroscopy revealed a gastric bezoar. An attempt for its extraction failed. She underwent a laparotomy in which a cholecystoduodenal fistula and a large impacted stone were found. Separation of the fistula, including closure of the duodenum side, cholecystectomy and removal of the obstructing gallstone were performed. Additional stones were found and retrieved during common bile duct (CBD) exploration. Surgery was finalized by duodenoplasty, closure and T-tube drainage of the CBD. Post-operative course was prolonged and uneventful.
Discussion and Conclusions: Bouveret syndrome is a rare cause of gastric outlet obstructions. In this case, unsuccessful endoscopic treatment necessitated surgery for removal of impacted gallstone in the duodenum.
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