Characteristics and management of ruptured distal middle cerebral artery aneurysms

Summary Objective. Distal middle cerebral artery (dMCA) aneurysms are very rare with a reported frequency of 2–6%. Typically, patients with ruptured distal MCA aneurysms have poor clinical outcomes because often there is both a subarachnoid haemorrhage (SAH) and an intracerebral haematoma (ICH). The goals of this study were to identify the characteristics of the distal MCA aneurysms and evaluate the optimal treatment for a good outcome. Methods. The clinical, neuroradiological and operative records of 8 patients with a ruptured distal MCA aneurysm who underwent surgical management were reviewed retrospectively. The outcomes were presented according to the Glasgow Outcome Scale (GOS). Results. The clinical characteristics of the patients with ruptured dMCA aneurysms included the following: (1) a fusiform appearance in five out of eight (63%) patients. (2) Mean aneurysm size of 9.4 mm (range 2–35 mm). (3) The location being M2 (insular segment) in three, M2-3 junction in three, and M3 (opercular segment) in two patients. (4) Brain CT images revealed both SAH and an ICH in six of eight (75%) patients with the mean size of the ICH being 10 cc (range 5–25 cc). (5) Re-bleeding occurred in four out of eight (50%) of patients. All patients underwent early surgical treatment and the procedures used for surgical repair were, clipping in five patients, trapping in two, and trapping with end-to-end bypass surgery in one patient. Clinical outcomes were poor in two patients (death) due to severe brain swelling. Conclusions. In this study, dMCA aneurysms had a fusiform shape and a high re-bleeding rate; if ruptured, there was generally ICH and SAH. A good clinical outcome was associated with adequate control of brain swelling and early surgery to prevent re-bleeding.     

Bypass – Surgery and Coil – Embolisation in the Treatment of Cerebral Giant Aneurysms

Summary  Objective. Operative clipping is the most effective method in the treatment of cerebral giant aneurysms. But about 50% of all giant aneurysms are treatable this way. We want to report about eight patients with giant cerebral aneurysms, which were in our opinion “unclippable” without causing ischaemia in depending brain areas.  Methods. We describe eight cases of giant aneurysms of the pericallosal artery (n=1), the middle cerebral artery (n=3), the basilar tip (n=3) and of the upper part of the basilar artery (n=1). One patient with an aneurysm of the pericallosal artery was treated with an extra-intracranial saphenous vein bypass saphenous bypass, in three cases of middle cerebral artery aneurysms an extra-intracranial bypass was also done combined with a resection of the aneurysm. The four patients suffering from an aneurysm of the basilar artery got an extra intracranial bypass too followed by an occlusion of the aneurysm with GD-Coils.  Results. There was no peri-operative mortality and no severe peri- or postoperative complication. The neurological symptoms of all patients were unchanged after the operation. An angiographic controll showed a complete obliteration of the aneurysm and a free running bypass in all cases.  Conclusion. Bypass surgery and combined bypass surgery and coil embolisation are effective methods in the treatment of giant cerebral aneurysms, which can not be treated by clipping alone.     

Subarachnoid hemorrhage caused by a dissecting aneurysm of the internal carotid artery

OBJECT: Subarachnoid hemorrhage (SAH) caused by the rupture of a dissecting aneurysm of the internal carotid artery (ICA) has been considered rare. Based on data from cooperatively collected cases, the clinical features of patients with dissecting aneurysms of the ICA who presented with SAH were examined. METHODS: Data from 18 patients with dissecting aneurysms of the ICA who presented with SAH diagnosed on the basis of clinical signs, neuroradiological findings, and intraoperative findings from 41 institutions were collected during a 5-year period between 1995 and 1999. The authors found that 0.3% of all cases of SAH and 3.1% of cases of SAH of unverified cause were attributable to a dissecting aneurysm of the ICA. Eleven patients (61%) were middle-aged women, and eight patients (44%) had hypertension. Rebleeding before admission was demonstrated in 13 patients (72%), and intraoperative bleeding was exhibited in half of the patients who underwent surgery during the acute stage. Postoperative growth of an aneurysm bulge or recurrent SAH was seen in five of 10 patients who had undergone wrapping or clipping of the aneurysm bulge in the acute phase. Trapping with or without bypass, which resulted in no postoperative recurrence, was performed in three patients in the acute stage and in two patients in the chronic stage. Twelve patients (67%) had a poor prognosis, primarily attributed to intraoperative bleeding and postoperative recurrence. CONCLUSIONS: Generally, dissecting aneurysms of the ICA are not thought of as frequent causes of SAH. Nonetheless. the presence of these aneurysms should be considered when dealing with SAH because they have a susceptibility to bleeding that can lead to a poor prognosis. Careful surgical planning is necessary to decrease intraoperative bleeding and to avoid postoperative recurrence.     

Endovascular coil trapping for ruptured vertebral artery dissecting aneurysms by using double microcatheters technique in the acute stage

Summary ?Background. In the treatment of vertebral artery (VA) dissecting aneurysms, only proximal occlusion of the VA does not necessarily prevent rerupture. We evaluated the efficacy of coil trapping for the ruptured VA dissecting aneurysms using the double microcatheters technique. Methods. We treated 11 patients who presented with subarachnoid haemorrhage (SAH) due to rupture of a VA dissecting aneurysm which did not involve the posterior inferior cerebellar artery at the site of dissection. All patients tolerated the balloon occlusion test. Within 3 days of the SAH, the dissection site was trapped with a Guglielmi detachable coil (GDC) using the double microcatheters technique. The proximal and distal sites of the dissecting aneurysm were embolized simultaneously. Findings. GDC trapping at the affected site was successful in all 11 patients. Radiographic findings showed complete occlusion of the dissection site and patency of the unaffected artery. Although one patient experienced transient dysphagia, there were no major complications. Interpretation. The double microcatheters technique is effective for coil trapping of ruptured VA dissecting aneurysms in selected patients. The risks posed by this simple technique are minimal, even in the acute stage. Published online May 26, 2003     

Dissecting aneurysms of the vertebral artery: a management strategy

OBJECT: The authors present a retrospective analysis of their experience in the treatment of vertebral artery (VA) dissecting aneurysms and propose a management strategy for such aneurysms, with special emphasis on the most formidable VA dissecting aneurysms, which involve the origin of the posterior inferior cerebellar artery (PICA). METHODS: Since 1998, 18 patients with VA dissecting aneurysms, 11 of whom presented with subarachnoid hemorrhage (SAH), have been treated by endovascular surgery at the authors' institution. Obliteration of the entire segment of the dissected site with coils (internal trapping) was performed for aneurysms without involvement of the origin of the PICA (12 cases; among these the treatment-related morbidity rate was 16.7%). The treatment strategy applied to PICA-involved VA dissecting aneurysms presenting with SAH (three cases) included proximal occlusion of the parent artery followed by internal trapping of the aneurysm (one case), proximal occlusion of the parent artery followed by occipital artery (OA)-PICA bypass (one case), and two-staged internal trapping of the aneurysm involving double PICAs (one case). For PICA-involved VA dissecting aneurysms that were not associated with SAH at presentation (three cases), OA-PICA bypass was performed and followed by internal trapping of the aneurysm (two cases). In the remaining case in which a fetal-type posterior communicating artery was present, internal trapping was performed following successful balloon test occlusion (BTO). Overall, there was no sign of infarction in the PICA territory, despite complete occlusion of aneurysms involving the PICA. There was no recurrent bleeding or ischemic symptoms during the follow-up periods. The overall treatment-related morbidity rate for the VA dissecting aneurysms involving the PICA was 16.7%. CONCLUSIONS: Dissecting VA aneurysms that do not involve the PICA can be safely treated by internal trapping. For those lesions that do involve the PICA, a decision-making algorithm is advocated to maximize the efficacy of the treatment as well as to minimize the risks of treatment-related morbidity based on BTO.     

Blood blister-like aneurysms of the internal carotid artery trunk causing subarachnoid hemorrhage: treatment and outcome

OBJECT: The object of this study was to evaluate cases of subarachnoid hemorrhage (SAH) from ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA) trunk. METHODS: The authors performed a single-center, retrospective study. Data analyzed were patient age, sex, Hunt and Hess grade, Fisher grade, time from SAH to hospitalization, aneurysm size and location, collateral capacity of the circle of Willis, time from hospitalization to aneurysm repair, type of aneurysm repair, complications, and Glasgow Outcome Scale (GOS) score at follow-up. RESULTS: A total of 211 patients suffered SAH from ICA aneurysms. Of these, 14 patients (6.6%) had ICA trunk BBAs; 6 men and 8 women. The median age was 47.8 years (range 29.9-67.7 years). The Hunt and Hess grade was IV or V in 7 cases, and SAH was Fisher Grade 3 + 4 in 6. All aneurysms were small (< 1 cm), without relation to vessel bifurcations, and usually located anteromedially on the ICA trunk. Three patients were treated with coil placement and 11 with clip placement. Of the 7 patients in whom the ICA was preserved, only 1 had poor outcome (GOS Score 2). In contrast, cerebral infarcts developed in all patients treated with ICA sacrifice, directly postoperatively in 2 and after delay in 5. Six patients died, 1 survived in poor condition (GOS Score 3; p < 0.001). CONCLUSIONS: Internal carotid BBAs are rare, small, and difficult to treat endovascularly, with only 2 of 14 patients successfully treated with coil placement. The BBAs rupture easily during surgery (ruptured in 6 of 11 surgical cases). Intraoperative aneurysm rupture invariably led to ICA trap ligation. Sacrifice of the ICA within 48 hours of an SAH led to very poor outcome, even in patients with adequate collateral capacity on preoperative angiograms, probably because of vasospasm-induced compromise of the cerebral collaterals.     

Early and Late Abdominal Bleeding After Roux-en-Y Gastric Bypass: Sources and Tailored Therapeutic Strategies

Bleeding is a potentially serious complication after Roux-en-Y gastric bypass (RYGB). Preventive measures and therapeutic strategies have not been adequately defined. We reviewed data on 742 consecutive patients treated at the University of California San Francisco to identify cases of early and late bleeding (less or greater than 30 days after surgery) after RYGB. Bleeding was defined as symptoms or signs of bleeding, associated with blood transfusion. We recorded patient characteristics, details of the operative technique, diagnostic approach, therapeutic strategies, and outcomes. Twenty-six patients (3.5%) had postoperative bleeding, which mostly occurred in the first 30 days postoperatively (N = 19). Hematocrit decreased significantly from preoperative values (−5.2 ± 3.1 without bleeding vs. −14.8 ± 4.7 with, p < 0.01). Type 2 diabetes was more prevalent in patients who had bleeding (58% vs. 32%, p = 0.03). No other patient characteristics or details of the operative technique were associated with different rates of bleeding. Therapeutic intervention other than transfusion was needed for seven patients with early bleeding (36.8%) and for all patients with late bleeding. Four patients with early bleeding required reoperation. Early bleeding source was intraluminal in four patients, intraperitoneal in five, and self-limited and of unknown location in ten. Late bleeding occurred on average at 62.6 months (range, 5 to 300 months) after index surgery, five patients required reoperation, and the source was always intraluminal. Bleeding after RYGB may be from various anatomic sites; details of the operative technique were not associated with different rates of bleeding, and therapy should be tailored to suspected location of bleeding.     

Impact of Sonoclot hemostasis analysis after cardiopulmonary bypass on postoperative hemorrhage in cardiac surgery

Purpose The Sonoclot Analyzer provides a functional test of whole blood coagulation by measuring the viscous property of the blood sample. In this study, we used a modified Sonoclot assay, using cuvettes with a glass bead activator containing heparinase, and compared the Sonoclot data before and after cardiopulmonary bypass (CPB) to assess the usefulness in predicting postoperative hemorrhage. Methods In 41 cardiac surgery patients, Sonoclot data were obtained immediately after heparin administration (pre-bypass) and just before protamine administration (post-bypass). Excessive bleeding was defined as chest tube drainage greater than 2 ml·kg⁻¹·h⁻¹ in 1 h during the first 4 h after surgery. Results There were no significant differences in Sonoclot values before and after CPB in patients with acceptable bleeding (n = 29). In patients with excessive bleeding (n = 12), Sonoclot variables reflecting fibrin formation (activated clotting time [ACT], rate of fibrin formation [clot rate], and peak clot signal) were preserved after CPB; however, the variables reflecting platelet-fibrin interaction (time to peak, peak angle, and clot retraction rate) were significantly different from their respective pre-bypass values. Sonoclot analysis showed impairment of clot maturation after CPB in patients with excessive postoperative bleeding. Conclusion Our results suggest that abnormal postoperative hemorrhage can be predicted by Sonoclot analysis with a new glass bead-activated heparinase test performed after CPB.     

Early Postoperative Hemorrhage After Open and Laparoscopic Roux-En-Y Gastric Bypass

Background  Early postoperative hemorrhage is an infrequent complication of both laparoscopic and open Roux-en-Y gastric bypass (RYGBP). The objective of our study is to review the incidence and management of this complication and identify contributing clinical and technical risk factors. Methods  Over a 3-year period, 1,025 patients underwent RYGBP at our institution. The medical records of patients who required postoperative blood transfusions were reviewed for clinical presentation, diagnostic evaluation and management. These patients were matched for surgical approach (open vs. laparoscopic) in a 1:3 ratio and compared to a random group of patients who underwent RYGBP during the same time period. Results  Thirty-three patients (3.2%) were diagnosed with postoperative hemorrhage, 17 (51.5%) of which were intraluminal. The incidence of hemorrhage was higher in the laparoscopic group (5.1% vs. 2.4%, p = 0.02). Comparing bleeders to nonbleeders, the average BMI, gender distribution, gastro-jejunostomy anastomotic technique (stapled vs. hand sewn) and the postoperative administration of ketorolac were not significantly different. The bleeding group was older (47.5 vs. 42.8, p = 0.02), had a longer hospital stay (4.9 vs. 3 days, p = 0.0001) and was more likely to have received low molecular weight heparin (LMWH) preoperatively (p = 0.03). Hemorrhage occurred earlier (13.8 vs. 25.9 h, p = 0.039) and was more severe (4.1 vs. 2.3 transfused blood units, p = 0.007) in the patients who required surgical reexploration (n = 9). Conclusions  A laparoscopic approach and the preoperative administration of LMWH may increase the incidence of early hemorrhage after RYGBP. This complication frequently requires surgical reexploration and significantly prolongs the hospital stay. Oral presentation and 1st prize winner, Bariatric surgery competition, CTACS meeting, November 2006. Poster presentation at the New England Surgical Society meeting, September 2007.     

Management-Related Morbidity and Mortality in Unselected Aneurysms of the Basilar Trunk and Vertebrobasilar Junction

Summary  Objects. To analyze the management-related morbidity and mortality in unselected aneurysms of the basilar trunk and vertebrobasilar junction. The secondary objective was to investigate the factors associated with favourable or unfavourable surgical outcome in order to define subgroups for surgical and endovascular treatment.  Methods. 24 consecutive patients with aneurysms of the basilar trunk and vertebrobasilar junction were included in this study. They comprised 2.7% of all aneurysms treated during the study period between 1990 and 1997. 22 patients presented with acute subarachnoid hemorrhage (SAH) and 2 patients with symptoms of brainstem compresssion. All patients were managed using a standard protocol including surgery at the earliest possible moment, aggressive tripe-H therapy in patients with symptomatic vasospasm and mandatory follow-up angiography. 23 patients underwent surgical clipping and one patient endovascular coiling of the aneurysm. 12 patients had an excellent outcome. 6 patients had a good outcome, resulting in a total of satisfactory outcomes in 18 patients (75%). 4 patients (17%) had moderate to severe deficits. Two patients died (8%). Both patients had fusiform basilar trunk aneurysms. Good or excellent outcome was observed in 7 of 8 patients with aneurysms of the vertebrobasilar junction, 13 of 14 patients with moderate or minor SAH or without SAH (Fisher grade 0 to 2) and all patients with small sized aneurysm (n=6). Factors mostly associated with poor outcome or death after surgical treatment were aneurysm location at the basilar trunk, large aneurysm size or fusiforme aneurysm type and severe SAH.  Conclusions. Location, aneurysm size and the severity of SAH may help to predict the subgroup which highly benefits from surgical clipping of these rare vascular lesions.     

Comparative early and midterm results of open juxtarenal and infrarenal aneurysm repair

Background and aims Since the introduction of endovascular aortic aneurysm repair (EVAR) for aortic aneurysms, the number of juxtarenal aortic aneurysms (JRA) has been growing steadily due to selection bias (neck morphology for EVAR). This case-match study compares the perioperative outcome and midterm results of suprarenally clamped JRA with infrarenal aortic aneurysms (AAA). Methods From 1997 to 2004, patients who received open surgery with suprarenal clamping for JRA were included in the study and compared to matched patients with infrarenal clamping (AAA). Measurements analyzed were the in-hospital mortality and morbidity. Midterm results were obtained through clinical investigation and magnetic resonance angiography imaging. Results Thirty-five patients (mean age, 68.4 years; 30 male and 5 female) received suprarenal cross-clamping for JRA. The overall in-hospital mortality for JRA and for the controls (AAA) with elective aortic repair was 4.5% (6.1% JRA; 3% AAA, p = 0.058). The morbidity of JRA was elevated according to the rate of pulmonary complications (p = 0.021) and the need for re-operation (p = 0.019). The mean follow-up time was 2.3 years (range, 8–96 months). At follow-up, 28 patients (80%) from the JRA group and 29 patients from the AAA group (82.9%) were alive. Conclusion Open aortic surgery for JRA with the need for suprarenal cross-clamping shows a slightly elevated in-hospital mortality rate without statistical significance and equal midterm mortality results in comparison with infrarenally clamped aortic aneurysms.     

Importance of Routine Preoperative Upper GI Endoscopy: Why All Patients Should Be Evaluated?

Background  Morbid obesity is associated with different gastrointestinal alterations and diseases. Surgically induced weight loss has become the best treatment for morbidly obese patients. Roux-en-Y gastric bypass is the most common procedure performed worldwide. Concerns regarding difficulties in further evaluation of stomach remnant for early detection of gastric cancer, however, have emphasized the routine use of preoperative upper endoscopy, even in asymptomatic patients, to detect upper gastrointestinal abnormalities. The main outcome of this study was to identify the most common preoperative endoscopic findings. Methods  Data was collected from a prospective database and medical records of patients with available endoscopic reports, who underwent Roux-en-Y gastric bypass from February 1999 to June 2006. Logistic regression analysis was performed to detect preoperative clinical variables that might be associated with abnormal endoscopy. Results  Six hundred twenty-six patients were identified. Four hundred fifty-two (72%) were female; age and body mass index were 38.5 ± 11.3 years and 42 ± 6.5 kg/m², respectively. Abnormalities were found in 288 (46%) patients. The age of patients with abnormal and normal endoscopy was 40 ± 11 and 36.8 ± 11 years, respectively (p < 0.001). The most common findings were gastritis 21% (n = 132), esophagitis 16% (n = 100), and hiatal hernia 10.7% (n = 67). Duodenitis has a frequency of 7.8% (n = 49), gastric ulcers of 2.7%(n = 17), duodenal ulcers of 2.6% (n = 16), gastric polyps of 1.3% (n = 8), Barrett’s esophagus of 0.16% (n = 1), and gastric cancer of 0.16% (n = 1). Age was the only clinical variable associated to abnormal endoscopy (odds ratio = 1.03; 95% confidence interval, 1.02–1.05). Conclusions  Routine preoperative endoscopy detects different abnormalities which need specific approach prior to surgery. Preoperative endoscopy should be performed to all patients prior to surgery.     

Prediction of rebleeding from angiographic features in vertebral artery dissecting aneurysms

To identify patient characteristics and angiographic features that predict high risk for rebleeding in vertebral artery (VA) dissecting aneurysms. We analyzed 62 patients treated for subarachnoid hemorrhage (SAH) from VA dissecting aneurysms (male: female, 46:16; mean age, 51.7  ±  8 years). Univariate and multivariate stepwise logistic regression analyses were performed to assess relationships between rebleeding rate and age, gender, history of hypertension, sidedness of the aneurysm, angiographic configuration, and location relative to the origin of the posterior inferior cerebellar artery (PICA). Rebleeding occurred in 22 patients (37%), mostly within 24 h. Patients without rebleeding had favorable outcomes, while patients with rebleeding showed higher mortality. Angiographic patterns with high rebleeding rates included “stenosis and dilation” (50%), and “lateral protrusion” (43%), contrasting with “dilation and stenosis” (20%) and other types. Rebleeding also was likely in aneurysms proximal to or at the PICA origin (rate, 47% or 46%) than distal to the PICA origin (21%). Multivariate logistic regression analysis found two factors independently associated with rebleeding: angiographic pattern of the aneurysm (odds ratio 1.88:1, P=0.0366), and location relative to the PICA origin (odds ratio 4.93:1, P=0.028). High risk of rebleeding in VA dissecting aneurysms can be predicted by angiographic configurations such as “stenosis and dilation” and “lateral protrusion” and by location at or proximal to the PICA origin.     

Usefulness of intraoperative laser Doppler flowmetry and thermography to predict a risk of postoperative hyperperfusion after superficial temporal artery–middle cerebral artery bypass for moyamoya disease

We investigated whether postoperative hyperperfusion in moyamoya disease can be predicted using intraoperative laser Doppler flowmetry and/or thermography. A prospective study was conducted on 27 patients (39 hemispheres) with moyamoya disease who underwent superficial temporal artery–middle cerebral artery (STA–MCA) bypass. During surgery, regional cerebral blood flow (rCBF) was measured with a laser Doppler flowmeter and the temperature of the cortical surface was measured with an infrared thermograph. Postoperative hyperperfusion was assessed immediately after surgery based on CBF study under sedation (propofol) as >100% increase in corrected rCBF compared to preoperative values. Postoperative hyperperfusion on CBF was observed in two patients (7.4%). A significant correlation was observed between intraoperative rCBF changes and postoperative rCBF increase (Pearson’s method: r = 0.555, p = 0.0003; simple regression: Y = 1.22X + 3.289, r ² = 0.308, p = 0.0004). Furthermore, the rCBF changes measured by laser Doppler flowmetry were significantly greater in patients with postoperative hyperperfusion (p = 0.0193) and CHS (p = 0.0193). The present study suggests that intraoperative rCBF measurement using laser Doppler flowmetry may predict a risk of post-EC–IC bypass cerebral hyperperfusion in moyamoya disease.     

How I do it: treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery by extracranial-to-intracranial bypass and trapping

Background

Blood blister-like aneurysms (BBAs) pose a significant challenge to neurosurgeons and neuro-interventionalists. These fragile broad-based aneurysms have a propensity to rupture with minimal manipulation during surgical or endovascular explorations because, unlike saccular aneurysms, they lack all layers of the arterial wall. Aneurysm trapping with extracranial-intracranial (EC-IC) bypass is a safe and durable treatment for BBAs.

Methods

We describe our technique and the guiding principles for surgical bypass and trapping of BBAs of the supraclinoid internal carotid artery (ICA).

Conclusions

Treatment of BBAs of the supraclinoid ICA remains difficult. Aneurysm trapping with EC-IC bypass treats BBAs definitively by eliminating the diseased segment of the ICA. We have found the technique and principles described here to be safe and durable in our hands.     

Effect of Gastric Bypass on Vitamin D and Secondary Hyperparathyroidism

Obesity as well as bariatric surgery may increase the risk for vitamin D deficiency. We retrospectively compared vitamin D levels in obese patients (n = 123) prior to bariatric surgery and 1 year postoperatively. We also evaluated parathyroid hormone levels (PTH) 1 year after surgery. A higher percentage of patients had baseline vitamin D deficiency (86%), defined as 25-hydroxy vitamin D <32 ng/mL, compared with the 1-year (post-surgical) levels, (70%; p < 0.001). Body mass index (BMI) inversely correlated with vitamin D deficiency at baseline (r = −0.3, p = 0.06) and at the postoperative follow-up (r = −0.2, p = 0.013). One third of the postoperative population had secondary hyperparathyroidism, defined by a serum PTH level >62 pg/mL; however, postoperative PTH and vitamin D levels were unrelated (r = −0.001, p = 0.994). Pre- and postoperative vitamin D levels were inversely correlated with BMI. Secondary hyperparathyroidism was observed in 33% of patients postoperatively; however, this did not correlate with vitamin D.     

Revisional Bariatric Surgery by Conversion to Gastric Bypass or Sleeve—Good Short-Term Outcomes at Higher Risks

This is a retrospective study of prospectively collected data from 34 patients who had revisional bariatric surgery at a single centre. The aim was to report the indications for revisional surgery, operative time, conversion to open surgery, mortality, hospital stay, early and late complications, reoperations and short-term efficacy. From 2006 to 2011, 31 patients who formerly had been operated for morbid obesity with restrictive operations and 3 patients who had been operated in the upper abdomen for other morbidities (fundoplications 2, Heller's myotomy 1) underwent a revisional Roux-en-Y gastric bypass operation (n = 30) or sleeve gastrectomy (n = 4). Demographic data, perioperative characteristics and follow-up data were entered prospectively in the hospital's database for bariatric patients. Twenty-five operations were done by laparoscopic and nine by open technique. The mean operative time was 113.17 (33.98, 54–184) min. The mean postoperative hospital stay was 3.25 (5.71, 1–32) days. Intra-operative complications occurred in six patients (17.65%), postoperative complications in nine (26.47%), and major complications in three patients (8.82%), including leakage in the gastrojejunal anastomosis in two (5.88%) patients. The conversion rate to open surgery was 2.94% (one emergency patient). There was no mortality. Excess weight loss (%, ±SD) at 3 months follow-up averaged 42.31%, ±21.54. Revisional bariatric surgery can be performed with an increased but acceptable risk, with at least short-term weight loss comparable to primary operations.     

Norepinephrine-induced hypertension dilates vasospastic basilar artery after subarachnoid haemorrhage in rabbits

Background  Vasopressor-induced hypertension is routinely indicated for prevention and treatment of cerebral vasospasm (CVS) after subarachnoid haemorrhage (SAH). Mechanisms underlying patients’ clinical improvement during vasopressor-induced hypertension remain incompletely understood. The aim of this study was to evaluate angiographic effects of normovolaemic Norepinephrine (NE)-induced hypertension therapy on the rabbit basilar artery (BA) after SAH. Methods  Cerebral vasospasm was induced using the one-haemorrhage rabbit model; sham-operated animals served as controls. Five days later the animals underwent follow-up angiography prior to and during NE-induced hypertension. Changes in diameter of the BA were digitally calculated in mean μm ± SEM (standard error of mean). Findings  Significant CVS of 14.2% was documented in the BA of the SAH animals on day 5 compared to the baseline angiogram on day 0 (n = 12, p < 0.01), whereas the BA of the control animals remained statistically unchanged (n = 12, p > 0.05). During systemic administration of NE, mean arterial pressure increased from 70.0 ± 1.9 mmHg to 136.0 ± 2.1 mmHg in the SAH group (n = 12, p < 0.001) and from 72.0 ± 3.1 to 137.8 ± 1.3 in the control group (n = 12, p < 0.001). On day 5 after SAH, a significant dilatation of the BA in response to norepinephrine could be demonstrated in both groups. The diameter of the BA in the SAH group increased from 640.5 ± 17.5 μm to 722.5 ± 23.7 μm (n = 12, p < 0.05; ). In the control group the diameter increased from 716.8 ± 15.5 μm to 779.9 ± 24.1 μm (n = 12, p < 0.05). Conclusion  This study demonstrated that NE-induced hypertension causes angiographic dilatation of the BA in the SAH rabbit model. Based on these observations, it can be hypothesised that clinical improvement during vasopressor-induced hypertension therapy after SAH might be explained with cerebral vasodilatation mechanisms that lead to improvement of cerebral blood flow. Volker Neuschmelting and Ali-Reza Fathi contributed equally to the study.     

Vagal Nerve Dissection During Pouch Formation in Laparoscopic Roux-Y-Gastric Bypass for Technical Simplification: Does it Matter?

Background  In Roux-Y gastric bypass surgery pouch formation is the most demanding part of the operation. The vagal nerve is usually tempted to be preserved although results reporting beneficial effects are lacking. Dividing the perigastric tissue including the anterior vagal trunk may technically alleviate gastric pouch formation. We evaluated the clinical outcome in patients with and without vagal nerve dissection in patients after Roux-Y gastric bypass (RY-BP). Methods  In this study 40 morbidly obese patients undergoing RY-BP have been included. Patients were divided into two groups according to vagal nerve preservation (Group 1, n = 25) or vagal nerve dissection (Group 2, n = 22). Clinical parameters (weight loss, complications, gastrointestinal symptoms), esophageal endoscopy, and motility data (manometry, pH-metry) and a satiety score were assessed. Serum values of ghrelin and gastrin were measured. Results  All procedures were performed by laparoscopy with a 0% mortality rate. One patient of each groups necessitated redo-laparoscopy (bleeding and a lost drainage). All patients significantly reduced body weight (p < 0.01 compared to preoperative) during a median follow-up of 36.1 months. Two patients of Group 2 showed acid reflux demonstrated by pathologic postoperative DeMeester scores. Esophageal body peristalsis and barium swallows did not reveal statistically significant differences between the two groups. Parameters of satiety assessment did not differ between the two groups as did serum values of gastrin and ghrelin. Conclusion  Pouch formation during RY-BP may be alleviated by simply dissecting the perigastric fatty tissue. In this way the anterior vagal trunk is dissected, however, no influence on clinical, functional and laboratory results occur.     

Combined anterior and posterior open treatment in infected pancreatic necrosis

Objective To compare the results of combined anterior and posterior open treatments (lesser sac marsupialization (LSM) + lumbostomy, LSM + L) in patients with infected pancreatic necrosis (IPN) with a previous experience of isolated LSM and with data in literature. Materials and methods Thirty-four consecutive patients operated on for IPN from 1981 to 2005 were divided into two groups based on the surgical technique used: single LSM (n = 23; period A, 1981–1998) and combined LSM + L (n = 11; period B, 1999–2005). Results The postoperative mortality rate was 38.1 (n = 8) and 9% (n = 1) during period A and B, respectively. The most important cause of death was recurrent or persistent sepsis with multiple organ failure. The overall postoperative surgical morbidity was 57 (n = 13) and 27.2% (n = 3) in the two consecutive groups. Conclusions IPN is a challenging condition associated with high mortality mainly because of a persistence of sepsis despite surgery. A comparative analysis of many proposed operative procedures is difficult because of the heterogeneity in the reported series. Open approaches seem to be more effective in controlling local infection and systemic sepsis. Combining open anterior and posterior approaches is in our experience an appropriate surgical treatment in IPN patients.