Laparoscopic Roux en-Y Gastric Bypass Using a Modified Retrocolic–Supracolic Approach: Outcomes from 300 Patients

Background

Laparoscopic Roux en-Y gastric bypass (LRYGB) achieves sustained long-term weight loss and reduced mortality in morbidly obese patients. It is routinely performed using an ante- or retrocolic approach with the jejuno-jejunostomy constructed in the infracolic compartment. We have modified the standard technique of performing LRYGB by constructing both anastomoses in the supracolic compartment. This study describes the outcomes of consecutive primary LRYGB performed using this novel retrocolic–supracolic approach.

Methods

Data were prospectively collected on consecutive primary LRYGB performed in a tertiary-referral Bariatric Centre in the United Kingdom from September 2009 to March 2013. Data included demographics, operative outcomes (duration of surgery, postoperative anastomotic leak/bleeding/reoperations), development of strictures, length of stay, excess weight loss (EWL) and resolution of diabetes mellitus.

Results

Hand-sewn LRYGB was successfully performed using the retrocolic–supracolic approach in 300 of 307 (98 %) consecutive patients (72 % female). Median (IQR) age, weight and baseline body mass index were 49 (41–56) years, 146 (134–163) kg and 52.9 (48.8–57.2) kg/m², respectively. There were 4 (1.3 %) anastomotic leaks and 8 (2.6 %) postoperative bleeds. The 30-day reoperation rate was 1.6 %. Median (IQR) hospital stay was 2 (2–2) days. Postoperative dysphagia requiring endoscopic balloon dilatation occurred in 19 (6.3 %) patients. Mean ± SD 12-month EWL was 69.9 ± 19.0 %. Within the follow-up period, 81 % of patients with type II diabetes mellitus achieved remission and 19 % reduced dosage of diabetes medication.

Conclusions

LRYGB performed using the retrocolic–supracolic approach was safe, feasible, technically advantageous and resulted in clinical outcomes akin to the standard infracolic approach.

     

Same-day <Superscript>90</Superscript>Y radioembolization: implementing a new treatment paradigm

Purpose

To assess the feasibility of conducting pretreatment mesenteric angiography, coil embolization, ^99mTc macroaggregated albumin (^99mTc-MAA) scintigraphy, and ⁹⁰Y radioembolization treatment in a single, same-day, combined outpatient encounter.

Methods

This was a retrospective study of 78 patients treated during the period 2008 – 2015 who were managed in a single outpatient encounter under the guidance of the Interventional Radiology Department and The Nuclear Medicine Department. Pretreatment planning was performed by reviewing baseline imaging and estimated perfused liver volume bearing the tumor. The region of interest was estimated using 3-D software; this value was used for dosimetry planning. Maximum lung shunting fractions of 10 % for hepatocellular carcinoma and 5 % for liver metastases were assumed. Subsequently, hepatic angiography and ^99mTc-MAA scintigraphy were performed followed by ⁹⁰Y treatment in one outpatient encounter. Total in-room procedure time was recorded.

Results

All patients underwent same-day angiography, ^99mTc-MAA scintigraphy and ⁹⁰Y radioembolization. Of the 78 patients, 16 received multiple segmental treatments to both lobes, 44 received treatment to the right lobe, and 18 received treatment to the left lobe. The median dose was 106 Gy. The median number of ⁹⁰Y vials needed was two (range one to six). The median in-room time was 160 min (75 – 250 min). The residential status of the patients was as follows, 18 % (14/78) were local residents, 55 % (43/78) traveled from outside the city limits, 18 % (14/78) were from out-of-state, and 9 % (7/78) were resident abroad. Of the 78 patients, 61 (77 %) had hepatocellular carcinoma, and 17 (22 %) had liver metastases. The median lung dose was 3.5 Gy.

Conclusion

This study demonstrated the feasibility of same-day ⁹⁰Y evaluation and treatment while maintaining the principles of safe and effective ⁹⁰Y infusion including tumoricidal dosimetry (lobar, segmentectomy), minimization of nontarget flow, and minimization of lung dose. This paradigm translates into expeditious cancer care and significant cost savings.

     

Uterine tachysystole in spontaneous labor at term

Objectives: The objective of this study is to determine the incidence of uterine tachysystole and its association with spontaneous labor at term.

Methods: A retrospective cohort study of 8008 women in spontaneous labor (without prostaglandins or oxytocin). Fetal heart tracings and uterine activity were recorded every 15?min. Primary outcome: occurrence of tachysystole (> 5 uterine contractions /10?min over 30?min periods). Secondary outcomes: non-reassuring fetal heart tracings (NRFHT), NICU admissions, and cesarean deliveries.

Results: About 890 patients (11.1 %) had at least one episode of tachysystole. Non-whites have higher incidence of uterine tachysystole; adjusted odds ratio (aOR) was 1.66 for Hispanics (95% CI 1.28–2.05), 1.58 for African Americans (95% CI 1.05–2.38), and 1.51 for Asians (95% CI?=?1.13–2.0). The use of epidural analgesia was higher in the tachysystole group (62.2% versus 40.9%, aOR 1.89, CI 1.58–2.26; p?< 0.001). Tachysystole was more frequent among nulliparous women and in women carrying higher weight fetuses. Oligohydramnios (aOR 1.62, CI 0.70–3.72; p?<?0.004), and NRFHT were more common in the tachysystole group (4.2% versus 2.5%, p?=?0.002). Newborns in the tachysystole group were two times more likely to be admitted to NICU (30 /890 [3.4%] versus 122 /7118 [1.7%], OR?=?2, p=0.001). There was no difference in the frequency of meconium-stained amniotic fluid or Apgar scores <7 at 5?min.

Conclusion: Uterine tachysystole occurs in more than 10% of spontaneous labors and is associated with NRFHR, increased rate of caesarean deliveries and NICU admissions. It is not associated with low Apgar scores or meconium-stained amniotic fluid.     

Incidence and risk factors of bacterial infections in children following autologous hematopoietic stem cell transplantation: Single‐center experience from Jordan

Bacterial infection is a serious sequela following AHSCT; however, limited data are available regarding pediatric recipients, especially in developing countries. We retrospectively analyzed the incidence and risk factors of bacterial infections during the first 100 days after AHSCT in children at KHCC in Amman, Jordan between January, 2005 and September, 2013. A total of 65 patients were identified, with median age of four yr (1–17). Forty‐seven patients (72.3%) had solid tumors and 18 (27.7%) had lymphoma. Bacterial infections were documented in 33 patients (50%), with a total of 63 episodes. Gram‐negative infection (57.1%) was more prevalent than Gram‐positive infection (38%). The risk of bacterial infections was higher among patients less than five yr of age (p = 0.028) and those who developed hypogammaglobulinemia requiring IVIG replacement (p = 0.001). Patients with solid tumors developed more bacterial infections compared to patients with lymphoma (p = 0.0057). No deaths were attributed to bacterial infection. Bacterial infection rate is high among recipients of AHSCT in Jordan with Gram‐negative bacteria being the most common.     

Specific Tips for General Controversies in Sacral Neuromodulation

The field of Sacral Neuromodulation is continually evolving and still in its infancy. Common dilemmas experienced with this therapy will be discussed in this article, including ways to avoid and manage them. The focus will be on test evaluations performed with either peripheral nerve evaluation (PNE) or staged procedure, the clinical effectiveness and safety of unilateral versus bilateral test stimulation for both the PNE and staged procedures, and best methods to determine the success of the trial phase. We will also discuss how to deal with the problem of declining efficacy of the device over time. The article presents a discussion on future technological innovations to enhance techniques and mode of positioning and use of leads, which along with a refined understanding of how neuromodulation is effective for different problems, will lead to better outcomes.     

Effective use of simple computer programmes and clay models to demonstrate the planning and operative steps for teaching and presentations

Background:Presenting and demonstrating a surgical procedure in the current era is difficult without good intraoperative pictures and videos. A long, complex, multi-staged surgery is better illustrated by detailed intraoperative images at various stages. Although desirable, it may be difficult due to various reasons.Results:It is a simple technique with a moderate learning curve. Once familiar with technique, one can effectively use the technique to convey the details in much more clear manner.Conclusion:It is a simple and effective way of communicating through digital images, and gives the audience a 3 dimensional idea about the concept.KEY WORDS: Clay models in plasticine surgery, photography, presentations in plastic surgery, teaching and patient education, use of clay models for presentations