The early use of Roux limb as surgical treatment for proximal postsleeve gastrectomy leaks

BackgroundLaparoscopic sleeve gastrectomy (LSG) is thought to be a simpler and safer operation compared with malabsorptive operations that include an enteric anastomosis. Leakage along the staple line at the gastroesophageal junction (GEJ) is difficult to treat and is a known complication of sleeve gastrectomy. Nonsurgical treatment methods often fail to heal the leaks and patients often require conversion to other procedures for definitive treatment. We report our experience with conversion to Roux-en-Y anastomosis over the leak site as a treatment option, comparing patients who had early treatment to late intervention. The purpose of the study is to stress the medical and social benefits of early surgical reintervention with conversion to Roux-en-Y anastomosis over the leak site.MethodsSix patients underwent Roux limb placement over the leak site. Four of the patients had delayed surgery (group A), and the other 2 had early intervention (group B).ResultsPatients in group A had a median increase of all medical cost by 500%, whereas the 2 patients who underwent early intervention (group B) had an increase by 200%. The mean time until complete recovery (removal of all drains, adequate oral intake, and return to normal daily activity) in group A was 131.25 days (range 99–165) versus 38 days (range 28–48) in group B.ConclusionsRoux-en-Y gastrojejunostomy over the leak site is an effective technique to treat refractory staple line leakage and can be adopted as early treatment in selected patients after stabilization, thereby reducing the cost and length of hospital stays.     

GNE myopathy: A prospective natural history study of disease progression

Mutations in the glucosamine (UDP-N-acetyl)-2-epimerase/N-acetylmannosamine kinase gene cause GNE myopathy, a mildly progressive autosomal recessive myopathy. We performed a prospective natural history study in 24 patients with GNE myopathy to select evaluation tools for use in upcoming clinical trials. Patient clinical conditions were evaluated at study entry and one-year follow-up. Of the 24 patients, eight (33.3%) completed a standard 6-min walk test without assistance. No cardiac events were observed. Summed manual muscle testing of 17 muscles, grip power, and percent force vital capacity (%FVC) were significantly reduced (p < 0.05), and scores for 6-min walk test and gross motor function measure were decreased (p < 0.1) after one year. The decrement in %FVC was significant among non-ambulant patients, whereas the decrement in grip power tended to be greater among ambulant patients. The 6-min walk test, gross motor function measure, manual muscle testing, grip power, and %FVC reflect annual changes and are thus considered good evaluation tools for clinical trials.     

Good radiological and functional results after intramedullary nailing of distal radius fractures

Abstract

To evaluate the results after fixation of distal radius fractures using Micronail® internal fixation, a prospective cohort study was performed, including displaced fractures of the distal radius (AO type A 2.2, A3.1, and A3.2). In total, 60 patients were included and 44 patients were available for 1-year follow-up (radiological and clinical examination) and 39 for 5-year follow-up (telephone interview). It was found that all fractures healed, with an average radial volar tilt of 2°, radial length of 11 mm, and a radial inclination of 22°. The functional result was excellent-to-good in 93% of the patients. Thirteen patients (30%) reported paraesthesia of the superficial branch of the radial nerve at the 1-year follow-up. In four patients the paraesthesia of the radial nerve was persistent. No other complications or reoperations were reported by the patients at the 5-year follow-up and only one implant had been removed. The study confirms that the Micronail® is a minimal invasive method that can provide a stable fixation of selected distal radius fractures and provide a good functional outcome with a very low need of implant removal after fracture healing with few complications related to the operation, the main complication being permanent damage to the radial nerve.     

Future role for endoluminal procedures in “high-risk” bariatric patients

Bariatric surgery remains the gold standard for therapy of the morbidly obese patient. However, these procedures are not without risk. Risk factors for adverse events and readmission after bariatric surgery are well studied. Included in these risk factors are preoperative weight, liver size, and medical comorbidities that can be improved with modest weight loss before bariatric surgery and other major abdominal procedures. This article reviews intragastric space-occupying devices, endoluminal gastric volume reduction procedures, gastric content aspiration therapy, and endoluminal duodenal exclusion as possible choices to “bridge” the high-risk patient to bariatric surgery and as a possible alternative to bariatric surgery. The current state of the literature is robust for the intragastric balloon, supporting both primary and preoperative indications. The limited literature support for gastric volume reduction, gastric content aspiration, and endoluminal barrier therapy is reviewed.     

GNE myopathy associated with congenital thrombocytopenia: A report of two siblings

GNE myopathy is an autosomal recessive muscular disorder caused by mutations in the gene encoding the key enzyme in sialic acid biosynthesis, UDP-N-acetylglucosamine 2-epimerase/N-acetylmannosamine kinase (GNE/MNK). Here, we report two siblings with myopathy with rimmed vacuoles and congenital thrombocytopenia who harbored two compound heterozygous GNE mutations, p.V603L and p.G739S. Thrombocytopenia, which is characterized by shortened platelet lifetime rather than ineffective thrombopoiesis, has been observed since infancy. We performed exome sequencing and array CGH to identify the underlying genetic etiology of thrombocytopenia. No pathogenic variants were detected among the known causative genes of recessively inherited thrombocytopenia; yet, candidate variants in two genes that followed an autosomal recessive mode of inheritance, including previously identified GNE mutations, were detected. Alternatively, it is possible that the decreased activity of GNE/MNK itself, which would lead to decreased sialic content in platelets, is associated with thrombocytopenia in these patients. Further investigations are required to clarify the association between GNE myopathy and the pathogenesis of thrombocytopenia.     

Informed Decision-Making for Bariatric Surgery: Benefits,Risks, Uncertainties and Choices

Decision-making is a critical aspect of good surgical care, and this principle is particularly important in bariatric surgery. Adequate communication of information to patients is essential in order to facilitate optimal uptake of bariatric surgery and choice of the most suitable procedure. This article reviews the most relevant advances in understanding of long-term efficacy associated with gastric banding, gastric bypass and sleeve gastrectomy.