Long-term effectiveness, outcomes and complications of bariatric surgery

Dietary imbalance and overeating can lead to an increasingly widespread disease - obesity. Aesthetic considerations aside, obesity is defined as an excess of adipose tissue that can lead to serious health problems and can predispose to a number of pathological changes and clinical diseases, including diabetes; hypertension; atherosclerosis; coronary artery disease and stroke; obstructive sleep apnea; depression; weight-related arthropathies and endometrial and breast cancer. A body weight 20% above ideal for age, gender and height is a severe health risk. Bariatric surgery is a set of surgical methods to treat morbid obesity when other treatments such as diet, increased physical activity, behavioral changes and drugs have failed. The two most common procedures currently used are sleeve gastrectomy and gastric bypass. This procedure has gained popularity recently and is generally considered safe and effective. Although current data show that perioperative mortality is low and better control of comorbidities and short-term complications is achieved, more randomized trials are needed to evaluate the long-term outcomes of bariatric procedures. This review aims to synthesize and summarize the growing evidence on the long-term effectiveness, outcomes and complications of bariatric surgery.

Hydatid cysts of the liver with concomitant massive peritoneal hydatidosis: a case report

The worldwide distribution of Echinococcus granulosus and its capability to persist in the human organism by causing serious medical and economical damage makes this parasite popular in terms of diagnosis and treatment implementation. Besides the liver as the primary target organ for this parasite, cases of secondary peritoneal hydatidosis are reported. Although rarely, they present with unusual abdominal symptoms with a bizarre presentation on abdominal ultrasound and Computerized Tomography scans. We present a case of a 44 years old male patient with concomitant presence of liver hydatid cysts and massive peritoneal hydatidosis treated with a combination of surgery and postoperative medications. The treatment of peritoneal hydatidosis consists of surgical removal of all the present cysts. In addition, anti-parasitic drugs are recommended to prevent a recurrence. The concomitant presence of liver hydatid cysts and peritoneal echinococcosis can appear as a result of abdominal trauma or iatrogenic spillage during abdominal surgery.

Mastering the learning curve significantly reduces operative time for laparoscopic treatment of complicated appendicitis

Laparoscopic appendectomy is the preferred operative method for acute appendicitistreatment. In terms of complicated appendicitis it can be effective in hands of an experiencedlaparoscopist that overwhelmed the learning curve for the method. Aim: Тhis retrospectivestudy examines whether the operative time for laparoscopic appendectomy for complicatedappendicitis is shortened after mastering the learning curve. Material and methods: A totalnumber of 196 patients were operated for the diagnosis of acute appendicitis, of whom 77were diagnosed with complicated appendicitis. They were subsequently divided in two groups(laparoscopic and open). Operative time in both groups was measured and the conversionand postoperative complications were noted. Results: Conversion rate was 2.3%. Operativetime was shorter in the laparoscopic group (67.4 ± 22.9 vs. 77.9 ± 17.9 minutes; p = 0.033).Overall postoperative morbidity was 25.97% with wound infection present only in the opengroup (p = 0.018). Intraabdominal abscess occurred in one patient from the laparoscopicgroup (0.38%). Length of hospital stay was shorter in the laparoscopic group (4.3 ± 2.2 vs. 5.7 ± 2.1, p = 0.0052).  

Surgical complications in COVID-19 patients in the setting of moderate to severe disease

The coronavirus disease 2019 (COVID-19) pandemic has had a considerable impact on the work of physicians and surgeons. The connection between the patient and the surgeon cannot be replaced by telemedicine. For example, the surgical staff faces more serious difficulties compared to non-surgical specialists during the COVID-19 pandemic. The primary concerns include the safest solutions for protecting healthcare staff and patients and the ability to provide adequate surgical care. Additionally, the adverse effects of any surgery delays and the financial consequences complicate the picture. Therefore, patients' admission during the COVID-19 pandemic should be taken into consideration, as well as preoperative measures. The COVID-19 situation brings particular risk to patients during surgery, where preoperative morbidity and mortality rise in either asymptomatic or symptomatic COVID-19 patients. This review discusses the recent factors associated with surgical complications, mortality rates, outcomes, and experience in COVID-19 surgical patients.

High expression of CD133 - stem cell marker for prediction of clinically agressive type of colorectal cancer

<b> Background:</b> Colorectal cancer (CRC) is one of the most common malignancies in the world. The cancer stem cell (CSC) markers are associated with aggressive cancer types and poor prognosis. The objective of the study was to evaluate the CD133 expression and to correlate it with clinicopathological features in patients with CRC. <br><b>Material and Methods:</b> Our study included ninety patients with CRC who underwent curative surgical resection from 2012 to 2017 at the University Clinic for Digestive Surgery, Skopje, North Macedonia. Tumor samples were first analyzed with standard histopathological methods and then the CD133 expression was investigated immunohistochemically. The level of expression of CD133 was classified semiquantitatively. Low positivity was defined as positive immunoreactivity in <50% of tumor glands, and high positivity was defined as positive immunoreactivity in ≥50% of tumor glands. Furthermore, clinicopathological features of patients were retrospectively reviewed. <br><b>Results:</b> High expression of CD133 was found in 47.8% of patients' CRC samples. In 69.6% of patients with metastatic lesions in visceral organs we found high expression of CD133. We found statistically significant differences in the expression of CD133 between patients with and without visceral metastatic lesions (P = 0.0153), between patients with a different T category (P = 0.0119), N status (P = 0.0066) and grade (G) (P = 0.0115). Our results showed that the stage of disease has the greatest impact on expression of CD133 (P < 0.00001). <br><b>Conclusion:</b> High expression of CD133 is a useful marker for prediction of the clinically aggressive type of CRC and can be routinely implemented in standard pathohistological diagnostics.

Challenging Treatment of a Female Patient with Extensive Fournier's Gangrene - Case Report

Fournier's gangrene (FG) is a necrotizing fasciitis of the genital, perianal and perineal regions, caused by multiple anaerobic/aerobic infection. It is a rare but very serious condition with multiple long-term complications and high mortality rate. Early diagnosis and multidisciplinary approach in treatment of complicated cases of FG are crucial to the successful outcome. We report a case of an extensive FG in a 59-years-old female patient with multiple risk factors such as obesity, type 2 diabetes and hypertension. She was hospitalized as an emergency case with diabetic ketoacidosis, sepsis and extensive necrotic lesions located perineal, perianal, genital and spread to inguinal, hypogastric, gluteal and sacrococcygeal region. Fournier's gangrene was diagnosed, and after prompt resuscitation, intravenous fluids, broad-spectrum antibiotics, insulin infusion, emergency aggressive surgical debridement was performed. Several aerobic and anaerobic bacteria were isolated from wound culture and hemoculture. Patient has second debridement after four days. After second debridement was applied metabolic control, broad-spectrum antibiotics coverage, dressing the wound and negative pressure wound therapy (NPWT). Patient was discharged home five weeks after a second debridement in good condition. One month later she underwent reconstructive surgical treatment. Besides extensive FG and multiple comorbidity she was successfully managed with good outcome. Fournier's gangrene remains a life-threatening and fulminant disease which need urgent diagnosis and aggressive medical and surgical treatment, to achieve a reduction in long term complications and mortality rate.

Inflammatory Pseudotumor/Inflammatory Myofibroblastic Tumor of Spleen – A Case Report

BACKGROUND: Splenic inflammatory pseudotumor (IPT)/inflammatory myofibroblastic tumor (IMT) is a rare pseudotumor/tumor of unknown origin, which is usually benign, although atypical and aggressive cases have been reported. It is a lesion composed of proliferated myofibroblastic cells (hence IMT by some authors) with admixed pleomorphic inflammatory cells of varying proportions. CASE REPORT: Herein, we report a case of 61-year-old male patient with ill-defined abdominal discomfort and no other symptoms and signs. Clinical and imaging investigations revealed a mass in the spleen that was equivocally interpreted as secondary neoplasm, although primary neoplasm of the spleen was not excluded by the radiologists. Splenectomy was performed and on gross examination a well demarcated greyish-livid tumor measuring 3.5 cm × 3 cm × 3 cm was discovered. Microscopic examination showed proliferation of loosely arranged spindle cells admixed with inflammatory cells (histiocytes, lymphocytes, neutrophils, eosinophils, occasional plasma cells, and/or plasmacytoid cells) with varying density and multifocal clustering, multifocal hemorrhage, and fibrinoid-like deposition. We performed additional histochemical and immunohistochemical stainings which were consistent with the diagnosis of IPT/IMT. Next-generation sequencing (TruSight Tumor 15) showed common TP53 polymorphism (c.215C>G; p.Pro72Arg) along with several intronic and synonymous single nucleotide variations (SNVs), as well as five low confidence missense SNVs. Sixteen months after the operation the patient has uneventful follow-up. CONCLUSION: Although the incidence of IPT/IMT is low, awareness of its existence is necessary. The prognosis is favorable following splenectomy in most cases. Careful microscopic examination of the specimen is mandatory, due to possible misdiagnosis. We believe that extensive NGS analysis on archive samples would provide more data about the spectrum of possible genetic changes in lesions like IPM/IMT.

Sentinel Lymph Node Detection in Colorectal Cancer - First Experience

BACKGROUND:

Colorectal cancer (CRC) is the second commonest cancer in women, the third in men, being the fourth commonest cause of cancer death. The most important factor for prognosis and staging in CRC patients is the status of the regional lymph nodes (LN).

AIM:

To implement the method for sentinel lymph node (SLN) detection in CRC patients using radiocolloid, and test its detection rate, sensitivity, accuracy, negative predictive value and the possibility for upstaging.

MATERIAL AND METHODS:

The study included 40 CRC patients, age 63 ± 14 years, without LNs detected on CT or MRI. SLN detection was performed after endoscopically peri- and intratumoral injection of 99mTc-SENTISCINT. All patients underwent resection with systemic lymphadenectomy, and the SLNs were detected ex vivo. Pathohistology was performed to all resected LNs.

RESULTS:

The identification rate was 95%, the accuracy of the procedure was 92.1%, the negative predictive value was 86.95%, the sensitivity was 83.3%, and the upstage was 22.5%.

CONCLUSION:

Identification of SLNs in CRC patients with this method is possible and the detection rate, negative predictive value, accuracy and sensitivity are reliable. We expect to contribute in the upstaging of stage II CRC patients and the selection of appropriate oncology treatment protocols.

New technique of compression anastomosis in colorectal surgery - first results in 25 patients in Macedonia

AIM

Clinical evaluation of the safety and effectiveness of compression anastomosis with ColonRing™ for large-bowel end-to-end anastomosis for rectal cancer and explanation of the procedure and the device itself since this device is used for the first time in our clinic.

MATERIAL AND METHODS

In November, 2012, a team of surgeons from our clinic attended the Clinical practice workshop in Belgrade, Serbia which was organized by the World Congress of Compression Anastomosis (WCCA) and held by its President Prof. Dr. Steven Wexner from Cleveland Clinic in USA. On this workshop, all aspects of technical point of view were obtained and surgeons were certified for the technique. A total of 25 patients have been scheduled for elective colorectal surgery with subsequent compression anastomosis using ColonRing. All patients were operated for high and mid rectal cancers excluding the low rectal cancers, since those patients are usually diverted with decompressive ileostomy. Patients, who are diverted, are at higher risk of retaining the ring, after its dislodgement, in the ampulla of the rectum since they do not have natural excretion of stool via the anus. All patients were followed for anastomotic leak, anastomotic bleeding, stricture formation, device (ColonRing) handling in general and time of expulsion of the ring via anus.

RESULTS

We used this technique for the first time in 2013 and since then a total of 25 patients underwent anterior resection of the rectum with subsequent colorectal compression anastomosis using ColonRing. Of all patients, 9 were female while 16 were male with median age of 64 years. All patients were operated for rectal cancers. The mean length of hospital stay was 7.4 days (range 5 to 9 days). None of the patients developed anastomotic bleeding or dehiscence. To date none of the patients developed anastomotic stricture, although some patients were followed for almost two years. The average day of expulsion from the body could not be calculated since despite, and although all patients were given instruction on how to check for ring expulsion, 21 of them did not report this event. Only 2 patients brought the ring to us. In two cases after 2 week of the initial operation, the ring was find and palpated on digital rectal examination, free in the ampulla of the rectum and was easily removed via the anus during the examination. Misfiring was reported in 1 patient (first patient) and reanastomosis was employed using another ColonRing, No perioperative mortality was observed in this patient population.

CONCLUSION

End-to end colorectal anastomosis with the ColonRing is feasible and safe procedure with fast learning curve. To date, this type of anastomosis is possible in left sided colon lesions where anastomosis is contemplated below the promontory. We find the device easy to use with high level of confidence. Further prospective studies including comparison between the ColonRing device and the conventional staplers evaluating long-term anastomotic complications (i.e., leak or stricture) are needed to evaluate the benefits and limitations of this device.

Retrorectal dermoid cyst manifested as an extrasphincteric perianal fistula - case report

Retrorectal tumors are very rare but well defined pathological entities in the literature. Also, an extrasphincteric fistula is a very rare form of perianal fistula which makes our case a very unusual and rare one, especially by the fact that it was successfully treated with the first operation and without protective stoma formation. The patient was first treated in hospital for a retrorectal abscess that had spontaneously ruptured in the postanal space. Because of the constant drainage of the suppurative content from the postanal opening in the following months, MRI and fistulography were performed, registering cystic formation in the retrorectal space with fistulous communication with the rectum above and completely separate from the sphincter mechanism. After that the patient was admitted for definitive treatment. The operation was performed with the patient in a prone jack-knife position. Complete excision of the cyst with the fistulous communication was performed and the rectum was sutured in two layers with separate slowly absorbable sutures. The wound was laid open and the patient was discharged on the 5th post operative day. After about ten months the defecation is normal, the wound is sealed and there are no signs of inflammation and secretion locally.

Splenectomy for haematological disorders

Splenectomy is therapeutic for a large host of conditions. It is a consequence of expanding the list of disorders and liberalizing the indications for splenectomy in many diseases. Red blood cells disorders: autoimmune hemolytic anemia, hereditary spherocytosis, hemoglobinopathies and thalassemia are prone to splenectomy after failure of medical therapy. A variety of thrombocytopenic disorders are improved by splenectomy, and the most common indication for splenectomy is ITP (idiopathic thrombocytopenic purpura). Splenectomy is successful in reversing hypersplenism in a spectrum of disease called myeloproliferative disorders. Relief of symptoms from splenomegaly is also achieved, but it does not affect the inexorable course of the disorder. The role of splenectomy in white blood cells disorders (leukemias and lymphomas) is only palliative and facilitates chemotherapy. Splenectomy in patients with hemathologic disorders imparts a risk of fulminant and life threatening infection "overwhelming postsplenectomy sepsis" that can be obviated by appropriate treatment. Although splenectomy for hemathologic disorders is only therapeutic and not curative, the relief of symptoms and for some disorders facilitation of chemotherapy leads to better quality of life and longer survival.

Multivisceral resection for advanced duodenal adenocarcinoma: a case report and review of literature

The aim of this paper is to address adenocarcinoma of the duodenum by reporting a case, reviewing the literature and discussing current knowledge, diagnostic modalities and treatment options. We present a case of a 42-year-old patient with duodenal adenocarcinoma at the second portion invading surrounding organs. The patient had a previous history of colon malignancy and was diagnosed with a new tumour formation on regular CT (computed tomography) follow-up. Pylorus-preserving pancreaticoduodenectomy (PPPD) was preformed for this T4 N2 M1 tumor. Duodenal adenocarcinoma is a rare tumor, most frequently involving the second duodenal portion. It has no specific symptoms and it is difficult to diagnose it due to its rarity and clinical presentation. Diagnosis, exact localization, and involvement of lymph nodes and surrounding organs have an impact on surgical strategy and prognosis.