Robotic Heller's myotomy using the new Hugo™ RAS system: first worldwide report

BACKGROUND

Achalasia is a rare disorder of the esophagus characterized by motor dysfunction in the esophagus and relaxation failure of the lower esophageal sphincter (LES). Currently, surgical myotomy procedures are considered the standard of care. Robotic Heller's myotomy (RHM) with fundoplication has been gaining popularity due to documented advantages in the precision of myotomy as well as avoiding the potential reflux following per-oral endoscopic myotomy (POEM). To the best of our knowledge, RHM has thus far has been performed exclusively by the da Vinci surgical system. The new Hugo RAS™ system offers a unique modular design and an open console which offers better maneuverability and docking options. In this study, we present the first worldwide series of patients undergoing RHM using the new Hugo RAS™ platform. Our objective is to propose optimal operating configuration and setup to fully harness the advantages of the unique modular design of this system.

METHODS

Ten consecutive achalasia patients underwent Robotic Heller's myotomy (RHM) with the Hugo RAS™ system. We prospectively collected patient data, including demographics, comorbidities, ASA class, Eckardt scores, pre-operative manometric data, and EndoFlip parameters. Additionally, we recorded the docking and total operative times.

RESULTS

Between December 2022 and August 2023, 10 patients underwent RHM with the Hugo™ RAS system. Patients had a median age of 42.5 years, 60% were female, and mean BMI was 23.2. Fifty percent had achalasia type 2 and 50% type 1. The median pre-operative integrated relaxation pressure (IRP) was 24.9. Median docking time was 10 min and overall operative time was 129.5 min. All patients, except one with acute coronary syndrome, had an uneventful peri-operative course and were discharged on post-operative day 2.

CONCLUSION

The Hugo™ RAS system is well designed for robotic Heller myotomy. The operative and clinical results are similar to the currently used robotic system; however, the modular design of the system has some differences. These translate to better docking angles and maneuverability as well as console surgeon's ergonomics. Further experience is needed to explore the advantages of the system's modular design and function.

Robotic inguinal hernia repair with the new Hugo RASTM system: first worldwide case series report

INTRODUCTION

Robotic-assisted surgery has been a part of surgical procedures for more than two decades. Recently new robotic platforms with a different design entered the market. The modular design with independent arms enables increased flexibility of arm docking to increase the range of motion and instrument maneuverability. We herein present the first case series of robotic inguinal hernia repair using the Hugo RAS system (Medtronic, Minneapolis, MN, USA).

MATERIAL AND METHODS

Thirteen inguinal hernia repairs were performed on ten patients. A description of the Hugo RAS system as well as the new concept of modular design is presented along with the description of the operation setup.

RESULTS

Mean docking time was 9.5 min and mean console time was 50.3 min and 74.7 min for unilateral and bilateral inguinal hernia repair, respectively. No intraoperative or postoperative complications occurred. There was one conversion to laparoscopic surgery due to a technical issue with the robot. Conclusions: The modular design of independent arms seems to enhance maneuverability of the instruments and contribute to fewer arm collisions. Further clinical data and experience with this new surgical system are necessary to understand if this new design has advantages over the standard robotic platforms.

Post-POEM Contrast-Enhanced Swallow Study: Is It Always Necessary?

BACKGROUND

Peroral endoscopic myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast-enhanced swallow studies (CESS) are routinely performed postoperatively to confirm mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM.

METHODS

A retrospective review of a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020 was performed. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, complete blood count, and POD-1 CESS were evaluated.

RESULTS

One hundred thirty-four consecutive patients were included in the study. Sixty-nine (51.49%) CESS showed abnormal findings; while most findings did not change the postoperative course, five (7.2%) demonstrated tunnel leaks, which did alter the overall management. Screening patients for fever, tachycardia, or leukocytosis on POD-1 had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS.

CONCLUSIONS

The study findings suggest that performing routine contrast-enhanced swallow studies on all patients is not necessary following POEM, as leaks can be screened for by clinical or laboratory abnormalities. Herein, we propose an algorithm based on objective measurable findings for the selection of patients who should undergo CESS.

Changes in bone mineral density following laparoscopic sleeve gastrectomy: 2-year outcomes

BACKGROUND

Emerging evidence suggests that sleeve gastrectomy (SG) leads to significant bone mineral density (BMD) losses, but there is a paucity of studies evaluating skeletal consequences beyond 12-months post-operatively.

OBJECTIVES

To evaluate BMD changes 2 years postoperatively.

SETTING

A university hospital.

METHODS

Thirty-three women (mean age: 34.4 ± 12.3 years) who underwent SG and completed 24 months of follow-up were evaluated prospectively at baseline and at 3 (M3), 6 (M6), 12 (M12), and 24 (M24) months postoperatively. Data collected included BMD at the total hip, femoral neck, and lumbar spine measured by dual-energy x-ray absorptiometry and anthropometrics, biochemical, nutritional, and physical activity parameters.

RESULTS

At M24, patients achieved a mean body mass index and excess weight loss of 32.4 ± 5.1 kg/m² and 64.5 ± 21.4%, respectively; however, weight stabilized at M12. Femoral neck BMD decreased significantly from baseline to M24 (.924 ± .124 versus .870 ± .129 g/cm², P < .001), with no change between M12 and M24 (P = .273). Total hip BMD decreased significantly from baseline to M24 (1.004 ± .105 versus .965 ± .132 g/cm², P < .001) but increased between M12 and M24 (P = .001). No significant changes were noted in lumbar spine BMD. The percentage of changes in the femoral neck and the total hip BMD from baseline to M24 positively correlated with postoperative excess weight loss (r = .352, P = .045, and r = .416, P = .018, respectively).

CONCLUSION

Despite notable weight loss, women who underwent SG experienced significant bone loss at the total hip and femoral neck more than 2 years postoperatively. Future studies should investigate intervention strategies to attenuate skeletal deterioration after SG.

Factors Associated with the Development of Anemia During Pregnancy After Sleeve Gastrectomy

PURPOSE

Nutritional deficiencies, particularly anemia, are commonly encountered following bariatric surgery. While anemia during pregnancy is associated with various adverse maternal and perinatal outcomes, the factors associated with its occurrence following bariatric surgery have not been established. We explored the factors associated with the development of anemia during pregnancy after laparoscopic sleeve gastrectomy (SG).

MATERIALS AND METHODS

We reviewed the records of women who underwent SG and delivered during 2010-2018 in a single university hospital.

RESULTS

Of 121 women, 68 (56.2%) had evidence of anemia (hemoglobin < 11.0 g/dL) prior to delivery, with significantly lower hemoglobin levels compared with those (n = 53) without anemia (median 9.9 vs. 11.4 g/dL, P < 0.001). Significantly lower hemoglobin levels were found among those with pre-delivery anemia, both at the pre-operative stage (median 12.9 vs. 13.3 g/dL, P = 0.02) and at early pregnancy (median 12.0 vs. 12.6 g/dL, P = 0.05), compared with those without anemia. In multivariate analysis, a lower pre-operative hemoglobin level was the only independent factor associated with pre-delivery anemia (OR (95% CI) 1.59 (1.05, 2.40), P = 0.03). The rate of blood transfusion was significantly higher in women with pre-delivery anemia than in women without anemia (7.4% vs. 0, P = 0.04).

CONCLUSIONS

Anemia during pregnancy after SG was common; pre-operative hemoglobin level was identified as an independent predictor of its occurrence. Efforts should be invested to implement anemia risk stratification before surgery among reproductive-age women, and to optimize maternal nutritional status prior to pregnancy, as well as during the prenatal course.

Sleeve Gastrectomy Failure-Revision to Laparoscopic One-Anastomosis Gastric Bypass or Roux-n-Y Gastric Bypass: a Multicenter Study

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure performed worldwide. However, many patients undergo secondary surgery due to either weight-related and complication-related reasons or both. Conversional options vary with one-anastomosis gastric bypass (OAGB) and Roux-n-Y gastric bypass (RYGB) being the most common. The aim of the study was to assess the safety and efficacy of converting failed LSG to either OAGB or RYGB, and compare weight-related results and post-conversion complications.

METHODS

Retrospective review of hospital records of patients who underwent conversion from LSG to either RYGB or OAGB due to insufficient weight loss or weight regain in 7 bariatric centers between 2013 and 2019. Data retrieved included demographics, anthropometrics, comorbidities, indication for conversion, conversion type, complications, and weight loss.

RESULTS

During the study period, 396 patients were included in the study. Eighty-four (21%) patients were lost to follow-up. RYGB and OAGB were performed in 119 and 144 patients, respectively. Mean age and body mass index (BMI) at revision were 44.2 years (range 19-72) and 40.6 ± 5.9 kg/m² (range 35-71), respectively. Of these, 191 (73%) were female. Percent total body weight loss (%TWL) was 16% ± 1% for the RYGB group vs. 23% ± 12% for the OAGB group (p = 0.0007) at a median follow-up of 29 months (range 7-78 months) following conversion. Gastroesophageal reflux disease (GERD) was significantly higher 1 year following conversion to OAGB vs. RYGB occurring in 25 (17.4%) and 9 (7.6%) patients, respectively (p = 0.018).

CONCLUSIONS

Conversion of LSG to OAGB, compared to RYGB, results in increased weight loss but a higher rate of GERD and potential nutritional deficiencies.

Complete vs partial fundoplication: a laboratory measurement of functionality and effectiveness

BACKGROUND

Complete or partial fundoplication remains controversial for the surgical treatment of GERD. While partial fundoplication is considered less effective, it is associated with less post-operative dysphagia and gas bloating compared with complete fundoplication.

AIM

To compare the mechanical efficiency of the three different types of fundoplication.

MATERIAL AND METHOD

Two studies of the LES were performed on explanted stomachs: distensibility and failure point. Measurements were taken before and after fundoplication.

RESULTS

There was no difference in distensibility between Nissen and Toupet fundoplication, however, the EGJ was more distensible following Dor fundoplication. According to failure point measurements, Nissen fundoplication was significantly more effective than Toupet, Toupet was significantly more effective than Dor (p = .016, p = .017, respectively).

CONCLUSIONS

There were significant differences in distensibility between Dor and both Nissen and Toupet, however no statistical difference between Toupet and Nissen. There was a significant difference in effectiveness between all three types of fundoplication according to the failure point. These laboratory findings demonstrate that the mechanical orientation of Nissen and Toupet have similar functionality suggesting that Toupet is as good as Nissen. While in clinical studies Toupet has fewer post-operative complications these findings support the proponents of Toupet for GERD. Abbreviation: GERD: Gastroesophageal reflux disease.

Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy: Low Efficacy of the Over-the-Scope Clip

PURPOSE

The over-the-scope clip (OTSC) enables non-surgical management of gastrointestinal defects. The aim of this study was to report our experience with OTSC for patients with staple line leaks following laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC for staple line leaks following LSG from 2010 to 2018. Primary outcome was complete resolution of leak following OTSC. Secondary outcome was the number of additional procedures needed following OTSC.

RESULTS

Twenty-six patients (13 males, 13 females) were treated with OTSC for staple line leaks following LSG. The median age was 35 years (range 18-62), and mean body mass index was 44 kg/m2. The median time from index operation to leak diagnosis and from leak diagnosis to OTSC was 18 days (range 2-118), and 6 days (range 1-120), respectively. The initial endoscopic treatment was OTSC (n = 19), stent (n = 5), clip (n = 1), and clip and biologic glue (n = 1). OTSC alone led to final resolution of leak in 8 patients (31%) within 43 days of clip deployment (range 5-87). Five leaks resolved after a combination of OTSC and stent (19%) and one leak (4%) resolved after endoscopic suturing following a failed OTSC. Eleven patients (42%) failed endoscopic management and underwent total gastrectomy and esophagojejunostomy. One mortality (4%) was noted. The number of additional endoscopic sessions ranged from 1 to 10 (median 2).

CONCLUSIONS

OTSC carries a low success rate for controlling staple line leaks following LSG.

Food Addiction and Binge Eating During One Year Following Sleeve Gastrectomy: Prevalence and Implications for Postoperative Outcomes

BACKGROUND

Food addiction and binge eating are common among individuals with obesity. However, a paucity of studies prospectively examined the prevalence and implications of food addiction before and post-bariatric surgery. We aimed to examine the prevalence of food addiction and binge eating before and after sleeve gastrectomy (SG) and to assess their associations with behavioral and weight loss outcomes.

METHODS

We followed at 3 (M3), 6 (M6), and 12 (M12) months postoperative, 54 women who underwent SG. Data collected including anthropometrics, nutritional intake, food tolerance, and physical activity measures. The Yale Food Addiction Scale and the Binge Eating Scale were used to characterize food addiction and binge eating, respectively.

RESULTS

The mean baseline age and BMI were 32.1 ± 11.1 years and 44.9 ± 4.9 kg/m², respectively. Pre-surgery, food addiction, and binge eating were identified in 40.7% and 48.1% of patients, respectively. The prevalence of food addiction decreased significantly up to M6, but increased to 29.3% at M12. The prevalence of binge eating decreased significantly through the follow-up up to 17.4% at M12. Those who met criteria for food addiction at M12 achieved significantly lower excess weight loss at M12 compared with those not meeting this criterion (P = 0.005). Food addiction scores at M12 negatively correlated with weekly physical activity (r = - 0.559; P < 0.001) and food tolerance scores (r = - 0.428; P = 0.005).

CONCLUSIONS

The reduction in food addiction observed at M6 was not maintained at M12. Food addiction at M12 was associated with poorer weight loss, eating, and lifestyle behaviors. Clinical practice should focus on the psychological aspects associated with obesity.

Longitudinal patterns of cytokine expression at the individual level in humans after laparoscopic sleeve gastrectomy

The study of the human response to injury has been hampered by the inherent heterogeneity in the models and methods used. By studying a standard injury longitudinally, using individual patient‐level analysis, we endeavoured to better describe its dynamics. We analysed clinical variables, clinical laboratory and plasma cytokines from 20 patients at five time points. Clustering analysis showed two prototype patterns of cytokine behaviour: a concordant type, where cytokines behave the same way for all patients (notably IL‐0 and TNFα), and a variable type, where different patterns of expression are seen for different patients (notably IL‐8, IL‐6 and IL‐1RA). Analysis of the cytokines at the individual patient‐level showed a strong four‐way correlation between IL‐1RA, GCSF, MIP‐1β and MCP‐1. As it holds for most patients and not just on average, this suggests that they form a network which may play a central role in the response to gastro‐intestinal injuries in humans. In conclusion, the longitudinal analysis of cytokines in a standard model allowed the identification of their underlying patterns of expression. We propose that the two prototype patterns shown may reflect the mechanism that separates the common and individual aspects of the injury response.

Knowledge, attitudes, and behaviors of women during pregnancy after bariatric surgery

BACKGROUND

Women of childbearing age constitute a substantial proportion of the patients who undergo weight loss procedures. However, little is known regarding attitudes and behaviors of women during pregnancy after bariatric surgery (BS).

OBJECTIVES

We explored women's experience and behavior during pregnancy after BS.

SETTING

University hospital.

METHODS

A cross-sectional survey study was performed among women who underwent sleeve gastrectomy and delivered at our center.

RESULTS

Overall, 111 women completed the questionnaire (response rate 88.1%). The median surgery-to-conception interval was 34 (25-50) months. For 28 (25.2%) women, future pregnancy was a motivation for undergoing the weight loss procedure. Only 10 (9.0%) received contraceptive advice perioperatively. Oral contraception was the most commonly used method after surgery (n = 47, 42.3%). Pregnancy was reported as unintended by 37 (33.3%) women. Only 14 (12.6%) women stated receiving an explanation regarding the implications of BS on pregnancy outcomes. Rates of follow-up with maternal-fetal medicine specialists, bariatric surgeons, and dieticians during pregnancy were 36.0%, 9.0%, and 23.4%, respectively. Forty-four women (39.6%) felt follow-up throughout gestation was inadequate. Satisfaction from BS improved after pregnancy in 23 (20.7%) women, and 75 (67.6%) stated that they would recommend BS to a friend with obesity who plans to conceive in the future.

CONCLUSIONS

Women reported insufficient knowledge regarding the expected outcomes of pregnancy after surgery, with low rates of medical and nutritional follow-up. Only a minority of respondents received contraceptive advice after surgery, and unintended pregnancies were common. These observations represent areas of improvement for following women of childbearing age who undergo weight loss procedures.

Nutritional Deficiencies in Patients with Severe Obesity before Bariatric Surgery: What Should Be the Focus During the Preoperative Assessment?

BACKGROUND

Nutritional deficiencies are a well-recognized long-term complication following bariatric surgery. The presence of preoperative deficiencies has been shown to be predictive of postoperative deficiencies.

OBJECTIVE

The aim of the study was to investigate the prevalence of micronutrient deficiency in a large sample of patients with severe obesity preoperatively, and to determine whether such deficiencies may be related to patient's sex, body mass index, or ethnic subgroup.

DESIGN

A cross-sectional study of data collected at the time of the preoperative evaluation.

PARTICIPANTS/SETTING

Data were collected during the preoperative evaluation of 872 bariatric surgery candidates in a university hospital in Israel between 2011 and 2018. The patients were 72.9% women, with a mean age of 37.9±12.1 years and mean body mass index of 42.4±4.7 MAIN OUTCOME MEASURES: Nutritional deficiencies according to blood assays. Data on anthropometrics, comorbidities, and demographic characteristics was also collected.

STATISTICAL ANALYSES

Baseline differences between patient subgroups were analyzed using independent-samples t test, analysis of variance, or χ² test.

RESULTS

Deficiencies of vitamin D, iron, folate, vitamin B-12, elevated parathyroid hormone and low transferrin saturation were present in 75.2%, 42.6%, 28.5%, 8.5%, 35.5%, and 70% of patients, respectively. Nutritional deficiencies were significantly more common among women compared with men for iron (45.9% vs 33.5%; P=0.002), low transferrin saturation (77.7% vs 44.6%; P<0.001), vitamin D (77.5% vs 69.2%; P=0.019) and elevated parathyroid hormone level (39.5% vs 22.9%; P=0.002). Iron, transferrin saturation, and vitamin D deficiencies were more prevalent in Arab patients compared with Jewish patients: 59.6% vs 36%; P<0.001, 80.2% vs 62.8%; P=0.003, and 85.1% vs 71.6%; P<0.001, respectively. Vitamin D and iron deficiency were more common among higher body mass index subgroups (P=0.004 and P=0.040, respectively).

CONCLUSIONS

The results indicate a high prevalence of nutritional deficiencies, mainly of iron and vitamin D in bariatric surgery candidates. Patients at higher risk for nutritional deficiencies include those with higher body mass index, women, and Arabs.

Hospital management of colonic perforations complicating ambulatory outpatient colonoscopy via over-the-scope clips or surgery: a case series

BACKGROUND

Colonoscopy is the standard of care for the diagnosis and treatment of many colonic disorders. Over the past few years, endoscopic closure of colonoscopy-related perforation has become more common. Endoscopic closure of perforation secondary to colonoscopy has been undertaken in patients in the hospital setting and often during the same colonoscopic procedure in which the perforation itself occurred. The aim of our study was to analyze our experience with emergency endoscopic closure of colonoscopy-related perforation with over-the-scope clip (OTSC) technique.

METHODS

We report five cases of colonic perforation that occurred during colonoscopy in an outpatient facility remotely located from our hospital and then referred as an emergency to our institution for endoscopic closure.

RESULTS

Bowel preparation was reported to be adequate in all cases. Prior to attempting endoscopic closure of colonic perforation, all patients were in stable clinical condition, early broad-spectrum antibiotic coverage was initiated, and a surgical consult was obtained. All patients had sigmoidoscopy and were found to have sigmoid colon perforations. In three cases, the perforations were closed successfully using an OTSC clip device 14 mm type t. Two patients were found to have greater than 4-cm sigmoid perforations with irregular margins, incompatible with OTSC closure, and were referred for emergency surgery. All patients had an uneventful course following either OTSC closure or surgery.

CONCLUSIONS

Based on the characteristics of the five cases and a review of the literature, we suggest a practical approach for undertaking closure of colonic perforations occurring during colonoscopy in the outpatient setting, focusing on clinical criteria to determine eligibility of patients for attempted endoscopic closure and outlining required therapeutic and monitoring steps needed to optimize outcomes.

[PER-ORAL ENDOSCOPIC MYOTOMY - SUMMARY OF FIVE YEARS EXPERIENCE]

INTRODUCTION

Esophageal achalasia is a rare condition, characterised by progressive dysphagia due to innervation of the esophageal muscles and non-relaxation of the lower esophageal sphincter. The standard of care of surgical treatment is laparoscopic Heller myotomy. POEM-Peroral endoscopic myotomy is a new approach offering incision-less and selective myotomy.

AIMS

This study aims to describe our experience and outcomes using this new surgical technique.

METHODS

We performed a retrospective study using prospectively maintained data of all achalasia patients treated by POEM in our department. Data collected included patient demographics, gender, age, BMI, data related to the disease course in addition to data related to the surgery itself as well as both short and long term post-operative follow-up.

RESULTS

Over the course of five years we performed 86 POEM operations, demonstrating a decrease in the Eckardt score from a mean of 8.87 to a mean of 0.7 in the immediate postoperative. Mean operative time was 86 minutes, with mean hospitalization time of 4 days. Intraoperative complications included 2 mucosal injuries while post-operative complications included 4 incomplete mucosal closures, 5 recurrent dysphagia and 5 patients with reflux requiring medical therapy.

CONCLUSIONS

In the last decade, POEM procedure is being performed worldwide and has been performed in our department for the past five years. Our results show a success rate of 94.2% with minor complications. In our institution, as in many institutions globally, POEM is the preferred method for treating achalasia.

Maternal nutritional status and related pregnancy outcomes following bariatric surgery: A systematic review

Up to 80% of patients who undergo bariatric surgery are women of childbearing age. Coupled with improved fertility in women with obesity after bariatric surgery, pregnancy postbariatric surgery has become increasingly more common. Although numerous studies have evaluated associations of bariatric surgery with pregnancy outcomes, the effect of maternal nutritional status on maternal and perinatal outcomes is not well established. We used Medline and Embase databases and a manual search of references for articles published until June 2018 to conduct a systematic review on nutritional status after bariatric surgery and its association with maternal and perinatal outcomes. Of the 306 initially identified articles, 27 met the study inclusion criteria, comprising 2056 women with pregnancies after bariatric surgery. Deficiencies were reported in maternal concentrations of vitamins A, B1, B6, B12, C, D, K, iron, calcium, selenium, and phosphorous. The only adverse events documented for these deficiencies encountered during pregnancy were anemia (vitamin B12, iron), night blindness (vitamin A), and urinary tract infections (vitamin A, D). This systematic review suggests that various micronutrient deficiencies are common among pregnant postbariatric surgery patients. Nevertheless, despite the concern that these deficiencies could adversely affect pregnancy outcomes (e.g., lower neonatal birth weight), evidence of such is lacking. Further prospective studies are warranted to confirm our findings and better delineate the optimal supplementation regimen during pregnancy after bariatric surgery.

Twin pregnancy outcomes after metabolic and bariatric surgery

BACKGROUND

The effect of bariatric surgery (BS) on twin pregnancy outcomes is unclear.

OBJECTIVES

We examined associations of BS with maternal and perinatal outcomes among women with twin gestation.

SETTING

A university hospital.

METHODS

A retrospective case-control study of twin deliveries during 2006 through 2017. The study group comprised all women with twin pregnancy who had undergone BS and delivered during the study period. A control group was established by matching preoperative body mass index, age, parity, and delivery year.

RESULTS

Data from 66 women with twin gestation were analyzed, 22 postBS and 44 matched control parturients. Compared with the control group, the study group had lower rates of gestational diabetes (9.1% versus 36.4%, P = .02) and gestational hypertensive disorders (0% versus 25.0%, P = .01); hemoglobin levels were lower at both early pregnancy (median 12.3 versus 13.4 g/dL, P < .001) and after delivery (9.3 versus 10.5 g/dL, P < .001). Median neonatal birthweights and the proportion of small-for-gestational-age infants were comparable between the groups. The degree of birth weight discordance between the twins was higher (17.2% versus 8.8%, P < .001) in the control group.

CONCLUSIONS

In this study involving twin gestations, pregnancy outcomes were more positive among women who had undergone BS; as noted by reduced prevalences of gestational diabetes and gestational hypertensive disorders as well as a lesser degree of birth weight discordance. Nevertheless, BS was associated with lower hemoglobin levels during pregnancy and the postpartum period. Future studies are warranted to confirm our findings and evaluate the long-term outcomes of newborns of postBS mothers.

Nutritional Management for Chronic Kidney Disease Patients who Undergo Bariatric Surgery: A Narrative Review

Bariatric surgery (BS) may be effective for chronic kidney disease (CKD) patients by reducing microalbuminuria and proteinuria, and by facilitating their meeting inclusion criteria for kidney transplantation. However, nutritional management for this population is complex and specific guidelines are scarce. A literature search was performed to create dietetic practice for these patients based on the most recent evidence. For the purposes of nutritional recommendations, we divided the patients into 2 subgroups: 1) patients with CKD and dialysis, and 2) patients after kidney transplantation. Before surgery, nutritional care includes nutritional status evaluation and adjusting doses of supplements to treat deficiencies and daily nutrient intake according to the dietary restrictions derived from kidney disease, including quantities of fluids, protein, phosphorus, potassium, and vitamins. After BS, these patients are at major risk for lean body mass loss, malnutrition and dehydration because of fluid restriction and diuretics. Postoperative nutritional recommendations should be carefully tailored according to CKD nutritional limitations and include specific considerations regarding protein, fluids, and supplementation, in particular calcium, vitamin A, and vitamin D. Nutritional management of CKD and kidney transplant patients undergoing BS is challenging and future studies are required to establish uniform high-level evidence-based guidelines.

Bone Health following Bariatric Surgery: Implications for Management Strategies to Attenuate Bone Loss

Bariatric surgery (BS) is an effective treatment for morbid obesity and its associated comorbidities. Following such a procedure, however, patients are at risk of developing metabolic bone disease owing to the combination of rapid weight loss, severely restricted dietary intake, and reduced intestinal nutrient absorption. Patients undergoing malabsorptive procedures are at a higher risk of postoperative bone health deterioration than those undergoing restrictive procedures; however, studies have demonstrated negative skeletal consequences of restrictive procedures as well. The clinical practice guidelines of some international associations have previously addressed preoperative evaluation and postoperative clinical care in order to maintain bone health in BS patients. Nevertheless, some issues regarding bone health in BS patients remain unclear owing to the lack of relevant randomized clinical trials, including doses of nutritional supplements pre- and post-BS. This review summarizes the current data regarding the skeletal consequences of BS and its mechanisms, with an emphasis on the preventive strategies and nutritional care that may be warranted in order to attenuate bone deterioration following BS.

Hypoglycemia during oral glucose tolerance test among post-bariatric surgery pregnant patients: incidence and perinatal significance

BACKGROUND

While hypoglycemia during an oral glucose tolerance test (OGTT) has been shown to occur in a considerable portion of nonpregnant post-bariatric surgery (BS) patients, its incidence among pregnant post-BS patients evaluated for gestational diabetes has only been sparsely studied.

OBJECTIVES

We investigated OGTT results and pregnancy outcomes in pregnant women who underwent 3 types of bariatric procedures before pregnancy.

SETTING

A university hospital.

METHODS

From medical records, data were collected on glucose measurements during a 100-g, 3-hour OGTT, as well as maternal and fetal outcomes.

RESULTS

Of 119 post-BS pregnant patients included in the study, 55 underwent laparoscopic sleeve gastrectomy, 34 laparoscopic adjustable gastric banding, and 30 laparoscopic Roux-en-Y gastric bypass surgery. Hypoglycemia (<55 mg/dL) was encountered in 59 (49.6%) patients during the OGTT. Among them, the nadir plasma glucose levels occurred 2 hours after glucose ingestion in 25 (42.4%) and after 3 hours in 34 (57.6%), with a median value of 47 (44-52) mg/dL. The risk of hypoglycemia was higher among women with prior laparoscopic Roux-en-Y gastric bypass surgery (83.3%) than among those with prior laparoscopic sleeve gastrectomy (54.5%; P = .009) or laparoscopic adjustable gastric banding (11.8%; P<.0001). Time from surgery to conception was significantly shorter among women with evidence of hypoglycemia during OGTT (median 711 versus 1246 days, P = .002). Compared with patients without evidence of hypoglycemia, patients who experienced hypoglycemia had lower rates of gestational diabetes (P = .03) but higher proportions of low birth weight (P = .01) and small for gestational age infants (P = .03).

CONCLUSIONS

Because hypoglycemia is common during OGTT among post-BS parturients, other diagnostic methods should be considered in this setting. The association found between hypoglycemia and poor fetal growth warrants investigation as to whether interventions to prevent hypoglycemia will improve fetal outcome.

Postoperative Outcomes, Weight Loss Predictors, and Late Gastrointestinal Symptoms Following Laparoscopic Sleeve Gastrectomy

OBJECTIVE

To evaluate the outcomes, weight loss predictors, and gastrointestinal symptoms of patients after laparoscopic sleeve gastrectomy (LSG).

METHODS

The postoperative medical status of the patients was obtained retrospectively using a questionnaire and was compared to existing medical data before the surgery.

RESULTS

We included 201 candidates, 178 patients completed mean of 3 years of follow-up. Mean excess body weight loss (%EWL) was 65.14% ± 15.74 at 6 months, 78.53% ± 20.28 at 12 months, and 74.32% ± 23.92 at 3 years after LSG. Older age (P = 0.018), higher baseline BMI (P = 0.003), and higher number of medications (P < 0.001) were negative predictors for EWL%. Total weekly hours of physical activity was found to be a positive predictor for EWL% (P = 0.008). Remission rates of co-morbidities were 83.5% for dyslipidemia (P < 0.001), 65.8% for hypertension (P < 0.001), 62.1% for type 2 diabetes mellitus (T2DM) (P < 0.001), and 60.7% for gastroesophageal reflux (GERD) (P < 0.001). Late gastrointestinal symptoms were as follows: emesis in 25.9%, constipation in 24.7%, diarrhea in 4.5%, food intolerance in 22.5% and alopecia in 42.7% of the patients.

CONCLUSION

Our study shows LSG as a potential tool in achieving almost 75% of EWL% with significant remission of co-morbidities, along with various late gastrointestinal symptoms.

Phytobezoar: a rare late complication following laparoscopic sleeve gastrectomy surgery

Case reports of bezoar after bariatric surgery are available to date only following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB), but not following laparoscopic sleeve gastrectomy (LSG). Presented here is the first case reports of phytobezoars occurrence post LSG. Two case reports are presented. The mechanisms involved and the therapeutic implications are discussed. Case 1: A 41-year-old woman with a body mass index (BMI) of 45 kg/m2 underwent LSG surgery. Seven months postoperatively she developed significant vomiting and an upper GI gastrografin swallow study revealed a gastric bezoar, confirmed by an esophagogastroduodenoscopy (EGD). The bezoar was broken up and removed with the endoscope. Case 2: A 34-year-old woman with initial BMI of 42.7 kg/m2 was readmitted 5 years post LSG due to reflux accompanied with epigastric pain, vomiting, dysphagia and constipation. An upper GI gastrografin swallow study revealed esophageal dilatation. EGD showed a gastric phytobezoar 3x4cm size, removed by the endoscope. The lack of reports on bezoar occurrence after LSG may be related to the higher rates of stricture reported for LRYGB procedure comparing to LSG. In addition, LSG is a relatively new bariatric procedure, and the interval between surgery and detection of bezoars may be many years later.  Thus, even being a rare late complication, bezoars should be suspected in LSG patients presenting with obstructive symptoms during the late post-surgery period. We recommend prompt endoscopic intervention to relieve the obstruction before parts of the bezoar migrate to the small bowel, necessitating operative intervention

Nutritional deficiencies four years after laparoscopic sleeve gastrectomy-are supplements required for a lifetime?

BACKGROUND

Data regarding long-term nutritional deficiencies following laparoscopic sleeve gastrectomy (LSG) are scarce.

OBJECTIVES

To assess the prevalence of nutritional deficiencies and supplement consumption 4 years post-LSG.

SETTING

Hebrew University, Israel.

METHODS

Data were collected prospectively from preoperative and 1 and 4 years postoperative including anthropometric parameters, biochemical tests, and supplement intake.

RESULTS

Data were available for 192, 77, and 27 patients at presurgery and 1 and 4 years post-LSG, respectively. Prevalence of nutritional deficiencies at baseline and 1 and 4 years postsurgery, respectively, were specifically for iron (44%, 41.2%, 28.6%), anemia (11.5%, 20%, 18.5%), folate (46%, 14.3%, 12.5%), vitamin B12 (7.7%, 13.6%, 15.4%), vitamin D (96.2%, 89%, 86%), and elevated parathyroid hormone (PTH) (52%, 15.4%, 60%). Vitamin D levels remained low throughout the whole period. PTH levels were 37.5 pg/mL at 1 year postsurgery and increased to 77.3 pg/mL at 4 years postsurgery (P = .009). Females had higher prevalence of elevated PTH and a tendency for higher rates of anemia, compared with males 4 years postsurgery (80% versus 20%, P = .025; and 28% versus 0%, P = .08, respectively). Of the patients, 92.6% reported taking a multivitamin and 74.1% vitamin D supplements during the first postoperative year, while after 4 years only 37% and 11.1% were still taking these supplements, respectively.

CONCLUSION

A high rate of nutritional deficiencies is common at 4 years post-LSG along with low adherence to the nutritional supplementation regimen. Long-term nutritional follow-up and supplementation maintenance are crucial for LSG patients. Future studies are needed to clarify the clinical impact of such deficiencies.

Abdominal thrombotic complications following bariatric surgery

BACKGROUND

Thrombotic events involving the portal-splenic-mesenteric venous system (PSMVT) are rare but potentially lethal after bariatric surgery.

OBJECTIVES

To investigate the incidence, clinical presentation, management, and outcome of thrombotic events after bariatric surgery.

SETTING

Two university hospitals.

METHODS

A retrospective review of individuals who underwent bariatric surgery between January 2006 and December 2015.

RESULTS

Overall, 4386 patients underwent bariatric surgery (laparoscopic sleeve gastrectomy [LSG; n = 2886], laparoscopic Roux-en-Y gastric bypass [n = 762], laparoscopic adjustable gastric banding [n = 668], and biliopancreatic diversion [n = 70]). Mechanical (thigh-length pneumatic compression stockings) and pharmacologic thromboprophylaxis (40 mg enoxaparin daily, starting 12 hours after surgery until discharge) was provided for all patients. A minority of patients (n = 543, 12.4%) also received an extended course of enoxaparin for 1-4 weeks after discharge. We observed 16 cases of PSMVT, all after LSG, with an incidence of .55% (16/2886). Twelve additional patients experienced deep vein thrombosis and 6 had pulmonary embolism. Follow-up imaging indicated complete resolution in all cases, with no sequelae, recurrent thrombosis, or mortality. The overall thrombosis rate was significantly lower in patients who received an extended course of anticoagulation after LSG (P = .01) and after any type of bariatric surgery (P = .02).

CONCLUSIONS

PSMVT was found to occur uncommonly after LSG. Prompt diagnosis and anticoagulation therapy led to favorable outcomes in most cases. Significantly lower rates of thrombosis were found in patients who received an extended course of anticoagulation. We support its use for at least 1 week after discharge.

Nutritional deficiencies after sleeve gastrectomy: can they be predicted preoperatively?

BACKGROUND

Nutritional deficiencies are common among morbidly obese patients. Data are scarce for patients who have undergone laparoscopic sleeve gastrectomy (LSG).

OBJECTIVES

The aim of the study is to clarify the prevalence of deficiencies and to identify risk factors for postoperative deficiencies.

SETTINGS

Hebrew University, Israel.

METHODS

Preoperative and 1-year postoperative data were collected. We included anthropometric parameters, obesity-related co-morbidities, and laboratory findings.

RESULTS

There were 192 candidates. Seventy-seven of them completed follow-ups at 12 months. Before surgery, 15% had anemia. Deficiencies of iron, folate, and B12 were 47%, 32%, and 13%, respectively. Women were more deficient in iron (56% women, 26% men, P<.001). Before surgery, low levels of vitamin D and elevated parathyroid hormone (PTH) were 99% and 41%, respectively. One year postsurgery, the deficiencies of hemoglobin and vitamin B12 worsened (20% and 17%, P<.001, P = .048, respectively). One year postsurgery, deficiencies of iron, folate, vitamin D, and PTH improved (28%, 21%, 94%, and 10%, respectively). Deficiencies of hemoglobin, folate, and B12 before surgery were predictors for deficiencies 1 year after surgery (P = .006 OR = .090; P = .012 OR = .069; P = .062 OR = .165, respectively).

CONCLUSIONS

LSG had a modest effect on nutritional deficiencies in our patients at 1-year postsurgery. Focusing on the preoperative nutritional status and tailoring a specific supplemental program for each individual should prevent postoperative deficiencies.

A Rare Case of Benign Pneumatosis Intestinalis with Portal Venous Gas and Pneumoperitoneum Induced by Acarbose

Alpha glucosidase inhibitors have been shown to be associated with pneumatosis intestinalis (PI) in recent reports. We herein report the case of a 73-year old man who received treatment with an alpha glucosidase inhibitor (acarbose) and presented with acute abdomen. A computed tomography scan demonstrated PI in addition to intrahepatic portal air and pneumoperitoneum. During exploratory laparotomy, we found no evidence of hollow organ perforation or bowel necrosis. The patient recovered after conservative treatment with cessation of the alpha glucosidase inhibitor. This is the first report to describe the combination of PI with portal venous gas and pneumoperitoneum caused by an alpha-glucosidase inhibitor.

Hepatic portal vein denervation impairs oral glucose tolerance but not exenatide's effect on glycemia

The hepatoportal area is an important glucohomeostatic metabolic sensor, sensing hypoglycemia, hyperglycemia, and hormones such as glucagon-like peptide-1 (GLP-1). We have reported previously that activation of hepatoportal sensors by intraportal infusion of glucose and GLP-1 or by subcutaneous administration of GLP-1 receptor activator exenatide and of intraportal glucose improved glycemia independent of corresponding changes in pancreatic hormones. It is not clear whether this effect is mediated via the portal vein (PV) or by direct action on the liver itself. To test whether receptors in the PV mediate exenatide's beneficial effect on glucose tolerance, we performed 1) paired oral glucose tolerance tests (OGTT) with and without exenatide and 2) intravenous glucose tolerance tests before and after PV denervation in canines. Denervation of the portal vein affected oral glucose tolerance; post-denervation (POST-DEN) OGTT glucose and insulin AUC were 50% higher than before denervation (P = 0.01). However, portal denervation did not impair exenatide's effect to improve oral glucose tolerance (exenatide effect: 48 ± 12 mmol·l⁻¹·min before vs. 64 ± 26 mmol·l⁻¹·min after, P = 0.67). There were no changes in insulin sensitivity or secretion during IVGTTs. Portal vein sensing might play a role in controlling oral glucose tolerance during physiological conditions but not in pharmacological activation of GLP-1 receptors by exenatide.

Essentiality of portal vein receptors in hypoglycemic counterregulation: direct proof via denervation in male canines

A major issue of in the treatment of diabetes is the risk of hypoglycemia. Hypoglycemia is detected both centrally and peripherally in the porto-hepatic area. The portal locus for hypoglycemic detection was originally described using the "local irrigation of the liver" approach in a canine model. Further work using portal vein denervation (DEN) in a rodent model characterized portal hypoglycemic sensing in detail. However, recent controversy about the relevance of rodent findings to large animals and humans prompted us to investigate the effect of portal DEN on the hypoglycemic response in the canine, a species with multiple similarities to human glucose homeostasis. Hypoglycemic hyperinsulinemic clamps were performed in male canines, before (PRE) and after (POST) portal vein DEN or sham surgery (CON, control). Insulin (30 pmol/kg·min) and glucose (variable) were infused to slowly decrease systemic glycemia to 50 mg/dL over 160 minutes. The average plasma glucose during clamp steady state was: 2.9 ± 0.1 mmol DEN-PRE, 2.9 ± 0.2 mmol DEN-POST, 2.9 ± 0.1 mmol CON-PRE, and 2.8 ± 0.0 mmol CON-POST. There were no significant differences in plasma insulin between DEN and CON, PRE and POST experiments. The epinephrine response to hypoglycemia was reduced by 62% in DEN but not in CON. Steady-state cortisol was 46% lower after DEN but not after CON. Our study shows, in a large animal model, that surgical disconnection of the portal vein from the afferent pathway of the hypoglycemic counterregulatory circuitry results in a substantial suppression of the epinephrine response and a significant impact on cortisol response. These findings directly demonstrate an essential role for the portal vein in sensing hypoglycemia and relating glycemic information to the central nervous system.

Reusable single-port access device shortens operative time and reduces operative costs

BACKGROUND

In recent years, single-port laparoscopy (SPL) has become an attractive approach for performing surgical procedures. The pitfalls of this approach are technical and financial. Financial concerns are due to the increased cost of dedicated devices and prolonged operating room time. Our aim was to calculate the cost of SPL using a reusable port and instruments in order to evaluate the cost difference between this approach to SPL using the available disposable ports and standard laparoscopy.

METHODS

We performed 22 laparoscopic procedures via the SPL approach using a reusable single-port access system and reusable laparoscopic instruments. These included 17 cholecystectomies and five other procedures. Operative time, postoperative length of stay (LOS) and complications were prospectively recorded and were compared with similar data from our SPL database. Student's t test was used for statistical analysis.

RESULTS

SPL was successfully performed in all cases. Mean operative time for cholecystectomy was 72 min (range 40-116). Postoperative LOS was not changed from our standard protocols and was 1.1 days for cholecystectomy. The postoperative course was within normal limits for all patients and perioperative morbidity was recorded. Both operative time and length of hospital stay were shorter for the 17 patients who underwent cholecystectomy using a reusable port than for the matched previous 17 SPL cholecystectomies we performed (p < 0.001). Prices of disposable SPL instruments and multiport access devices as well as extraction bags from different manufacturers were used to calculate the cost difference. Operating with a reusable port ended up with an average cost savings of US$388 compared with using disposable ports, and US$240 compared with standard laparoscopy.

CONCLUSION

Single-port laparoscopic surgery is a technically challenging and expensive surgical approach. Financial concerns among others have been advocated against this approach; however, we demonstrate herein that using a reusable port and instruments reduces operative time and overall operative costs, even beyond the cost of standard laparoscopy.

[Single incision laparoscopic combined cholecystectomy, bilateral salpingo-oophorectomy and omentectomy]

Single Incision Laparoscopic Surgery (SILS) is gaining popularity as a modality in surgery which reduces the number and size of skin incisions. General surgeons and urologists were the first to implement this technique, however, recently gynecologists have also started performing SILS procedures. We present the case of a 70 year old female who underwent a combined SILS procedure which included cholecystectomy, bilateral oophorectomy and omentectomy. The procedure lasted 100 minutes and the patient was discharged home the day after the operation. No operative or post-operative complications were noted. In this case report we present the technical details and demonstrate the collaboration between different disciplines which enables performing this complex and demanding procedure.

Laparoscopic Sleeve Gastrectomy with Transgastric Visualization

Background. Laparoendoscopic single-site sleeve gastrectomy is gaining acceptance. However, totally natural orifice translumenal endoscopic surgery (NOTES) in morbidly obese patients is still controversial due to safety and technical issues. To this end, we have developed a technique for sleeve gastrectomy in which the surgical field view is achieved through transgastric approach and the operating channel will eventually be through the vagina to form a dual lumen totally NOTES procedure for sleeve gastrectomy. As a step toward this approach, we performed a single abdominal incision in order to simulate the transvaginal route. This study is another step toward combined transvaginal and transgastric totally NOTES sleeve gastrectomy. Methods and Procedures. A combined NOTES and single trocar sleeve gastrectomy was performed on 8 porcine animal models. The endoscope was inserted through the gastric wall and served as the vision source for the procedure. A second endoscope was inserted via the transabdominal trocar together with the surgical instruments. Results. Sleeve gastrectomy was performed on 8 porcine models. The operative time for the first procedure was 5 hours, but after determining the technique, the time was reduced by half. Conclusion. Combined NOTES and single trocar sleeve gastrectomy is feasible in a porcine model. We achieved an excellent view of the surgical field through the transgastric approach. We believe that in the near future, combining the transgastric visualization of the surgical field together with a transvaginal approach may enable performing a total NOTES sleeve gastrectomy procedure. This hypothesis will be studied in further animal experiments before implementation in humans.

Early outcome after laparoscopic sleeve gastrectomy of type two diabetes mellitus patients with extremely elevated glycated hemoglobin (HbA1c)

BACKGROUND

Due to high prevalence of type 2 diabetes mellitus (T2DM) and increasing popularity of bariatric and metabolic operations, Surgeons are faced with patients with relatively more severe T2DM disease. High level of glycated hemoglobin (HbA1c) is widely considered as a marker for uncontrolled T2DM. The aim of this study was to explore the correlation between high level of pre-operative HbA1c, peri-operative morbidity and post operative outcome after laparoscopic sleeve gastrectomy.

METHODS

We conducted a retrospective study based on our medical center metabolic and bariatric registry. The inclusion criteria for selecting patients to the study group was HbA1c of 9 gram/dL and higher. A comparison control study was designed to include T2DM patients similar in all characteristics except for HbA1c of 7.5 gram/dl and less.

RESULTS

We included 20 patients who underwent laparoscopic sleeve gastrectomy. Each group of patients included half of the patients. The mean pre operative HbA1c in the studied and the control group were 10.4 gram/dL and 7.1 gram/dL respectively (p<0.001). There were no differences in peri-operative morbidity and length of stay at the hospital. Mean excess weight loss, fasting glucose levels and HbA1c levels were similar six months post surgery mean.

CONCLUSIONS

According to our study we have not found correlation between high HbA1c levels and increased peri-operative morbidity or insufficient excess weight loss among patients who underwent laparoscopic sleeve gastrectomy.

Laparoscopic partial nephrectomy using a flexible CO2 laser fiber

The application of a CO₂ laser through a flexible fiber for partial nephrectomy produced good parenchymal incision and hemostasis in an animal model.

Background and Objectives:

Laparoscopic partial nephrectomy (LPN) is a challenging surgery that requires precise tissue cutting and meticulous hemostasis under warm ischemia conditions. In this study, we tested the feasibility of performing LPN using CO₂ laser energy transmitted through a specialized flexible mirror optical fiber.

Methods:

General anesthesia and pneumoperitoneum were induced in 7 farm pigs. Various portions of a kidney, either a pole or a midportion of the kidney, were removed using a novel flexible fiber to transmit CO₂ laser energy set at a power of 45W and energy per pulse of 100mJ. The collecting system was approximated with a suture or 2, but no hemostatic measures were taken besides applying a few pulses of the laser to bleeding points. The pigs were sacrificed 3 wk later.

Results:

Average renal mass removed was 18% of the total kidney weight. All pigs tolerated surgery well. Sharp renal cutting was accomplished in a single continuous incision, with minimal tissue charring and minimal blood loss (<10cc) in all animals. Necropsy revealed no peritoneal or retroperitoneal abnormalities. Histologic examination of the cut surface showed a thin sector of up to 100 μm of coagulation necrosis.

Conclusions:

We report on the first LPN done using a CO₂ laser transmitted through a flexible fiber in an animal model. This novel application of the CO₂ laser produced excellent parenchymal incision and hemostasis along with minimal damage to adjacent renal tissue, thus, potentially shortening ischemia time and kidney function loss. Further studies comparing this laser to standard technique are necessary to verify its usefulness for partial nephrectomy.

Endovascular management of blunt renal artery trauma

BACKGROUND

Renal artery injuries are rarely encountered in victims of blunt trauma. However, the rate of early diagnosis of such injuries is increasing due to increased awareness and the liberal use of contrast-enhanced CT. Sporadic case reports have shown the feasibility of endovascular management of blunt renal artery injury. However, no prospective trials or long-term follow-up studies have been reported.

OBJECTIVES

To present our experience with endovascular management of blunt renal artery injury, and review the literature.

METHODS

We conducted a retrospective study of 18 months at a level 1 trauma center. Search of our electronic database and trauma registry identified three patients with renal artery injury from blunt trauma who were successfully treated endovascularly. Data recorded included the mechanism of injury, time from injury and admission to revascularization, type of endovascular therapy, clinical and imaging outcome, and complications.

RESULTS

Mean time from injury to endovascular revascularization was 193 minutes and mean time from admission to revascularization 154 minutes. Stent-assisted angioplasty was used in two cases, while angioplasty alone was performed in a 4 year old boy. A good immediate angiographic result was achieved in all patients. At a mean follow-up of 13 months the treated renal artery was patent in all patients on duplex ultrasound. The mean percentage renal perfusion of the treated kidney at last follow-up was 36% on DTPA renal scan. No early or late complications were encountered.

CONCLUSIONS

Endovascular management for blunt renal artery dissection is safe and feasible if an early diagnosis is made. This approach may be expected to replace surgical revascularization in most cases.

Robotic-assisted enucleation of a large lower esophageal leiomyoma and review of literature

Leiomyoma is the most common benign esophageal neoplasm. Different invasive surgical approaches have been described for management of such lesions. The literature is reviewed and a robotic assisted left thoracoscopic enucleation with the patient in the right side position is described. A 40-year-old male patient, otherwise healthy, found to have a lower midiastinal mass on screening X-ray, is described. Physical examination and blood tests were within normal limits. Diagnostic work-up included: computerized tomography (CT) scanning of the chest and midiastinum that revealed a 40 × 30 mm mass of the distal esophagus, an upper gastrointestinal endoscopy showed a lower protruding esophageal submucosal mass with intact mucosa, a filling defect was apparent on esophagography. Endoscopic ultrasonography (EUS) showed the same findings, biopsies were taken and leimyoma was diagnosed. Under general anesthesia with a double-lumen endotracheal tube, the patient was positioned on his right side. A 30 robotic scope was introduced in the left 7th intercostal space on the posterior axillary line. Two 8-mm robotic trocars were inserted in the left 5th and 9th intercostals spaces on the same line. Operative field was clearly exposed and an additional 5-mm ethicon trocar was inserted. The inferior pulmonary ligament was released, the parietal pleural space opened, proximal and distal control was achieved using Penrose. The muscular layer of the lower esophagus was opened by coagulation hook, the lesion was enucleated without mucosal penetration. Intraoperative endoscopy permitted localization of the lesion and ensured mucosal integrity. The muscular layer was not closed and the chest drain was left. Total operative time was 200 min and blood loss was less than 20 mL. A Gastrograffin swallow on the first post-operative day showed good esophageal clearance and absence of leak, the patient was allowed a liquid diet. He was discharged on the third post-operative day in a good general condition, benign pathology was confirmed.