Rectal Biopsy for Hirschsprung's Disease: A Multicentre Study Involving Biopsy Technique, Pathology and Complications

BACKGROUND

The heterogeneity of rectal biopsy techniques has encouraged us to search for a surgical and pathological standardisation of this diagnostic technique to exclude Hirschsprung's disease. The different amounts of information on the anatomopathology report prompted us to compile a template for the anatomopathology report for diagnostic rectal biopsies for surgical colleagues and pathologists working on Hirschsprung's disease.

METHODS

We gathered the anonymous biopsy information and its pathology information from five hospitals for all patients in which rectal biopsies were taken to diagnose Hirschsprung's disease over two years (2020-2021).

RESULTS

Of the 82 biopsies, 20 suction (24.4%), 31 punch (37.8%) and 31 open biopsies (37.8%) were taken. Of all biopsies, 69 were conclusive (84.2%), 13 were not (15.8%). In the suction biopsy group, 60% were conclusive and 40% were not; for punch biopsy, the values were 87% and 13%, respectively and for open biopsy, 97% and 3%. Inconclusive results were due to insufficient submucosa in 6/8 suction biopsies, 4/4 punch biopsies and 0/1 open biopsies. An insufficient amount of submucosa was the reason for an inconclusive result in 6/20 cases (30%) after suction biopsy, 4/31 (12.9%) cases after punch biopsy and 0 cases (0%) after open biopsy. We had one case with major postoperative bleeding post suction biopsy; there were no further adverse effects after biopsy.

CONCLUSIONS

Diagnostic rectal biopsies in children are safe. Non-surgical biopsies are more likely to give inconclusive results due to smaller amounts of submucosa present in the specimen. Open biopsies are especially useful when previous non-surgical biopsies are inconclusive. An experienced pathologist is a key factor for the result. The anatomopathology report should specify the different layers present in the specimen, the presence of ganglion cells and hypertrophic nerve fibres, their description and a conclusion.

Post-bariatric Abdominoplasty: Identification of Risk Factors for Complications

PURPOSE

The aim was to evaluate the complication rate after abdominoplasty procedures performed in a high volume post-bariatric center and to identify predictors of complications.

MATERIAL AND METHODS

A retrospective analysis was performed and included all abdominoplasty procedures performed between January 2011 and December 2019. Complications classified according to the Clavien-Dindo classification were documented and potential risk factors were statistically evaluated.

RESULTS

A total of 898 patients were included. Overall complication rate was 29.8%. Type I complications (minor wound problems) occurred in 15.8% (n = 140). Type II complications requiring medical intervention occurred in 10% (n = 90). Five patients had deep venous thrombosis or pulmonary embolism; others received antibiotic treatment for wound infections. In total 42 type III complications occurred in 36 patients, with re-intervention for wound problems (n = 16), seroma (n = 16), umbilical necrosis (n = 4), and bleeding (n = 6). The weight of tissue resected (p < 0.001), the interval between bariatric and body contouring surgery (p < 0.05), preoperative BMI (p < 0.05), male gender (p < 0.05), diabetes mellitus type 2 (p = 0.05), and smoking (p < 0.05) were important predictors for developing complications.

CONCLUSION

In this large retrospective post-bariatric abdominoplasty series, the overall complication rate is low compared to other published series as a consequence of our completely standardized approach and technique. Our analysis shows a significant linear correlation between the amount of skin tissue resected and postoperative complications. Moreover, the longer the interval between bariatric surgery and abdominoplasty, the higher the complication rate. High preoperative BMI, diabetes mellitus type 2, smoking, and male gender were identified as independent significant risk factors for complications.

Hypermetabolic lesion in the prevascular mediastinum - always a thymoma/lymphoma?

Cholesterol granuloma is a foreign-body giant cell reaction that can occur in response to the presence of cholesterol crystals. They are usually found in the middle ear, paranasal sinuses or mastoid process due to chronic inflammation. Presentation in the prevascular mediastinum is a rare finding. We describe a case of a cholesterol granuloma located in the prevascular mediastinum in a symptomatic 57-year-old male patient.

Textiloma-Induced 1,25-Dihydroxyvitamin D-Mediated Hypercalcemia: A Case Report and Literature Study

Foreign body causing 1,25-dihydroxyvitamin D [1,25(OH)2D]-induced hypercalcemia is an uncommon yet clinically significant cause of hypercalcemia. We report an unusual case of hypercalcemia due to a textiloma (a surgical gauze inadvertently left in place during surgery). A PubMed search for (HYPERCALCEMIA) and (FOREIGN BODY) was performed. A foreign body (surgical gauze) left over after removal of a kidney transplant caused 1,25(OH)2D-induced hypercalcemia. The diagnosis was complicated by end-stage renal disease, low PTH, and high 1,25(OH)2D.

A one-step conversion from gastric banding to laparoscopic Roux-en-Y gastric bypass is as safe as a two-step conversion: A comparative analysis of 885 patients

AIMS

To achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (LAGB) can be converted to a laparoscopic Roux-en-Y gastric bypass (RYGB). There is limited data on the feasibility and safety of routinely performing a single-step conversion. We assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution.

METHODS

Between October 2004 and December 2015, a total of 885 patients who underwent LAGB removal with RYGB were identified from a prospectively collected database. In all cases, a single-stage conversion procedure was planned. The feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed.

RESULTS

A single-step approach was successfully achieved in 738 (83.4%) of the 885 patients. During the study period, there was a significant increase in performing the conversion from LAGB to RYGB single-staged. No mortality or anastomotic leakage was observed in both groups. Only 45 patients (5.1%) had a 30-d complication: most commonly hemorrhage (N = 20/45), with no significant difference between the groups.

CONCLUSION

Converting a LAGB to RYGB can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. With increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. Only a migrated band remains a formal contraindication for a one-step approach.

Smaller staple height for circular stapled gastrojejunostomy in laparoscopic gastric bypass: early results in 1,074 morbidly obese patients

BACKGROUND

Anastomotic leaks, stenosis, and bleeding from the gastrojejunal anastomosis (GJA) after gastric bypass may carry high morbidity and mortality. To date, the standard operation with the circular stapler (CS) used the 25 mm with a staple height of 4.8 mm. We present herein our experience with the 3.5-mm staple height.

METHODS

A total of 1,074 morbidly obese patients who underwent fully stapled laparoscopic Roux-en-Y Gastric Bypass over a period of 18 months were included in the study. Mean body mass index was 41.9 (range 28.6-70.7). Mean age was 40.9 years (range 15-74 years). Mean operating time was 73 min (range 43-210 min) and the mean length of stay was 4.2 days (range 1-25 days). The 30-day complication rate associated with GJA was prospectively analyzed.

RESULTS

Twenty patients (1.86%) developed postoperative bleeding. Four developed GJA bleeding (0.37%). One leak was recorded from the vertical staple line of the gastric pouch, but no leaks from the GJA were seen. Conversion to open approach was required in two patients (0.18%). Reoperation and readmission rates were 1.7% and 1.8%, respectively. Perioperative complications were observed in 34 patients (3.1%). One case of clinical GJA stenosis was detected in a mean follow-up of 10.5 months (range 5-20 months). There was no mortality in our series.

CONCLUSION

Compared to our previous experience with 4.8 mm CS, creating the GJA using a smaller staple height significantly reduced the bleeding rate and seems to be a safe technique that potentially reduces other complications related to the GJA as reported in the literature.

Laparoscopic adjustable banded roux-en-y gastric bypass as a primary procedure for the super-super-obese (body mass index > 60 kg/m²)

BACKGROUND

Currently, there is no consensus opinion regarding the optimal procedure of choice in super-super-morbid obesity (Body mass index, BMI > 60 kg/m²). Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients. Also, percent EWL is significantly less after 1-year in the super-super-obese group as compared with the less obese group and many patients are still technically considered to be obese (lowest post-surgical BMI > 35) following RYGB surgery in this group. The addition of adjustable gastric band (AGB) to RYGB has been reported as a revisional procedure but this combined bariatric procedure has not been explored as a primary operation.

METHODS

In a primary laparoscopic RYGB, an AGB is drawn around the gastric pouch through a small opening between the blood vessels on the lesser curve and the gastric pouch. The band is then fixed by suturing the gastric remnant to the gastric pouch both above and below the band to prevent slippage.

RESULTS

Between November 2009 and March 2010, 6 consecutive super-super-obese patients underwent a primary laparoscopic adjustable banded Roux-en-Y gastric bypass procedure at our institution. One male patient (21 years, BMI 70 kg/m²) developed a pneumonia postoperatively. No other postoperative complications were observed.

CONCLUSION

To the best of our knowledge, this is the first series of patients that underwent a laparoscopic adjustable banded RYGB as a primary operation for the super-super obese in the indexed literature. With the combined procedure, a sequential action mechanism for weight loss is to be expected. The restrictive, malabsorptive and hormonal working mechanism of the RYGB will induce weight loss from the start reaching a stabilised plateau of weight after 12 - 18 months. At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss. Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time.