Publications by authors named "Catalin Copaescu"

46 Publications

A Novel Indocyanine Green Fluorescence-Guided Laparoscopic Technique to Map the Site of Obscure Gastrointestinal Haemorrhage.

Chirurgia (Bucur) 2021 Jan-Feb;116(1):89-101

The aim of our study was to explore the feasibility of a novel fluorescence-guided laparoscopic technique to localize the obscure GI haemorrhage, using the vascular wash-out properties of indocyanine green (ICG). Method: The feasability study included patients with previous surgical modifications of the gut architecture, qualified as an overt obscure GI bleeding with an urgent need to be localized and controlled. Five mL of ICG was injected intravenously and laparoscopic infrared inspection was performed 30 minutes after the dye was eliminated from the bloodstream. The bleeding area mapping was demonstrated and the haemostasis was carefully performed using endoscopy or laparoscopic techniques. A series of two cases were included in our fesability study so far. Case 1. A 43-year old male, who recently received a Laparoscopic Roux-en-Y gastric bypass (RYGB), developed a recurrent GI bleeding. Post dye wash-out intense signal was demonstrated at the level of duodenum and weaker at the gastric remnant. The laparoscopic trans-gastric exploration of the remnant identified an active bleeding source siding the stapled line and haemostasis was achieved with laparoscopic ligation using stitches. Case 2. A 66-year old male patient who underwent an open Whipple resection nine months before, was admitted for a repeated GI bleeding. The inspection of the biliopancreatic limb noticed an intense fluorescent signal toward the enteral proximal end. Upper digestive endoscopy confirmed the presence of an active bleeding source from ectopic jejunal varices siding the choledoco-jejunal anastomosis. Argon plasma coagulation was performed endoscopically and achieved hemostasis. A successful novel ICG fluorescence-guided laparoscopic mapping technique was used to localize the site of the obscure GI haemorrhage and to facilitate the prompt bleeding control. To the best of our knowledge these are the first published cases for which this technique was used.
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http://dx.doi.org/10.21614/chirurgia.116.1.89DOI Listing
April 2021

Fluorescence-based bowel anastomosis perfusion evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry.

Surg Endosc 2021 Jan 25. Epub 2021 Jan 25.

Ospedale di Vaio, Fidenza, Italy.

Background: Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry.

Methods: Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications.

Results: A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013-0.89 mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not.

Conclusion: The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery.
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http://dx.doi.org/10.1007/s00464-020-08234-8DOI Listing
January 2021

EAES Recommendations for Recovery Plan in Minimally Invasive Surgery Amid COVID-19 Pandemic.

Surg Endosc 2021 01 10;35(1):1-17. Epub 2020 Nov 10.

Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

Background: COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts' opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across different sub-specialities after the COVID-19 pandemic.

Methods: Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to different surgical specialities following the COVID-19 crisis. Sixty-five experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specific key questions. Anonymous voting on the statements was performed until consensus was achieved, defined by at least 70% agreement.

Results: A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specific attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the first round of Delphi voting (91.3%) and another 8 during the following round after substantial modification, resulting in a 100% consensus.

Conclusion: The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across different healthcare systems.
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http://dx.doi.org/10.1007/s00464-020-08131-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653984PMC
January 2021

The impact of the surgical technique on stenosis after laparoscopic sleeve gastrectomy.

Minerva Surg 2021 Feb 9;76(1):43-49. Epub 2020 Nov 9.

Bariatric Center of Excellence IFSO EAC-EC, Ponderas Academic Hospital, Bucharest, Romania.

Background: Laparoscopic sleeve gastrectomy (LSG) has gained worldwide popularity in the last 10 years as self alone bariatric procedure. Symptomatic stenosis (SS) is a potential severe postoperative complication and it can be divided in organic stenosis (OS) and functional stenosis (FS). The aim of this paper is to propose a modified surgical technique to prevent FS.

Methods: A retrospective review on 5235 LSG performed in Ponderas Academic Hospital between January 2011 and December 2019, searched FS in two consecutive patients groups, divided based on the modified surgical technique introduced in 2015, with fixation of the gastric tube to the prepancreatic fascia and stapler line's over-sewn running suture.

Results: Group A (2011-2014) included 1332 LSG, 16 SS were registered (1.2%), 7 OS and 9 FS; 3903 LSG included in group B (2015-2019), counting for 37 SS (0.95%), 27 OS and 10 FS. A statistically significant difference between the 2 groups was observed for the FS incidence (P=0.03), while it was non-significant for the OS (P=0.52) and the total number of SS (P=0.43). The endoscopic approach was used in forty-eight SS (90.5%) with a successful rate of 83%, while specifically for the FS it was 100%; only one complication was registered during endoscopic treatment, that required further surgical solution.

Conclusions: Fixation of the gastric tube to the prepancreatic fascia and stapler line's over-sewn running suture during LSG, introduced lately, are beneficial in preventing the postoperative functional stenosis of the LSG, contributing to the improvement of the patient's quality of life.
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http://dx.doi.org/10.23736/S0026-4733.20.08505-3DOI Listing
February 2021

Posterior Microscopic and Anterior Robotic Assisted STAGED Approach for Voluminous "Dumbbell" Ganglioneuroma - Surgical Technique and Literature Review.

Chirurgia (Bucur) 2020 Sept-Oct;115(5):656-664

ganglioneuromas are benign tumors emerging from the sympathetic nervous system that could grow up to significant sizes before becoming symptomatic. Aim: to describe the surgical technique of the posterior microscopic and anterior robotic assisted staged approach for voluminous "dumbbell" ganglioneuroma. Besides this, a detailed report of the evolution of 9 years old female patient with such a tumor who underwent a staged bipolar approach, under direct neuromonitoring is presented. The literature has been reviewed on this topic. the neurosurgical approach consisted in S2-S3 laminectomy, resecting the intracanalar and intraforaminal S2 tumor, ligating and sectioning the S2 root, the surgical approach was minimally invasive using the DaVinci XI platform for excising the anterior retrorectal extension. As for the posterior surgical stage, the neurosurgical operating time was 165 minutes with a five days hospital stay, and the second anterior surgical staged step took 660 minutes with five days hospital stay. There were no complications in both surgical stages, and the postoperative outcome was uneventful. The 6 months MRI evidenced no recurrency. the posterior microscopic and anterior robotic-assisted staged approach with continuous neuromonitoring for "dumbbell" ganglioneuroma has proven to be an efficient surgical strategy and technique. Further studies may support the effectiveness of this novel surgical approach and strategy.
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http://dx.doi.org/10.21614/chirurgia.115.5.656DOI Listing
December 2020

Colorectal Surgery in Romania during the COVID-19 Pandemic.

Chirurgia (Bucur) 2020 Mar-Apr;115(2):129-137

As the COVID-19 pandemic extends, its negative consequences on the effectiveness of therapeutic programs - previously assumed by the medical community and imperatively suspended for a difficult-to-predict period of time - are becoming increasingly worrying. In this context, as the evidence-based recommendations are not possible, most of the national and international scientific societies tried to develop balanced recommendations (1-4). The Romanian Society of Coloproctology (SRCP) and the Romanian Association for Endoscopic Surgery (ARCE) have created a working group that, taking into account recent publications, the statements of international academic societies, the national legislative context and the unique experience of countries severely affected by this pandemic (China, Italy, Spain, USA, etc.) proposes for Romania, the following recommendations for medical practice in colorectal surgery during the COVID-19 pandemic. These recommendations are subjected to continuous review, depending on the global and national situation of the pandemic, the particular needs of each hospital, the recommendations of the competent authorities and the evolution of the literature that publishes the conclusions of ongoing clinical trials.
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http://dx.doi.org/10.21614/chirurgia.115.2.129DOI Listing
November 2020

Short Term Outcomes of Using Fecal Immunochemical Test for a Pilot Colorectal Cancer Screening Program. A Single Center Study on 3024 Consecutive Patients.

Chirurgia (Bucur) 2020 Jul-Aug;115(4):448-457

In Romania, colorectal cancer does not benefit yet from a national screening program. In order to decrease the harm and burden of colorectal cancer (CRC), opportunistic programs relying on endoscopy has been adopted by each centre according to its capacity. A colorectal cancer (CRC) screening programme based on faecal immunochemical test (FIT) was launched at Ponderas Academic Hospital (PAH) in 2019. Aim: The present study analyses the outcomes after the first 1500 tests in the PAH-FIT-CRC Screening Program. We have also aimed to compare the efficiency of the FIT testing program with the screening colonoscopies performed in our Center, withing the same time interval (2019). The test was recommended in asymptomatic patients over 45 years, and it was followed by a colonoscopy when the test results were positive. Furthermore, we performed a retrospective observational study gathering data from all the consecutive patients prospectively included in the respective databases of our hospital, comparing the efficacy of the two colorectal cancer screening methods (FIT versus colonoscopy). Between 01.01.2019 and 01.01.2020, 1524 screening colonoscopies were performed, and the resulting data were compared with those obtained in the FIT group (1500 FIT tests freely distributed). In the screening colonoscopy group, the polyp detection rate was 38.98% and 22 (1.44%) adenocarcinomas were identified. In the FIT group, the FIT uptake rate was 71% with a positivity rate of 21.7%. The colonoscopy compliance rate for positive FIT patients was 29.4%, with only 2 adenocarcinomas detected. Following data analysis, the need for improvement of uptake rate and colonoscopy compliance rate was suggested, due to the lower acceptance of FIT tests and colonoscopies, especially among men. Moreover, special efforts should be made in order to improve quality indicators for screening colonoscopies (especially adenoma detection rate) with the purpose of decreasing interval CRC.
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http://dx.doi.org/10.21614/chirurgia.115.4.448DOI Listing
October 2020

The First Modified Delphi Consensus Statement for Resuming Bariatric and Metabolic Surgery in the COVID-19 Times.

Obes Surg 2021 01 1;31(1):451-456. Epub 2020 Aug 1.

CHI Memorial Hospital, Chattanooga, TN, USA.

The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst ≥ 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area.
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http://dx.doi.org/10.1007/s11695-020-04883-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395568PMC
January 2021

Evolution of Inflammatory and Oxidative Stress Markers in Romanian Obese Male Patients with Type 2 Diabetes Mellitus after Laparoscopic Sleeve Gastrectomy: One Year Follow-Up.

Metabolites 2020 Jul 28;10(8). Epub 2020 Jul 28.

NIDNMD "Prof. N.C. Paulescu", 2nd district, 020042 Bucharest, Romania.

Geography is one of the key drivers of the significant variation in the etiopathogenic profile and prevalence of type 2 diabetes mellitus (T2DM) and obesity, therefore geographically based data are fundamental for implementing the appropriate interventions. Presently, the selection criteria of T2DM and obesity patients for laparoscopic sleeve gastrectomy (LSG) have not reached a worldwide consensus-highlighting the need for sharing experts' guidance in the preoperative evaluation, choice of the interventional procedure, perioperative management and patient long-term care. The aim of the current study was to evaluate the impact of LSG on T2DM (T2DM) remission in Romanian obese male patients, based on a multiparametric, prospective investigation. We have conducted a randomized controlled study on 41 obese male participants with the body mass index (BMI) ≥ 30 kg/m, aged 30-65 years, which were randomly divided in two study groups: one receiving conventional treatment and the second undergoing LSG. The clinical and anthropometrical parameters, resting metabolic rate, general biochemical status, adipocytes profile, gastrointestinal hormones levels, proinflammatory, oxidant and antioxidant profiles were determined at three time points: V1 (baseline), V2 (after six months) and V3 (after 12 months). Glycated hemoglobin (HbA1c), blood glucose levels, BMI, weight, visceral fat level, HDL-cholesterol, incretin hormones, proinflammatory and the oxidative stress status were significantly improved in the LSG versus conventional treatment group. This is the first study reporting on the evaluation of metabolic surgery impact on Romanian obese male patients with T2DM. Our results confirm that LSG could contribute to T2DM remission in patients with diabesity, but this beneficial effect seems to be critically influenced by the duration of T2DM rather than by the obesity status. Our results show that, in addition to the parameters included in the prediction algorithm, the proinsulin levels, proinsulin/insulin ratio and the visceral fat percentage could bring added value to the assessment of metabolic status.
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http://dx.doi.org/10.3390/metabo10080308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7464585PMC
July 2020

Platelet-rich plasma PRP vs. absorbable mesh as cruroplasty reinforcement: a study on an animal model.

Minim Invasive Ther Allied Technol 2020 Jul 23:1-10. Epub 2020 Jul 23.

General Surgery and Bariatric Centre of Excellence IFSO-EC, AUSL LT-ICOT, Department of Medico-Surgical Sciences and Biotechnologies, University La Sapienza of Rome, Latina, Italy.

Background: Reinforcement of posterior cruroplasty has been proposed to minimize the failure of hiatal hernia repair (HHR). The applications of autologous platelet-rich plasma (PRP) and absorbable mesh are barely reported in this area.

Aims: To analyze local macroscopic and microscopic changes induced by mesh vs. PRP as reinforcement of HHR, using a reliable laparoscopic experimental porcine model.

Material And Methods: This prospective, comparative pilot study was conducted on 14 female pigs, aged four to six months. An iatrogenic hiatal defect was laparoscopically simulated and repaired, reinforced with Bio-A® mesh (group A) or PRP (group B). Specimen retrieval was performed after seven months for histopathological (HP) examination.

Results: No local or general complications were registered, with complete resorption of reinforcements, that determined inflammatory infiltrates with local collagen production and tissue neo-vascularization. Group A had an increased mean chronic inflammation score ( = .3061), showing significant sclerotic collagenizing process. PRP enhanced angiogenesis, collagenizing, myofibroblast recruitment and tissue ingrowth.

Conclusions: No residual materials or evidence of anatomical distortion were found. Animal model was safe and reliable. This is the first report of complete absorption of Bio-A positioned on crural area. HP results suggest the clinical application of PRP in HHR as a promising co-adjuvant to local remodeling and healing. ASA: American Society of Anesthesiologists; AB: Alcian Blue; PAS: Periodic Acid-Schiff; CP: platelet concentrate; fPC: filtered plasma concentrate; GERD: gastro-esophageal reflux disease; HSA: hiatal surface area; HHR: hiatal hernia repair; HP: histopathological; HH: hiatal hernia; HE: hematoxylin and eosin; HR: hiatus repair alone; HRM: hiatus repair and acellular dermal matrix; NM: Nicolae Manolesccu; LNF: laparoscopic Nissen fundoplication; PC: posterior cruroplasty; PPP: platelet-poor plasma; RP: platelet-rich plasma.
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http://dx.doi.org/10.1080/13645706.2020.1795686DOI Listing
July 2020

SRED-ARCE Recommendations for Minimally Invasive Interventions During the COVID-19 Pandemic in Romania.

Chirurgia (Bucur) 2020 May-Jun;115(3):289-306

The Romanian Society of Digestive Endoscopy (SRED) and the Romanian Association of Endoscopic Surgery (ARCE) have decided to establish a joint working group to elaborate specific recommendations for organizing the diagnostic and the minimally invasive interventional procedures, in the context of the COVID-19 pandemic. The recommendations are based on the guidelines of the international societies of endoscopy and gastroenterology (ESGE / BSG / ASGE / ACG / AGA), respectively endoscopic surgery (EAES SAGES) (4-8), on the experience of countries severely affected by the pandemic (Italy, France, Spain, USA, Germany, etc.) and they will be applied within the limits of measures imposed at local and governmental level by the competent authorities. On the other hand, these recommendations should have a dynamic evolution, depending on the upward or downward trend of the COVID-19 pandemic at regional and local level, but also according to the findings of professional and academic societies, requiring regular reviews based on the publica tion of further recommendations or international clinical trials. The objectives of the SRED and ARCE recommendations target the endoscopic and laparoscopic surgery activities, to support their non discriminatory used for diagnostic or therapeutic purposes, pursuing the demonstrated benefits of these procedures, in safe conditions for patients and medical staff.
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http://dx.doi.org/10.21614/chirurgia.115.3.289DOI Listing
July 2020

Ghrelin Levels and Hunger Sensation after Laparoscopic Sleeve Gastrectomy Compared with Laparoscopic Greater Curvature Plication in Obese Patients.

Clin Lab 2020 May;66(5)

Background: The aims of our study were to compare serum acylated ghrelin (the active form of ghrelin) concentrations before and after the surgery of patients undergoing laparoscopic sleeve gastrectomy (LSG) or laparoscopic greater curvature plication (LGCP) and to correlate these levels with excess weight loss and hunger sensations on a short-term basis.

Methods: The patients included in the study had either (1) a body mass index (BMI) over 35 kg/m2 and one comorbidity or (2) a BMI over 40 kg/m2. Ghrelin levels were measured on the day of the surgery, 1 month after the procedure, and 3 months after the procedure. A questionnaire about hunger sensation was administered to the patients, and changes in the patients' weights were evaluated on the same timeline as the measurement of the ghrelin levels.

Results: Eighteen obese patients were included in the study, including 10 patients in the LSG group and 8 patients in the LGCP group. All the procedures were performed laparoscopically. The average level of preoperative ghrelin in the LSG group was 212.21 pg/mL ± 140.57 SD. After 1 month, the average ghrelin level in the LSG group was 74.47 pg/mL ± 29.55 SD (p = 0.01), and it was 41.47 pg/mL ± 15.19 SD (p = 0.002) after 3 months. The average level of preoperative ghrelin in the LGCP group was 318.08 pg/mL ± 161.70 SD. It decreased to 190.58 pg/mL ± 116.75 SD (p = 0.01) after 1 month and to 91.57 pg/mL ± 56.70 SD (p = 0.004) after 3 months. Comparing the two groups, hunger sensation had decreased more in the LSG group (p = 0.03) 3 months after the surgery.

Conclusions: Laparoscopic sleeve gastrectomy (LSG) and laparoscopic greater curvature plication (LGCP) produced the same weight loss and diminished hunger sensation in the short term on the selected patients. LSG had an increased effect on ghrelin levels when compared with LGCP at 1 month after the procedure and 3 months after the procedure.
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http://dx.doi.org/10.7754/Clin.Lab.2019.191012DOI Listing
May 2020

Giant Cavernous Hemangioma of the Right Atrium - A Rare Case and Literature Review.

Chirurgia (Bucur) 2020 Mar-Apr;115(2):267-273

A 52 years old woman, asymptomatic, with no significant medical history, presented to a thoracic surgery department for excision of a giant mediastinal mass that was incidentally detected during a routine abdominal ultrasound. Various imaging methods (echocardiography, chest X-ray, CT-scan, MRI) located the mediastinal mass as paracardiac and the excision using video-assisted thoracoscopic surgery (VATS) was proposed, in general thoracic surgery department. Although initially considered a paracardiac mass, intraoperatively the tumor location proved to be intrapericardial. Reaching the limits of VATS, a median sternotomy and longitudinal pericardiotomy were performed, demonstration a right atrium tumor with intrapericardial extension. At this stage, the excision was considered impossible without cardiopulmonary bypass and cardiac arrest. Having this information, the case was deferred to cardiovascular surgery, one week after and, a complete resection of the tumor was performed without incidents. Both atria were reconstructed with patches of autologous and bovine pericardium. The postoperative outcome of the patient was very good and the histopathology report showed that the tumor was a cavernous hemangioma. The literature was reviewed for this pathology. a rare case of a giant cavernous hemangioma of the heart, with diagnostic pitfalls had a successful multidisciplinary staged approach.
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http://dx.doi.org/10.21614/chirurgia.115.2.267DOI Listing
May 2020

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP.

Surg Endosc 2020 06 23;34(6):2332-2358. Epub 2020 Apr 23.

Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.

Background: Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery.

Methods: A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards.

Results: Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure.

Conclusion: This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.
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http://dx.doi.org/10.1007/s00464-020-07555-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214495PMC
June 2020

Krukenberg Tumor in Association with Ureteral Stenosis Due to Peritoneal Carcinomatosis from Pulmonary Adenocarcinoma: A Case Report.

Medicina (Kaunas) 2020 Apr 17;56(4). Epub 2020 Apr 17.

Department of Surgery, "Ponderas" Academic Hospital, 021188 Bucharest, Romania.

Krukenberg tumors from pulmonary adenocarcinoma represent an extremely rare situation; only a few cases have been reported. The aim of this paper is to report an unusual such case in which almost complete dysphagia and ureteral stenosis occurred. The 62-year-old patient was initially investigated for dysphagia and weight loss. Computed tomography showed the presence of a thoracic mass compressing the esophagus in association with a few suspect pulmonary and peritoneal nodules, one of them invading the right ureter. A biopsy was performed laparoscopically on the peritoneal nodules. The right adnexa presented an atypical aspect; right adnexectomy was also found. The histopathological and immunohistochemical studies confirmed that the primitive origin was pulmonary adenocarcinoma. Although both peritoneal carcinomatosis and ovarian metastases from pulmonary adenocarcinoma represent a very uncommon situation, this pathology should not be excluded, especially in cases presenting suspect pulmonary lesions.
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http://dx.doi.org/10.3390/medicina56040187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231401PMC
April 2020

Bariatric Surgery in Obesity: Effects on Gut Microbiota and Micronutrient Status.

Nutrients 2020 Jan 16;12(1). Epub 2020 Jan 16.

Department of Pharmaceutical Botany, Faculty of Pharmacy, "Iuliu Hatieganu" University of Medicine and Pharmacy, 23 Gheorghe Marinescu Street, 400337 Cluj-Napoca, Romania.

Obesity is associated with reduced gut microbial diversity and a high rate of micronutrient deficiency. Bariatric surgery, the therapy of choice for severe obesity, produces sustained weight loss and improvements in obesity-related comorbidities. Also, it significantly alters the gut microbiota (GM) composition and function, which might have an important impact on the micronutrient status as GM is able to synthesize certain vitamins, such as riboflavin, folate, B, or vitamin K. However, recent data have reported that GM is not fully restored after bariatric surgery; therefore, manipulation of GM through probiotics represents a promising therapeutic approach in bariatric patients. In this review, we discuss the latest evidence concerning the relationship between obesity, GM and micronutrients, the impact of bariatric surgery on GM in relation with micronutrients equilibrium, and the importance of the probiotics' supplementation in obese patients submitted to surgical treatment.
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http://dx.doi.org/10.3390/nu12010235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019602PMC
January 2020

Re-sleeve Gastrectomy - An Efficient Revisional Bariatric Procedure - 3 Years Results.

Chirurgia (Bucur) 2019 Nov-Dec;114(6):809-823

Laparoscopic gastric sleeve is a well-known bariatric procedure with good results on weight loss and remission of comorbidities. For patients with weight regain and a large sleeved stomach, the laparoscopic re-sleeve (re-LSG) can be considered a revisional option.

Aim: The objective of this study is to evaluate the results of laparoscopic re-sleeve as revisional procedure in patients with weight regain after gastric sleeve, in a Center of Excellence in Bariatric Surgery (BS-CoE).

Method: A retrospective evaluation of a prospectively maintained database identified 27 patients who underwent laparoscopic gastric re-sleeve after gastric sleeve from January 2013 - December 2016 in our BS-CoE. Patients were monitored in conformity with our standard bariatric program and the efficiency of re-sleeve in terms of weight loss and comorbidities outcome was evaluated at 6 months, 1 year and 3 years postoperative. Re-sleeve gastrectomy was performed by laparoscopic approach in all cases and 24 (89%) patients had concurrent surgical procedures, all of them hiatal hernia repair. No intra or postoperative complications were found except one case of gastric tube stenosis. Mean BMI before resleeve was 35.69 kg/m2 (range 28,58-52) and follow-up results at 6 months after re-sleeve revealed mean BMI was 28.39 +- 5.32 kg/m2 with EWL 83.88%, at 1 year mean BMI 27.23 +- 5.23 kg/m2 with EWL 94.45% and at 3 years BMI 27.65 +- 5.13 kg/m2 with EWL 85.41%. There are statistically significant differences (p 0.01), between BMI before re-sleeve and BMI for all other moments of measurement 6 months, 1 year and 3 years after re-sleeve. All the 6 patients (22%) with comorbidities before re-sleeve had remission of their diseases at ne year postoperative, but 1 patient had recurrence of hypertension at 3 years postoperative.

Conclusion: Laparoscopic redo sleeve is an efficient revisional surgery option for weight regain after primary gastric sleeve with effective weight loss and improvement of comorbidities in a medium term follow-up.
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http://dx.doi.org/10.21614/chirurgia.114.6.809DOI Listing
January 2020

Roux-en-Y Feeding Jejunostomy - The Preferred Surgical Option for Enteral Nutrition in Patients with Leaks or Fistula after Gastric Sleeve.

Chirurgia (Bucur) 2019 Nov-Dec;114(6):798-808

Leaks are rare complications of laparoscopic sleeve gastrectomy (LSG) but, they may cause significant and prolonged morbidity. Enteral nutrition is mandatory for the gastric leak or fistula therapy's success and the naso-jejunal tube (NJT) as well the loop feeding jejunostomy (LFJ) have some limitations and morbidities. We propose an alternative, the laparoscopic Roux-en-Y feeding jejunostomy (LRYFJ) to support the mid- and long-term nutritional need of the patients complicated with gastric leaks or fistulas. Aim: to investigate the laparoscopic Roux-en-Y feeding jejunostomy (LRFJ) and to evaluate the surgical technique, its efficiency and outcomes. The surgical steps of LRFJ are described in detail and the technical challenges are commented. The IRB approval was obtained for performing the LRYFJ in patients with gastric leaks or fistulas after LSG and to run the present study. All the patients who received LRYFJ in our center since 2015 were included into a prospective study. The patient's medical characteristics, as well the procedure's technical challenges and outcomes are analyzed. Six patients (4 females, 2 males; age 37.1 +- 11.5 years) who previously underwent LSG, were referred to our unit after the initial drainage for gastric leak in other institution and, LRYFJ was performed in all. Mean operative time was 127.5 +- 61.2 minutes. Mean duration of jejunal nutrition was 183.83 +- 128.2 days. No related mortality was encountered. Laparoscopic fistulo-jejunostomy was the definitive fistula treatment in five of the patients (83.3 %) while in one patient (16.6 %) the leak was spontaneously healed. Conclusion: Adequate nutritional support is mandatory for the gastric sleeve leak treatment. LRYFJ has many advantages over naso-jejunal tube and loop type feeding jejunostomy particularly in treatments of prolonged sleeve leaks or fistulas. Our experience demonstrates that LRYFJ can be implemented safely with the technique we described.
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http://dx.doi.org/10.21614/chirurgia.114.6.798DOI Listing
January 2020

Hiatal Hernia is More Frequent than Expected in Bariatric Patients. Intraoperative Findings during Laparoscopic Sleeve Gastrectomy.

Chirurgia (Bucur) 2019 Nov-Dec;114(6):779-789

obesity is a risk factor for gastro-esophageal disease (GERD) and hiatal hernia (HH) occurrence. A substantial number of obese patients have HH. Esophago-gastro-duodenoscopy (EGD) and Barium X-ray oral study are used for preoperative gastrointestinal evaluation. Not all HH can be diagnosed before surgery, some are discovered during laparoscopic sleeve gastrectomy (LSG).

Aim: to assess the possible correlations between intraoperative presence of hiatal hernia (known or new discovered) and preoperative clinical, radiological and endoscopic data specific for GERD and HH.

Setting: single institution Ponderas Academic Hospital, Center of Excellence in Bariatric and Metabolic Surgery. Material and The prospectively maintained database of the institution was retrospectively quired to identify all the patients who underwent primary Laparoscopic Sleeve Gastrectomy (LSG) without/with concomitant hiatal hernia (HH) repair between January 2015 to May 2016. Patient characteristics, co-morbidities, GERD symptoms, radiologic oral contrast study, endoscopy and operative details were analyzed. six hundred ninety-five patients (260 male and 435 female) were identified meeting inclusion criteria (LSG +- HH repair). Mean age of patients was 41 +- 11.71years and average body mass index (BMI) was 41.96 +- 7.28 kg/m2. Preoperative upper gastrointestinal contrast series and endoscopy were performed for entire group study and demonstrated a hiatal hernia in 339 patients (48.78%). In all these cases, HH was repaired concomitantly with LSG. One hundred ninety-two patients (56.63%) were diagnosed with HH before operation and confirmed intraoperatively (Group A). The diagnosis of hiatal hernia was established intraoperatively for 147 patients (43.37%) - group B, using the surgical protocol for active identification of preoperative undiagnosed hiatal hernia - SPAIH.

Conclusion: preoperative investigations such as EGD and barium X-ray oral study are suboptimal in diagnosing HH, therefore, in a significant number of patients, the presence of HH has been established using our surgical protocol - SPAIH. Crura approximation (HHR) concomitantly with laparoscopic sleeve gastrectomy is reproducible, may prevent the HH progression and possible GERD complications in the postoperative period of time.
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http://dx.doi.org/10.21614/chirurgia.114.6.779DOI Listing
January 2020

Excellent Short- and Medium-term Result of Bariatric Surgery in Adolescence. A Single Center Study.

Chirurgia (Bucur) 2019 Nov-Dec;114(6):753-760

Childhood obesity is becoming more frequent and the age of diagnosis has decreased. Although initially sceptic about bariatric surgery in children and adolescents the number of papers to advocate earlier bariatric interventions in this age group is now considerable. However, there are still a lot of controversies about bariatric surgery's indications and long-term results in these patients. Aim/Objective: To analyze the outcomes of bariatric surgery in a group of adolescents with obesity operated in our hospital. We analyzed retrospectively all the consecutive adolescent patients who underwent laparoscopic gastric sleeve or gastric bypass between 2013 and November 2019 in a Bariatric Center of Excellence, tracking the perioperative morbidity, the changes of BMI and comorbidities at 12 and 36 PO months. Sixty-four adolescent patients were included in the study, 62 with sleeve gastrectomy (SG) and two with gastric bypass (GBP). Mean age at operation was 15 years and 5 months (SD 18 months). Mean BMI before operation was 39.45 kg/m2 (SD 6.9) and decreased to 24.92 kg/m2 and 22.7kg/m2 by 12 and 36 months respectively. There were no major perioperative complications, but early transitory postoperative dysphagia in one case. The mean length of hospital stay was 3.2 days. Mild, medically manageable complications were encountered in the first postoperative year: (anemia (6/61), folate deficiency (5/61), constipation (22/61), temporary hair loss (12/61). Bariatric surgery is safe and effective in treating adolescent obesity, when preformed in experienced centers.
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http://dx.doi.org/10.21614/chirurgia.114.6.753DOI Listing
January 2020

The Impact of Bariatric Surgery on Diabetes and Other Cardiovascular Risk Factors.

Chirurgia (Bucur) 2019 Nov-Dec;114(6):725-731

Nowadays, obesity is a major worldwide health problem due to its serious consequences and toits increasing prevalence. Bariatric surgery has demonstrated a sustained weight loss and an efficient long-term control of the co-morbidities associated with obesity. The objective of our study was to compare cardiovascular risk factors before and after bariatric surgery. Material and Method: We have retrospectively studied 59 consecutive patients scheduled for bariatric surgery (gastric sleeve) in Ponderas Academic Hospital between January and March 2016, excluding the ones that didn't commit to respect the follow-up terms. The preoperative, 6 and 12 postoperative months blood tests and anthropometric measurements were comparatively analyzed. BMI, waist circumference and total body weight decreased by 38%, 31%, and 41%; Glycemia, triglycerides and LDL cholesterol decreased by 16%, 37% and 9% respectively; HDL cholesterol increased by 18%. The decline was statistically significant for all variables (P 0.001) except for LDL cholesterol. The need for antihypertensive treatment was reduced by 60% and for lipid lowering treatment diminished by 21%. In diabetic patients glycated hemoglobin (HbA1c) decreased by 28% and the necessity for antidiabetic medical treatment dropped by 69%. Weight loss obtained by bariatric surgery in this study, improved the metabolic syndrome in all its components, obesity, hyperglycemia/type 2 diabetes, hypertension, and dyslipidemia, thus reducing the cardiovascular risk.
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http://dx.doi.org/10.21614/chirurgia.114.6.725DOI Listing
January 2020

Portal Vein Thrombosis a Rare but Life-threatening Complication after Laparoscopic Sleeve Gastrectomy: A 5 Years Study in a Bariatric Center of Excellence.

Chirurgia (Bucur) 2019 Nov-Dec;114(6):711-724

Background And Aim: Laparoscopic sleeve gastrectomy (LSG) is actually the most performed bariatric procedures in the world, and porto-mesenteric vein thrombosis (PVT) has been increasingly reported as a rare but serious complication. The best algorithm for PVT's prevention and therapy is still under discussion. The aim of this study is to explore the incidence and the outcomes of the PVT after LSG in a Bariatric Surgery Center of Excellence (BS-CoE) and elaborate a diagnostic and therapeutic algorithm for PVT after LSG. We retrospectively reviewed all the consecutive patients who underwent elective LSG within the last five years, between November 2014 and October 30th 2019, in Ponderas Academic Hospital, Bucharest, Romania. All the patients received an extended DVT prophylaxis protocol with adjusted doses of LMWH. Anti-factor Xa concentrations measurement to monitor the activity of LMWH in all the high-risk patients was used for the last two years. The patients suspected of PVT were scanned by computed tomography using IV contrast. All PVT patients were initially treated with systemic anticoagulation (Heparin), further interventions, such as systemic thrombolysis or surgery, being considered. After the acute stage, the PVT patients received longterm anticoagulation. Of the 3861 patients who underwent elective LSG, three were readmitted 7-60 days after the bariatric procedure for PVT, equating to an incidence of 0.077%. The average age of the patients developing PVT was 40 years (SD 11.97), the average body mass index (BMI) was 40.34 (SD 7.994) kg/m2 and all of them underwent the same protocol for LSG. Two patients underwent conservative therapy with heparin anticoagulation and no surgery was needed. The third patient had a fulminant evolution in ICU, due to an extensive PVT, with death within two hours from his admission despite all resuscitation measures taken. The two patients remained on long life anticoagulant therapy.

Conclusion: A high clinical suspicion of PVT after LSG is required with prompt diagnosis and treatment. The BS-CoE protocol with adjusted doses of LMWH and extended prophylaxis proved to be very efficient showing a very low incidence of PVT.
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http://dx.doi.org/10.21614/chirurgia.114.6.711DOI Listing
January 2020

The Effect of Bariatric Surgery on Premalignant Endometrial Pathology in Morbidly Obese Patients.

Chirurgia (Bucur) 2019 Nov-Dec;114(6):704-710

Aim: To investigate the effect of bariatric surgery on premalignant endometrial pathology in postmenopausal morbidly obese patients. Material and Between 2014 and 2019, in "Ponderas" Academic Hospital six postmenopausal morbidly obese patients with premalignant endometrial pathology were submitted to bariatric surgery consisting of sleeve gastrectomy. At the time of bariatric surgery, the mean body mass index (BMI) value was of 43.5 kg/m2 (range = 41.5 kg/m2 - 48.5 kg/m2) while the mean age was of 61 years (range = 58 - 63 years). The preoperative biopsy of the endometrial lining demonstrated the presence of simple endometrial hyperplasia in five cases and complex endometrial hyperplasia in one case while the mean thickness of the endometrial lining at magnetic resonance imaging (MRI) was of 2.1 cm (range = 1.5 - 2.8 cm). At one year follow-up, the mean BMI was of 26.5 kg/m2 (range = 24 kg/m2 - 28 kg/m2) while the mean thickness estimated at MRI was of 0.8 cm (range = 0.5 - 1.1 cm). The biopsy demonstrated the presence of normal endometrium in four cases and simple hyperplasia in two cases. Bariatric surgery seems to have an important effect on premalignant endometrial conditions. Therefore, bariatric surgery and consecutive weight loss might decrease the risk of malignant transformation in postmenopausal morbidly obese women.
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http://dx.doi.org/10.21614/chirurgia.114.6.704DOI Listing
January 2020

Postoperative Bleeding Risk after Sleeve Gastrectomy. A Two Techniques of Stapled Line Reinforcement Comparative Study in 4996 Patients.

Chirurgia (Bucur) 2019 Nov-Dec;114(6):693-703

Aim Of The Study: To compare the effectiveness of two different techniques used to control the postoperative bleeding after laparoscopic sleeve gastrectomy (LSG): over-sewing the stapled line and applying hemostatic clips on the visible bleeders along the stapled line. Material and Prospectively collected data of the patients submitted to LSG in Ponderas Academic Hospital, since January 2012 to November 2019 were retrospectively reviewed. Before and including the year of 2014, the control of the stapled line bleeding sources was provided by hemostatic clips while, starting with 2015, hemostasis was controlled by over-sewing the stapled line. For both groups, the blood pressure (BP) was intraoperatively raised up with 30% as compared to the preoperative level, in order to finally verify the surgical hemostasis. Between 2012 and 2019, 4996 gastric sleeve procedures were performed in our center, 1093 operations (Group A) being performed during the first interval (2012-2014) while the remaining 3903 procedures (Group B) have been performed during the second interval (2015 to 2019). Nine patients of the Group A (0.8%) developed early postoperative hemoperitoneum, in five of these cases the source being localized on the stapled line; among patients in the Group B early postoperative re-operation for hemoperitoneum was needed in 15 cases (0.38%), but in none of these cases the source was located at the stapled line; the difference was statistically significant (p=0.002). The intraoperative risen of the blood pressure (BP) with 30% helps identifying and controlling the bleeding sources thus reducing the incidence of postoperative bleeding in LSG. Oversewing the stapled line provided better hemostasis in LSG as compared with the application of metallic clips. No stapled line bleeding was encountered after systematically over-sewing it.
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http://dx.doi.org/10.21614/chirurgia.114.6.693DOI Listing
January 2020

Partial Adrenalectomy - Arguments for the Minimally Invasive Surgical Approach.

Chirurgia (Bucur) 2019 Sept-Oct;114(5):611-621

Partial adrenalectomy has been widely performed in the last decades in order to diminish the number of patients who would become lifetime dependent of hormonal replacement. Method: between 2016 and 2018 seven patients were submitted to minimally invasive partial adrenalectomy in Ponderas Academic Hospital. the median age at the time of surgery was 56 years (range 42-67 years) while the indications for partial adrenalectomy (PA) were represented by Conn's syndrome in four cases, bilateral pheochromocytoma in one cases and nonfunctional adrenal tumors in two cases. Preoperatively successful adrenal vein sampling was performed in one case. The indocyanine green test (ICG) as well as intraoperative ultrasound were used each in three cases. The transperitoneal approach was used for PA in all patients, laparoscopic in five and robotic assisted in two patients. No conversion to open surgery or to total suprarenalectomy was encountered. minimally invasive surgery seems to be a safe and effective method to perform partial adrenalectomy. Moreover, development of novel technologies such as adrenal vein sampling, indocyanine green test or intraoperative ultrasound seem to increase the feasibility of the method as well as the number of cases who could benefit from the type of approach. Use of new technology?
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http://dx.doi.org/10.21614/chirurgia.114.5.611DOI Listing
November 2019

Laparoscopic total hysterectomy still not routinely chosen Operative description and available instruments.

J Med Life 2019 Jul-Sep;12(3):301-307

Obstetrics & Gynecology Department, Emergency University Hospital, Bucharest, Romania.

Hysterectomy is the most common gynecological surgical intervention; therefore, there are many technical variations in different healthcare systems around the world. We aimed to review, step by step, the technique of laparoscopic hysterectomy as well as to present the available variety of surgical instruments impartially so that the operative team can decide in an informed manner the model and characteristics of the equipment used. The surgical technique is presented based on the experience of the authors, focusing mainly on intraoperative recommendation and suggestions. Advantages and disadvantages of the available instruments are also extensively detailed. Surgical positioning, as well as inserting the uterine manipulator are essential steps. The open technique is used to create pneumoperitoneum. The utero-ovarian ligament or the infundibulopelvic ligament is identified, coagulated and cut. The round ligament is incised, entering the space between the two layers of the broad ligament and advancing caudally in this space, which, if correctly identified, should be avascular. The uterine vessels located on the posterior sheet of the broad ligament are dissected and coagulated. The vaginal wall is sectioned with the help of the manipulator's cap, making it easier to expose the insertion line of the vagina on the cervix. The uterus is removed through the vagina or through a trans-parietal incision. Thereafter, the vagina is sutured using separate Vicryl sutures. Between 2011 and 2016, laparoscopic hysterectomy had an increasing trend all over Europe. With a reported percentage of 3%, Romania ranks last in hysterectomies performed laparoscopically. The laparoscopic approach offers the advantages of minimal invasiveness: less pain, faster recovery and early social reintegration; therefore, this trend of improvement should become more accepted.
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http://dx.doi.org/10.25122/jml-2019-0051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814877PMC
December 2019

Impact of retrograde transillumination while securing the airway in obese patients undergoing bariatric surgery.

J Clin Monit Comput 2020 Oct 25;34(5):1069-1077. Epub 2019 Sep 25.

Institute of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland.

Video laryngoscopy (VL) is a well-established technique used in anaesthetising obese patients who present with higher risks of airway-related difficulties and desaturations due to shorter safe apnoea periods. However, VL has certain limitations and may fail. We present the Infrared Red Intubation System (IRRIS), a new technique facilitating glottis identification in severely obese patients undergoing anaesthesia for bariatric surgery. This single-centre, prospective trial assessed the efficacy of the IRRIS for VL tracheal intubation in 20 severely obese adult patients undergoing elective bariatric surgery under general anaesthesia. We assessed the ability of the IRRIS to differentiate the transilluminated glottis from the oesophagus and laryngeal folds and evaluated the ease of intubation. The average weight in the investigated patient cohort was 145 ± 29 kg, the suprasternal tissue thickness was 12 ± 4 mm. The median IQR [range] larynx recognition time was 10 [2-50] s, which was similar to that of lean patients. The degree of obesity correlated with the duration to achieve optimal laryngoscopic view and complete the intubation procedure. We achieved successful VL insertion on the first attempt in 13 of 20 cases (65%), and on the second attempt in 7 cases (35%), emphasising the increased probability of successful intubation on the first attempt. Tracheal intubation with the IRRIS lasted 50 [IQR 20-100] s. The lowest SpO during intubation was 98 [IQR 83-100] %. Addition of IRRIS to VL insertion facilitated the intubation of difficult airways in severely obese patients. IRRIS improves the visualization of the intubation pathway by selectively highlighting the airway entrance and shortens the time to successfully conclude the intubation procedure.
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http://dx.doi.org/10.1007/s10877-019-00389-7DOI Listing
October 2020

Laparoscopic Pancreas-Sparing Duodenectomy with Roux en Y Reconstruction for Duodenal Polyposis.

Chirurgia (Bucur) 2019 Jul-Aug;114(4):494-505

Duodenal polyposis (DP) is often associated in patients with in patients with familial adenomatous polyposis (FAP) and the risk of malignancy is endoscopically assessed using the Spigelman score. Endoscopic therapy is the first option for PD while surgery is indicated for the advanced stages of the disease (Spiegelman III-IV). Pancreas-sparing duodenectomy (PSD) was proposed as a less aggressive alternative to pancreatoduodenectomy (PD), leaving the entire pancreas in situ while the number of anastomoses is reduced. Open PSD with Billroth or pillorus preserving reconstruction is the general used. The use of a Roux limb is very limited in literature, as it increases the procedure complexity, the number of anastomosis and it may reduce the endoscopic access for the postoperative surveillance after total duodenectomy. We aim to describe the technique for Laparoscopic Pancreas Sparing Total Duodenectomy (LPSTD) with Roux-en-Y reconstruction and to present the procedure's outcomes in a patient presenting Spigelman IV duodenal polyposis associated with FAP after open total colectomy. Laparoscopic Pancreas Sparing Total Duodenectomy (LPSTD) with antrectomy cholecystectomy and Roux en Y reconstruction was performed in a 39-year-old man with a history of FAP, open colectomy with ileorectal anastomosis and duodenal polyps. The preoperative investigations and the surgical steps of the laparoscopic approach are described in details. The operative time was 280 minutes. Two postoperative complications were encountered, a self-limited pancreatico-jejunal anastomosis hemorrhage occurred in POD 1 and necrosis of the cystic duct stump with bile peritonitis (POD7). Both of them required laparoscopic exploration. Oral feeding was introduced in the POD 2. The patient has been discharged in the POD 14. No other complications like delayed gastric emptying, pancreatic or biliary fistula at the site of PJA or ulcer were encountered. The 6 months postoperative evaluation, including the CT scan and the endos-copic retrograde inspection of the neo-papilla revealed no recurrence on the jejunum. Although it is a complex technique, LPSTD represents a good alternative to PD for patients with FAP and large, periampullary villous adenoma especially those with high grade dysplasia. The use of laparoscopy and of Roux en Y reconstruction may reduce the postoperative morbidity rate in PSD.
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http://dx.doi.org/10.21614/chirurgia.114.4.502DOI Listing
October 2019

Early Laparoscopic Ileostomy Reversal After Rectal Cancer Surgery - Technique and Outcomes.

Chirurgia (Bucur) 2019 May-Jun;114(3):392-400

A temporary diverting ileostomy (TDI) is performed in a significant number of patients undergoing colorectal surgery. The best timing for ileostomy reversal (IR), early or late after its formation and the proper technique used for its closure are controversial.The objective of the present study is to describe the particular aspects of the laparoscopic technique of ileostomy reversal and to analyze the outcomes of its early closure. A retrospective analysis on all the patients who underwent laparoscopic ileostomy reversal (LIR) after MIS rectal surgery between 2015 and 2018 in Ponderas Academic Hospital was performed. No patient was excluded from the study. The outcomes of the early laparoscopic closure of the diverting ileostomy (less than 30 days) were analyzed and compared with the standard closure ones. Twenty-one patients, (10 males), average age and BMI of 57 years (range 33-77) and 21.6 kg/m2 (range 14.4-34) were included into the study. All the procedures were completed laparoscopically. No patient was lost from follow-up. The laparoscopic ileostomy reversal was performed at 50.4 days (range 7-150) from the open (1 patient) or laparoscopic (20 patients) rectal cancer resection. Twelve patients had preoperative RCT (48%), 17 low colorectal anastomosis and the coloanal one was performed in three patients with TDI. Eleven patients (52%) had an early ileostomy reversal after 23.6 days (7-30 days). A very early LIR (7-10 days) was necessary in 3 patients with complicated evolution after TDI. No significant intra-operative or postoperative complications between the two subgroups of early or late LIR was encountered. The hospital stay (LOS) after LIR was 3.9 days (2-5) with no difference between the two subgroups. We encountered one postoperative complication (5%), - enteral bleeding conservatively treated. Laparoscopic ileostomy reversal may be considered as a primary option for temporary diverting ileostomy after colorectal resection. The early ileostomy reversal is safe and improved postoperative outcomes in are demonstrated selected patients. Careful investigation and rigorous selection of the patients for EIR is mandatory.
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http://dx.doi.org/10.21614/chirurgia.114.3.392DOI Listing
July 2019

Laparoscopic Mobilization of the Splenic Flexure as the First Step of Restorative Colorectal Resection.

Chirurgia (Bucur) 2019 Mar-Apr;114(2):268-277

Mobilization of the colonic splenic flexure (SFM) is an essential surgical step of the restorative rectal resections. However, the surgical procedures are technically complex thereby overcoming the learning curve may not be an easy process. Looking for improved expertise and better outcomes, in 2016, we have decided to routinely perform SFM as a first step of all the laparoscopic or robotic sigmoid and rectal resections. The aim of this paper is to describe the technique of laparoscopic splenic flexure mobilization and to discuss the advantages of using it as the first surgical step in colorectal rectal resection analyzing our last 12 months experience (2018). Method: A detailed description of the laparoscopic surgical technique for SFM is performed. There are four routes for SFM: two from medial to lateral, one starting from the splenic vein the other one from the promontory, a superior to inferior approach and a lateral to medial approach. However, the combination of different maneuvers for an easier, safer approach decreases the morbidity and is saving surgical time. Between January and December 2018, 47 patients had SPM as a first step of the performed colorectal procedure in our institution. There were 30 patients with rectal cancer, 10 with sigmoidal tumors, five with sigmoidal resection for diverticulitis and Hartmann reversal was indicated in two. The robotic approach has been used in 40% (16 patients). No intraoperative incidents were associated with the SFM. No colorectal fistula was encountered. No early cancer recurrence, deaths or major complication were encountered. The mean follow-up for these patients is 7 months (range, 4-12 months). In our perspective, the routine mobilization of the splenic flexure as a first step of the colorectal restorative resections associate many advantages and these strategies should be largely used. There is a learning curve involved in such procedure and it can easily be overcome in high volume centers.
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http://dx.doi.org/10.21614/chirurgia.114.2.268DOI Listing
July 2019