Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology.

METHODS

A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved.

RESULTS

A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations.

CONCLUSION

This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Fluorescence-based sentinel lymph node mapping and lymphography evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry

BACKGROUND

The identification of metastatic lymph nodes is one of the most important prognostic factors in gastrointestinal (GI) cancers. Near-infrared fluorescence (NIRF) imaging has been successfully used in GI tumors to detect the lymphatic pathway and the sentinel lymph node (SLN), facilitating fluorescence image-guided surgery (FIGS) with the purpose to achieve a correct nodal staging. The aim of this study was to analyze the current results of NIRF SLN navigation and lymphography through data collected in the EURO-FIGS registry.

METHODS

Prospectively collected data regarding patients and ICG-guided lymphadenectomies were analyzed. Additional analyses were performed to identify predictors of metastatic SLN and determinants of fluorescence positivity and nodal metastases outside the boundaries of standard lymphadenectomies.

RESULTS

Overall, 188 patients were included by 18 surgeons from 10 different centers. Colorectal cancer was the most reported pathology (77.7%), followed by gastric (19.1%) and esophageal tumors (3.2%). ICG was injected with higher doses (p < 0.001) via extraparietal side (63.3%), and with higher volumes (p < 0.001) via endoluminal side (36.7%). Overall, NIRF SLN navigation was positive in 75.5% of all cases and 95.5% of positive SLNs were retrieved, with a metastatic rate of 14.7%. NIRF identification of lymph nodes outside standard lymphatic stations occurred in 52.1% of all cases, 43.8% of which were positive for metastatic involvement. Positive NIRF SLN identification was an independent predictor of metastasis outside standard lymphatic stations (OR = 4.392, p = 0.029), while BMI independently predicted metastasis in retrieved SLNs (OR = 1.187, p = 0.013). Lower doses of ICG were protective against NIRF identification outside standard of care lymphadenectomy (OR = 0.596, p = 0.006), while higher volumes of ICG were predictive of metastatic involvement outside standard of care lymphadenectomy (OR = 1.597, p = 0.001).

CONCLUSIONS

SLN mapping helps identifying potentially metastatic lymph nodes outside the boundaries of standard lymphadenectomies. The EURO-FIGS registry is a valuable tool to share and analyze European surgeons' practices.

Robotic Resection of Ectopic Thyroid Tissue of the Mediastinum - Case Report and Literature Review

Introduction: Ectopic thyroid tissue (ETT) is a rare cause of mediastinal masses, representing less than 1% of all mediastinal tumors (1). ETT could be detected anywhere along the path of the first embryonic descent of the thyroid gland from the primordial foregut floor to its usual pre-tracheal position. ETT mediastinal localization accounts for fewer than 1% of all ectopic thyroid cases (2,3). Various surgical methods for approaching mediastinal masses have been documented in the literature, including median sternotomy, posterolateral thoracotomy, and, video-assisted thoracoscopic surgery (VATS) (4). More recently, robotic-assisted thoracoscopic surgery (RATS) has been proposed for these masses. The aim of this article is to present the use of robotic-assisted thoracoscopic surgery (RATS) for a rare case of a mediastinal ETT. Case presentation: We present the case of a 40-year-old male with no significant medical history who discovered a mediastinal mass on a thoracic CT scan following COVID-19 infection. Symptoms were dysphagia and anterior thoracic pain with cervical extension. Scintigraphy confirmed the presence of ectopic thyroid tissue in the mediastinum as well as a normal cervical thyroid gland. ETT was histologically confirmed by endoscopic ultrasound guided biopsy. Robotic assisted surgery was the chosen approach to surgically treat this mass and the technical details are presented. The mass was extracted through the cervical incision. Total surgical time was 230 minutes, and the blood loss was 60 ml. The patient was discharged after 48 hours with follow up showing a full recovery with no residual pain or respiratory symptoms. Conclusion: Ectopic thyroid tissue (ETT) is a rare cause of mediastinal masses, and the diagnosis is always a challenge. Robotic assisted thoracoscopic surgery was proved to be safe and efficient in this rare case of ETT developed in the superior mediastinum.

Reconstruction of the phreno-esophageal ligament (R-PEL) prevents the intrathoracic migration (ITM) after concomitant sleeve gastrectomy and hiatal hernia repair

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) is the most attractive bariatric procedure, but the postoperative intrathoracic gastric migration (ITM) and "de novo" GERD are major concerns. The main objective of our study was to evaluate the efficiency of the concomitant HHR with or without partial reconstruction of phreno-esophageal ligament (R-PEL) to prevent ITM after LSG. The secondary objectives focused on procedure's metabolic and GERD-related outcomes.

PATIENTS AND METHOD

Consecutive patients who underwent primary LSG and concomitant HHR were included in a single-center prospective study. According to the HHR surgical technique, two groups were analyzed and compared: Group A included patients receiving crura approximation only and Group B patients with R-PEL. The patients' evolution of co-morbidities, GERD symptoms, radiologic, and endoscopic details were prospectively analyzed.

RESULTS

Two hundred seventy-three patients undergoing concurrent HHR and LSG were included in the study (Group A and B, 146 and 127 patients) The mean age and BMI were 42.6 ± 11.3 and 43.4 ± 6.8 kg/m². The 12-month postoperative ITM was radiologically found in more than half of the patients in Group A, while in group B, the GEJ's position appeared normal in 91.3% of the patients, meaning that R-PEL reduced 7 times the rate of ITM. The percentage of no-improvement and "de novo" severe esophagitis (Los Angeles C) was 4 times higher in group A 3.4% vs. 0.8% with statistical significance, and correlated to ITM. The GERD symptoms were less frequent in Group B vs Group A, 21.3% vs 37%, with statistical significance. No Barrett's esophagus and no complication were recorded in any of the patients.

CONCLUSION

Concurrent LSG and HHR by crura approximation only has a very high rate of ITM in the first postoperative year (over 50%). R-PEL is an innovative technique which proved to be very efficient in preventing the ITM after HHR.

The Role of Thromboprophylaxis in Patients with Portal Vein Thrombosis: A Life-Threatening Complication after Laparoscopic Sleeve Gastrectomy Following 8 Years of Experience in a Bariatric Center of Excellence

Porto-mesenteric vein thrombosis (PVMT) is a rare but life-threatening complication after laparoscopic sleeve gastrectomy (LSG). Laparoscopic sleeve gastrectomy (LSG) is considered the most common procedure for efficiently realizing weight loss and treating obesity-related co-morbidities. This study aimed to shed light on this relatively rare complication by presenting a series of patients who developed PMVT after LSG in light of the need to change the specific protocol of thromboprophylaxis in bariatric patients. We proposed to answer two questions: whether we should perform a thrombophilia workup as a standard practice and whether we should extend chemoprophylaxis to more than 3 weeks among all bariatric patients. This study also aimed to investigate the possible risk factors and eventually present our updated protocol for PMVT management and prophylaxis.

Quantitative contrast-enhanced endoscopic ultrasound in pancreatic ductal adenocarcinoma and pancreatic neuroendocrine tumors: can we predict survival using perfusion parameters? A pilot study

AIM

Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) parameters may be used to predict prognosis of pancreatic ductal adenocarcinoma (PDAC) and pancreatic neuroendocrine tumors (pNET). The aim of this study was to investigate the association between several perfusion parameters on CEH-EUS performed before treatment and survival outcome in patients with PDAC or pNET.

MATERIAL AND METHODS

Thirty patients with PDAC or pNET who underwent CEH-EUS and EUS-guided fine needle aspiration (EUS-FNA) were included. Quantitative analysis of tumor vascularity was performed using time-intensity curve (TIC) analysis-derived parameters, obtained from processing CEH-EUS recordings with a commercially available software (VueBox). Cox proportional hazards models were used to determine associations with survival outcome.

RESULTS

Median overall survival (OS) for PDAC patients was 9.61 months (95% CI: 0.1-38.7) while the median OS for pNET patients was 15.81 months (95% CI: 5.8-24.75. In a multivariate model for OS, a lower peak enhancement (HR=1.76, p=0.02) and a lower wash-in area under the curve (HR=1.06, p=0.001) were associated with worse survival outcome for patients with PDAC.

CONCLUSIONS

CEH-EUS parameters may be used as a surrogate to predict PDAC aggressiveness and survival before treatment. After validation by large-scale studies, CEH-EUS perfusion parameters have the potential to be used in pretreatment risk stratification of patients with PDAC and in evidence-based clinical decision support.

Robotic Assisted Thoracoscopic Repair of Iatrogenic Tracheal Rupture

Introduction: Tracheal rupture is a rare condition, and its most common cause is head and neck trauma. Iatrogenic rupture is extremely rare and has multiple causes of which orotracheal intubation is the most common (1). Its importance derives from the associated high morbidity and mortality. The specific therapy is either conservatory or surgical, either through a posterolateral thoracotomy or minimally invasive (VATS). Robotic assisted surgery to repair the postintubation iatrogenic tracheal rupture after elective surgery has not been described so far in the literature. Case presentation: We present a 54-year-old female patient with no significant underlying conditions, who presented subcutaneous emphysema of the supraclavicular fossa less than 24 hours after surgery for an L5-S1 disc herniation. The CT and bronchoscopy confirmed the suspicion of tracheal rupture in the membranous area, revealing a lesion of more than 5 cm, with minimal chances of healing through a conservative attitude. Surgery was decided and a robotically assisted approach was offered by a team with experience in applying this technology for thoracic/mediastino-pulmonary pathology. Using the DaVinci Xi platform, the mediastinal dissection was performed, the 5 cm tracheal breach was revealed at the lateral border of the membranousa, azygos vein and vagus nerve, followed by closing the defect with resorbable PDO 4-0 monofilament thread and the application of co-polymer adhesive (Coseal) on the suture line. The operative time was 220 minutes and the intraoperative bleeding was minimal, (50 ml), without intraoperative complications. The robotic approach demonstrated the advantages of a generous exposure of the operative field, with a clear visibility of the meticulously dissected structures and facilitated the efficient suturing of the tracheal defect. Favorable post-operative outcome with both bronchoscopy and follow-up radiographs showed no signs of recurrence. Conclusion: The presented case demonstrates the advantages of an efficient use of robotic assisted thoracoscopic surgery to treat a very rare complication, the iatrogenic rupture of the trachea. Although the good results are obvious, the large-scale application of robotic technology for tracheal surgery requires prospectively analyzed comparative studies.

EAES rapid guideline: systematic review, network meta-analysis, CINeMA and GRADE assessment, and European consensus on bariatric surgery-extension 2022

BACKGROUND

The European Association for Endoscopic Surgery Bariatric Guidelines Group identified a gap in bariatric surgery recommendations with a structured, contextualized consideration of multiple bariatric interventions.

OBJECTIVE

To provide evidence-informed, transparent and trustworthy recommendations on the use of sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, gastric plication, biliopancreatic diversion with duodenal switch, one anastomosis gastric bypass, and single anastomosis duodeno-ileal bypass with sleeve gastrectomy in patients with severe obesity and metabolic diseases. Only laparoscopic procedures in adults were considered.

METHODS

A European interdisciplinary panel including general surgeons, obesity physicians, anesthetists, a psychologist and a patient representative informed outcome importance and minimal important differences. We conducted a systematic review and frequentist fixed and random-effects network meta-analysis of randomized-controlled trials (RCTs) using the graph theory approach for each outcome. We calculated the odds ratio or the (standardized) mean differences with 95% confidence intervals for binary and continuous outcomes, respectively. We assessed the certainty of evidence using the CINeMA and GRADE methodologies. We considered the risk/benefit outcomes within a GRADE evidence to decision framework to arrive at recommendations, which were validated through an anonymous Delphi process of the panel.

RESULTS

We identified 43 records reporting on 24 RCTs. Most network information surrounded sleeve gastrectomy and Roux-en-Y gastric bypass. Under consideration of the certainty of the evidence and evidence to decision parameters, we suggest sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass over adjustable gastric banding, biliopancreatic diversion with duodenal switch and gastric plication for the management of severe obesity and associated metabolic diseases. One anastomosis gastric bypass and single anastomosis duodeno-ileal bypass with sleeve gastrectomy are suggested as alternatives, although evidence on benefits and harms, and specific selection criteria is limited compared to sleeve gastrectomy and Roux-en-Y gastric bypass. The guideline, with recommendations, evidence summaries and decision aids in user friendly formats can also be accessed in MAGICapp:  https://app.magicapp.org/#/guideline/Lpv2kE CONCLUSIONS: This rapid guideline provides evidence-informed, pertinent recommendations on the use of bariatric and metabolic surgery for the management of severe obesity and metabolic diseases. The guideline replaces relevant recommendations published in the EAES Bariatric Guidelines 2020.

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

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.

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

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.

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

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.

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

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.

Colorectal Surgery in Romania during the COVID-19 Pandemic

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.

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

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 (p = .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.Abbreviations: 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.

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

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.

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

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.

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

Background: 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. Methods: 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. Results: 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). Conclusions: Bariatric surgery is safe and effective in treating adolescent obesity, when preformed in experienced centers.

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

Introduction: 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. Results: 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%. Conclusions: 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.

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

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 Methods: 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. Results: 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). Conclusions: 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.

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

Background: 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 Methods: 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. Results: 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.

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

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.

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

Background: 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. Method: 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. Results: 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. Conclusions: 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.

Symptomatic Stenosis after Laparoscopic Sleeve Gastrectomy - Incidence and Management in a High-Volume Bariatric Surgery Center

Background: Owing to the increased use of laparoscopic sleeve gastrectomy (LSG) as a metabolic procedure, a rarely associated complication, the Symptomatic Stenosis (SS) will be more often encounter. The objective of this study is to establish a safe and effective management of SS after LSG. Methods: We have analyzed all the patients with SS after LSG treated in Ponderas Academic Hospital from 2011 to 2018. The information was retrospectively extracted from a prospectively maintained database. Laparoscopy and/or endoscopy were used to treat the organic or functional SS. The procedure's outcomes (effectiveness and complications) were analyzed. Results: Out of the 4304 patients with LSG 47 (1.1%) patients were identified with SS after LSG. The incidence is depending on the LSG technique. Other 4 patients referred to our center have been added. Surgery was the first choice in 9 cases with only 33.3% success rate. For the 46 patients referred to endoscopy there have been 79 pneumatic dilation with an average of 1.7+- 1.1 per patient. We have encountered 1 perforation but any hemorrhage or death. Follow-up rate was 93.5%. Over all, the success rate of endoscopic dilatations was 90.7%. Conclusion: The incidence of SS is low. Endoscopic pneumatic dilation is a safe and effective procedure and should be the front line choice in the management of SS after LSG.

Retroperitoneal Laparoscopic Radical Prostatectomy

Introduction: Retroperitoneal Laparoscopic Radical Prostatectomy (RLRP) has been introduced in our department as the first line treatment for patients with localized prostatic cancer and life expectancy over 10 years. At the time, the surgical team had already extensive experience in minimally invasive urologic surgery. Our aim is to describe the laparoscopic technique we currently use and to analyze our oncologic and functional results. Patients and Methods: All the patients who underwent RLRP in our institution (PONDERAS ACADEMIC HOSPITAL) from January 2015 to March 2017 were included into a prospective study. The standard preoperative protocol included blood tests, prostate biopsy, pelvis MRI and bone scintigraphy, while the particular therapy was discussed and approved by the Institutional Multidisciplinary Tumor Board. In all the 45 cases, RLRP was indicated for localized prostate cancer. Results: The average patient’s age was 68 years (range 45 â€" 74 years), mean preoperative prostate specific antigen (PSAi) level was 8 ng/mL (range 3â€"15 ng/mL) and prostatic volume between 26 and 52 cc. The laparoscopic approach was completed in all 45 cases â€" no conversions to open surgery. Bilateral nerve sparing was performed in 7 cases (16%) and unilateral in 23 cases (51%). The mean operative time was 165 minutes (range 120 - 240 min), while the average blood loss was 255 mL (range 20â€"800) and two patients received blood transfusions. The mean catheterization time was 10 days (range 7â€"14 days). Positive surgical margins were observed in 8 cases (17.7%). Overall, 86% and respectively, 93% of the patients were continent during the following 3 and 6 months. 51% of the patients had erectile disfunction 6 month after the intervention. Four complications were encountered: intraoperatively - rectal injury (1 case) and postoperatively - bleeding (2 cases) and stenosis at the vesicourethral anastomosis (1 case). No mortality or late morbidity encountered. Conclusions: The radical laparoscopic prostatectomy is a safe and efficient procedure for localized prostate cancer with minimal complications and short hospitalization time, but it requires an experienced team of laparoscopic surgeons. The functional and oncological outcomes of LRP are expected to be improved as the medical team experience is extended.

Laparoscopic Spleen Preserving Distal Pancreatectomy with Splenic Vessels Preservation

Spleen preserving Distal Pancreatectomy (SPDP) is commonly applied in patients with benign or low-grade malignant tumors in the body and tail of the pancreas. Our aim is to present our technique and the early results in performing laparoscopic spleen preserving distal pancreatectomy with splenic vessel preservation (LSPDP-SVP) during 2017-2018 in Ponderas Academic Hospital.

Assessment of the Metabolic Response After Echo-endoscopic Gastric Bypass An experimental animal study

The increasingly higher incidence of obesity and type 2 diabetes witnessed in today�s society led to a continuous research for innovative medical and surgical solutions to this pathology. Our aim is to evaluate the metabolic effects of endoscopic ultrasound-guided gastric bypass (EUGB) in an experimental pig model. Eight female pigs were equally distributed into two groups: the endoscopic ultrasound-guided gastrojejunostomy group and a control group. Body weight and blood glucose concentration were assessed before the procedure and weekly in the postoperative setting for 6 months.

Comparison of Sleeve Gastrectomy and Conservatory Treatment Effect on Biochemical and Hormonal Profile of Obese Type 2 Diabetes Subjects: CREDOR Randomized Controlled Study Results

Metabolic surgery is the most efficacious method for the treatment of morbid obesity and was recently included among the antidiabetes treatments recommended in obese type 2 diabetes (T2D) patients. The aim of this study was to compare in a randomized controlled trial the effect of sleeve gastrectomy (SG) to that of intensive lifestyle intervention plus pharmacologic treatment on some markers of insulin resistance and beta cell function as well as some appetite controlling hormones in a group of male obese T2D subjects. The study groups comprised 20 subjects for SG and 21 control subjects. Fasting blood glucose, insulin, proinsulin, adiponectin, leptin, ghrelin, HOMA-IR, HOMA-%B, proinsulin-to-insulin ratio and proinsulin-to-adiponectin ratio were evaluated at baseline and after one year follow-up. Overall, patients in the SG group lost 78.98% of excess weight loss (%EWL) in comparison with 9.45% in the control group. This was accompanied by a significant improvement of insulin resistance markers, including increase of adiponectin and decrease of HOMA-IR, while no changes were recorded in the control group. Weight loss was also associated with a significant improvement of proinsulin-to-insulin and proinsulin-to-adiponectin ratio, both surrogate markers of beta cell dysfunction. These also improved in the control group, but were only marginally significant. Our findings suggest that improved insulin resistance and decreased beta cell dysfunction after sleeve gastrectomy might explain diabetes remission associated with metabolic surgery.

Early Improvement in Glycemic Metabolism after Laparoscopic Sleeve Gastrectomy in Obese Patients - A Prospective Study

BACKGROUND

according to W.H.O. in 2014 more than 600 million adults were obese, (more than doubled since 1980), and face a major risk for the onset of metabolic syndrome, including T2DM. Due to the poor control of glycemic imbalance for the conservative treatment of T2DM, the metabolic surgery was able to gain an important role in modern management of T2DM, with significant reported improvements or remissions for these patients.

OBJECTIVE

to study the effects of laparoscopic sleeve gastrectomy (LSG) on glycemic metabolism in obese patients, with or without T2DM.

METHODS

60 consecutive patients were included in a prospective study and were submitted to laparoscopic sleeve gastrectomy in Ponderas Hospital between February - March 2013. BMI, waist circumference and glycemic parameters were studied at the moment of entering the study, 10 days after surgery and at 6 months follow up.

RESULTS

the glycemic control was significantly improved starting with postoperative day 10. Statistically significant improvements were noticed after six months postoperatively in BMI values (p 0,0001), waist circumference (p 0,0001), glycemic levels (p 0,0001), insulin (p 0,0001), C-peptide (p 0,0001) and HOMA.

CONCLUSIONS

a rapid induced improvement of glucose metabolism in both diabetic and non-diabetic patients occurs before a significant weight loss (POD 10). At 6 months, when associated with an important weight loss, both diabetic and non-diabetic patients present a furthermore improvement in glycemic metabolism, that enables us to consider that sleeve gastrectomy is an efficient method for a sustained improvement in the metabolic status of patients with obesity. These beneficial changes that can explain the remission of T2DM can also explain the prevention of T2DM after metabolic surgery.

IGF-1 and Insulin Resistance Are Major Determinants of Common Carotid Artery Thickness in Morbidly Obese Young Patients

We assessed the relationship between insulin resistance, serum insulin-like growth factor 1 (IGF-1) levels, and common carotid intima–media thickness (CC-IMT) in morbidly obese young patients. A total of 249 patients (aged 37.9 ± 9.8 years, body mass index [BMI] 45.6 ± 8.3 kg/m2) were evaluated (metabolic tests, serum IGF-1 measurements, homeostasis model assessment—insulin resistance [HOMA-IR], and ultrasonographically assessed CC-IMT) in a research program for bariatric surgery candidates. After adjusting for age, gender, BMI, systolic blood pressure, uric acid, antihypertensive and lipid-lowering treatment, metabolic syndrome, and metabolic class, both HOMA-IR and IGF-1 z-score were significantly associated with CC-IMT. These results were confirmed in logistic regression analysis, in which age (β = 1.11, P = .001), gender (β = 3.19, P = .001), HOMA-IR (β = 1.221, P = .005), and IGF-1 z-score (β = 1.734, P = .009) were the only independent determinants of abnormal CC-IMT, presumably modulating the effect of the other risk factors included in the regression. Area under the receiver–operating characteristic curve for the model was 0.841 (confidence interval: 0.776-0.907; P < .001). In conclusion, in morbidly obese young adults, insulin resistance and IGF-1 z-score are significantly associated with CC-IMT, independent of other major cardiovascular risk factors.

Association of serum adiponectin and insulin-like growth factor I levels with parameters of cardiac remodeling in severely obese patients

BACKGROUND

Obesity is associated with various changes in cardiac geometry and this process involves both hemodynamic and non-hemodynamic factors, among which adipocitokines and growth factors may play an important role. The aim of this study was to identify the extent and pattern of cardiac remodeling in a group of severely obese patients and analyze the relationship between adiponectin, IGFI and cardiac parameters reflecting obesity-associated structural changes.

SUBJECTS AND METHODS

Our study included 344 patients (104 men) with severe obesity [mean body mass index (BMI)= 45.7 ± 8.5 kg/m(2)], extensively evaluated clinically and biologically (complete metabolic tests, serum adiponectin, and IGF-I measurements). Left ventricular (LV) mass index (LVMI), left atrium (LA) size, and LV geometry were determined by means of cardiac ultrasound.

RESULTS

The most prevalent pattern of LV geometry was eccentric hypertrophy (28.7% of patients). In a gender-, age-, BMI-, diabetes- and hypertension-adjusted general linear model, patients with concentric or eccentric hypertrophy had significantly lower values of adiponectin than those with normal geometry (6.75 ± 0.41, 6.96 ± 0.53, vs 9.04 ± 0.42 mg/l, p<0.05). In multivariate analysis, independent determinants for LVMI were BMI (β=0.364, p<0.001), systolic blood pressure (BP) (β=0.187, p=0.004), age (β=0.246, p<0.001), adiponectin (β=-0.151, p=0.012), and IGF-I z-score (β=0.134, p=0.025) while factors independently related to LA size were systolic BP (β=0.218, p<0.001), BMI (β=0.194, p<0.001), age (β=0.273, p<0.001), gender (β=-0.195, p<0.001), and adiponectin (β=-0.180, p=0.005).

CONCLUSIONS

In patients with severe obesity, IGF-I z score and adiponectin correlate with parameters of cardiac remodeling independently of anthropometric, hemodynamic or metabolic factors.

Adiponectin, body mass index and hepatic steatosis are independently associated with IGF-I status in obese non-diabetic women

OBJECTIVE

Low IGF-I levels have been associated with obesity, insulin resistance, hepatic steatosis, and were shown to predict cardiovascular mortality. Adiponectin, on the other hand, was proved to have an important protective role against metabolic and cardiovascular diseases. This study investigates the relation between hepatic steatosis, adiponectin and IGF-I levels in a group of non-diabetic obese Romanian women.

DESIGN

This cross-sectional study included 201 obese non-diabetic women, with mean age of 41.1±11.9 years and mean body mass index (BMI) of 44.1±8.3 kg/m(2), consecutively admitted to the Endocrinology Department of a University Hospital to be evaluated as candidates for bariatric surgery. Main measured parameters included total adiponectin (detected by ELISA method), insulin, C reactive protein (CRP), and IGF-I (all by chemiluminescence methods). Insulin sensitivity was assessed using the Quantitative Insulin Sensitivity Check Index (QUICKI). Patients were considered IGF-deficient if IGF-I z score was ≤2 standard deviations from mean for age. Hepatic ultrasound was used to determine the presence of significant steatosis (SS+).

RESULTS

Significant steatosis was observed in 60.7% of our patients and this feature was associated with reduced total adiponectin levels (p<0.001) and lower IGF-I z scores (p<0.001). IGF-I z score negatively correlated with BMI (r=-0.283, p<0.001), alanine aminotransferase (ALT) (r=-0.130, p=0.032), gamma glutamyltransferase (GGT) (r=-0.158, p=0.018) and logarithmic transformed (log) CRP (r=-0.232, p=0.001) and positively correlated with QUICKI (r=0.148, p=0.023) and log adiponectin (r=0.216, p=0.003). The relationship between IGF-I z score and log adiponectin remained significant after adjusting for age, BMI, ALT, QUICKI and log CRP (r=0.183, p=0.012). IGF-I deficiency was present in 33.3% of these obese women. In multivariate logistic analysis, BMI (p<0.001), ALT (p=0.003), log adiponectin (p<0.001) and SS (p=0.043) proved to be independently associated with IGF-I deficiency.

CONCLUSIONS

Adiponectin is significantly correlated with IGF-I z scores and, along with BMI, ALT and significant steatosis, is independently associated with IGF-I deficiency in obese non-diabetic women.

[Hynes-Andersen pyeloplasty by mini-laparoscopy transperitoneal approach]

Laparoscopy had significantly gained in the field of urologic surgery, almost all the surgical procedures in the retroperitoneal space being made, from the simple ones (renal cystectomy, varicocelectomy) to the ones requiring higher expertise (nephrectomy, adrenalectomy) by retro-peritoneoscopy and also transperitoneal. At the Surgery Department of "Sf. Ioan" Hospital, Bucharest, we approached initially the retroperitoneal pathology by lomboscopy, but afterwards we choose the transperitoneal approach because of the generous workspace and the clearer anatomical landmarks, regardless of the procedures (renal cystectomy, varicocelectomy, adrenalectomy, nephrectomy, pyelo-lithotomy, ureterolithotomy). In association with the Urology Department of "Sf. Ioan" Hospital we practiced two Hynes Andersen pyeloplasty for pyelo-ureteral junction stenosis by transperitoneal approach, using mini-laparoscopy tools. In one of the cases we also perform a basinetal lithotomy.

Liver involvement in Langerhans' cell histiocytosis. Case report

Langerhans'cell histiocytosis (Histiocytosis X) is a rare disease of unknown cause characterized by oligoclonal proliferation of Langerhans cells. It occurs mostly in children and young adults and involves one or more body systems such as bone, hypothalamus, posterior pituitary gland, lymph nodes, liver or various soft tissues. The diagnosis is always made by a histological approach. We report a case of Langerhans'cell histiocytosis in a young patient with clinical signs of diabetes insipidus and hepatic involvement in whom the immunohistochemical analysis of the liver tissue led to the definitive diagnosis.