The understanding of the pathogenesis of Crohn's disease continues to evolve and is believed to be multifactorial. Surgical intervention is suitable in some patients when medical treatment has been exhausted. Within the realm of surgery, the debate continues about the configuration of anastomosis and extent of mesenteric resection on the long-term impact of recurrences.1 Kono-S anastomosis has emerged in the last decade as an alternative.2 Minimally invasive ileocolic resection is standard of care. However, the anastomosis aspect is still largely performed extracorporeally through a midline incision. We would like to share our standardized steps of performing an intracorporeal Kono-S anastomosis (Supplement Video S1). The patient is placed in a modified lithotomy position on a bean bag with both arms tucked in. Prophylactic antibiotics are given. Optical entry is performed using a 5 mm port and 5 mm 30 endoscope at Palmer's point. Pneumoperitoneum is established. Three further ports are inserted; 5 mm port at the 'dome' of the abdomen, 5 mm port at the suprapubic and 12 mm port between the left lower rib and left anterior superior iliac spine. The patient is positioned in a reversed Trendelenburg and right side up. The ileocolic pedicle is identified its peritoneum is scored to gain access into the retrocolic space (Fig. 1a). The duodenum is swept down. The ileocolic pedicle is dissected and ligated high with Hem-o-loc clips. The right colon and terminal ileum are mobilized from caudal to cranial approach with hepatic flexure completely mobilized (Fig. 1b). The colonic mesentery is ligated at the level of ascending colon. The ascending colon is divided perpendicular to the mesentery with endoscopic linear stapler (Fig. 1c). The healthy terminal ileum is identified. A small window between the ileum and mesentery is created (Fig. 1d). The ileum is divided perpendicular to the mesentery with endoscopic linear stapler (Fig. 1e). Extended mesenteric resection is performed in this case due to underlying malignancy (Fig. 1f). Indocyanine green was used to check for bowel perfusion (Fig. 1g). The ileum and the ascending colon staple lines are aligned together. The supporting column is created by suturing the two staple lines together, starting at the midpoint towards the superior aspect with 3/0 V-Loc (Fig. 1h). A separate 3/0 V-Loc commenced at the midpoint towards the inferior aspect. A ruler is used to measure 7 cm (Fig. 1i) to mark the longitudinal enterotomy/colotomy at the anti-mesenteric border, 1 cm away from the staple line at both the ileum and colon (Fig. 1j,k). Gauze is placed around the planned incision site to absorb any spillage. A hook diathermy is used to incise sharply at the marked area. A 2/0 PDS suture is used as a stay at the superior apex and the inferior apex respectively (Fig. 1l). The posterior wall is created with 3/0 V-Loc (23 cm) full thickness bites starting at the midpoint towards the superior apex (Fig. 1m). Another 3/0 V-Loc is used to head towards the inferior apex (Fig. 1n). These are tied to the 2/0 PDS stay sutures. A new 3/0 V-Loc (23 cm) is used for the anterior wall starting from the superior apex towards midpoint (Fig. 1q). Another 3/0 V-Loc commences from the inferior apex meets the other suture at the midpoint and tied together (Fig. 1r). A new 3/0 V-Loc (23 cm) is used to perform the second layer of Lembert stitch (Fig. 1s,t). A Pfannenstiel incision is made (Fig. 1w). A wound retractor is used. The specimen is extracted. The wound is closed in layers with 0 Vicryl. Pneumoperitoneum is re-established. The right paracolic gutter and right upper quadrant are irrigated with saline (Fig. 1v). Zi Qin Ng: Conceptualization; data curation; formal analysis; writing – original draft preparation. Edward Forrest: Data analysis; writing – review & editing. Satish Warrier: Supervision; writing – review & editing. The patient has provided written consent for the publication of the manuscript and video. Video S1. Laparoscopic extended ileocolic resection with Kono-S anastomosis. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
To evaluate the long-term outcomes of revisional malabsorptive bariatric surgery.Malabsorptive bariatric procedures are increasingly performed in the revisional setting. We collated and analysed prospectively recorded data for all patients who underwent a revisional Biliopancreatic diversion + / - duodenal switch (BPD + / - DS) over a 17-year period.We identified 102 patients who underwent a revisional BPD + / - DS. Median follow-up was 7 years (range 1-17). There were 21 (20.6%) patients permanently lost to follow-up at a median of 5 years postoperatively. Mean total weight loss since the revisional procedure of 22.7% (SD 13.4), 20.1% (SD 10.5) and 17.6% (SD 5.5) was recorded at 5, 10 and 15 years respectively. At the time of revisional surgery, 23 (22.5%) patients had diabetes and 16 (15.7%) had hypercholesterolaemia with remission of these occurring in 20 (87%) and 7 (44%) patients respectively. Nutritional deficiencies occurred in 82 (80.4%) patients, with 10 (9.8%) patients having severe deficiencies requiring periods of parenteral nutrition. Seven (6.9%) patients required limb lengthening or reversal procedures. There were 16 (15.7%) patients who experienced a complication within 30 days, including 3 (2.9%) anastomotic leaks. Surgery was required in 42 (41.2%) patients for late complications.Revisional malabsorptive bariatric surgery induces significant long-term weight loss and comorbidity resolution. High rates of temporary and permanent attrition from follow-up are of major concern, given the high prevalence of nutritional deficiencies. These data question the long-term safety of malabsorptive bariatric procedures due to the inability to ensure compliance with nutritional supplementation and long-term follow-up requirements.• Revisional bariatric surgery workload is increasing • Revisional malabsorptive surgery is efficacious for weight loss and comorbidity resolution • Revisional malabsorptive surgery is associated with high rates of nutritional deficiencies • Attrition from follow-up in this specific cohort of patients is of particular concern due to the risk of undiagnosed and untreated nutritional deficiencies.
The haemodynamic response to the insertion of the laryngeal mask airway (LMA) was assessed and compared to that of laryngoscopy and tracheal intubation in a study of forty patients (ASA 1) randomly allocated into two groups and anaesthetised using a standard balanced anaesthetic technique. The results show that the changes in all cardiovascular parameters measured following LMA insertion were significantly less (P < 0.05) when compared with those following laryngoscopy and tracheal intubation. We conclude that airway management with the LMA may be used to avoid the haemodynamic response to tracheal intubation where such a response is undesirable.
Abstract Background Conservative parotidectomy for benign tumours reduces facial nerve palsy, without increasing local recurrence. We report a modified technique of partial parotidectomy and using a novel description of tumour position, explore relationships between tumour position and histological margins, facial nerve palsy and local recurrence. Methods A prospectively collected single surgeon parotidectomy database was analysed, including tumour location (superficial/deep lobe; central/peripheral) and outcomes. A partial parotidectomy identified the facial nerve and the proximal portion of its branches with a macroscopically clear resection margin. Mean follow up was 5.9 years for pleomorphic adenomas. Results Three hundred and three patients underwent parotidectomy; 257 (84.8%) were superficial and 46 (15.2%) deep lobe. Tumour position was recorded in 291: 236 (81.1%) were peripheral tumours and 55 (18.9%) central. Histological margin involvement was similar in central and peripheral tumours, both overall and for superficial and deep lobe tumours, but was commoner in central deep lobe tumours, ( P = 0.003). Temporary partial facial nerve palsy occurred in 21 (6.9%), with one permanent partial nerve palsy (0.3%). Deep lobe tumours and total parotidectomy were associated with facial nerve palsy ( P = 0.01). Facial nerve monitoring reduced the risk of palsy ( P < 0.01). Local recurrence of pleomorphic adenomas was uncommon, occurring in 3 (2.0%) of 151 patients. Conclusion This series confirms the safety and adequacy of more conservative partial parotidectomy for benign tumours, highlighting most tumours are peripheral, but not more prone to histological margin involvement or local recurrence, and with routine intraoperative facial nerve monitoring, is achieved with low facial nerve palsy rates.
Background: Routine preoperative vocal cord (VC) assessment with laryngoscopy in patients undergoing thyroidectomy allows clear documentation of baseline VC function, aids in surgical planning in patients with palsies, and facilitates interpretation of intraoperative neuromonitoring (IONM) findings. We aimed to determine the incidence of preoperative vocal cord palsy (VCP); to evaluate the associated risk factors for preoperative VCP; and to calculate the cost-savings potential of implementing a selective approach. Methods: Patients with a pre-thyroidectomy VC assessment by fiberoptic laryngoscopy were retrospectively recruited from the Monash University Endocrine Surgery Unit database from 2000 to 2018. Cases with preoperative VCP were reviewed for potential contributing factors and compared with a non-palsy cohort. Results: Of the 5987 patients who had preoperative laryngoscopy, VCP was documented in 41 (0.68%) patients. Four clinical parameters were found to be potential indicators of VCP, including: age (p < 0.001), nodule ≥3.5 cm recorded on ultrasound imaging (p = 0.01), presence of voice symptoms (p < 0.001), and previous neck surgery (p < 0.001). Malignant cytology (p = 0.5) and exposure to head and neck irradiation were not different between the groups. Utilizing these risk factors, 2354 (39%) patients had at least one feature that may raise suspicion for preoperative VCP. By performing preoperative laryngoscopy only on this subset of patients, the potential cost savings exceeds 400 Australian Dollars per patient. Conclusions: Using this large dataset, we have established that a VCP is rare in the absence of a large nodule, hoarseness, or previous neck surgery. Therefore, in the era of IONM, we support a selective approach to preoperative laryngoscopy by using the aforementioned criteria.
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