Symptomatic gallstone disease occurred only in 6.9% of patients post-LRYGBP. Multivariate analysis identified weight loss at 3 months post-LRYGBP of more than 50% of excess weight as the sole significant independent predictor of delayed symptomatic cholecystolithiasis. Prophylactic CCE should not be recommended at the time of LRYGBP.

A CT scan can help in confirming the diagnosis of an IH, especially if a mesenteric swirl is present. However, since the presented sensitivities are variable and do not reach 100%, IH might be missed, implicating that a high index of suspicion with a low threshold for explorative laparoscopy/-tomy remains the cornerstone of appropriate treatment.

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed to determine the incidence, etiology, clinical symptoms, radiologic diagnostic accuracy and operative outcomes of SBO. Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH. In 41 (91%) cases, the IH was at the jejunojejunostomy (JJ), four cases had an IH at Petersen's space. Adhesions and ventral hernia were found in 14 (2.1%) and four (0.6%) cases, respectively. Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB.

In our series, hospital stay, morbidity, and mortality of rRYGB were not significantly higher compared with pLRYGB. Furthermore, we believe that this type of revisional bariatric surgery should be performed in high-volume bariatric centers.

In this article, we give an explanation for the clinical evolution presented in our case using the "integrated organ" and the "concomitant resistance" hypotheses. We believe that, if these theories continue to prove their viability, the search for disseminated tumor cells will be essential for good clinical practice in this type of pathology.

LRYGB has an acceptable complication rate in the elderly. Since all obesity-related comorbidities improved during follow-up, there is a plea not to exclude this subgroup of patients from the well-known benefits of gastric bypass surgery.

An 81-year-old man underwent an aortobifemoral bypass graft because of a ruptured abdominal aortic aneurysm. His postoperative recovery was complicated by unilateral lower limb paralysis caused by perioperative ischemia of the lumbosacral plexus. Ischemic lumbosacral plexopathy is an uncommon complication after infrarenal aortic surgery with serious morbidity.Despite a good surgical technique and knowledge of the vascularization of the spinal cord, its occurrence remains unpredictable.An 81-year-old man was urgently referred to the emergency services by his treating physician because of acute abdominal pain, mainly in the left flank. On admission, he was pale and suffered from hypotension (blood pressure 50/30 mm Hg). A computerized tomography (CT) was performed, which showed a ruptured juxtarenal abdominal aortic aneurysm. The patient was rushed to the operating room, where an aortobifemoral bypass was performed. There was a suprarenal clamp time of 25 minutes. As nefroprotection rescuvolin (folic acid) and lysomucil (acetylcysteine) were given. There were no important periods of hypotension perioperatively, despite the need for massive transfusion (2 L of autotransfusion, 8 units of packed cells, 4 units of fresh frozen plasma, and 2 pools of thrombocytes, perioperatively). The patient was extubated the same day. The next morning, he complained of hypoesthesia and paresis of his right leg. We also noticed rising of his serum creatinine and urea levels and a potassium level of 6.5 mmol/L (3.5-5.1 mmol/L). Glucose and insulin were started to correct the potassium level, and a subclavian dialysis catheter was used for dialysis. After a few days, potassium, creatinine, and urea levels normalized and all therapies were stopped, but the paralysis and paresthesia of the right limb remained. A CT scan of the brain ruled out any central etiology and an electromyogram (EMG) confirmed peripheral pathology (combined drop foot and plantar flexion paralysis) and our diagnosis of ischemic lumbar plexopathy. Magnetic resonance imaging (MRI) of the lumbar spine 3 weeks postoperative was negative. When the patient was discharged, limited mobilization was possible with aid. DiscussionLower limb paralysis following aortoiliac procedures is a known but rare complication. The overall neurologic risk of endovascular and open infrarenal abdominal aortic surgery ranges between 0% and 1%. 1 The risk is higher for emergency cases (1.4-2%) than for elective cases 2 (0.1-0.2%) and consists of central cord, lumbosacral, and peripheral nerve From the Department of Vascular and Thoracic Surgery, AZ Groeninge Kortrijk, Belgium.

When using cement in a hip arthroplasty, high intramedullary pressures are generated. This may lead to several complications, ranging from local extravasation to systemic complications such as the implantation syndrome. Until now, venous migration of cement after hip arthroplasty has never been associated with morbidity or mortality. We present a case in which cement pressurization led to migration of cement up to the level of the inferior vena cava with subsequent deep vein thrombosis.