Hypersplenism, secondary to portal hypertension, is common in hepatocellular carcinoma (HCC) with liver cirrhosis. Hepatic resection in the patient with hypersplenic thrombocytopenia (HSTC) may cause a perioperative bleeding episode and sometimes, liver failure. In order to investigate the effect of concomitant splenectomy in HCC patients with HSTC, clinical parameters are retrospectively reviewed for 18 HCC patients who underwent hepatic resection with or without splenectomy. Among 581 HCC patients who underwent hepatic resection during the past 17 years, 18 patients with HSTC were investigated. Twelve of them underwent hepatic resection for HCC and had a concomitant splenectomy and the remaining 6 patients underwent hepatic resection for HCC only. The clinical outcomes and postoperative changes in platelet count, serum albumin level, serum total bilirubin levels, prothrombin time and clinical staging (Child-Pugh Classification) were reviewed. The resected spleen mean weight was 350.7 +/- 102.9 g. Postoperative platelet counts were significantly increased with albumin levels and clinical staging scores also improved after the splenectomy. Among the 12 patients who had a splenectomy, 6 patients had postoperative complications and one died of recurrent variceal bleeding. According to this data, it is not harmful to perform a concomitant splenectomy and hepatectomy for the HCC patient with severe HSTC, it can even be beneficial in improving both the platelet count and clinical staging.

Offering surgery to treat metabolic disease or diabetes rather than as a mere weight-reduction therapy changes demographical and clinical characteristics of surgical candidates. This has important and practical ramifications for clinical care and support consideration of metabolic/diabetes surgery as a novel practice distinct from traditional bariatric surgery.

Objective: To elucidate the specific role of gastric vs. intestinal manipulations in the regulation of body weight and glucose homeostasis. Design and Methods: The effects of intestinal bypass alone (duodenal-jejunal bypass -DJB) and gastric resection alone (SG) in Zucker Diabetic Fatty (ZDF) rats were compared. Additional animals underwent a combination procedure (SG þ DJB). Outcome measures included changes in weight, food intake (FI), oral glucose tolerance (GT) and gut hormones. Results: DJB did not substantially affect weight and FI, whereas SG significantly reduced weight gain and food consumption. DJB rats showed weight-independent improvement in GT, which improved less after SG. Furthermore, SG significantly suppressed plasma ghrelin and increased insulin, glucagon like peptide-1 (GLP-1), glucose-dependent insulinotropic peptide and peptide YY response to oral glucose whereas DJB had no effects on postprandial levels of these hormones. DJB restored postprandial glucagon suppression in diabetic rats whereas SG did not affect glucagon response. The combination procedure (SG þ DJB) induced greater weight loss and better GT than SG alone without reducing food intake further. Conclusions: These findings reveal a dominant role of the stomach in the regulation of body weight and incretin response to oral glucose whereas intestinal bypass primarily affects glucose homeostasis by a weight-, insulin-and incretin-independent mechanism Obesity (2014) 21, 159-169.

In the pediatric population with choledochal cyst, total intracorporeal Roux-en-Y hepaticojejunostomy and jejunojejunostomy during laparoscopic surgery is feasible without the need for exteriorization of the bowel.

The increased sensitivity of many imaging devices has increased the identification of asymptomatic nodules in the thyroid gland. In this study we investigated the actual incidence of nonpalpable thyroid nodules and occult carcinoma in women. Between January and June 2003, among the women who were scheduled to undergo breast ultrasonography, 697 without palpable thyroid nodules were screened for thyroid nodules. They were classified into four categories according to ultrasonographic findings: negative, benign, indeterminate and malignant. Ultrasound-guided fine-needle aspiration biopsy (FNAB) was carried out for all malignant lesions and for some of the benign and indeterminate ones. The nodule detection and malignancy rates were determined and the effectiveness of ultrasonography as a diagnostic tool was also investigated. Out of the 697 subjects, 246 (35.3%) were found to have thyroid nodules. The malignancy detection rate based on the FNAB results, including both suspicious and malignant groups, was 3.6% (25/697) for all subjects. In addition, 3.0% (21/697) of all the women were confirmed to have thyroid cancer by surgery. The sensitivity of sonographic classification was increased from 80% to 100% when the indeterminate class was added to the malignant one, although this decreased the specificity from 91.7% to 33.3%. In conclusion, high-resolution ultrasonography detected a high percentage of malignant nodules. Ultrasonography can augment its value by guiding FNAB, in addition to providing diagnostic images.

Conventional bariatric operations, including Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding, and biliopancreatic diversion (BPD) appear to be a safe and effective treatment for many severely obese patients with type 2 diabetes mellitus (T2DM). These operations improve glucose homeostasis through a variety of mechanisms, however, not only due to reduced food intake and body weight. Research to elucidate the weight-independent antidiabetic mechanisms of gastrointestinal (GI) surgery and to clarify the molecular mechanisms responsible for the benefits of GI surgery on glucose homeostasis is a compelling research objective. We review the existing knowledge regarding the clinical outcomes and of the mechanisms of GI surgery to treat T2DM.

Type 2 diabetes mellitus (T2DM) is a major health priority globally, having achieved pandemic status in the twenty-first century. Several gastrointestinal procedures that were primarily designed to treat morbid obesity result in dramatic remission of diabetes. Studies in experimental rodent models and humans have shown that the glycemic benefits of surgery are at least in part weight-independent and extend to non-morbidly obese subjects with T2DM. Bariatric procedures differ in their ability to ameliorate type 2 diabetes, with intestinal bypass procedures being more effective than purely restrictive procedures. Several studies have demonstrated that the benefits of bariatric surgery extend beyond amelioration of hyperglycemia and include improvement in other cardiovascular risk factors such as dyslipidemia and hypertension. The safety and cost-effectiveness of bariatric surgery are also well established by several studies. In this paper, the authors present the surgeon perspective on the management of type 2 diabetes focusing on the efficacy, safety and cost-effectiveness of metabolic surgery. The available evidence warrants the inclusion of metabolic surgery in the treatment algorithm of type 2 diabetes.

Left colonic antegrade continence enema (ACE) has been reported only as an alternative to right colonic ACE-the Malone appendicostomy and Monti retubularized ileostomy. This paper evaluated the advantages of left colonic ACE using a retubularized sigmoidostomy (RS) as an appropriate method for maintaining fecal continence and as a first-line surgical treatment for patients with fecal incontinence or intractable constipation. Ten patients underwent surgery between March 2002 and June 2003: seven with meningomyelocele, one with cloacal anomaly, one with anorectal malformation, and one with lipoma of the spine. An RS tube was fashioned and then implanted using a segment of the sigmoid colon and exteriorized through the umbilicus. An enema was done 10 days after surgery using only normal saline. The outcomes were assessed after adjusting to the appropriate enema regimen for the 10 cases. The mean duration of the enema was 23.0+/-8.4 min, with 250 ml (range 80-800) as the median volume of fluid used. The enema interval ranged from 1-3 days. No patient showed any abdominal discomfort or soiling episodes, with the exception of one who experienced daytime fecal staining, but this occurred less than once per month. The self-cosmesis for the umbilical stoma was satisfactory. The RS procedure provided excellent continence control, with a shortening of the enema duration, a lower fluid volume, and good cosmesis, and without any ACE-related abdominal pain. This procedure can be used as a first-choice surgical treatment for intractable constipation and fecal incontinence.