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Background Ghrelin is secreted mainly in the stomach and plays a role in food intake regulation. Morbidly obese (MO) individuals report a decline in appetite after sleeve gastrectomy (SG), presumably due, in part, to ghrelin cell removal. Ghrelin cell distribution and expression were determined in three areas of resected stomach specimens from MO patients subjected to SG. Methods Resected stomach specimens from 20 MO patients undergoing SG were analyzed. Real-time polymerase chain reaction of ghrelin mRNA and immunohistostaining for ghrelin cells in three stomach regions (fundus, body, and pre-antral areas) were performed. Body mass index (BMI) and total plasma ghrelin levels were obtained before and 3 months postoperatively. Results Ghrelin mRNA was detected throughout the stomach, its expression decreasing from the fundus towards the antrum. The relative quantification for ghrelin mRNA expression was 0.043, 0.026, and 0.015 at the fundus, body, and pre-antral region, respectively ( P  = 0.05, fundus vs. pre-antral region). Average ghrelin cell counts declined from 60 ± 40 to 45 ± 20 and 39 ± 13 cells/high power fields in the fundus, body, and pre-antral region, respectively. Three months after surgery, total plasma ghrelin levels decreased from 1,676 ± 470 to 1,179 ± 188 pg/ml ( P  < 0.00001) and BMI dropped from 46 ± 6 to 38 ± 5 kg/m 2 ( P  < 0.00001). Conclusions Distribution and expression of ghrelin-secreting cells throughout the stomach were defined, emphasizing the importance of meticulous resection of the fundus during SG for maximal ghrelin cell removal.

Introduction: Rectal cancer surgery is continuously evolving. Transanal total mesorectal excision (TaTME) is a relatively new surgical approach with possible advantages in comparison to current standard surgical techniques. Several studies in recent years have validated this approach regarding safety and effectiveness. We describe our initial experience with TaTME evaluating surgical parameters, post-operative outcomes and short-term oncological outcomes. Methods: This is a retrospective study reviewing all patients who underwent TaTME in a single institution from May 2015 to April 2018. Results: The cohort included 25 patients with an average age of 60.4 (range: 40-86), of which 13 (52%) patients were male. The average body mass index was 26.1. The overall 30-day morbidity rate was 40%, with 20% (five cases) being severe complications, defined by Clavien-Dindo Grade of 3b or above. There were three major interoperative complications. Four cases (16%) required reoperation during the first 30 post-operative days. The median length of stay was 8 days. The surgery duration was on average 296 min (range: 205-510). Negative resection margins were achieved in all patients. At a median follow-up period of 14 months, there were no local recurrences, and 4 cases (16%) had a distant recurrence. Conclusion: This study describes our initial experience with TaTME, which requires a substantial learning curve to minimise complications and morbidity. Oncological outcomes as expressed by the resection margins, number of lymph nodes harvested and local recurrence rates were all comparable to previously published data.

ORC was the major predictor of the odds of rehospitalization in a logistic regression analysis after adjustment of the confounding variables that added significantly to the model (P < 0.05). There were 540 laparoscopic operations; four were converted in-hospital (one death due to complications) and another two patients were reoperated on because of bile leaks. [...]the total open operation rate was 6/540 or 1.1 per cent (95% CI: 0.4-2.4%). Mohamed Abou Arisheh, M.D. Moris Venturero, M.D. Department of General Surgery Sanz Medical Center Laniado Hospital Netanya, Israel Paul Froom, M.D. School of Public Health Tel Aviv University Tel Aviv, Israel Department of Clinical Utility Laniado Hospital Netanya, Israel Mohamed Abou Arisheh, Moris Venturero, and Paul Froom contributed to the conception and writing of the manuscript.

Background We present data acquired in our institution about the incidence of incidental appendiceal carcinoids over a period of 16 years. The possibility of occult carcinoids raises the question of appendectomy of a noninflamed appendix during diagnostic laparoscopy for suspected appendicitis. Methods We performed a retrospective chart analysis of the surgical registry of a university-affiliated tertiary care center of a major population area for the past 16 years. Data were collected on all patients ( n  = 7592) who underwent appendectomy for the presumed diagnosis of acute appendicitis. Outcome measures were the incidence of incidental carcinoids of the appendix found during appendectomies and whether the introduction of laparoscopic appendectomy should alter the surgical management of a normal-appearing appendix. Results A total of 20 carcinoid appendices were resected by open surgery and 17 by laparoscopy. The diagnosis of a carcinoid tumor was not suspected in any patient before the operation, nor was a tumor identified at the time of the operation. In 6 (16%) patients the appendix appeared normal at the time of the operation. Conclusions It has long been the standard of care to remove any appendix found in laparotomy for suspected appendicitis, but it is not clear what should be done during laparoscopy for suspected appendicitis when the appendix appears normal. Our data confirm the presence of occult carcinoids in normal-appearing appendices. Further studies are needed to determine the clinical significance of this finding.