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Concept: Surgical procedures


Roux-en-Y gastric bypass (RYGB) has greater efficacy for weight loss in obese patients than gastric banding (BAND) surgery. We hypothesise that this may result from different effects on food hedonics via physiological changes secondary to distinct gut anatomy manipulations.

Concepts: Obesity, Bariatric surgery, Gastric bypass surgery, Bariatrics, Duodenum, Surgical procedures, Beriberi, The Band


Many obese subjects suffer from an increased hedonic drive to consume palatable foods, i.e., hedonic hunger, and often show unfavorable dietary habits. Here, we investigated changes in the hedonic hunger and dietary habits after Roux-en-Y gastric bypass (RYGB) surgery.

Concepts: Nutrition, Obesity, Bariatric surgery, Gastric bypass surgery, Bariatrics, Duodenum, Surgical procedures, Beriberi


despite an exponential rise in the number of medically initiated elective caesarean sections over the last two decades, women’s experiences of this birth mode remain largely unknown. The aim of this study was to address this gap by describing women’s experiences of medically necessary elective caesarean section.

Concepts: Childbirth, Obstetrics, Caesarean delivery on maternal request, Caesarean section, Surgical procedures



PURPOSE: Male patients with bladder and cloacal exstrophy are born with demure genitalia and often desire phalloplasty during late adolescence or early adulthood. Radial forearm free flap phalloplasty has been used successfully for congenital aphallia in a few small series. The authors present a series of patients who have undergone phalloplasty by means of radial forearm free flap following repair of bladder and cloacal exstrophy. METHODS: A review of 10 patients who underwent radial forearm free flap phalloplasty between 2007 and 2012 was completed. Indications for phalloplasty were classical bladder exstrophy (8) and cloacal exstrophy (2). Nine patients underwent prior urinary diversion and 1 patient underwent urethroplasty at the time of phalloplasty. For each subject, details of prior exstrophy repair, size of flap, donor and recipient vessels, complications, need for subsequent surgeries, and self-reported sensation were reviewed. RESULTS: The graft survived in all 10 patients. Short-term complications requiring surgical intervention occurred in 2 patients. Five patients subsequently underwent placement of a penile prosthesis, and 2 devices had to be removed secondary to erosion. All 10 patients reported protective sensation and erogenous sensation with ability to orgasm at last follow-up. CONCLUSION: Radial forearm free flap phalloplasty results in a sensate and cosmetic neophallus. No patient developed long-term complications related to their phalloplasty; however, complications related to penile prostheses continue to be a challenging aspect of phalloplasty. The long-term results with use of the forearm free flap are encouraging in this series of patients with bladder and cloacal exstrophy who desire phalloplasty.

Concepts: Time, Surgery, Urology, Prosthetics, Penis, Cloacal exstrophy, Surgical procedures, Bladder exstrophy


Postoperative outcomes of animals that have undergone cesarean delivery have been reported previously; however, in most studies results were influenced by a combination of surgery per se and the preoperative condition of the animal, which was frequently impaired because of the presence of dystocia. To evaluate the effects of the cesarean section itself we conducted a matched cohort study comparing postpartum complications and future reproductive performance of 162 ewes subjected to elective cesarean section and 162 ewes that had an unassisted vaginal delivery. Survival and subsequent growth of their lambs were also compared. Effect of mode of delivery on weight gain was estimated using linear mixed models. Case ewes, which underwent surgery during the period from 1996 through 2004, and control ewes were from the flock at the Animal Production Experimental Centre, Norway. Two ewes (1.2%) that underwent cesarean section died; one developed peritonitis and the other experienced uterine prolapse and did not recover. Postoperatively, four ewes suffered from metritis, three suffered a wound infection, and four a delayed wound healing; all recovered after treatment. One of the ewes that delivered vaginally died 3 days after lambing. The incidences of fetal and postnatal deaths did not differ significantly between the cesarean and the vaginal delivery groups (fetal deaths, 3.5% and 3.1%, and postnatal deaths, 9.9% and 7.1%, respectively). Survival rates and weight gains of the lambs the subsequent months were similar for the two groups. Seventy percent of the ewes that had a cesarean section and 72% of those that had a vaginal delivery were bred the next season; conception rates were 89% and 90%, respectively. However, the ewes subjected to surgery the previous year gave birth to significantly fewer live-born lambs (mean, 1.64) than those that had had a vaginal delivery (1.93). The difference was the result of a reduced litter size and an increased number of fetal deaths in the former group. Birth weights of the live-born lambs the second year did not differ between the groups. In conclusion, severe short-term complications were rare among the ewes that underwent elective cesarean section. Survival and growth of their lambs and their conception rate the subsequent season did not differ from the corresponding outcomes of the ewes that delivered vaginally, but their fertility was reduced in the sense that they gave birth to fewer live-born lambs the following lambing season.

Concepts: Childbirth, Wound healing, Uterus, Obstetrics, Caesarean delivery on maternal request, Caesarean section, Surgical procedures, Dystocia



Population-based studies on the prevalence of symptoms after Roux-en-Y gastric bypass (RYGB) surgery are sparse. Knowledge about possible predictors of these symptoms is important for prevention.

Concepts: Obesity, Coronary artery bypass surgery, Bariatric surgery, Gastric bypass surgery, Bariatrics, Duodenum, Surgical procedures, Beriberi


Postoperative neuropathic pain exacerbated by movement is poorly understood and difficult to treat but a relatively common complication of surgical procedures such as endoscopic thoracic sympathectomy. Here, we describe a case of unexpected, immediate, complete and sustained remission of postoperative intercostal neuralgia after the patient engaged in an open-water swim in markedly cold conditions. Though an incidental chance association is possible, the clear temporal proximity linking the swim with pain remission makes a causal relationship possible. We discuss plausible mechanisms that may underlie the relationship and discuss the potential implications for postoperative pain management and patient-centred mobilisation. We recommend further evaluation of cold forced open-water swimming as a mobility-pain provocation challenge to see if the observed unexpectedly positive outcome can be replicated. With the poor response to traditional management, there is a need for novel, curative interventions for postoperative neuropathic pain and associated impaired mobility.

Concepts: Pain, Neurosurgery, Surgical procedures, Endoscopic thoracic sympathectomy


Siliconoma from ruptured breast implants has been reported in multiple body sites, including but not limited to the breast parenchyma, axillary lymph nodes, upper arm, and even lower leg. In this regard, we report a rare case of distant silicone migration to the lower extremities after traumatic breast implant rupture. A 55-year-old Asian woman who received bilateral augmentation mammoplasty 20 years ago presented with ruptured breast implants from a car accident 2 years earlier. Magnetic resonance imaging confirmed intracapsular and extracapsular rupture of the right breast implant, showing “linguine sign.” We removed the bilateral breast implants and performed capsulectomy and bilateral reduction mammoplasty using inverted-T incisions. The implant was confirmed as a smooth, silicone gel-filled mammary implant of 125 cm(3) by a Japanese manufacturer, Koken. During her regular follow-up outpatient visits, physical examination revealed 2.5- × 1.5-cm ill-defined, tender, subcutaneous nodules on both knees and 8.5- × 3.0-cm inflammatory changes in the inguinal area with persistent pain. Computed tomography showed no definite mass, but rather infiltrative, nonenhancing soft-tissue densities in the subcutaneous layers of the bilateral inguinal and knee areas. Surgical excision was performed, and pathologic findings confirmed variable vacuoles with foreign body reaction and fibrosis, consistent with siliconoma. It is important to acknowledge that siliconomas can be encountered in patients with ruptured breast implants, especially those manufactured decades ago. Our patient with masses as remote as the inguinal and knee areas is a prime example of how far siliconomas can migrate.

Concepts: Surgery, Implants, Plastic surgery, Breast, Surgical procedures, Breast reconstruction, Silicone, Breast implant