Mahmoud ElSafty

Introduction: The management of gallbladder disease during metabolic and bariatric surgery (MBS) remains controversial. Cholelithiasis is common in patients with obesity, yet the approach to concomitant or prophylactic cholecystectomy varies, with limited data from Egypt. This study aimed to assess Egyptian bariatric surgeons’ practices, attitudes, and decision-making regarding cholecystectomy during MBS. Methods: A national cross-sectional survey was distributed to bariatric surgeons in Egypt, collecting information on demographics, surgical experience, preoperative screening, intraoperative decision-making, postoperative management, and prophylactic practices. The questionnaire included structured, closed-ended questions. Data were analyzed descriptively and compared between IFSO members and non-members using chi-square or Fisher’s exact tests, with p < 0.05 considered significant. Results: A total of 117 surgeons participated, predominantly male (99%), with 16.2% IFSO members. Bariatric surgery was concentrated in Cairo (42%) and Alexandria (26%). Most surgeons (97%) screened gallstones preoperatively using abdominal ultrasound. Concomitant cholecystectomy was preferred for documented gallstones by 78%, while 82% never performed prophylactic cholecystectomy in patients with normal gallbladders. The majority performed the bariatric procedure first (82%) in reverse Trendelenburg position (88%), minimizing additional ports. Routine intraoperative cholangiography was rare (1.7%). Postoperative management largely mirrored isolated bariatric surgery, although antibiotic and drain practices differed between groups. Surgeons generally perceived combined procedures as safe, with 76% reporting no increase in complications and 89% reporting similar length of stay. Conclusion: Egyptian bariatric surgeons consistently screen for gallstones and favor concomitant cholecystectomy for documented stones, while largely avoiding prophylactic removal of normal gallbladders. Variation exists in intraoperative management and postoperative care. These findings highlight areas for standardization and support the development of a national pathway and multicenter registry to optimize gallbladder management in MBS.

Secondary aortoenteric fistula is a rare and life-threatening complication following aortic reconstructive surgery, most commonly involving the duodenum. Erosion of an aortofemoral bypass graft into the sigmoid colon is exceptionally uncommon; all reported cases were managed via open surgery with significant morbidity. Laparoscopic management with graft preservation has not been documented. A 59-year-old man presented with massive hematochezia 9 months after bilateral aortobifemoral bypass for an abdominal aortic and common iliac aneurysm. Colonoscopy revealed a vascular graft 25 cm from the anal verge. Computed tomography confirmed penetration of the graft into the sigmoid lumen without abscess or contrast extravasation. The patient underwent laparoscopic sigmoid colectomy with graft preservation and peritoneal coverage, followed by colorectal anastomosis and defunctioning ileostomy. He was discharged on postoperative Day 7. He was maintained on a 6-week course of targeted oral antimicrobial therapy. At 6-month follow-up, the patient remains well with a patent graft, no recurrent bleeding, and no graft-related complications. This case highlights the feasibility of minimally invasive management and selective graft preservation in carefully selected patients, challenging the paradigm of mandatory graft excision.

Purpose This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to evaluate the efficacy and safety of septoplasty versus non-surgical management for patients experiencing nasal obstruction due to deviated nasal septum (DNS). Methods We conducted a comprehensive search of PubMed, Scopus, Embase, Web of Science, Cochrane Library, Clinicaltrials.gov, ICTRP, and ISRCTN for relevant RCTs. The primary outcomes included the Nasal Obstruction Symptom Evaluation (NOSE) scale, Sino-Nasal Outcome Test (SNOT-22), Peak Nasal Inspiratory Flow (PNIF), surgical complications, and quality of life. Data were synthesized using RevMan 5.4 and STATA 18, with effect estimates presented as mean differences (MD) or risk ratios (RR) with 95% confidence intervals (CI). The study protocol was registered with PROSPERO (ID: CRD42024538373). Results Our search identified 537 studies, of which 3 RCTs involving 721 participants met the inclusion criteria. The meta-analysis revealed that septoplasty significantly improved NOSE and SNOT-22 scores compared to non-surgical interventions at 6 and 12 months of follow-up, despite no notable differences at 3 months post-treatment. No significant difference was observed regarding nasal flow assessed by PNIF. The rate of complications was low, ranging from 0.31% (revision rate) to 4.12% (bleeding and infection rates). Additionally, our qualitative synthesis showed an improvement in the quality of life at 6 and 12 months in the septoplasty group compared with the non-surgical group. Conclusions This systematic review and meta-analysis of 721 patients revealed the efficacy of septoplasty, with or without turbinate surgery, in improving nasal obstruction symptoms at 6 and 12 months. Additionally, septoplasty consists of a relatively low rate of complications such as bleeding, infection, and septal perforation. Furthermore, a low revision rate was found. Septoplasty improved the quality of life, especially after 6 and 12 months. However, our findings should be interpreted with caution, and further research is needed to consolidate our results.