Laparoscopic transhiatal resection of a large mid-esophageal diverticulum: a case report.

This is a description of transhiatal laparoscopic approach for mid-esophageal diverticulum. Traditionally mid-esophageal diverticula are approached by thoracotomy or thoracoscopy, with the laparoscopic technique being reserved for epiphrenic diverticula. A 78-year-old Caucasian female with a secondary dilatative ischemic cardiomyopathy presented with dysphagia, tenderness in the epigastrium and a considerable weight loss. A large mid-esophageal diverticulum was found on barium swallow and confirmed by CT scan. Underlying achalasia was recorded on manometry. The patient underwent diverticulectomy via transhiatal approach, followed by Heller myotomy and Dor fundoplication. Throughout the procedure auxiliary, esophagoscopic image was provided by interventional gastroenterologist due to a very narrow operating field and lack of orientation points. Based on our experience with this case, we propose transhiatal approach as a feasible alternative to thoracoscopy, in particular with patients who suffer from cardiac or pulmonary co-morbidities which make traditional techniques of high risk.

Changes in metabolic hormones after bariatric surgery and their predictive impact on weight loss.

BACKGROUND: Although various metabolic hormones have been implicated in bariatric-related weight loss, their use as predictors of weight loss is unknown. Our study evaluates changes in metabolic hormones after bariatric surgery, and their role as predictors of weight loss. METHODS: This nonrandomized study included 51 patients, 21 underwent laporascopic adjustable gastric banding (LAGB), 15 laparoscopic sleeve gastrectomy (LSG) and 15 Roux-en Y gastric bypass (RYGB). Serum ghrelin, leptin, insulin, growth hormone, HOMA-IR and HOMA-ß was recorded at baseline and 1, 3, 6 and 12 months, and correlated with weight loss. Successful weight loss was defined as excess weight loss >50% at 12 months for all groups. RESULTS: Weight loss pattern was similar in all groups. Ghrelin increased only in the LAGB group (P = 0·016). However, baseline ghrelin concentrations >664·6 pg/mL in the LSG group predicted successful weight loss with 81·8% sensitivity and 100·0% specificity, and ghrelin >969·8 pg/mL in the 1st postoperative month predicted success with 83·3% sensitivity and 83·3% specificity in the LAGB group. Insulin and HOMA-IR decreased significantly in the LSG and RYGB group, HOMA-ß increased in the LAGB and LSG group. Serum leptin decreased and GH increased in all groups (P < 0·001 for all changes). Changes in insulin, leptin and growth hormone were not predictors, but a consequence of weight loss. CONCLUSIONS: LSG is the most effective procedure for improvement of beta-cell function. High baseline ghrelin in the LSG group and an adequate 1st month increase in the LAGB group are associated with greater weight loss. Validation studies are required to confirm the role of ghrelin in predicting weight loss after bariatric surgery, but also in selecting candidates for specific bariatric procedures.

Initial Weight Loss after Restrictive Bariatric Procedures May Predict Mid-Term Weight Maintenance: Results From a 12-Month Pilot Trial.

Background: Bariatric procedures are effective options for weight loss (WL) in the morbidly obese. However, some patients fail to lose any weight after bariatric surgery, and mid-term weight maintenance is variable. The aim of this study was to investigate whether initial WL could predict mid-term weight maintenance. Methods: Eighty patients were enrolled, of whom 44 were treated with the BioEnterics Intragastric Balloon (BIB), 21 with laparoscopic adjustable gastric lap-banding (LAGB), and 15 with laparoscopic sleeve gastrectomy (LSG). Percentage of body WL and percentage of excess weight loss (EWL) were calculated at baseline and after 1, 3, 6, and 12 months. Successful WL was defined as EWL >20% for patients treated with BIB and >50% for patients treated with LAGB and SG. Results: Success in the 6th and 12th month was achieved in 80% and 58% of patients in the BIB group, 33% and 40% in the LAGB group, and 60% and 73% in the LSG group. In the BIB group, WL in the 1st month correlated positively with WL at the 6th and 12th month, and an initial WL >6.5% best predicted success (sensitivity 50%, specificity 80%). A similar association was observed in the LAGB group at the 6th and 12th month and an initial WL >9.4% best predicted success (sensitivity 90.0%, specificity 81.2%). In patients treated with LSG, WL in the 3rd month correlated positively with EWL at the 6th and 12th month, with a cutoff value of 17% (sensitivity 66.7%, specificity 100%). Conclusions: WL in the 1st month in patients treated with BIB and LAGB and WL in the 3rd month in patients treated with LSG could be used as a prognostic factor to predict mid-term weight maintenance.

Regional bone loss following femoral neck fracture: A comparison between cemented and cementless hemiarthroplasty.

The aim of this prospective, randomised study was to measure and evaluate regional bone mineral changes and clinical results following the use of cemented and cementless hemiarthroplasty (HA) for treatment of femoral neck fracture in elderly patients. The study comprised 60 patients, 30 with cemented HA (group A) and 30 with cementless HA (group B). All patients underwent osteodensitometry of the contralateral hip, lumbar spine and bilateral distal femur. Dual-energy x-ray absorptiometry (DEXA) was scheduled at 1 month, 6 months and 1 year after surgery. Harris Hip Score (HHS) was used for functional assessment. Overall mortality rate was 20.3% within 1 year after surgery. There were no significant differences in morbidity, mortality and hospital stay between the two groups of patients. The implantation of cemented prosthesis took statistically significantly longer than that of cementless prosthesis (79.03±3.59 vs 68.02±5.97min; p=0.00). Functional score in patients treated with cemented HA was significantly higher compared with those with cementless HA. There was a trend of less intensive reduction of bone mineral density (BMD) in regions of interest of the lumbar spine and ipsilateral distal femur in patients with cemented HA (group A), whereas bone loss was less pronounced for the contralateral hip and distal femur in patients treated with cementless HA (group B). Management of displaced femoral neck fractures in elderly patients with cemented and cementless HA provides a comparable outcome with regard to morbidity and mortality; however, functional outcome of patients treated with cementless HA tends to be lower. There is less intensive BMD reduction in lumbar spine and ipsilateral distal femur in patients treated with cemented HA, whereas BMD reduction in patients treated with cementless HA is more likely to be less intensive in contralateral hip and distal femur.

Periprosthetic bone loss following hemiarthroplasty: a comparison between cemented and cementless hip prosthesis.

The aim of this prospective randomized clinical study was to evaluate the magnitude of bone mineral changes as well as the clinical results after cemented and cementless haemiarthroplasty (HA) for femoral neck fracture. The study was comprised of 60 patients (mean age 85.2 years); 30 of them underwent cemented HA and 30 cementless HA. All patients underwent osteodensitometry for the purpose of Bone Mineral Density (BMD) evaluation. BMD was measured with dual-energy X-ray absorptiometry test (DEXA scans), which was scheduled at 1 month, 6 months and 1 year after surgery. BMD was evaluated at each of the seven Gruen zones. Harris Hip Score (HHS) at 3 months, 6 months and 12 months was used for evaluation of functional outcome. No difference was found between the two groups of patients in terms hospital stay, morbidity and mortality. The procedure took longer time in group A (cemented HA) compared to group B (cementless HA) (79.03 ± 3.59 vs 68.02 ± 5.97 minutes; p = 0.00). The Harris hip score averaged 76.97 ± 7.49 one year after surgery. At each follow - up examination the HHS was significantly higher in patients with cemented HA. We noted a trend of less intensive BMD reduction in all Gruen zones in group A compared to group B. However, the difference in BMD reduction between these two groups was significant only in zones 2, 3 and 4. Our results support the view that cemented hemiarthroplasty should be used for the management of displaced femoral neck fractures providing better functional outcomes and lower periprosthetic bone loss.

Internal fixation with locking plate of 3- and 4-part proximal humeral fractures in elderly patients: complications and functional outcome.

Despite recent advances in operative techniques, internal fixation of (3- and 4-part) displaced proximal humeral fractures in elderly patients with osteoporotic bone remains controversial, sometimes followed by poor results. The aim of the present study was to evaluate outcomes of internal fixation with locking plate of multi-fragment proximal humeral fractures in elderly patients. The study cohort comprised 59 consecutive patients (mean age 70.1) with 3- and 4-part fractures who had undergone open reduction and internal fixation with locked plate at Sestre milosrdnice University Hospital Center in Zagreb, Croatia. All patients were invited for follow-up examinations and underwent standard x-ray examination preoperatively to assess fracture pattern in the operating theatre as well as at 6 weeks, 3 and 6 months, 1 year, and then annually after surgery to assess fracture healing or complications. Clinical outcomes were measured by constant score. Patients were followed-up for 14 to 36 months. The overall complication rate was 27.1%. The mean constant score at 1-year follow-up was 70.2 points for 3-part fractures vs. 64.2 for 4-part fractures (p < 0.0001). In conclusion, despite a relatively high overall complication rate, internal fixation with locking plate provided moderate to good functional results in the treatment of osteoporotic complex proximal humeral fractures.

Approach to distal femur by osteotomy of the patellar distal pole and internal fixation with basket plate in complex articular fracture: report of five cases.

According to AO classification, 33-C3 (complete articular multifragmentary) fracture of distal femur is characterized by complex articular involvement, along with short distal femoral block with multiple small fragments and usually with severe soft tissue abruption. In such cases of complex articular fracture of distal femur with extensive comminution of the femur condyle that is often seen in these fractures, anatomical reduction is quite difficult. Minimal fixation strategies sometimes do not provide an optimal degree of reduction and stability of the distal femoral block osteosynthesis. We describe 5 cases of treatment of the 33-C3 distal femoral fractures using arthrotomy of the knee joint by osteotomy of the distal pole of the patella and internal fixation with basket plate as an alternative approach for anatomical reduction of the comminuted articular surface.

Combined sleeve gastrectomy and mini-gastric bypass in a new bariatric procedure of mini-gastric bypass and proximal sleeve gastrectomy.

Surgery is the most effective method for the treatment of morbid obesity. Beneficial effects of bariatric surgery are due to both changed anatomy and consequential alterations in hormonal and metabolic status. Based on the experience with former standard bariatric procedures, the idea came out of a new combined bariatric procedure that could provide better control of glucose level and weight loss. The procedure is a hybrid of sleeve gastrectomy and mini-gastric bypass, therefore uniting advantages of both procedures: one anastomosis, achieved effects of restriction and malabsorption and affection of both dominant endocrine systems that result in an increase in incretin level and a decrease in ghrelin level. However, the procedure is yet a novel one and these hypotheses are about to be examined in the already announced research project.

Single incision laparoscopic spigelian hernia repair--an approach with standard instrumentarium.

Spigelian hernia is a rare type of abdominal wall ventral hernia caused by defect in the spigelian fascia and presented with pain and/or palpable mass. This diagnosis is an indication for surgical procedure due to the high risk of incarceration. There are two surgical approaches (open and laparoscopic), both using two methods of repair (mesh-free primary closure and tension-free mesh repair), depending on the hernia ring size. We present a case of a 62-year-old woman with a palpable mass localized in the left spigelian hernia belt, verified by ultrasonography as a spigelian hernia. A single incision intra-abdominal laparoscopic approach with a tension-free underlay mesh-repair technique was used to treat the condition. Operating time was 40 minutes and the procedure was completed without complications. Postoperative recovery was uneventful as well as 1-week and 2-month follow up. To our knowledge, this is the first report of spigelian hernia repair by single incision laparoscopic surgery. Although this approach is more demanding in comparison to multiport laparoscopy, it proved to be safe and feasible for experienced laparoscopic team. Besides cosmetic improvement, the single incision approach reduces to minimum the risk of bleeding, organ injury and incisional postoperative hernia. To determine optimal indications and limits of this approach, further data collection and follow up are required.

Lack of prognostic significance of connexin-43 labeling in a series of 46 gastrointestinal stromal tumors.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors with variable malignant potential. Connexin-43 (Cx43) is the commonest gap-junction protein and has been frequently investigated in oncology. Our aim was to establish the immunohistochemical expression of Cx43 in relation to GIST location, size, Ki67 index, tumor grade and follow-up.? MATERIALS AND METHODS: The study included postoperative samples of 46 patients treated for GIST in the 1999-2010 time frame. Complete clinical workup was available for 38 patients (82.6%); total surgical resection was carried out in 32 (84.2%) patients, while 13 (34.2%) patients underwent chemotherapy. Median follow-up was 40.7 months (range, 1-134). ? RESULTS: The calculated incidence of GIST in our setting was 11.5 per million. Cx43 was expressed in 43/46 (93.5%) GIST cases, with a significant difference between stomach- and small intestine-derived tumors (p=0.006). Ki67 was 10% on average (range, 1-22) and was not correlated with tumor location (p=0.194). Cx43 did not show significance with regard to tumor size (p=0.264) or higher tumor grade (p=0.658), as opposed to Ki67, which significantly correlated with both (p=0.0048 and p<0.001, respectively). Cx43 and Ki67 were not significantly correlated (p=0.708). Ki67 correlated with time to recurrence (p=0.022). Ki67 >11% was taken as the indication to start imatinib chemotherapy (sensitivity 61.5%, specificity 92.0%, p=0.022). Ten (66.7%) of 15 patients with long-term (>5 years) follow-up were in remission.? CONCLUSION: Cx43 was frequently expressed in GISTs regardless of tumor site. However, no significant relationships to histopathological parameters suggestive for prognosis were found. Further investigations might clarify the roles of Cx43 in GIST oncogenesis.

Morbidly obese are ghrelin and leptin hyporesponders with lesser intragastric balloon treatment efficiency : ghrelin and leptin changes in relation to obesity treatment.

BACKGROUND: Ghrelin and leptin recently emerged as the most influential neuroendocrine factors in the pathophysiology of obesity. The said peptides act in reciprocity and are responsible for regulation of appetite and energy metabolism. Intragastric balloons acquired worldwide popularity for obesity treatment. However, the roles of ghrelin and leptin in intragastric balloon treatment were still not systematically studied. METHODS: A prospective single-center study included 43 Caucasians treated with BioEnterics intragastric balloon, with age range of 18-60, and divided to non-morbid (body mass index cutoff 40 kg/m(2)) or morbid type of obesity, with 12 months follow-up. Serum hormonal samples were taken from fasting patients and kept frozen until analyses. RESULTS: Significant differences were observed in anthropometrics and there were no differences between genders or comorbidities. The baseline weight for non-morbid vs. morbid was 104 kg (90-135) vs. 128.5 kg (104-197). Weight loss was statistically different between the studied groups during the study course with a median control weight at 6 months of 92 kg (72-121) vs. 107 kg (84-163), p < 0.001. Treatment was successful for 18 (94.7%) vs. 16 (66.7%) patients, p = 0.026. Ghrelin varied from 333.3 to 3,416.8 pg/ml and leptin from 1.7 to 61.2 ng/ml, with a statistically significant time-dependent relationship. A significant difference (p = 0.04) with emphasized ghrelin peak was found in the 3rd month of treatment for non-morbidly obese subjects. CONCLUSIONS: The importance of ghrelin and leptin in treatment-induced changes was reaffirmed. Ghrelin hyper-response in non-morbidly obese subjects characterized greater short-term treatment efficiency and landmarked an inclination to weight regain. The results suggest a potential pattern of individualization between obese patients according to body mass index towards intragastric balloon or bariatric surgery. Further studies are needed in order to get better insights in the pathophysiologic mechanisms of obesity.

Obesity treatment using a Bioenterics intragastric balloon (BIB)--preliminary Croatian results.

AIM OF STUDY: This study aims to assess the effectiveness, tolerance, safety, and patient satisfaction of obesity treatments using the Bioenterics intragastric balloon (BIB). METHODS: Prospective controlled trial of 33 obese patients who were treated with the BIB from March 2008 to March 2009 and who completed the 6 months treatment. Patients were selected on the basis of workup by a multidisciplinary team. The 33 obese patients (26 females, seven males) had a median age of 35 years (range 20-58). Their median baseline body weight (BW) was 114 kg (range 89-197) and their median body mass index (BMI) was 41.4 kg/m(2) (range 31.2-60.8). RESULTS: Average weight reduction was 14 kg (range 2-37), loss total weight 10.1% (range 1.4-23.1), control BMI 35.6 kg/m(2) (range 29.4-50.3), delta BMI 4.5 (range 0.6-13.1), percentage excess weight loss 29.2 (range 2.8-53.6), and percent of excess BMI loss 29.3 (range 2.7-67.4). In one female patient the BIB was removed early due to intolerance. During the first week, minor side effects were noticed: nausea/vomiting occurred in 21 patients (63.6%), and abdominal cramps in 15 (45.5%). There was one balloon deflation and one impaction in the stomach. Those incidents were both successfully treated endoscopically. Patients had no major complications from mucosal lesions and no need for surgical interventions. All intragastric balloons were successfully removed endoscopically. Patients' treatment satisfaction correlated with the degree of BW loss (p = 0.0138). CONCLUSION: BIB treatment in our setting showed the best results for individuals with BMI from 35 to 40 kg/m(2). Our preliminary results showed that BIB is safe, well tolerated with minor side effects, and alters quality of life for the better. The complication rate was negligible, due to the detailed pretreatment examinations and follow-up.

Position of intragastric balloons in global initiative for obesity treatment.

Obesity is chronic disease with multiple health consequences and among the most severe health problems worldwide. According to public health records around 65% of population in Croatia are overweight and 20% obese. National physicians chamber with support of Health and Social Welfare Ministry gave recommendations on diagnosing and treating of obesity in form of national consensus. Treatment of obesity is complex and enrolls multiple clinical specialties. Change of life style, strenuous physical activity and pharmacotherapy are part of conservative treatments. Patients are treated more efficiently by minimally invasive endoscopic procedures or bariatric surgery depending on starting body mass index score. Implantation of intragastric balloons is conceptually simple method of obesity treatment. Modern devices as Bio-Enterics intragastric balloons (BIB), (Inamed Health, USA) are gaining wide popularity among both patients and physicians. BIB intragastric offers the best gains with individuals ranging BMI from 35 to 40. Efficiency has relative timeline dependance from 85% at 6 months to 24% at 36 months. BIB offers substantial ameliorative influence on obesity comorbidities, particularly cardiovascular risk. Treatment with BIB is also efficient but transient treatment modality in morbidly and superobese individuals to reduce preoperative risks of general and bariatric surgery. Obesity treatment with BIB is well tolerated and safe, offering better quality of life. Nevertheless, due to relative poor results of conservative obesity treatments on long-term follow up further investigations defining new clinical parameters for solving treatment resistance. In order to provide resourcefully individualized approach modern perspectives are focused on endocrine constitutes of obesity. Hormonal effects of BIB treatment in compare to bariatric surgery are potentially interesting for the prospect studies.

Laparoscopic Roux-en-Y gastric bypass for morbid obesity -- case report.

Morbid obesity is currently one of the leading problems worldwide. More than 1 of 5 adults in Croatia are considered obese, with a body mass index (BMI) higher than 30 kg/ m(2), with no sex differences. Indications for bariatric surgery are BMI >40 kg/m(2) or BMI >35 kg/m(2) with comorbidities. Bariatric procedures are divided into restrictive, malabsorptive, and combined procedures. The Roux-en-Y gastric bypass is a combined bariatric procedure, already being accepted as the standard one in the USA and gaining ground in Europe as well. A 47-year-old woman with BMI of 48.2 kg/m(2) (105.5 kg) was hospitalized at our department. Her increasing attempts to lose weight using conservative methods showed no success. She also suffered from glucose intolerance, gastritis, chronic obstructive pulmonary disease, hypertension and depression as comorbidities. Based on our experience in bariatric surgery (gastric banding, sleeve gastrectomy, duodenal switch), we decided for the first time in our hospital to perform laparoscopic Roux-en-Y gastric bypass. The patient was released on the fifth postoperative day with BMI of 40.56 kg/m(2) (100 kg body weight), excess weight loss 12.5%. One month after the procedure, her BMI was 38.54 kg/m(2), excess weight loss 23.92% (body weight 95 kg).

First report of connexin 43-positive gastrointestinal stromal tumor (GIST).

Gastrointestinal stromal tumors (GISTs) are mesenchymal neoplasms most frequently found in the stomach and presenting without symptoms or with unspecific ones such as hemorrhage and abdominal pain. The malignant potential of GIST is variable and there are several prognostic indexes for treatment and follow up. The superior diagnostic method is endoscopic ultrasound combined with fine needle aspiration biopsy (EUS-FNA) immunocytochemistry. Surgery is the preferable treatment option, while recurrent or advanced disease is best managed with thyrosine kinase inhibitors. We report a case of a 20-year-old man that presented with gastrointestinal bleeding and anemia. Upper gastrointestinal endoscopy detected a submucosal lesion and computerized tomography revealed a node near the liver. EUS-FNA immunocytochemistry found CD-117 positive cells suggestive of GIST and the patient was operated on. The diagnosis was confirmed by histopathology with immunostaining. Prognostic assessment was done according to tumor size and Ki-67 index with mitosis count on microscopy. Many studies have shown that tumors demonstrate an abnormal number, structure and occurrence of connexin proteins with altered connexin-mediated intercellular communication. Since a great deal of gastroenterological tumors express connexin 43, our aim was to find out whether it was present in GIST. Immunohistochemically, the tumor was positive for connexin 43, which was not previously described as typical. The early postoperative course was uneventful, free from complications. At three-year postoperative follow-up, the patient was subjectively well and without clinical signs of disease recurrence.

Prompt treatment of intestinal obstruction after biliopancreatic diversion can save the intestinal loop.

Bariatric surgery is becoming an accepted method for weight reduction. Biliopancreatic diversion is reserved for high initial BMI. With the increasing number of these procedures, the reports of complications become more important and prepare a wider range of specialties to deal with them. We report a 62-year-old woman who developed a volvulus of the biliopancreatic loop after a biliary diversion operation with a sleeve gastrectomy and antro-ileal anastomosis. Symptoms of biliopancreatic loop obstruction are rather vague, presenting with atypical abdominal pain, nausea, sometimes vomiting, preserved bowel motility, stool, and gas passage and normal upper GI X-ray. Due to the patient's prompt reaction and straight referral to a bariatric surgeon, freeing of the loop was enough to maintain its viability. The patient's further recovery and follow-up were uneventful. With this case, we stress the importance of an expert in such cases and a need to consider familiarizing doctors with these patients and with the peculiarities of their treatment.

Multifragment fracture of the patellar apex: basket plate osteosynthesis compared with partial patellectomy.

INTRODUCTION: The purpose of the present study was to evaluate and compare the long-term results of operative treatment of a multifragment fracture of the inferior patellar pole by basket plate osteosynthesis and partial patellectomy. MATERIALS AND METHODS: We retrospectively studied two groups of patients who had operative treatment of a multifragment fracture of the inferior patellar pole between 1988 and 2004. Seventy-one patients who had osteosynthesis by basket plate (Group 1) and 49 patients who had partial patellectomy (Group 2) were followed for an average of 5.3 years. The final evaluation was based on the modified Cincinnati Knee rating system test. RESULTS: The results were excellent or good in 90.1% patients of Group 1, and 73.5% patients of Group 2. Significant differences between the groups were noted with regard to knee pain, swallowing, level activity, compression pain, range of motion, muscular atrophy, muscular strength, and final patellofemoral score which confirms statistical analysis. CONCLUSION: The stability of the osteosynthesis by basket plate allows osseous consolidation of the fracture and permits immediate mobilization and early weight bearing. Osteosynthesis by basket plate can provide better clinical results.