Advice of General Practitioner, of Surgeon, of Endocrinologist, and Self-determination: the Italian Road to Bariatric Surgery.

PURPOSE: Bariatric surgery (BS) is considered the most efficient treatment for severe obesity. International guidelines recommend multidisciplinary approach to BS (general practitioners, endocrinologists, surgeons, psychologists, or psychiatrists), and access to BS should be the final part of a protocol of treatment of obesity. However, there are indications that general practitioners (GPs) are not fully aware of the possible benefits of BS, that specialty physicians are reluctant to refer their patients to surgeons, and that patients with obesity choose self-management of their own obesity, including internet-based choices. There are no data on the pathways chosen by physicians and patients to undergo BS in the real world in Italy. METHODS: An exploratory exam was performed for 6 months in three pilot regions (Lombardy, Lazio, Campania) in twenty-three tertiary centers for the treatment of morbid obesity, to describe the real pathways to BS in Italy. RESULTS: Charts of 2686 patients (788 men and 1895 women, 75.5% in the age range 30-59 years) were evaluated by physicians and surgeons of the participating centers. A chronic condition of obesity was evident for the majority of patients, as indicated by duration of obesity, by presence of several associated medical problems, and by frequency of previous dietary attempts to weight loss. The vast majority (75.8%) patients were self-presenting or referred by bariatric surgeons, 24.2% patients referred by GPs and other specialists. Self-presenting patients were younger, more educated, more professional, and more mobile than patients referred by other physicians. Patients above the age of 40 years or with a duration of obesity greater than 10 years had a higher prevalence of all associated medical problems. CONCLUSIONS: The majority of patients referred to a tertiary center for the treatment of morbid obesity have a valid indication for BS. Most patients self-refer to the centers, with a minority referred by a GP or by specialists. Self-presenting patients are younger, more educated, more professional, and more mobile than patients referred by other physicians. Older patients and with a longer duration of obesity are probably representative of the conservative approach to BS, often regarded as the last resort in an endless story.

Biliopancreatic Diversion (BPD), Long Common Limb Revisional Biliopancreatic Diversion (BPD + LCL-R), Roux-en-Y Gastric Bypass [RYGB] and Sleeve Gastrectomy (SG) mediate differential quantitative changes in body weight and qualitative modifications in body composition: a 5-year study.

AIMS: Bariatric surgeries induce profound weight loss (decrease in body mass index, BMI), through a decrease in fat mass (FM) and to a much lesser degree of fat-free mass (FFM). Some reports indicate that the weight which is lost after gastric bypass (RYGB) and sleeve gastrectomy (SG) is at least partially regained 2 years after surgery. Here we compare changes in BMI and body composition induced by four bariatric procedures in a 5 years follow-up study. METHODS: We analyzed retrospectively modifications in BMI, FM and FFM obtained through Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), biliopancreatic diversion (BPD) and a long common limb revisional biliopancreatic diversion (reduction of the gastric pouch and long common limb; BPD + LCL-R). Patients were evaluated at baseline and yearly for 5 years. Of the whole cohort of 565 patients, a subset of 180 patients had all yearly evaluations, while the remaining had incomplete evaluations. Setting University Hospital. RESULTS: In a total of 180 patients evaluated yearly for 5 years, decrease in BMI and FM up to 2 years was more rapid with RYGB and SG than BPD and BPD + LCL-R; with RYGB and SG both BMI and FM slightly increased in the years 3-5. At 5 years, the differences were not significant. When analysing the differences between 2 and 5 years, BPD + LCL-R showed a somewhat greater effect on BMI and FM than RYGB, BPD and SG. Superimposable results were obtained when the whole cohort of 565 patients with incomplete evaluation was considered. CONCLUSIONS: All surgeries were highly effective in reducing BMI and fat mass at around 2 years; with RYGB and SG both BMI and FM slightly increased in the years 3-5, while BPD and BPD + LCL-R showed a slight further decreases in the same time interval.

Revision of Biliopancreatic Diversion for Side Effects or Insufficient Weight Loss: Codification of a New Procedure.

PURPOSE: Addressing the problem of proctologic sequelae after Scopinaro's classical BPD, we elongated the common limb from 50 to 200 cm at the expense of the alimentary limb and simultaneously, with the aim of avoiding weight regain, reduced the gastric pouch from 500 to 40 ml. After increased experience with the new procedure, we observed a favourable tendency towards further weight loss. Thus, we subsequently extended the indication to the procedure to patients with unsatisfactory weight loss after Scopinaro's classical BPD (SBPD). METHODS: We retrospectively reviewed our clinical experience with the new procedure. RESULTS: From March 2008 to December 2014, 38 patients were submitted to the revisional procedure. The indication to surgical revision was proctologic in 26 patients and unsatisfactory weight loss in 12. After the revisional procedure, a significant reduction in bowel movements per day was observed, together with a significant reduction in body weight (from preoperative 87.1 ± 21 to 69.2 ± 13.5 kg at post-operative year 1 and 68.1 ± 11.9 kg at year 5; p < 0.001) and a parallel reduction in BMI (from preoperative 33.03 ± 7.6 to 26.8 ± 4.1 at post-operative year 1 and 26.9 ± 2.8 at year 5; p < 0.001). Mean excess BMI percent loss was 49.5 ± 94.6% at post-operative month 3, 76.51 ± 74.9% at year 1 and 76.2 ± 31.3% at year 5. Nutritional and metabolic parameters remained stable. Similar results were observed, analysing separately both groups of patients. CONCLUSIONS: Our preliminary data suggest that the proposed procedure could represent a safe and effective revisional tool to treat invalidating proctologic sequelae after SBPD, or when weight loss may be deemed unsatisfactory.

Clinical and Metabolic Effects of Biliopancreatic Diversion Persist After Reduction of the Gastric Pouch and Elongation of the Common Alimentary Tract. Preliminary Report in a Series of Patients with a 10-Year Follow-Up.

BACKGROUND: Biliopancreatic diversion (BPD) is a bariatric technique burdened, in some instances, by clinical evidence of malabsorption and malnutrition, and by intractable diarrhea. OBJECTIVE: The objective of this study was to assess metabolic and nutritional effects on patients undergoing BPD and BPD plus revisional surgery because of side effects. METHODS: Thirty-five consecutive BPD patients underwent revisional surgery (elongation of the common limb from 50 to 200 cm and reduction of the gastric pouch from 500 to 40 ml) after a median 48-month period [48.3 ± 9.17 months (mean ± SD)] and were observed for a total period of 116.2 ± 6.21 months; 88 patients only undergoing BPD (controls) were observed for 120 months. RESULTS: Revisional surgery significantly improved side effects of BPD, with resolution of clinical symptoms in most instances. After revisional surgery, patients had a further decrease of body weight. The effect on disappearance of diabetes mellitus (DM) was remarkable, with no difference between revisional surgery and BPD. Triglycerides and transaminases decreased in a similar way, while cholesterol levels differed significantly. Estimated glomerular filtration rate improved. Nutritional parameters were similarly affected. CONCLUSION: This study suggests that it is possible to maintain the clinical and metabolic effects of BPD after a revisional procedure that leads to lesser malabsorption and to a greater restriction of the stomach. In particular, the positive effects on DM still persist after revisional surgery. This approach should be kept in mind in the presence of significant side effects due, inter alia, to excessive malabsorption.

Abnormal calcium, 25(OH)vitamin D, and parathyroid hormone after biliopancreatic diversion; correction through elongation of the common tract and reduction of the gastric pouch.

BACKGROUND: Biliopancreatic diversion (BPD) is a surgical technique burdened, in some instances, by clinical evidence of malabsorption and intractable diarrhoea. OBJECTIVES: To compare calcium metabolism together with weight in patients undergoing BPD versus BPD followed by revisional surgery because of side effects of BPD or ineffectiveness of BPD. SETTING: University hospital. METHODS: Twenty-seven patients underwent BPD. After a median period of 48 months, they underwent revisional surgery (elongation of the common limb from 50 to 200 cm and reduction of the gastric pouch from 500 to 40 mL) and were observed for a total period of 120 months; 40 patients only underwent BPD (controls) and were observed for an identical period. RESULTS: At baseline, 24 patients (8 revisional surgery and 16 controls) had increased parathyroid hormone (PTH) levels, and only 3 patients had normal 25(OH)vitamin D levels; calcium declined, even within normal limits, and PTH increased in the revisional surgery group. After revisional surgery, patients experienced a further decrease of weight, together with a reduction of PTH levels, an increase of 25(OH)vitamin D levels, and an increase of calcium levels. Weight loss was inverserly associated with an increase of 25(OH)vitamin D and directly associated with change of PTH. CONCLUSION: This study suggests that it is possible to control effects of BPD on calcium metabolism through a revisional procedure leading to lesser malabsorption and to greater restriction of the gastric pouch. It should be considered in the presence of significant side effects due to excessive malabsorption.

Totally laparoscopic right colectomy: theoretical and practical advantages over the laparo-assisted approach.

BACKGROUND: The improvement in intracorporeal anastomotic techniques and the consequent switch from a laparo-assisted (LA) to a totally laparoscopic (TL) right colectomy seem to have overcome the initial concerns, giving rise to the widespread use of such a procedure. By comparing the LA and TL approaches, our study was aimed at verifying the possible advantages of the more recent technique, while also focusing on some technical implications for the surgeon. SUBJECTS AND METHODS: We prospectively collected and matched data from 27 consecutive LA right colectomies and 28 consecutive TL right colectomies (TLRCs). Clinical, biochemical, pathological, and cosmetic parameters were examined. Operating times were recorded and analyzed, in order to evaluate the learning curve for the different phases of the procedure. RESULTS: The LA and TL groups were homogeneous for demographic and pathological features. We had no mortality, and surgical complication rates were similar (3.6% versus 3.7%). The TLRC group presented a significantly shorter laparotomy (4.8 cm versus 7.2 cm, P=.002), whereas no significant difference was recorded for outcome parameters. Operating time for carrying out anastomosis was significantly longer for the TL group (55.6 minutes versus 20.6 minutes, P<.0001). A rapid decrease in anastomosis time throughout the series attests to a short learning curve for intracorporeal ileotransverse anastomosis. CONCLUSIONS: Further studies are needed to demonstrate possible clinical advantages of TLRC over the LA approach. The cosmetic benefit for patients along with safety and the prospective usefulness for surgeons (practice in intracorporeal suturing techniques) would seem to justify an inclination toward this technical development.

Laparoscopic subtotal colectomy with antiperistaltic cecorectal anastomosis: a new step in the treatment of slow-transit constipation.

BACKGROUND: Subtotal colectomy with antiperistaltic cecorectal anastomosis (SCCRA) has proved to be an effective alternative to total colectomy for the treatment of severe slow-transit constipation. The laparoscopic approach has made this procedure even more attractive. This is the first controlled trial on laparoscopic SCCRA. The study compares the laparoscopic and the open approach. METHODS: Since 2001, all SCCRAs have been performed laparoscopically at our institution. Only severely symptomatic patients are offered surgery, after stringent patient selection. Laparoscopic SCCRA was performed following the same steps that we first described for the open approach, by utilizing a five-trocar technique. Outcome parameters were prospectively collected every 3 and 6 months. Wexner constipation and incontinence scales (WCS, WI) and gastrointestinal quality of life index (GIQLI) were adopted for functional results. We conducted a case-control study of 15 consecutive patients who underwent laparoscopic SCCRA (VL) and 15 patients previously operated on by the open approach (Op) to compare postoperative and functional outcomes. RESULTS: The VL group had better postoperative outcomes (pain, ileus) while complication rates were similar. Resolution of constipation was impressive in both groups, with no significant difference at follow-up. The VL group presented with a higher number of bowel movements at 3 months (3.8 vs. 2.8, p = 0.039), resulting in a significantly higher incontinence rate at 3 months (WI 6.4 vs. 2.73, p = 0.004), although the difference was no longer significant at 1-year follow-up. The quality of life was good for both groups; the VL group showed a significant improvement at 1-year follow-up (64.18 vs. 114.79, p < 0.01). CONCLUSIONS: Laparoscopic SCCRA confirmed the good functional results of the open approach, with no increase in morbidity rate and a faster postoperative recovery. An early higher incontinence rate did not affect quality of life.

Prospective comparison of laparoscopic incisional ventral hernia repair and Chevrel technique.

PURPOSE: Laparoscopic incisional hernia repair has become an attractive and widely adopted alternative to open procedures. The Chevrel technique is still frequently performed, owing to its safety and effectiveness. Our study prospectively compares the new and the old technique. METHODS: We prospectively collected data from laparoscopic and open incisional ventral hernia repairs performed from January 2006 to December 2008. Twenty-one patients were ultimately enrolled in the open and 20 in the video-laparoscopic (VL) group for the statistical analysis. RESULTS: Open and VL groups were homogeneous for demographics and size of parietal defect. No differences were observed in operating time and postoperative pain, although in the VL group, we found a tendency toward shorter hospital stays and higher postoperative quality of life. We reported a significantly higher rate of wound complications in the open group (7 vs. 1; P=0.03). CONCLUSIONS: Both techniques proved to be effective, although Chevrel presented a high rate of wound complications.

Biofeedback therapy plus anal electrostimulation for fecal incontinence: prognostic factors and effects on anorectal physiology.

BACKGROUND: The current literature does not provide unequivocal data on prognostic factors in conservative management of fecal incontinence. Moreover, the physiopathologic effects of pelvic floor rehabilitation on anorectal function are not well understood. Our aim is to identify some prognostic parameters and assess their effects on anorectal physiology of biofeedback therapy plus anal electrostimulation for fecal incontinence. METHODS: We studied prospectively 45 consecutive adult patients with fecal incontinence treated at our institution with biofeedback plus electrostimulation. The outcome parameter was modification of the Wexner Incontinence Score (WIS) at the end of treatment. In addition, we studied the modifications of anorectal manometry and the rectal sensitivity threshold after treatment. RESULTS: At univariate analysis, age, the pretreatment WIS, and the pretreatment resting and maximum squeeze pressures were correlated with the clinical outcome. Patients showed a significant reduction in the rectal sensitivity threshold but no significant change in manometric parameters after treatment. CONCLUSIONS: We identify good sphincter function and mild to moderate symptomatology as favorable prognostic factors in biofeedback and anal electrostimulation therapy. Improvement in rectal sensitivity can be implicated in symptomatic improvement. The impossibility of correlating the clinical results with the effects on anorectal physiology suggests a nonspecific effect of conservative treatment.

Gallbladder ulcer eroding the cystic artery: a rare cause of hemobilia.

We report a hemorrhage from an eroded cystic artery in an ulcer of an inflamed calcolous gallbladder. Bleeding from the papilla was observed at side-view endoscopy. Echo endoscopy and contrast-enhanced computed tomography suggested a gallbladder bleeding. A clear-cut diagnosis was made by selective angiography, followed by embolization of the cystic artery, hence stopping the hemorrhage. Cystic artery bleeding into the gallbladder is rare. The diagnostic and therapeutic implications are discussed.