[Complications after the operation of laparoscopic adjustable gastric banding in treatment of patients with obesity].

Operations of laparoscopic adjustable gastric banding (LAGB) have been fulfilled on 2958 patients for treatment of different forms of obesity. The age of the patients was 38 +/- 7.5 years (from 16 to 60 years). There were 80% of women (2366) and 20% of men (592). Mean preoperative body mass index was from 35 to 54 kg/m2, i.e 43 +/- 3.8 kg/m2, fluctuating from 35 kg/m2 to 54 kg/m2. Bands of the following firms were used: Lap Band, Inamed, (USA), AMI Soft Band, Austria, Swedish Band J & J, USA. A description of complications in the early and late postoperative periods are given, associated with the dilatation of the formed "miniature ventricles, occlusion of intercommunication between the miniature ventricle and large ventricle with disturbed evacuation of the content, erosion of the gastric mucosa in the area of the band without its penetration, slippage of the band, complications associated with the regulation system etc. Recommendations were worked out for decreasing the number of complications. The data obtained suggest that LAGB is a highly effective method giving good results of treatment of patients with obesity and coexisting diseases. Most of the appearing complications can be eliminated laparoscopically.

Laparoscopic management of acute small bowel obstruction.

BACKGROUND: As minimally invasive surgery gains ground, it is entering realms previously considered to be relative contraindications for laparoscopy. We reviewed our experience with the laparoscopic approach to the management of small bowel obstruction (SBO). METHODS: From December 1997 to November 2002, 65 patients underwent laparoscopic treatment for SBO. The operating surgeon attempted to identify a transitional point between distended and collapsed bowel and then address the obstruction at that point. RESULTS: Postoperative adhesions were the cause of the obstruction in 44 patients. Tumor was identified in five cases, hernia in four, bezoar in three, intussusception in three, acute appendicitis and pseudoobstruction in two cases each, and terminal ileitis in one case. The diagnostic accuracy of laparoscopy was 96.9%. Thirty-four patients (52%) were treated by laparoscopy alone. Thirteen patients (20%) required a small target incision for segmental resection. Eighteen operations were converted to formal laparotomy. The mean laparoscopy time was 40 min (range, 25-160). Patients resumed oral intake in 1-3 days. The complication rate was 6.4%. There were two deaths, but none related to laparoscopy. The mean hospital stay was 4.2 days. CONCLUSIONS: Laparoscopy is a useful minimally invasive technique for the management of acute SBO. It is an excellent diagnostic tool and, in most cases, a therapeutic surgical approach in patients with SBO. However, a significant number of patients will require conversion.

Laparoscopic treatment of gastroduodenal perforations: comparison with conventional surgery.

BACKGROUND: Laparoscopic techniques have been proposed as an alternative to open surgery for the treatment of peptic ulcer perforation. This study compared the outcome of laparoscopic and open approaches for the repair of gastroduodenal perforations. METHODS: A retrospective review was conducted with 134 consecutive patients treated for gastroduodenal perforations. These patients included 122 with perforated duodenal ulcers, 10 with perforated gastric ulcers, and 2 with iatrogenic duodenal perforations. Whereas 68 patients were treated laparoscopically, 66 patients underwent conventional (open) surgery. RESULTS: Laparoscopic repair was successful in 65 cases (96 %). The mean operating time was shorter with the laparoscopic technique (68 vs 59 min), but the difference was not significant. The duration of postoperative nasogastric aspiration and time to resumed oral intake were shorter in the laparoscopic group (2.6 vs 4.1 days and 4.4 vs. 5.2 days, respectively; p = 0.043). The postoperative analgetic requirements, and overall complications rate were significantly lower after laparoscopic surgery (p = 0.03 and p = 0.004, respectively). There was no statistically significant difference in hospital stay (5.1 vs 6.1 days) or mortality rate between the two procedures. CONCLUSION: Laparoscopic repair of gastroduodenal perforations is a safe alternative treatment offering certain significant short-term advantages.

Laparoscopic repair of large incisional hernias.

BACKGROUND: Traditional approaches to incisional hernias (IH)--particularly in cases with large fascial defects--are plagued by a significant recurrence rate as well as frequent wound infections. The laparoscopic repair of incisional hernias was designed to offer a minimally invasive and tension-free technique that yields less morbidity and fewer recurrences than the standard open repair. Several years ago, we adopted the laparoscopic technique in our department and set out to appraise its touted advantages. METHODS: During the years 1997-2000, 103 patients underwent laparoscopic IH repair with implanted Dual Gore-tex mesh. Forty percent of them were obese, and 41% had undergone more than one previous attempt at conventional repair. All patients were discharged home within 24-72 hs. RESULTS: In three patients, the operation was converted to open surgery due to severe adhesions and technical difficulties. In two cases, inadvertent enterotomies were repaired laparoscopically, and since there was no major spillage, the repair was continued as planned, with no adverse consequences. Twelve patients underwent additional laparoscopic procedures at the initial operation. Two graft infections and four recurrences were observed during the 1-49 month follow-up period. CONCLUSIONS: Laparoscopic IH repair is technically feasible and safe in patients with large fascial defects as well as in obese patients. This operation decreases postoperative pain, hastens the recovery period, and reduces postoperative morbidity and recurrence.

The use of laparoscopy in abdominal emergencies.

BACKGROUND: The purpose of this article is to describe our experience using laparoscopy in the management of emergent and acute abdominal conditions. METHODS: Between March 1997 and November 2001, 277 consecutive minimally invasive procedures were performed for various nontrauma surgical emergencies. The indications for operation were nonspecific abdominal pain in 129 cases (46%), peritonitis in 64 cases (23%), small bowel obstruction in 52 cases (19%), complications after previous surgery or invasive procedures in 24 cases (9%), and sepsis of unknown origin in 8 cases (3%). RESULTS: Laparoscopy obtained a correct diagnosis in 98.6% of the cases. In 207 patients (75%), the procedure was completed laparoscopically. An additional 35 patients (12.5%) required a target incision. The remaining 35 patients (12.5%) underwent formal laparotomy. The morbidity rate was 5.8%. No laparoscopy-related mortality was observed. CONCLUSIONS: For patients with abdominal emergencies, the laparoscopic approach provides diagnostic accuracy and therapeutic options, avoids extensive preoperative studies, averts delays in operative intervention, and appears to reduce morbidity.

The effect of a high partial pressure of carbon dioxide environment on metabolism and immune functions of human peritoneal cells-relevance to carbon dioxide pneumoperitoneum.

OBJECTIVE: Our purpose was to evaluate in vitro the effect of a high partial pressure of carbon dioxide environment used in laparoscopy on metabolic and immune response of various human peritoneal cells. STUDY DESIGN: Polymorphonuclear leukocytes were obtained from 5 healthy volunteers, peritoneal macrophages were obtained from the effluent of 8 patients undergoing continuous ambulatory peritoneal dialysis, and human peritoneal mesothelial cell cultures were prepared from omentum derived from 5 patients undergoing elective surgery. The cells were exposed to a laparoscopy-like environment (1 atmosphere carbon dioxide and 0.2 atmosphere oxygen), to a control gas mixture (1 atmosphere helium and 0.2 atmosphere oxygen), or air for 3 hours. After exposure to gas mixtures, cell functions were tested at various recovery periods. RESULTS: Three hours of exposure to a high partial pressure of carbon dioxide had no effect on viability of peritoneal macrophages and human peritoneal mesothelial cells, tested by trypan blue dye uptake and lactate dehydrogenase release. A high partial pressure of carbon dioxide decreased the mitochondrial dehydrogenases activity of peritoneal macrophages and human peritoneal macrophage cells by 60%, assayed by 3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide reduction. High partial pressure of carbon dioxide blocked the superoxide release from activated polymorphonuclear leukocytes and the secretion of interleukin 1beta from stimulated peritoneal macrophages, and human peritoneal macrophage cells were decreased by 15% and 30% and the secretion of tumor necrosis factor-alpha from peritoneal macrophages was suppressed by 85%. Mitochondrial activity, polymorphonuclear leukocyte function, and interleukin 1beta and tumor necrosis factor-alpha secretion returned to normal after a recovery period of 12 to 24 hours, 4.5 hours, and 24 hours, respectively. In the control experiments exposure of cells to helium had no suppressive effect. CONCLUSIONS: Exposure of cells to a high partial pressure of carbon dioxide environment suppresses the inflammatory and metabolic responses of peritoneal cells. We suggest that this suppressive effect may contribute to the low postsurgery adhesion formation and the reduction in postoperative pain observed in laparoscopy. Nevertheless, the suppression of the immune response should also be taken into account for operations involving a high risk of bacterial dissemination.

Weight Loss and Food Intake 18 Months following Vertical Banded Gastroplasty or Gastric Bypass for Severe Obesity.

BACKGROUND: vertical banded gastroplasty (VBG) and gastric bypass Roux-en-Y (GBP) are adjunctive to lifelong commitment to energy restricted diet in the attempt by the severely obese to lose weight and maintain weight loss. METHODS: the outcome of 48 subjects (36 VBG and 12 GBP) is presented. RESULTS: 18 months nutritional counseling and follow-up indicated VBG and GBP to be equally effective in maintaining appreciable weight loss. Achievement of 'functional weight', such as minimum 50% loss of excess body weight for at least 12 months Post-operatively occurred in the majority of patients. Excess weight loss by GBP and VBG was 77% and 54% respectively during the first 6 months, with 7-15% additional loss during the next 12 months. BMI decreased from an average 43 to 27 kg m(2) after 12 months. During the first 3 months, energy intake was approximately 2930 kJ, increasing to;4605 kJ at 6 months, to; 5860 kJ at 12 months and then stabilizing. Intake of;50% of the Recommended Daily Allowance (RDA) for most vitamins and minerals was reached. Hemoglobin, iron, folic acid and thiamin values were in the normal range for the entire 18 months follow-up, while serum vitamin B12 levels decreased to deficiency levels during the same period. The pre-operative moderately elevated triglycerides, cholesterol, glucose and insulin levels returned to normal range, thereby alleviating the need for medication and reducing the risk of obesity-related morbidity. Most subjects were quickly satiated with small amounts of solid foods and did not report hunger feelings for the first 6 months post-operatively. The main significant changes in food preferences in the first 6 months were the decrease in starch-based products and the increase in semi-solid milk products and eggs. CONCLUSION: taken together these observations suggest that the subjects should be strongly advised to partake in structured counseling for an extended period of time.

Nutrient Intake following Vertical Banded Gastroplasty or Gastric Bypass.

BACKGROUND: This study explored eating habits, nutrient intake, and blood vitamin and mineral levels to determine whether severely obese subjects (BMI 40-50kg m(2)) post-vertical banded gastroplasty (VBG) or gastric bypass Roux-en-Y (GBR) are at risk of developing compounded under-nutrition. METHODS: A dietary follow-up of 36 VBG and. 19 GBR was maintained for 18 months via 7-day food intake diaries and 24-h recalls. Food intake was analyzed for energy and nutrient composition and for its relative amount to recommended dietary allowances (RDA). RESULTS: Weight loss was greatest during the first 6 months, continued at a slower rate for the next 6 months, nearly ceasing thereafter. The results following GBR were not substantially different from those following VBG 18 months postoperatively. The median weight loss at 1 year postoperatively was 48, 46, 48 and 36 kg; expressed as residual excess body weight: 0.2, 16, 13 and 22% for GBR Men, Women, VBG Men, Women, respectively. According to the classification proposed by Reinhold, all subjects achieved excellent treatment outcomes 18 months postoperatively. Despite the relatively low reported energy intake (2050% below RDA), no correlation was found between rate of weight loss and energy intake at 6 months postoperatively. The intake of most vitamins and minerals was below 50% of RDA during the 18 months follow-up. The increase in energy intake did not improve the level of the nonenergy-contributing nutrients. Compliance to multivitamin and mineral supplement intake deteriorated with time. CONCLUSION: The low to within-normal range of blood vitamin and mineral levels 12 months postoperatively suggests the slow development of subclinical nutritional deficiency which could jeopardize the subjects' long-term health status.