Changes in headache frequency in premenopausal obese women with migraine after bariatric surgery: a case series.

BACKGROUND: The association between migraine and obesity gives the clinician with an exciting possibility to alleviate migraine suffering through weight-reduction gastric-restrictive operations. We hypothesized that bariatric weight-reduction intervention (gastric banding) will be associated with reduction of migraine burden in this population. METHODS: A total of 105 women between 18 and 50 years of age, admitted for bariatric surgery between April 2006 and February 2007, were screened for migraine. Twenty-nine with diagnosis of migraine were enrolled into the prospective phase. We followed the migraine pattern of these patients for 6 months post bariatric surgery. RESULTS: Baseline median migraine frequency was six headache days a month. Post bariatric surgery, the migraine-suffering women reported of a lower frequency of migraine attacks (p < 0.001), shorter duration of the attacks (p = 0.02), lower medication use during the attack (p = 0.005), less non-migraine pain (44.8 vs. 33%, p = 0.05), and post-bariatric surgery reduction in headache-related disability assessed by the MIDAS and HIT-6 scores. There was a reduction in migraine frequency among both episodic (from four to one episodes a month) and chronic (from 16.8 to 8.5 episodes per month) migraine patient cohorts separately and combined. CONCLUSIONS: Among migraine-suffering premenopausal obese women, we found a reduced frequency of migraine attacks and improvement of headache-related disability post bariatric surgery. Our findings should be interpreted cautiously. The absence of a control group and the non-blinded nature of our small study make it difficult to draw firm conclusions about the causal nature of the headache changes observed in this population. Further study is needed to evaluate the possible specific effects of surgical weight loss on migraine in obese women.

[Laparoscopic adjustable gastric banding in treatment of patients with obesity].

Laparoscopic adjustable gastric banding (LAGB) has been fulfilled in 2958 patients in the period since 1998 through 2006 for treatment of different forms of obesity. The age of the patients was from 16 to 60 years (mean age 38 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. The observation of 2485 (84%) patients operated in the terms in question showed the influence of LAGB on metabolic derangement, arterial pressure. Statistical data on possible early and late postoperative complications are presented. The operation of LAGB is one of minimally invasive methods for adjustable decreasing the excess body weight and its effectiveness exceeds other methods of restrictive interventions on the stomach, has a number of advantages compared with other bariatric interventions, it is relatively safe and completely reversible bariatric operation with all advantages of minimally invasive techniques.

[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 accessory splenectomy using intraoperative gamma probe guidance.

In cases of accessory splenic tissue in postsplenectomy patients, it is of utmost importance to localize the accessory spleen prior to surgery. Several studies have shown the feasibility of laparoscopic resection of accessory splenic tissue using preoperative scintigraphy. We present the cases of three postsplenectomy patients with accessory splenic tissue causing relapsing hematologic disease. Accessory spleens were diagnosed and localized preoperatively by positive uptake of heat-damaged Tc99m-labeled red blood cells using scintigraphy. Two patients with relapse of immune thrombocytopenic purpura and one with hemolytic anemia underwent handheld gamma probe-assisted laparoscopic accessory splenectomy. One patient with immune thrombocytopenic purpura recovered his platelet count at 3-year follow-up. The other patient had a relapse of disease within 3 months despite successful removal of the accessory spleen. The patient with hemolytic anemia had postoperative relapse; two accessory spleens were identified on radionuclide investigation. The use of intraoperative nuclear imaging can greatly aid in localization and provide confirmation of complete laparoscopic excision of the nuclear focus. The technique is especially useful in cases of a small accessory spleen, by avoiding a major open procedure and contributing to good postoperative results.

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.

Pneumomediastinum causing pneumoperitoneum.

Pneumomediastinum is characterized by the presence of air in the mediastinum and has been recognized since 1827, when described by Laënnec. To the best of our knowledge, pneumoperitoneum as a result of spontaneous pneumomediastinum has not yet been described in the English literature. We observed and treated a young patient in the intensive care unit who presented with spontaneous pneumomediastinum. Free intra-abdominal gas was observed on the chest x-ray film on the day after admission. Management was conservative. Intra-abdominal and mediastinal air disappeared within four days. This condition, when recognized, needs only observation; we report this as a medical curiosity.

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.

Isolated popliteal artery occlusion in the young.

Three young patients with an isolated popliteal artery occlusion are presented, two with severe claudication and the third with a critical ischaemic foot. The work-up of these patients leads to certain aetiologic possibilities: microtrauma, smoking and contraceptive pills. Two of our patients underwent thromboembolectomy, the third managed conservatively. The follow-up was between six months and seven years and up to now all three patients remain well.

PIP: 3 cases of popliteal artery occlusion are described, in 2 young Israeli women and a young man, and the etiologic factors in this rare disorder are reviewed. The 1st case was a 20-year old healthy woman with no contributing factors except use of low dose oral contraceptives for 5 months. She had suffered for 3 months with claudication of her left leg. Her Doppler ankle-brachial index was 0.7, and her angiogram showed complete occlusion of the popliteal artery and partial occlusion of the tibio-peroneal. She was treated with aspirin and cardoxine, discontinuation of oral contraceptives and walking, and recovered. The 2nd case was a 33-year old woman with history of rheumatic fever, obesity, hirsutism, venous thrombosis, hormone therapy for infertility, multiple spontaneous abortions, smoking, and possible Cushings disease. Her findings included and AB index of 0.45 on the right, and spotty stenosis of the popliteal artery. She was treated surgically with a Fogarty catheter, and is well 3 years later with the help of anticoagulants. The 3rd patient was a 30-year old male athlete who smoked heavily. He had an AB index of 0.4 on the left and complete blockage of the popliteal artery, so he received longitudinal arteriotomy and thrombectomy. He was put on anticoagulants, and is well, 6 months after surgery. Oral contraceptives were considered the likely cause of the 1st young woman's claudication, and possibly involved in the 2nd patient's ischemia. It is usually difficult to define the cause of isolated popliteal artery occlusion in young adults. Multidisciplinary management with thrombolytics or surgery should be considered, and discontinuation of oral contraceptives should be a priority, especially if a young woman began using them in the last year.

Unusual pseudoaneurysm of Dacron femoro-popliteal graft shaft. A case report.

An unusual case of pseudoaneurysm in the mid segment of a Dacron femoro-popliteal graft is reported. The radiological diagnosis was based on computed tomography which correlated well with the surgical findings. A manufacturing defect seems to be the most likely cause of this pseudoaneurysm.

Should chemical sympathectomy precede below knee amputation?

Lumbar sympathectomy has a controversial place in the management of severe limb ischemia for limb preservation. In a consecutive clinical series laser Doppler (LD) blood flow was measured at the distal limit of an anterior below knee skin flap in 21 patients. Amputation level was selected by clinical judgement. Mean LD value in 15 patients who had primary BK healing was 42V (range 20-85) compared to 11V (9-20) in six patients who proceeded to AK amputation (p < 0.001) establishing 20V as a critical value for BK healing. To examine the effect of chemical sympathectomy 21 further patients with severe ischemia had LD measurements at the same BK site before and one week after chemical sympathectomy. LD values rose significantly from 26V (10-75) to 50V (10-100), (p < 0.001). In particular seven patients had initial LD levels below 20V and in five chemical sympathectomy produced elevation to levels commensurate with BK healing. We conclude that chemical sympathectomy can improve below knee skin blood flow and may enhance primary wound healing.

Adrenal cysts: diagnosis and therapeutic approach.

We report nine cases of adrenal cysts, treated in our hospital, between 1980 and 1990. The majority of the cases (5/9) were incidental findings on US and CT examinations. We operated on 4/9 cases because of their symptomatology or their size. Four other cases were managed conservatively; one last case was treated by percutaneous drainage under CT. In our series, 1/9 (11%) was a malignant cyst. The follow-up shows excellent results in the benign cases and 40 months' survival in the malignant case, until today.

Lower limb sympathectomy assessed by laser Doppler blood flow and transcutaneous oxygen measurements.

In a retrospective study of critical ischaemia of the lower limb, sympathectomy appeared to be of value in the majority of patients. We therefore assessed sympathectomy by measuring skin blood flow before and after the procedure using laser Doppler flowmetry (LDF) and transcutaneous oxygen tension (TCpO2) techniques. Twenty patients underwent chemical sympathectomy and there was one surgical procedure. Measurements were performed before and 1 week after sympathectomy below the knee and on the forefoot. Symptomatic improvement occurred in 20 of 21 patients. This study demonstrates that skin blood flow in the leg and foot is improved by sympathectomy and confirms objectively our clinical impression.

[Vein ligation in cavosuprahepatic disinsertion]. / Ligature veineuse pour désinsertion cavo-sus-hépatique.

We report one case of multiple injuries sustained in a traffic accident, including severe injury to the liver and rupture of one of the major suprahepatic veins. We review the techniques for controlling massive hemorrhage, which is still too often fatal in this type of hepatic injury. We notably emphasize the fact that major injury to the liver does not necessarily require wide resection such as formal lobectomy. This approach is advocated by numerous authors, as shown in our review of the literature.

[Characteristics of changes in the kinin system of blood in hypertensive disease]. / Osobennosti izmenenii kininovoi sistemy krovi pri gipertonicheskoi bolezni

The state of the kinin system of blood was studied in terms of its content of kininogen, prekallikrein, kallikrein inhibitor and the spontaneous esterase activity. The examination was conducted in 10 normal individuals and in 81 hypertensive patients with labile and stable arterial pressure and an uncomplicated course. The studies were conducted at rest, during the transfer into an orthostatic position, and after 15 or 60 minutes of walking. The normals demonstrated an activation of the kinin system that ensued in orthostasis, but was more distinct at walking. A significant correlation was noted between the content of prekallikrein and kininogen in all the states under examination. In cases of labile arterial hypertension an increased activation of the blood kinin system was observed at rest, a lack of its activation at walking, and disorders in the correlation between the content of prekallikrein and kininogen. The observed changes in the kinin system may affect the central haemodynamics and the formation of the hyperkinetic type of circulation.

[Certain mechanisms of prophylactic effect of physical training in hypertensive disease]. / O nekotorykh mekhanizmakh profilakticheskogo deistviia fizicheskoi trenirovki pri gipertonicheskoi bolezni

Physical training produces definite changes in the state of the blood and renal kininine system. In skilled sportsmen the renal kinine system has a higher resistance to the effect of an intensive muscular work than that in physically untrained individuals. At rest the level of the kinine system enzymes in the blood of sportsmen is lower than in untrained persons. On effort sportsmen demonstrate a moderate, but protractedly rising kininogenesis. The functional potentialities of the renal kinine system in sportsmen th hypertensive disease of the I degree continue to be higher than they are in untrained patients. The development of an adequate reaction of the renal and blood kininine system under different conditions appears as one of the mechanisms of the prophylactic effect produced by physical training in hypertensive disease.