Learning curve for laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomosis: analysis of first 600 consecutive patients.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a challenging operation for the treatment of morbid obesity with well-demonstrated effectiveness in weight lost. There are several variations to the technique. METHODS: From September 2000 to July 2004, 600 consecutive patients underwent surgery for morbid obesity at our institution. The surgical technique employed was LRYGB with totally hand-sewn gastrojejunal anastomosis (GJA). All patients were considered candidates for laparoscopic approach regardless of age, gender, body mass index (BMI), or previous bariatric or digestive surgery. RESULTS: Mean BMI was 44.4 +/- 7.6 kg/m2. Thirty-two patients had undergone previous failed bariatric procedures. Conversion to an open procedure was necessary in three patients. Seventy-two patients (12%) developed early complications, including 23 (3.8%) leaks at the GJA (eight in the first 18 patients). Mortality rate was 1.1% (one death was related to GJA leakage). Early and late reoperation rates were 5.3 and 1.8%, respectively. Rate plateau of morbidity and mortality was reached after the first 18 patients when the surgical technique was fully standardized. CONCLUSIONS: LRYGB is a technically demanding procedure for the surgical treatment of morbid obesity with significant morbidity during the learning curve. The learning curve can be soon overcome, reaching a rate plateau of complications after adequate training. Morbidly obese patients should be operated on in expert bariatric surgical laparoscopic units to obtain the best results.

Quality of life in morbid obesity.

INTRODUCTION: Morbid obesity (MO) is a chronic disease that is reaching epidemic proportions and becoming an increasing health problem in developed countries. Obesity-related comorbidities reduce both the quality and expectancy of life. OBJECTIVES: To validate the GIQLI (Gastrointestinal Quality of Life Index) test as a reliable and effective tool for the evaluation of quality of life in morbidly obese patients. PATIENTS AND METHODS: The GIQLI test is made up of 36 individually scored items, the addition of which give up a final score. A higher score correlates with a better quality of life. Items can be separated into five groups or dimensions: digestive symptoms, emotional status, effects of treatment, and physical as well as social dysfunction. The GIQLI test was administered to a randomized sample of 1990 morbidly obese patients who fulfilled the indication criteria for bariatric surgery, and to a control group of 100 healthy individuals with no known medical, functional or psychiatric disease. Overall test and specific dimension scores were evaluated for each group. RESULTS: Overall test and specific dimension scores were significantly lower in patients with MO when compared to the control group. The overall GIQLI score decreased as age increased, as did the number of associated comorbidities. CONCLUSIONS: The GIQLI test proved to be a rather useful tool to evaluate quality of life in morbidly obese patients. These patients present a poorer quality of life not only because of the presence of digestive symptoms but also because of their emotional, physical, and social status.

Laparoscopic Billroth II distal subtotal gastrectomy with gastric stump suspension for gastric malignancies.

BACKGROUND: Laparoscopy has played an ill-defined role as a diagnostic tool for the staging of gastric and other intra-abdominal malignancies for a long time. The widespread use of the laparoscopic approach for the treatment of some benign abdominal diseases, such as biliary lithiasis and gastroesophageal reflux disease, has encouraged the authors toward its use in the treatment of malignant gastric neoplasms, both for palliation and for curative surgery. METHODS: A five-puncture technique for laparoscopic distal subtotal gastrectomy, omentectomy, division of the left gastric artery at its origin, and D1 lymph node dissection has been developed by the authors, and is fully depicted and discussed. Reconstruction of digestive continuity is achieved through a posterior transmesocolic side-to-side stapled gastrojejunostomy, facilitated by an original method of suspension of the gastric stump to the anterior abdominal wall. RESULTS: In a preliminary series of 10 cases, this technique was demonstrated to be safe, showing no mortality, and having morbidity rates comparable to those of open surgery. CONCLUSION: The operation is effective, with a mean number of resected nodes comparable to that usually achieved in open surgery, and no cases of conversion to laparotomy.

Laparoscopy in acute biliary pancreatitis.

BACKGROUND: The high mortality rates (20-30%) still occurring in some forms of acute pancreatitis demands adequate clinical and instrumental protocols in order to establish the most suitable therapeutic option to employ. The use of laparoscopic surgery can reduce hospital stay and time for functional recovery. METHODS: The study enrolled 73 patients referring for acute biliary pancreatitis in whom staging with clinical, laboratory and instrumental criteria was performed. According to Ranson classification 63 patients (86.3%) had a mild-moderate acute biliary pancreatitis, 10 (13.6%) a severe one. In the first group laparoscopic cholecystectomy with retrograde cholangiography was performed within seven days of admission, in the second group surgical procedure followed medical treatment between eight and 30 days after the onset of the disease. No preoperative ERCP was performed. RESULTS: The rate of main biliary tract calculosis was 8.2% in group A: six cases all treated through laparoscopy. Two switches (2.7%) due to intolerance to the pneumoperitoneum, eight major postoperative complications (10.9%), and two deaths (2.7%) occurred and a mean hospital stay of 7.4 days was observed in group A versus 8.2 days in group B. CONCLUSIONS: The management suggested in this study for mild-moderate acute biliary pancreatitis showed consistent results with those of the recent literature, as far as morbidity (6.3%) and mortality (1.5%) are concerned. A higher number of severe biliary pancreatitis (10 cases) should be observed to assess the role of ERCP with endoscopic sphincterotomy rather than laparoscopic or combined treatment.

The contribution of laparoscopy to the treatment of gastric cancer.

BACKGROUND: Laparoscopy plays a role in the preoperative diagnosis of gastric cancer, particularly in determining the location and extent of the neoplasia. In addition to its use in staging, laparoscopy is indicated for the gastric resection of T1-T2, and its middle- and long-term results are comparable to those obtainable with open surgery. Herein we describe our experience with the laparoscopic resection of gastric carcinomas, including the dissection of lymph nodes and the Billroth II reconstruction of digestive continuity with gastrojejunostomia. METHODS: We carried out laparoscopic gastric resections in 25 patients with adenocarcinomas. Our method involved installing five trocars, tying the left and right gastric vessels and the right gastro-epiploic vessels, sectioning the duodenum 3 cm from the pylorus, sectioning the remaining portion of the stomach obliquely 3 cm from the cardias, and performing Billroth II reconstruction. RESULTS: The average duration of the operation was 4 h 45 min. The average number of removed lymph nodes was 30.5 (range, 22-41). Five patients were converted to laparotomy. Significant complications were observed in four cases (16%). Hospitalization ranged from 5 to 16 days. The average follow-up was 38 months (range, 7-63), without evidence of relapse. CONCLUSION: In terms of morbidity, our results were similar to those obtained with open surgery. Lymphectomy according to the extent and number of lymph nodes is acceptable in the treatment of tumors of the lower third of the stomach. More case studies are needed to provide further indications of the applicability of the technique (which is currently used only in a few centers) and long-term results.

Emergency laparoscopic treatment for acute massive bleeding of an esophageal ulcer.

Laparoscopic fundoplication is now considered the treatment of choice for the management of severe gastroesophageal reflux disease (GERD) and its complications. The laparoscopic approach achieves the same good results as open surgery in elective surgery for GERD; it also has all the advantages of minimally invasive surgery. Today, laparoscopy plays also a significant role in a great variety of emergency abdominal situations and acute abdominal pain. A 30-year-old man was admitted to our center due to an upper gastrointestinal bleed caused by a esophageal ulcer over a Barrett's esophagus located in lower third of the esophagus. Two therapeutic esophagogastroscopies were done in 24 h, but urgent surgical intervention was indicated because of recurrent transfusion-demanding bleeding. A combined laparoscopic-endoscopic approach was followed. Surgery began with a complete hiatal dissection, including the distal third of the esophagus, diaphragmatic crus, and wide retrogastric window. Intraoperative flexible esophagoscopy revealed an active ulcer bleeding on the right anterior quadrant in the lower esophagus. Two transfixive stitches were applied through the wall of the esophagus at the site indicated by the light of the flexible endoscope, and complete hemostasis was achieved. Finally, employing the anterior wall of the fundus, a short Nissen-Rossetti fundoplication was performed. The operating time was 140 min. There were no complications and there has been no recurrence of the bleeding.

Laparoscopic surgery in the elderly patient.

BACKGROUND: Elderly patients represent a unique surgical challenge because of the associated complex comorbidity and diminished cardiopulmonary reserve. Therefore, minimally invasive surgery in the elderly may have a larger impact compared to the younger population. The aim of this study was to prospectively evaluate the experience of laparoscopic surgery in patients >or=70 years of age in our unit. METHODS: Two hundred and thirty-two patients (34 females and 98 males) older than 70 years who underwent various elective and emergency laparoscopic procedures between 1992 and 1997 were assessed prospectively. Preoperative comorbidity, operative results, and postoperative outcomes were analyzed. RESULTS: The median age of the patients was 76 years. The majority of patients were ASA class II. The mean hospital stay was 3.4 days. The overall morbidity and mortality rates were 10.8% and 3.4% respectively, and the conversion rate was 4.3%. CONCLUSIONS: Our experience suggests that laparoscopic surgery in the elderly is safe, is associated with short hospital stay, and produces less morbidity and mortality. Therefore, it should be adopted widely if the expertise in the area of laparoscopic surgery is available for this group of patients.

Laparoscopic gastric banding for morbid obesity with expanded PTFE: technique and early results in the first 100 consecutive cases.

BACKGROUND/AIMS: Surgery is the only effective treatment for the truly morbidly obese patient. Gastric banding was demonstrated to be a safe, effective, and easily reversible technique in the open surgical approach. METHODOLOGY: A five-puncture technique, developed by the authors, for laparoscopic gastric banding utilizing an expanded polytetrafluoroethylene (ePTFE) band is fully described and discussed. This technique was utilized in 100 consecutive patients operated on between October 1995 and November 1996. RESULTS: We recorded no mortality, no cases of conversion, a 1% rate of major complications, a low minor morbidity rate (10%), and an acceptable length of operative time (106+/-8 minutes). This was significantly related to body weight, B.M.I. and % of I.B.W. being longer in more obese patients, but not to the experience of the surgical team. Weight loss (35.0+/-5.1 kg), percentage of excess weight lost (55.3+/-5.3%), percentage of ideal body weight achieved (149.1+/-8.4%), and body mass index (33.8+/-2.0) were all significantly improved at 3, 6, 9 and 12-months follow-up. CONCLUSIONS: Early results of this series are promising, showing low morbidity and a rate of weight loss comparable to that achievable by means of open gastric banding or vertical banded gastroplasty. Any statement about long-term results deserves a longer follow-up.

Iatrogenic perforations of the esophagus.

The authors herein report their personal experience in the management of 21 patients with iatrogenic perforation of the esophagus, collected in a fifteen-year period. The etiology was more commonly a hiatal surgical procedure (28.6%), following diagnostic endoscopy (19%), endoscopic dilatation for achalasia (19%) and foreign body (19%). Consequently, 47.6% of the lesions were located in the abdominal, 28.6% in the thoracic and 23.8% in the cervical esophagus. Treatment was set up at surgery in 28.6%, within 6 hours in 47.6% and within 48 hours in 9.6%. Conservative medical management was successfully carried out in three cases (14.2%). As a result of their policy of "tailored" treatment on single lesion characteristics (size and location, underlying esophageal diseases, early or delayed diagnosis) they report an overall mortality rate of 28.6%, the prognosis being worse in thoracic (50%) than in abdominal perforations (30%). Based on this series and on a literature review the authors suggest that the best management should be "tailored" to single patients characteristics. Early diagnosis and treatment are the most important prognostic factors.

[Comparative analysis in gastric cancer of total gastrectomy extended with lymphadenectomy and the other surgical technics. 10 years' experience]. / Analisi comparativa nel cancro gastrico della gastrectomia totale allargata con linfoadenectomia con le altre tecniche chirurgiche. Dieci anni di esperienza.

Of 220 patients operated for gastric cancer, 74 with subtotal gastrectomy and 145 with total gastrectomy (60 with lymphadenectomy), the results and indications for total gastrectomy extended with lymphadenectomy are analysed. The importance of lymph node emptying in relation to the possibility of breakdown of the lymphnode chains with R2 metastasis is particularly stressed. Analysis of perioperative mortality and long-term survival indicates results that are close to the data reported by Japanese schools.

[Laparoscopic surgery in patients over 75 years of age]. / La chirurgia laparoscopica nel paziente anziano ultrasettantacinquenne.

Laparoscopic surgery in over-75-year-olds. Surgery in the elderly is becoming increasingly frequent and in some series accounts for around 40% of operations performed. Morbidity and mortality are still high in relation to the type of surgery and anesthesiological risk, with complications linked above all to respiratory and thromboembolic pathologies. The use of a laparoscopic technique in elective and emergency digestive tract surgery may reduce the problems linked to the onset of cardiorespiratory failures and parietal infections. This prospective study aims to evaluate the results of laparoscopic surgery in over-75-year-old patients hospitalised in the Department of Laparoscopic Surgery at Bellvitge Hospital compared to data reported in the literature. Out of 379 patients undergoing laparoscopic surgery, 32 were over-75-year-olds (range 75-89). Ten patients had been diagnosed with gallstones, 9 with acute cholecystitis, 10 with biliary pancreatitis, 2 with iatal hernia and 1 with cancer of the sigma. A total of 29 cholecystectomies were performed, of which 10 in association with pancreatic drainage, 2 Nissen and one left hemicolectomy. Overall mortality was 6.2% following the death of 2 patients: 1 patient, who had been admitted for acute cholecystitis and had undergone laparoscopic cholecystectomy, presented an acute pulmonary edema three days after surgery with cardiac tamponade which represented the cause of death; another patient, admitted for acute biliary pancreatitis, presented a cerebral thromboembolism on the sixth day after surgery leading to death. Other complications included: parietal abscess, basal atelectasis, 2 residual choledochal calculosis and one case of external biliary fistula, with an overall mortality of 9.3%. The results reported in the literature do not report extensive series of over-75-year-olds undergoing laparoscopic surgery. Some authors report high percentages of laparotomic conversion, others a slightly higher morbidity rate with nil mortality. The present results are comparable to those of other authors with regard to the lower morbidity (3.1%) of laparoscopic compared to laparotomic (18.3%) surgery in elderly, high-risk patients. Even if the present series is relatively small (32 patients), the results obtained encourage the use of laparoscopic techniques in over-75-year-old patients so as to reduce mortality and morbidity compared to conventional surgery.

Laparoscopic procedures in patients who have previously undergone laparotomic operations.

BACKGROUND: Patients who have undergone laparotomy can undergo laparoscopic procedures and thus benefit from the advantages that the technique offers without significantly increasing the risk of the operation. METHODS: We present the results of 240 patients, chosen at random who underwent laparoscopic procedures and who had already had 1 or more laparotomic abdominal operations. We carried out 180 cholecystectomies, 12 of which for acute inflammation of the gall bladder, 10 for acute biliary pancreatitis, 3 with exploration of the common bile duct, 45 Nissen fundoplication procedures, of which 16 with removal of the gall bladder, 4 subtotal gastrectomies, 2 GEAs, 2 left colectomies, 4 adhesiolyses. RESULTS: The duration of the procedure varied from 40 to 300 minutes, and hospitalization time after the operation from 1 to 15 days, depending on the previous operation and on the laparoscopic procedure used. A traditional operation (conversion) became necessary in 1.35% of patients. Complica-tions arose in 4% of cases: 4 hematomas, 1 infected wound, 2 bile leaks and 2 bowel fistulas at low flow. CONCLUSIONS: Laparoscopic surgery in pa-tients who have previously undergone abdominal operations is difficult. The extent of conversions and complications can be contained within acceptable limits by choosing carefully the insertion point of the first trocar and dissecting the bowel with great precision.

Comparative study between total gastrectomy and subtotal gastrectomy for treatment of gastric cancer.

The authors present a comparative study between subtotal and total gastrectomy with and without lymphadenectomy, analysing the morbidity and mortality as well as survival of the different groups, relating them to the site of the tumour and TNM staging. Two hundred and nine patients operated on for carcinoma of the stomach were analysed, 158 of whom corresponded to retrospective studies, 72 subtotal gastrectomies and 79 total gastrectomies with a mean 5-year survival of 16.66 and 16.76 months respectively. A comparison is made with the prospective group of 51 patients to whom total gastrectomy plus resection of the spleen and body and tail of the pancreas was performed, associated with regional lymphadenectomy relating lymph node spread with tumour location. The mortality rate for the three groups was 11.1% for subtotal gastrectomy, 11.1% for total gastrectomy and 7.8% for total gastrectomy plus lymphadenectomy. The mean survival rate in months shows no difference for stage I and is greater after gastrectomy plus lymphadenectomy in the remainder: 37.5% for stage II, 26.7% for stage III and 21.6% for stage IV. The cause of the difference is analysed and it is concluded that gastrectomy associated with lymph node resection performed by a trained team is the technique of choice for gastric cancer.

Value of roentgenograms in the diagnosis and prognosis of carcinoma of the stomach.

Roentgenograms of the chest and abdomen of 102 patients with proved carcinomas of the stomach were studied regarding diagnosis, dissemination, resectability and survival. The three main signs looked for were changes in tone, distortion of fundic gas bubble and an increase in the fundus to lung base distance. Positive diagnoses were reached in 78.4 per cent of the patients with carcinoma in the upper part of the stomach but in only 29.4 per cent of all patients being studied. Of 29 patients with positive diagnostic criteria for proximal gastric growth, 24 had distant metastases, resection being possible in only seven; 27 did not survive beyond three months. Of eight patients with negative diagnostic criteria for carcinoma of the proximal part of the stomach, only one patient had proved distant metastases, four had regional lymph nodes involved and all were amenable to resection. Five have survived for more than two years postoperatively.

Calidad de vida en la obesidad mórbida / Quality of life in morbid obesity

Introducción: la obesidad mórbida (OM) es una enfermedadcrónica que alcanza dimensiones epidémicas en los países desarrollados.La OM suele acompañarse de enfermedades graves asociadasque provocan una menor expectativa y peor calidad de vida.Objetivos: validar el cuestionario GIQLI (GastrointestinalQuality of Life Index) como herramienta fiable y eficaz en la evaluaciónde la calidad de vida en el paciente obeso mórbido.Pacientes y métodos: el cuestionario GIQLI consta de 36ítems cuya suma de cada puntuación individual otorga un valor final.A mayor puntuación, mejor calidad de vida. Dichos ítems seagrupan en 5 apartados: sintomatología digestiva, emocional,efectos sobre el tratamiento, disfunción física y social. Se ha aplicadoel GIQLI a una muestra aleatoria de 190 pacientes afectosde OM que cumplían los requisitos necesarios para someterse a cirugíabariátrica, y a un grupo control de 100 individuos sanos sinenfermedades orgánicas, funcionales, ni psíquicas conocidas. Seevaluó, en cada grupo, tanto la puntuación global del cuestionariocomo aquellas que hacían referencia a sus apartados específicos.Resultados: las puntuaciones fueron significativamente inferioresen los pacientes con OM frente al grupo control, tanto en lapuntuación global del cuestionario como en todas sus dimensiones.La puntuación global GIQLI disminuyó en función de la edady del número de enfermedades comórbidas asociadas.Conclusiones: el cuestionario GICLI se ha mostrado comouna herramienta útil en la valoración de la calidad de vida en elpaciente obeso mórbido. Los pacientes con OM tienen una peorpercepción en su calidad de vida que los pacientes no obesos, nosólo en cuanto a la presencia de síntomas digestivos, sino tambiénen la dimensión emocional, estado físico y vida de relación social

Introduction: morbid obesity (MO) is a chronic disease that isreaching epidemic proportions and becoming an increasing healthproblem in developed countries. Obesity-related comorbidities reduceboth the quality and expectancy of life.Objectives: to validate the GIQLI (Gastrointestinal Quality ofLife Index) test as a reliable and effective tool for the evaluation ofquality of life in morbidly obese patients.Patients and methods: the GIQLI test is made up of 36 individuallyscored items, the addition of which give up a final score.A higher score correlates with a better quality of life. Items can beseparated into five groups or dimensions: digestive symptoms,emotional status, effects of treatment, and physical as well as socialdysfunction. The GIQLI test was administered to a randomizedsample of 1990 morbidly obese patients who fulfilled the indicationcriteria for bariatric surgery, and to a control group of100 healthy individuals with no known medical, functional or psychiatricdisease. Overall test and specific dimension scores wereevaluated for each group.Results: overall test and specific dimension scores were significantlylower in patients with MO when compared to the controlgroup. The overall GIQLI score decreased as age increased, as didthe number of associated comorbidities.Conclusions: the GIQLI test proved to be a rather useful toolto evaluate quality of life in morbidly obese patients. These patientspresent a poorer quality of life not only because of the presenceof digestive symptoms but also because of their emotional,physical, and social status