Five-Year Outcome of Laparoscopic Sleeve Gastrectomy, Resolution of Comorbidities, and Risk for Cumulative Nutritional Deficiencies.

BACKGROUND AND AIMS:: The aim of this study was to evaluate the long-term (5-year follow-up) results of laparoscopic sleeve gastrectomy in terms of weight loss and obesity-related comorbidities, as well as the risk factors associated with postoperative nutritional deficiencies. MATERIAL AND METHODS:: The first 99 consecutive patients who underwent laparoscopic sleeve gastrectomy for the treatment of morbid obesity between October 2008 and August 2011 at Tartu University Hospital were followed prospectively in cohort study. The outpatient hospital follow-up visits were conducted at 3 months, 1 year, and 5 years postoperatively. At 5 years, the follow-up rate was 90.9%; 86 laparoscopic sleeve gastrectomy patients were included in final analysis. RESULTS:: The mean excess weight loss (%EWL) was 44.3% ± 13.0%, 75.8% ± 23.1%, and 61.0% ± 24.3% at 3 months, 1 year, and 5 years, respectively. A linear association between preoperative weight and weight at 5 years was found. Remission rates at 5-year follow-up for type 2 diabetes, hypertension, dyslipidemia, and obstructive sleep apnea were 68.8%, 32.7%, 27.4%, and 61.5%, respectively (all p < 0.05). There was a statistical difference (p < 0.05) in the dynamics of triglyceride, low-density lipoprotein, and high-density lipoprotein level at 5-year follow-up but the level of total cholesterol did not show significant improvement. The risk for cumulative iron, vitamin B12 deficiency, and anemia was 20%, 48%, and 28%, respectively. CONCLUSION:: In conclusion, laparoscopic sleeve gastrectomy ensured long-term excess weight loss 61.0% at 5 years. Laparoscopic sleeve gastrectomy has a long-term effect on significant improvement in the median values of triglycerides, low-density lipoproteins, and high-density lipoproteins, but not on total cholesterol levels. There is a risk of postoperative vitamin B12 and iron deficiency.

Surgical complications accompanying liver transplantation in Estonia.

The purpose of this study was to evaluate surgical complications accompanying the introduction of orthotopic liver transplantation (OLT) in Estonia. Between 1999 and 2009, we performed the first 12 liver transplantations. Eight patients were males and four were females of age range 12 to 67 years. Their diagnoses were cholestatic disease (n = 5); tumor (n = 3); hepatitis C virus cirrhosis (n = 2); Budd-Chiari syndrome (n = 1); and cystic fibrosis (n = 1). Technical complications occurred in 7/12 patients. The early vascular complications in two patients were a suprahepatic vena cava lesion occurring at liver extraction, which resulted in uncontrolled suprahepatic bleeding after liver perfusion; the recipient died during transplantation. The other case displayed a right intrahepatic portal venous thrombosis, which was treated successfully with thrombolysis and anticoagulant therapy. Early biliary complications of biliary leaks occurred in three patients: two had undergone duct-to-duct reconstructions, which were treated by endoscopic retrograde cholangiography that successfully managed the anastomotic and recipient cystic duct leaks with a papillotomy and stenting. In one patient with a duct-to-jejunum anastomosis, a bile leak stopped at 3 weeks but he needed surgical therapy 2 years later due to an anastomotic stricture. Severe decubitus occurred in the lumbosacral region of the subjects with operating times of 14 hours. They required necretectomy and plastic surgery. One of them with postoperative intra-abdominal hypertension also displayed wound eventration requiring reoperations. The rate of hepatic (5/12) and extrahepatic (3/12) surgical complications, as well as of 1-year survival (9/12), in our period of implementation of OLT were satisfactory to continue OLT development in Estonia.

Diversity of Helicobacter pylori genotypes among Estonian and Russian patients with perforated peptic ulcer, living in Southern Estonia.

To compare the genomic variation of Helicobacter pylori in samples obtained from patients with perforated peptic ulcer, living in the same area of Estonia but belonging to different nationalities, 50 non-consecutive patients (32 Estonians and 18 Russians) admitted in the Tartu University Hospital in 1997-1999 were studied. Gastric samples of antral mucosa were obtained during operation and analysed histologically and with PCR for detection of different genotypes of H. pylori (cagA and vacA s and m subtypes). Among the 50 perforated peptic ulcer patients with histologically proven H. pylori colonisation no sample of gastric mucosa showed the s1b subtype of the vacA gene. The perforated peptic ulcer patients were mainly infected with cagA (82%) and s1 (98%) genotypes of H. pylori. The distribution of s1a/m1, s1a/m2 and s2/m2 subtypes of vacA genes was statistically different in Estonian and Russian patients (P<0.05). In conclusion differences in the distribution of vacA s and m subtypes of H. pylori were revealed between Estonian and Russian patients with perforated peptic ulcer from Southern Estonia.

Perforated peptic ulcer: is there a difference between Eastern Europe and Germany? Copernicus Study Group and Acute Abdominal Pain Study Group.

BACKGROUND AND AIMS: Ulcer surgery and the epidemiology of peptic ulcer perforation have changed considerably in recent decades. PATIENTS/METHODS: Within two prospective studies, 170 perforated peptic ulcer patients from 12 Eastern European centres and 37 patients from 11 German centres were analysed. RESULTS: The median age of patients was 43 years in the Copernicus study and 49 years in the MEDWIS study (P=n.s.), being higher for MEDWIS female patients (73 vs 53 years, respectively; P<0.05). Female patients made up 17% (29/170) of the Copernicus study and 35% (40/170) of the MEDWIS study (P<0.05). Twenty-three per cent (40/170) of patients in the Copernicus study and 54% (20/37) in the MEDWIS study had gastric ulcer perforation (P<0.001). The proportion of definitive operations was higher in Eastern Europe (41.1%; 67/163) than it was in Germany (16.1%; 5/31) (P<0.01). German patients experienced more general complications than Eastern European patients (35 vs 12%, respectively; P<0.01) and a higher mortality [13% (5/37) vs 2% (4/170), respectively; P<0.01]. Delayed admission > or =12 h and age > or =60 years remained predictors for complications in multivariate logistic regression analysis. CONCLUSION: The proportion of both women and gastric ulcers was higher among German patients, while Eastern European patients underwent more definitive operations. German patients experienced more general complications and a higher mortality. Complications were related to high age and delayed admission.

Evaluation of risk factors for mortality in surgically treated perforated peptic ulcer.

BACKGROUND/AIMS: The aim of our study was to evaluate complications and possible risk factors for mortality in perforated peptic ulcer patients with a special reference to the fact whether definitive or non-definitive operation was performed. METHODOLOGY: All 394 patients (mean age: 45.5 years; range: 15-93) from Tartu county hospitalized for PPU at Tartu University Clinic in the period 1978-97 were included in a retrospective study. RESULTS: Twenty-two patients (5.6%) of 394 died. In 73 patients 93 concomitant diseases (mortality 19.2%) and in 81 patients 114 complications were observed. There were 245 non-definitive operations and 141 definitive operations with a mortality rate of 7.3% and 1.4%, respectively. Univariate logistic regression analysis of 386 operatively treated patients revealed that age > or = 65 years, concomitant diseases, treatment delay > or = 12 hours, female sex and non-definitive operations were significantly associated with mortality. However, multivariate analysis showed that only age > or = 65 years and concomitant diseases were independent predictors of mortality. CONCLUSIONS: Patients' high age and presence of concomitant diseases were related to lethal outcome after surgical procedure performed for perforated peptic ulcer. The result did not depend on the fact whether definitive or non-definitive operation was applied.

[Reconstruction of the cervical esophagus using a revascularized ileal graft (experimental study)]. / Rekonstruktsiia sheinogo otdela pishchevoda revaskuliarizovannym ileotransplantatom (éksperimental'noe issledovanie).

The clinic and histomorphology of the revascularized ileum autograft used for the reconstruction and/or replacing the cervical oesophagus in 76 adult mongrel dogs were examined from the 1st to 372nd postoperative days. In 46% of the cases complete recovery of autografts has been established. In 54% of the cases various complications were noticed-very long ischemia, necrosis and spontaneous detachment of the autografts injury of the superficial (endothelial) layer of blood vessels. Thrombosis of blood vessels, tissue haemorrhage, bleeding of the contact areas, wound infections, stenosis of the tubular autografts, unknown cases of abnormalities and mortality could also take place. There are a so-called split or detached contact within the oesophagus and the ileum graft as well as a lowering and enlargement of the villi, atypical crypts, partial replacement of the epithelium columnar cells with goblet cells, inflammatory lymphocytic infiltration of propria and epithelium, high phagocytic activity of the macrophages. The transplant changes can be more rapid if the defect of the cervical oesophagus is filled with a small intestine patch. At the junction of the morphological picture a strong hypo- and atrophy can be observed as well as the destruction and irritation, complete replacement of the columnar cells with mucous cells. In the so-called resorptive contact typical epitheliocytes have been replaced by a polymorphic cell mass. Acute inflammatory infiltration penetrated regionally all over the transplant. The simple columnar epithelium of the ileus transplant has been replaced by the non-keratinized stratified squamous epithelium.

[Changes in the tissues of a revascularized transplant of small intestine in the dog under different operating conditions]. / Izmeneniia tkanei revaskuliarizirovannogo transplantata tonkoi kishki sobaki pri razlichnykh usloviiakh operatsii.

Histomorphological changes of revascularized autotransplant were studied in 34 dogs in different conditions of the operation. It was established that revascularization is necessary for transplantation. Organ disintegrates without vascular peduncle. Prolonged operative ischemia (up to 3 hrs) of the transplant causes its essential alternative and destructive changes up to the complete disintegration of part of the villi. Autotransplant of the small intestine preserves tissue and cell composition on the neck for a long period (more than a year) and may be used in replacing operations on the esophagus. However, complete organotypic and tissue restoration of the structure does not occur. Villi disappear, crypt epithelium forms structures resembling terminal regions of cardial glands, simple intestinal epithelium is replaced with the stratified one.