LigaSure Impact™ reduces complications after abdominoplasty in weight loss patients.

PURPOSE: Bariatric surgery is on the rise worldwide. With the desired weight loss after bariatric surgery, patients frequently develop massive skin flaps resulting in the need of abdominoplasty. In these patients, this surgical technique is frequently associated with perioperative complications. Strategies to minimize complications are sought after. The objective of our study was to compare two different dissection techniques and their impact on postoperative outcome. METHODS: We included 66 patients in our study who underwent abdominoplasty after massive weight loss following bariatric surgery. In group 1, abdominoplasty was performed using the conventional technique of diathermia (n = 20). In group 2, abdominoplasty was performed using LigaSure Impact™ (n = 46). The duration of the surgical procedure and perioperative complications were recorded as primary endpoints. Secondary endpoints were length of hospital stay and assessment of additional risk factors. RESULTS: Baseline characteristics were comparable between groups. The duration of surgery was significantly shorter in group 2. Postoperative complications were significantly less frequent in group 2 (p = 0.0035). Additional risk factors, e.g., smoking and diabetes mellitus, were not associated with increased rates of perioperative complications. CONCLUSIONS: The choice of technical device for dissection in abdominoplasty alone will not guarantee minimized complication rates. Yet, the utilization of LigaSure Impact™ in refined surgical techniques may facilitate reduced rates of complications, especially wound infections, and a shortened duration of surgery.

Short-term Results of Transit Bipartition to Promote Weight Loss After Laparoscopic Sleeve Gastrectomy.

Objective: To evaluate (1) the efficacy of transit bipartition (TB) as revisional bariatric surgery (RBS) after laparoscopic sleeve gastrectomy (LSG); (2) the impact of the length of the common channel (CC) on weight loss. Background: LSG in combination with TB has been shown to be highly efficacious for treating morbid obesity. The role of TB as RBS to address the problem of primary failure or weight recidivism after LSG is less well defined. Methods: Observational study of outcomes in 100 morbidly obese patients who received a TB following LSG. Follow-up examinations (FE) were performed at 1, 3, 6, and 12 months. Variables analyzed included BMI, percent excess weight loss (%EWL), total body weight loss (%TBWL), effect on obesity-related conditions and complications. Results: The mean BMI before LSG was 49.9 ± 8.5 kg/m2. A nadir of 32.7 ± 6.1 kg/m2 was reached 22.1 ± 16.9 months after LSG (%EWL 70.0 ± 14.5). The time interval between LSG and TB was 52.2 ± 26.6 months at which the BMI had increased to 37.6 ± 7.1 kg/m2 and %EWL decreased to 49.4 ± 19.7. Following TB, the BMI decreased continuously to 31.4 ± 5.7 kg/m2 after 12 months with a parallel increase in %EWL to 74.7 ± 20.3 and %TWL reaching 36.3 ± 10.5. Weight loss was significantly higher for CC length of 250 versus 300 cm after 12 months (BMI 29.4 ± 5.3/33 ± 5.3 kg/m2, P = 0.002; %EWL 79.8 ± 26.6/70.4 ± 17; P = 0.009). Improvement of comorbidities was observed in a high proportion of patients. Major early complications occurred in 3% of the patients. Conclusion: TB is an effective second-step procedure to address insufficient weight loss or weight recidivism after LSG. CC length of 250 versus 300 cm had a significant impact. While most improvements of obesity-related comorbidities are likely linked to weight loss, amelioration of GERD is largely mediated by accelerated gastric emptying. Major complications were observed in 3% of patients and managed without fatalities.

The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients.

OBJECTIVE: To analyze patient outcome in the first 14 months of the German natural orifice translumenal endoscopic surgery (NOTES) registry (GNR). SUMMARY BACKGROUND DATA: NOTES is a new surgical concept, which permits scarless intra-abdominal operations through natural orifices, such as the mouth, vagina, rectum, or urethra. The GNR was established as a nationwide outcome database to allow the monitoring and safe introduction of this technique in Germany. METHODS: The GNR was designed as a voluntary database with online access. All surgeons in Germany who performed NOTES procedures were requested to participate in the registry. The GNR recorded demographical and therapy data as well as data on the postoperative course. RESULTS: A total of 572 target organs were operated in 551 patients. Cholecystectomies accounted for 85.3% of all NOTES procedures. All procedures were performed in female patients using transvaginal hybrid technique. Complications occurred in 3.1% of all patients, conversions to laparoscopy or open surgery in 4.9%. In cholecystectomies, institutional case volume, obesity, and age had substantial effect on conversion rate, operation length, and length of hospital stay, but no effect on complications. CONCLUSIONS: Despite the fact that NOTES has just recently been introduced, the technique has already gained considerable clinical application. Transvaginal hybrid NOTES cholecystectomy is a practicable and safe alternative to laparoscopic resection even in obese or older patients.

Short- to medium-term results of single-anastomosis duodeno-ileal bypass compared with one-anastomosis gastric bypass for weight recidivism after laparoscopic sleeve gastrectomy.

BACKGROUND: Single-anastomosis duodeno-ileal bypass (SADI) and the one-anastomosis gastric bypass (OAGB) are 2 revisional procedures to address the problem of weight recidivism after laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: To evaluate the efficacy and safety of SADI and OAGB as revisional bariatric surgery (RBS) in initially super-obese patients (body mass index [BMI] >50 kg/m2). SETTING: Academic hospital, bariatric center of excellence, Germany. METHODS: Observational study of outcomes in 84 initially super-obese patients who had undergone RBS after LSG (SADI n = 42, OAGB n = 42) between July 2013 and April 2018. Follow-up examinations were performed at 1, 6, 12, 24, and 36 months after RBS. The variables analyzed included time between LSG and RBS, BMI, excess weight loss, total weight loss, operation time, and complications. RESULTS: The time interval between LSG and RBS was 45.5 ± 22.8 and 43.5 ± 24.2 months for SADI and OAGB, respectively. At the time of RBS, the mean BMI was 42.8 ± 7.9 kg/m2 for SADI and 43.4 ± 9.2 kg/m2 for OAGB. The follow-up examinations rates (%) after SADI were 97.6, 92.8, 90.5, 78.6, 57.1, and 100, 97.6, 95.2, 85.7, and 59.5 after OAGB. The BMI at the follow-up examinations were 39.1 ± 7.2, 34.2 ± 6.9, 31.2 ± 5.8, 30.2 ± 5.3, 29.3 ± 5.1 for SADI, and 39.5 ± 8.1, 36.6 ± 7.4, 34.7 ± 7.9, 32.9 ± 6.3, and 31.6 ± 5.9 for OAGB. The mean operating times for SADI and OAGB were 138 ± 40 and 123 ± 39 minutes, respectively. Three patients in the SADI group and 1 patient in the OAGB group developed a major complication within the first 30 postoperative days. CONCLUSION: SADI and OAGB were effective second-step procedures for further weight reduction after LSG in initially super-obese patients after short to medium follow-up. There was a trend toward higher weight loss for SADI though this did not reach statistical significance. Substantial differences concerning surgery time and complications between the 2 procedures were not observed.

Evaluation of the Efficacy of Single Anastomosis Sleeve Ileal (SASI) Bypass for Patients with Morbid Obesity: a Multicenter Study.

BACKGROUND: Single anastomosis sleeve ileal (SASI) bypass is a newly introduced bariatric and metabolic procedure. The present multicenter study aimed to evaluate the efficacy of the SASI bypass in the treatment of patients with morbid obesity and the metabolic syndrome. METHODS: This is a retrospective, seven-country, multicenter study on patients with morbid obesity who underwent the SASI bypass. Data regarding patients' demographics, body mass index (BMI), percentage of total weight loss (%TWL), percentage of excess weight loss (%EWL), and improvement in comorbidities at 12 months postoperatively and postoperative complications were collected. RESULTS: Among 605 patients who underwent the SASI, 54 were excluded and 551 (390; 70.8% female) were included. At 12 months after the SASI, a significant decrease in the BMI was observed (43.2 ± 12.5 to 31.2 ± 9.7 kg/m2; p < 0.0001). The %TWL was 27.4 ± 13.4 and the %EWL was 63.9 ± 29.5. Among the 279 patients with type 2 diabetes mellitus (T2DM), complete remission was recorded in 234 (83.9%) patients and partial improvement in 43 (15.4%) patients. Eighty-six (36.1%) patients with hypertension, 104 (65%) patients with hyperlipidemia, 37 (57.8%) patients with sleep apnea, and 70 (92.1%) patients with GERD achieved remission. Fifty-six (10.1%) complications and 2 (0.3%) mortalities were recorded. Most complications were minor. All patients had 12 months follow-up. CONCLUSIONS: The SASI bypass is an effective bariatric and metabolic surgery that achieved satisfactory weight loss and improvement in medical comorbidities, including T2DM, hypertension, sleep apnea, and GERD, with a low complication rate.

Comparison of pancreas-transplanted type 1 diabetic patients with portal-venous versus systemic-venous graft drainage: impact on glucose regulatory hormones and the growth hormone/insulin-like growth factor-I axis.

CONTEXT: Pancreas grafts can be drained through the iliac vein (systemic drainage) or the portal vein. OBJECTIVE: We hypothesized that normalization of portal insulin in patients with portal pancreas graft drainage stimulates the GH/IGF-I axis and thereby contributes to glucose control. METHODS: We compared patients after combined kidney and pancreas transplantation with portal drainage (n = 7) to patients with systemic drainage of the pancreas graft (n = 8) and nondiabetic controls (n = 8). Overnight fasting sera were analyzed for free and total IGF-I and IGF-binding proteins. Glucose regulatory hormones were examined after an oral glucose tolerance test and GH after stimulation with GHRH. RESULTS: Systemic drainage led to higher basal and stimulated insulin levels than portal drainage (P < 0.05), but increments in response to oral glucose were reduced in both transplanted groups (P < 0.05 vs. controls). However, glucose tolerance was similar in all groups. Circulating free and total IGF-I and IGF-binding protein-3 were similar to control levels in the systemic drainage group but elevated in the portal drainage group (P < 0.05). Consistently, the GH response was reduced in the portal drainage group (P < 0.05 vs. controls) and correlated inversely with free IGF-I (r = -0.63, P < 0.05). CONCLUSION: Portal drainage of pancreatic endocrine secretion in pancreas graft recipients raises IGF-I and lowers GH secretion. These changes might explain that glucose regulation is maintained despite lower peripheral insulin levels, compared with patients with systemic graft drainage and nondiabetic control subjects.

Oral High-Dose Vitamin D Dissolved in Oil Raised Serum 25-Hydroxy-Vitamin D to Physiological Levels in Obese Patients After Sleeve Gastrectomy-A Double-Blind, Randomized, and Placebo-Controlled Trial.

BACKGROUND: Osteomalacia and cardiometabolic disorders are favored in morbidly obese patients due to an inadequate vitamin D (VD) status. Former trials supplementing orally VD (20-50 µg/day) in crystalline form after sleeve gastrectomy (SG) could not stabilize serum 25-hydroxycholecalciferol levels at predefined concentrations (≥50 nmol/l). We hypothesized that VD in an oily suspension would increase its bioavailability resulting in normal serum VD levels minimizing markers of cardiometabolic risk. METHODS: Morbidly obese patients (n = 94, BMI 51.8 ± 11.5 kg/m(2)) received orally 80 µg/day VD3 dissolved in oil or placebo (pure oil) in a randomized, double-blind, parallel-group study for 12 weeks after SG. 25-hydroxycholecalciferol, parathyroid hormone, albumin, alkaline phosphatase, phosphate, magnesium, calcium, creatinine, C-reactive protein, lipids, glucose, and glycated hemoglobin were determined in serum/plasma before surgery and after 4 and 12 weeks of supplementation. Intake of energy, fat, and VD were monitored using a 3-day food record. RESULTS: Seventy-nine patients were included in statistical analysis. Preoperatively, 77.2 and 40.5 % presented 25-hydroxycholecalciferol levels <75 and <50 nmol/l, respectively. After 12 weeks of supplementation, significantly more patients in the VD group exhibited levels >50 nmol/l (92 %) and >75 nmol/l (68 %) compared to the placebo group (54 and 22 %, respectively). Parameters of mineral metabolism and cardiometabolic risk were not modulated by intervention. CONCLUSION: Supplementation of 80 µg/day VD3 by oil is an effective and safe measure to prevent VD deficiency and to treat a preexisting undersupply in patients after SG. Cardiometabolic risk factors were, however, not affected; probably, higher VD doses might be necessary. CLINICAL TRIAL REGISTRATION: This trial was registered retrospectively on November 14, 2014, at the German Clinical Trials Register as DRKS00007143.

Preoperative micronutrient status in morbidly obese patients before undergoing bariatric surgery: results of a cross-sectional study.

BACKGROUND: Reliable information on micronutrient status before bariatric surgery is needed to optimize preoperative nutritional status and postoperative nutritional therapy. OBJECTIVE: To investigate the pro-/vitamin and mineral status and its association with nutrient intake in morbidly obese patients seeking bariatric surgery SETTING: Klinikum Vest, Recklinghausen, Germany. METHODS: The cross-sectional study investigated retinol, ascorbic acid, tocopherol, and ß-carotene (high-pressure liquid chromatography), 25-hydroxycholecalciferol (enzyme-linked immunosorbent assay), and calcium, phosphate, and magnesium (photometry) in serum/plasma in 43 patients (body mass index: 52.6±10.5 kg/m(2)) before sleeve gastrectomy. Albumin, parathyroid hormone, and alkaline phosphatase were analyzed. Data were compared with accepted cutoff values. Dietary intake was estimated by 3-day food records, and nutrient intake was compared with recommended values. RESULTS: One third of participants had ascorbic acid concentrations<28 nmol/L. All patients had ß-carotene levels≤.9 µmol/L, although retinol was below the cutoff value (<.7 µmol/L) in only 5%. Tocopherol/cholesterol-ratio was always>2.8 µmol/mmol. Of the patients, 84% had 25-hydroxycholecalciferol levels below 50 nmol/L. Parathyroid hormone was elevated in 23% (>6.5 pmol/L). Calcium, magnesium, and alkaline phosphatase were always, and phosphate was mostly (98%) above cutoff values. Intake of retinol (23%), ascorbic acid (55.8%), vitamin D (90.7%), tocopherol (48.8%), and ß-carotene (<2.0 mg/d; 37.2%) were often below recommendations. Correlations between serum/plasma concentrations and nutritional intake and associations between low concentrations and inadequate intake were not observed. CONCLUSIONS: Many morbidly obese patients in Germany suffer from deficiencies in multiple micronutrients, particularly vitamin D, ascorbic acid, and ß-carotene before sleeve gastrectomy. Measurement of preoperative micronutrient status will help supplement patients before, and optimize nutritional therapy after, surgery.

Contrast enhanced ultrasound of a gallbladder lesion in a patient with a history of renal cell and rectal cancer.

The gallbladder is an uncommon site of metastatic cancer. Although ultrasound can be regarded as a first line investigation for the detection of gallbladder lesions, differentiation between benign and malignant tumors usually requires resection. Real-time contrast enhanced ultrasound (CEUS) is a well-established technique for the classification of liver, pancreatic, and renal diseases (Weskott, 2008). The application of CEUS in the diagnosis of gallbladder tumors has rarely been described. We report the application of contrast enhanced ultrasound for the characterization of a gallbladder lesion in a 63-year-old patient with a history of renal cell and rectal cancer.

Gastroduodeno-plasty performed by distal gastric transection.- A new technique for large duodenal defect closure.

INTRODUCTION: Duodenal ulcer lesions can represent a surgical challenge, especially if the duodenal wall is chronically inflamed, the defect exceeds a diameter of 3 cm and the ulceration is located in the second part of the duodenum. PATIENT AND METHOD: We present the case of a 70-year-old male, who suffered from a 3 x 4 cm duodenal defect caused by duodenal pressure necrosis due to a 12.5 x 5.5 x 5 cm gallstone. Additionally, this stone caused intestinal obstruction (Bouveret's syndrome) and bleeding with signs of shock. Besides the gallstone extraction, the common bile duct was drained by a T-tube and the duodenal defect closure was performed by a gastroduodeno-plasty and Bilroth II gastroenterostomy. The postoperative phase was uneventful. The reconstructed duodenum was endoscopically accessible and showed no pathological findings on follow-up. CONCLUSION: The reconstruction of a large defect (> 3 cm) of the second part of the duodenum is safely feasible by a gastroduodeno-plasty. The critical gastroduodenal anastomosis can be protected by duodenal decompression, achieved by placing a T-tube in the common bile duct.