Late Band Migration After SAGB. Case Report.

Obesity, a major public health issue of the 21st century, is increasingly common in adults and children. No good results of pharmacological treatment of obesity results in rapid development of bariatric surgery, which treats obesity and comorbidities associated. There are many surgical options for treating obesity. Options for surgical management of morbid obesity include restrictive (adjustable gastric banding, vertical band gastroplasty), restrictive/resective (sleeve gastrectomy), restrictive/malabsorptive (Rouxen-Y gastric by-pass, biliopancreatic diversion with duodenal switch) and purely malabsorptive procedures (duodenal switch). Among them, swedish adjustable gastric banding (SAGB) or laparoscopic adjustable gastric banding (LAGB) have been more frequently performed. SAGB is considered to be safe and effective method of weight loss and elimination of diseases associated with obesity. Laparoscopic gastric banding offers the advantages of minimally invasive surgery, adjustability, and reversibility. Despite fewer number of complications than other bariatric operations, patients after SAGB may have unique complications that are characteristic of the SAGB and require special management and treatment. This paper presents a rare case of complete migration of the band into the gastric lumen.

Primary ileo-anal pouch anastomosis in patients with acute ulcerative colitis.

INTRODUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) was performed in ulcerative colitis (UC) for emergent or urgent indications in three stages. Since the three-step procedure imposes enormous demands on a patient, there was an attempt to introduce primary IPAA for urgent indications. The aim of this study was to compare early complications after Hartmann's colectomy (HC) and IPAA in a selected group of patients. MATERIAL AND METHODS: Medical records of 274 patients who underwent surgery for UC between 1996 and 2010 were retrospectively evaluated. Finally, a group of 77 patients with acute form of UC entered this study. RESULTS: All patients were divided into two groups. Group 1 consisted of 32 (42%) patients who underwent HC, whereas group 2 comprised 45 (58%) patients after IPAA. There was no postoperative mortality. Respiratory failure occurred in 8 (24%) patients after HC and in 6 (14%) patients who underwent IPAA. Intra-abdominal sepsis developed in 4 (12%) patients after HC and in 8 (17%) undergoing IPAA. Fascia dehiscence was present in 3 (8%) patients after HC and in 4 (9%) with IPAA. Bowel obstruction occurred in 1 (4%) patient after the former operation and in 3 (6%) patients after the latter one. Wound infection was diagnosed in 6 (20%) patients after HC and in 9 (20%) after IPAA. The differences between the investigated groups of patients were not statistically significant. CONCLUSIONS: The IPAA could be performed for urgent indications only in the patients with no critical dilatation of the colon or with active UC but without signs of severe malnutrition.

Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders: a prospective multicentre study.

PURPOSE: To assess local control after preoperative radiation and local excision and to determine an optimal radiotherapy regimen. METHODS: Eighty-nine patients with G1-2 rectal adenocarcinoma <3-4 cm; unfavourable cT1N0 (23.6%), cT2N0 (62.9%) or borderline cT2/cT3N0 (13.5%) received 5 × 5 Gy plus 4 Gy boost (71.9%) or 55.8 Gy in 31 fractions with 5-FU and leucovorin (28.1%). Local excision (traditional technique 56.2%, transanal endoscopic microsurgery 41.6%, Kraske procedure 2.2%) was performed 6-8 weeks later. If patients were downstaged to ypT0-1 without unfavourable factors (good responders), this was deemed definitive treatment. Immediate conversion to radical surgery was recommended for remaining patients. RESULTS: Good response to radiation was seen in 67.2% of patients in the short-course group and in 80.0% in the chemoradiation group, p = 0.30. Local recurrence at 2 years (median follow-up) in good responders was 11.8% in the short-course group and 6.2% in the chemoradiation group, p = 0.53. In the total group, a lower rate of local recurrence at 2 years was observed in elderly patients (>69 years, median value) when compared to the younger patients; 8.3% vs. 27.7%, Cox analysis hazard ratio 0.232, p = 0.016. A total of 18 patients initially managed with local excision required conversion to abdominal surgery but either refused it or were unfit. In this group, local recurrence at 2 years was 37.1%. CONCLUSIONS: This study suggests an acceptable local recurrence rate after preoperative radiotherapy and local excision of small, radiosensitive tumours in elderly patients.

[Severe complications of total pelvic floor repair using polypropylene mesh--case report]. / Ciezkie powiklania po operacji calkowitej rekonstrukcji krocza przy uzyciu siatki polipropylenowej--opis przypadku.

The authors present a case of 58 years old woman suffering from complex pelvic floor pathology diagnosed with rectal prolapse, genitary organs prolapse, descending pelvic floor, rectocele and enterocele as well as advanced diverticular disease of the left colon. She suffered from chronic constipation. The surgery consisted of left hemicolectomy, hysterectomy, reconstruction of the pelvic floor and sacrocoloporectopexy using polypropylene mesh. The out-come complicated mesenteric vessels thrombosis, small bowel perforations and intraabdominal abscesses. Despite intensive care and subsequent ileal resections, debridement and drainage of the abscesses the patient died five months after beacause of multi organs insufficiency.

Local anesthesia in thyroid surgery--own experience and literature review.

UNLABELLED: The local anesthesia in thyroid surgery is rarely used, only in selected patients. Majority of centers performing thyroid surgery with local anesthesia have possibility to convert to the general anesthesia. The aim of the study was to present our experiences with partial thyroidectomy under local anesthesia performed in 49 consecutive subjects in the Central African Republic (bilateral subtotal strumectomy, total resection of the one lobe, subtotal resection of the one lobe). MATERIAL AND METHODS: All admitted patients with clinically significant goiter were accepted for surgical treatment. For infiltration anesthesia 1% lignocaine was used. Because of the shortage of medical resources, potential conversion to the general anesthesia was impossible. Before the operation patients had received an oral sedation and antibiotic. In 16 patients general anesthesia was used, in other 33 it was impossible. RESULTS: Subtotal bilateral thyroidectomy was performed in 37 patients, 12 patients underwent lobectomy or partial lobectomy of the affected portion of the gland. There were no intraoperative and postoperative complications noticed in the reported group, including complications related to laryngeal nerve injury. The mean duration of the procedure was 127 minutes and mean medical follow-up was 3 days. General condition of all patients on the day of discharge from hospital was good. CONCLUSIONS: Surgery for goiter under local anesthesia may be a safe alternative where general anesthesia is not available or contraindicated for medical reasons. The infiltration anesthesia is simple to perform and reduces the number of complications potentially occurred at the C2-C4 neck plexus block.

The diameter of the ileal J-pouch-anal anastomosis as an important risk factor of pouchitis - clinical observations.

BACKGROUND: Patients' quality of life after restorative proctocolectomy depends on the potential complications. Stricture of the ileal pouch-anal anastomosis is one of the complications following restorative proctocolectomy. MATERIAL/METHODS: We analyzed the correlation between the diameter of the anastomosis and clinical parameters, including pouchitis disease activity index (PDAI), the activity of fecal M2-pyruvate kinase and maximum tolerable volume of the pouch. The study group consisted of 31 patients in whom covering ileostomy had been closed 72 ± 50 months before enrolement to the study. Restorative proctocolectomy for ulcerative colitis or familial adenomatous polyposis coli had been performed in this group. RESULTS: The study did not show any correlation between the diameter of the anastomosis and primary indication for surgery, the time elapsed after restoration of the bowel continuity, the activity of fecal M2-pyruvate kinase, or maximum tolerable volume. However, meaningful correlations between the stricture of the anastomosis and the presence and activity of pouchitis, together with the ileal villi atrophy, were detected. CONCLUSIONS: Stricture of the anastomosis appears to be an important factor increasing the incidence of pouchitis, and is independent of the underlying condition and time after the operation. Dilation of the anastomosis and prevention of stricture should constitute a permanent element of postoperative follow-up.

Abdominal rectopexy with absorbable and non-absorbable materials in the treatment for rectal prolapse.

UNLABELLED: THE AIM OF THE STUDY was to present and compare own results of abdominal rectopexy performed with absorbable and nonabsorbable materials used in surgical repair of rectal prolapse. MATERIAL AND METHODS: In the years 1991-2009, 50 patients were operated on for rectal prolapse. The first 8 patients (group I) were operated using absorbale polyglycolic acid mesh. The next 42 patients were operated using non-absorbable polypropylene mesh (group II). 12 patients with chronic, incurable constipation had sigmoidectomy and rectopexy performed at the same operation. Rectopexy was performed with the mesh and fixed to the pelvic fascia and periosteum and mesorectum, leaving the anterior one third of the rectum free. 6 months after surgery functional outcomes were evaluated. Statistic analysis with the level of statistical significance p < 0.005 was applied to obtained functional results. RESULTS: On the follow up visits, there were no symptoms of the recurrence of rectal prolapse in 5 patients (62.5%) from group I and in 25 patients (92.6%) from group II. Patients relapsing were reoperated 24 to 98 months after primary surgery. In all patients from group I (absorbable mesh), prosthetic material was not found at reoperation. In redo surgery only non-absorbable mesh was used. CONCLUSIONS: The effectiveness of rectal fixation depends on the on the durability of the prosthetic material. In the studied group polypropylene mesh was superior in rectopexy to absorbable mesh.

Vacuum-assisted closure therapy in patients with large postoperative wounds complicated by multiple fistulas.

Vacuum-assisted closure (VAC) therapy is a widely acknowledged method for chronic and traumatic wound healing. The feasibility of VAC therapy used for the treatment of intestinal fistulas is still a subject of debate. Complex postoperative wounds pose significant therapeutic problems, especially when there are several fistula openings in the wound area and other sites, usually at the site of previous drains. This paper describes the treatment of three patients in a critical condition, with complex postoperative wounds complicated by multiple fistulas. Vacuum-assisted closure therapy was based on effective drainage of the biggest fistula opening and ensuring conditions promoting the healing process of other fistulas and the wound. A considerable improvement in general condition and wound healing was noted within 2-4 weeks and both the number of fistulas and the volume of excreted contents decreased. After 5-7 weeks a significant improvement in wound healing was observed in all patients. Once the general condition of all patients was considered satisfactory (2-6 months), they underwent surgery aimed at restoration of the digestive tract continuity.In our opinion, VAC therapy used for the treatment of postoperative wounds with multiple fistulas in the wound area and other sites should aim mainly at the improvement of patients' general condition, limitation of the number of fistulas as well as accelerated wound healing. This may lead to formation of one stoma-type fistula, which can be dressed and cared for by patients until the continuity of the digestive tract has been surgically restored.

Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders.

BACKGROUND AND PURPOSE: To report an early analysis of prospective study exploring preoperative radiotherapy and local excision in rectal cancer. MATERIALS AND METHODS: Mucosa at tumour edges was tattooed. Patients with cT1-3N0 tumour <3-4 cm were treated with either 5x5Gy+4Gy boost (N=31) or chemoradiation (50.4Gy+5.4Gy boost, 1.8Gy per fraction+5-fluorouracyl and leucovorin; N=13). Thirteen patients from the short-course group were unfit for chemotherapy. The interval from radiation to full-thickness local excision was 6 weeks. The protocol called for conversion to a transabdominal surgery in case of ypT2-3 disease or positive margin. RESULTS: The postoperative complications requiring hospitalization were recorded in 9% of patients. The rate of pathological complete response was 41%. The rate of patients requiring conversion was 34%; however, 18% actually underwent conversion and the remaining 16% refused or were unfit. During the 14 months of median follow-up, local recurrence was detected in 7% of patients and all underwent salvage surgery. Of 19 patients in whom initially anterior resection was likely, 16% had abdominoperineal resection performed for a conversion or as a rescue procedure. CONCLUSION: Our study suggests that the short-course radiation prior to local excision is a treatment option for high-risk patients.

Partial thyroidectomy under local anaesthesia-the analysis of 49 subsequent cases.

BACKGROUND AND AIMS: Partial thyroidectomy under local anaesthesia was performed in 49 subsequent individuals in the Central African Republic. Because of the shortage of medical resources, all patients with goitre were scheduled for an operation under local anaesthesia. MATERIALS AND METHODS: There were no inclusion or exclusion criteria applied for patient selection for the procedure. Before the operation, patients had received an oral sedation and antibiotic. For infiltration anaesthesia, 1% lignocaine was used. RESULTS: Subtotal bilateral thyroidectomy was performed in 37 patients; 12 patients underwent lobectomy or partial lobectomy of the affected portion of the gland. There were no intraoperative complications in any of the patients. The mean time of the procedure averaged 127 min. There were no postoperative complications noticed in the reported group, and this includes also complications related to laryngeal nerve injury. General condition of the operated on patients allowed for full self-dependency within 4 to 6 h postoperatively. Patients remained under medical surveillance for mean 3 days, and cutaneous stitches were removed on the first postoperative day. General condition of all patients on the day of discharge from hospital was good. CONCLUSION: Surgery for goitre under local anaesthesia may be a safe alternative where general anaesthesia is not available or contraindicated for medical reasons.