Bowel obstruction after biliopancreatic diversion: a deceptive complication.

BACKGROUND: Although obesity surgery is now practiced in most of the world, many general surgeons, faced with an emergency, are not experienced in the diagnostic problems associated with these techniques, or about the most suitable treatment to resolve the acute pathology while preserving the weight loss. The biliopancreatic diversion (BPD), because of its complexity, could cause a delay in the diagnosis and therapy, with possible catastrophic consequences for the patient. METHODS: We report 3 patients with bowel obstruction after BPD. In the first patient intestinal occlusion was due to an adhesion obstructing the alimentary tract; in the other two patients the occlusion was localized to the biliopancreatic tract, due to a serrate stenosis of the entero-entero anastomosis in one patient and due to volvulus of the biliopancreatic loop in the other patient. RESULTS: Signs and symptoms were different according to whether the obstruction was in the alimentary tract or the biliopancreatic tract. In all cases a prompt gastrointestinal x-ray with barium and ultrasound scan and/or CT scan induced us to a mandatory laparotomy with resolution of the obstruction. CONCLUSIONS: After BPD, diagnosis of an intestinal obstruction must be made promptly. Even colleagues who express doubts must be persuaded to perform immediately an upper gastrointestinal tract x-ray and an U/S or CT scan. In this way, it may be possible to avoid intestinal resection and catastrophic complications.

Biliopancreatic diversion for treatment of morbid obesity: experience in 50 cases.

BACKGROUND: Biliopancreatic diversion (BPD) by Scopinaro's method is an operation advocated by some surgeons as an effective treatment for morbid obesity. METHODS: Between February 1995 and April 1997 we performed BPD by Scopinaro's method on 50 patients with morbid obesity (23 males), average age 41.4 years (range 20-63 years), average body weight 135.08 kg (range 89-256 kg), mean body mass index (BMI) 50.65 kg/m2 (range 37.01-81.56 kg/m2). RESULTS: In all cases a gradual decrease in weight was obtained [mean BMI at 1 month: 44.8 kg/m2, at 6 months (31 patients): 35.09 kg/m2, at 1 year (23 patients): 31.36 kg/m2, at 18 months (14 patients): 29.89 kg/m2 and at 2 years (5 patients): 29.27 kg/m2]. At the same time a significant improvement in the pathological conditions associated with morbid obesity was observed. The patients were able to suspend oral antihypertensive and antidiabetic therapy as these parameters spontaneously returned to normal values by the sixth postoperative month; all cases showed a marked reduction in hypercholesterolemia and hypertriglyceridemia. Postoperative complications were: one death (2%) on the third day due to heart failure; two late intestinal occlusions (4%); one acute dilatation of the stomach (2%); one peritonitis caused by early dehiscence of the anastomosis (2%); five anastomotic ulcers (10%); two cases of protein malnutrition (4%). CONCLUSIONS: BPD by Scopinaro's method is a bariatric procedure which is technically complex. However is it safe and reproducible and it induces a substantial weight loss.

Biliopancreatic diversion preserving the stomach and pylorus in the treatment of hypercholesterolemia and diabetes type II: results in the first 10 cases.

BACKGROUND: Besides weight loss Scopinaro's operation produces correction of hypercholesterolemia and noninsulin dependent diabetes mellitus in all patients who suffer from these conditions. These results encouraged us to perform biliopancreatic diversion (BPD) without gastric resection, thus preserving the functions of the stomach and pylorus in moderately overweight patients with hypercholesterolemia associated with diabetes type II and hypertriglyceridemia. METHODS: Between March 1996 and July 1997 we performed BPD without gastric resection on 10 moderately overweight patients [mean body mass index (BMI) = 33.2 kg/m2]. All patients had suffered from hypercholesterolemia and hypertriglyceridemia for more than 5 years. Ten patients suffered from diabetes type 11; four of them had had insulin treatment or oral anti-diabetic agents; the other patients all had hyperglycaemia in the fasted state and diabetes confirmed by preoperative oral glucose tolerance test (OGTT). Five patients suffered from hypertension. RESULTS: In all patients, cholesterol and triglyceride levels returned to normal within the first postoperative month. Glycemia also stabilized at normal values in nine patients within the early weeks after surgery. One patient who took 70 U of insulin reduced his daily intake to 35 U 2 months postoperatively. In all patients blood pressure returned to normal. Weight loss was predictably slight (10-15 kg). CONCLUSIONS: Our experience with the procedure found that this new method seems to be as effective in controlling lipidic metabolism and diabetes II as the original version of BPD. As expected, weight loss is only moderate, so that the modified BPD is not suitable for very obese patients.

Orally administered ranitidine plasma concentrations before and after biliopancreatic diversion in morbidly obese patients.

BACKGROUND: Patients undergoing biliopancreatic diversion (BPD) may develop gastric ulcers, particularly within the first postoperative year. The prophylactic use of antisecretory compounds at the usual therapeutic doses, mainly conventional H2-receptor antagonists such as ranitidine, may reduce the incidence of this complication, which occurs in approximately 5% of patients after BPD. METHODS: The authors measured the plasma concentrations of ranitidine (300 mg orally) in obese patients, before and 8 months after BPD, and in control subjects of normal weight. The study included 11 obese patients undergoing BPD (age 45+/-14 years; preoperative and postoperative weights 124+/-21 and 92+/-11 kg) and 10 normal-weight subjects (age 37+/-13 years, weight 67+/-9 kg). RESULTS: Postoperative ranitidine plasma concentrations showed only minor differences from preoperative levels, with slightly higher maximum concentrations occurring sooner. The mean area under the curve was on the average 30% higher than preoperatively. All parameters, however, were similar to those in control subjects. CONCLUSIONS: BPD per se does not greatly affect the pharmacokinetic behavior of ranitidine, and therefore a conventional dosage regimen appears adequate for the prophylaxis and therapy of gastric ulcers associated with this operation.

A case of primary hydatidosis of the thyroid gland.

A 54-year-old woman presented with an expansive mass in the anterior cervical region (front of the neck) with abscess. Laboratory tests and thyroid profile proved normal. Surgical exploration revealed a hydatid cyst in the left lobe of the thyroid gland with parasitic metastasis of the left lateral cervical lymph node chain. Postoperative examination of the nodule showed it to be a solitary primary thyroid hydatid cyst.

A case of primary hydatidosis of the thyroid gland.

A 54-year-old woman presented with an expansive mass in the anterior cervical region (front of the neck) with abscess. Laboratory tests and thyroid profile proved normal. Surgical exploration revealed a hydatid cyst in the left lobe of the thyroid gland with parasitic metastasis of the left lateral cervical lymph node chain. Postoperative examination of the nodule showed it to be a solitary primary thyroid hydatid cyst.

The use of the Valtrac ring in the upper and lower gastrointestinal tract, for single, double, and triple anastomoses: a report of 50 cases.

The Valtrac biofragmentable anastomotic ring (V-BAR) technique has been widely used in clinical practice, particularly in anastomoses of the colon. The success of this method encouraged some surgeons to use it also in anastomosis of the small intestine. We are convinced that the method can be used successfully also in anastomosis of the small intestine and the upper gastrointestinal tract, particularly in cases of technically difficult and high-risk anastomoses. Between 1995 and 1998, we used the V-BAR in 35 patients, performing a total of 50 anastomoses. In 13 patients a double anastomosis was created in the same operation, and in one patient a triple anastomosis was created. In all we performed one end-to-end esophagojejunostomy, one gastrojejunostomy, six gastroileostomies, two duodenojejunal anastomoses, 13 end-to-end duodenoileostomies, one jejuno-jejunal anastomosis, 18 end-to-side ileoileal anastomoses, one ileocolic anastomosis, and seven colocolic anastomoses. Follow-up at between 2 and 36 months showed good overall results with regard to resumption of intestinal transit and canalization, even in those cases in which a double and triple suture was performed using the Valtrac ring. In our experience, the V-BAR can be used in upper gastrointestinal surgery with excellent results. Compared with manual sutures, the ring allows better and faster resumption of transit and canalization.

[Preliminary results of biliopancreatic diversion in the treatment of morbid obesity. Clinical considerations on 69 patients with a 3-year follow-up]. / Risultati preliminari della diversione biliopancreatica nel trattamento della grande obesità. Considerazioni cliniche su 69 pazienti con follow-up a 3 anni.

BACKGROUND AND AIMS: The aim of this study was to evaluate the results obtained using Scopinaro's biliopancreatic diversion technique (AHS-BPD) in the surgical treatment of morbid obesity. METHODS: A retrospective study was carried out in 69 patients with a follow-up ranging between 6-44 months. All patients were operated and monitored by the Obesity Surgery Centre operating in Sardinia since february 1995 at the Department of Emergency Surgery of Sassari University. All the patients were severely obese with a mean BMI of 51.58 and, in the majority of cases, presented associated metabolic diseases with the following incidence: type 2 diabetes in 40.57%, arterial hypertension in 36.23%, severe alteration of lipid status in 52.17%; in overall terms, a plurimetabolic syndrome was present in 24.63% of cases. All patients underwent biliopancreatic diversion using Scopinaro's classic technique (AHS-BPD). Controls were carried out at set intervals (1-3-6-12-18 and 24 months) to evaluate weight loss and the metabolic effects of surgery in terms of the lipid, glucose and protein status. RESULTS: Results were good, as confirmed by the marked weight loss (BMI after 24 months: 30) and the normalisation of cholesterol and glycemia. No major reductions were observed in proteinemia and albuminemia levels. CONCLUSIONS: In the light of these results, the authors affirm that Scopinaro's technique is a valid solution for the treatment of morbid obesity. Its relatively invasive nature is justified by the results obtained in terms of weight control and its effect on associated metabolic diseases.

[Congenital anomalies of the inferior vena cava]. / Le anomalie congenite della vena cava inferiore.

Congenital anomalies of the inferior vena cava are a relatively rare pathology, usually with an asymptomatic iter. They are usually diagnosed by chance during surgery on the aorta or retroperitoneal structures. From bioptic material their incidence is estimated to be 2-3% and the percentage of intraoperative findings varies in different series between 0.2 and 0.6%. Of the various kinds of anomaly, caval duplication and a left-positioned vena cava are those most commonly found. The recent report of a case of a malpositioned vena cava and iliac veins prompted us to re-examine the literature and revise our series of cases.

[Non-recurrent inferior laryngeal nerve: anatomy, frequency and surgical considerations]. / Il nervo laringeo inferiore non ricorrente: anatomia, incidenza e considerazioni chirurgiche.

AIM: Systematic exposure and isolation of the inferior laryngeal nerve in thyroid surgery is a secure method to prevent complications. The knowledge of the nerve anatomy and its anomalies is essential to reduce laryngeal nerve injuries. By a re-examination of literature we underline the importance and some particular anatomical aspects of the anomalies which, even if rare, present an incidence of about 1%. METHODS: From January 1995 to December 2002 in our hospital we performed 299 interventions for thyroid diseases: total thyroidectomy (254 cases), partial thyroidectomy (45 cases). In 2 cases we observed a high variant (type I) of non recurrent laryngeal nerve. RESULTS: The global incidence of non recurrent laryngeal nerve was 0.66% (2/299 operations) and 0.72% if we consider the explorations of the cervical right side (2/274) where this anomaly is more frequent. The incidence of nerve injuries was 2/299 (0,66%); we had no complications in the 2 cases of non recurrent nerve observed. CONCLUSIONS: Our experience in thyroid surgery confirms the common opinion that only the knowledge of the laryngeal nerve anatomy and the awareness of its anomalies, associated to the systematic exposure of the nerve during surgery can prevent surgical injuries.

[Total thyroidectomy in surgical treatment of euthyroid goiter]. / La tiroidectomia totale nel trattamento chirurgico del gozzo eutiroideo.

BACKGROUND AND AIMS: The aim of this study was to compare the experiences and results achieved by a single surgeon using total thyroidectomy and partial exeresis in the treatment of uni- and multinodular euthyroid goiter. METHODS: The results of two groups of operations performed at two different periods were analysed: a more recent group (1995-97) in which management tended to prefer total thyroidectomy, and a retrospective group (1984-1994) in which a more conservative attitude was adopted to benign thyroid pathology. RESULTS: An analysis of the results and complications in each group showed that there were no statistically significant differences between the percentage of recurrent and parathyroid lesions during total thyroidectomy and partial exeresis. In practice, the risk of these lesions is higher during redo surgery for cancer and/or recurrence. The recidivation of goitrogenic pathology is high, amounting to around 29% of total cases. The most significant findings, however, which further justifies the use of total thyroidectomy is the increasingly frequent observation of "occult carcinomas" within the benign pathology, registered in the retrospective group (13.27%) and in the more recent one (12.35%). CONCLUSIONS: On the basis of this analysis, the authors confirm their support for the use of total thyroidectomy on principle as the correct and rational treatment for euthyroid goiter, and reserve the use of conservative treatment for single nodular lesions where it is possible to perform a correct hemithyroidectomy and isthmectomy following the patient's informed choice.

Plasma lipids and lipoprotein changes after biliopancreatic diversion for morbid obesity.

BACKGROUND: The reduction in plasma cholesterol with increase in large and lower dense LDL (pattern A) obtained by statins is usually associated with a prompt reduction in cardiovascular risk, but after bariatric surgery for morbid obesity a delay of some years is observed. No data regarding LDL pattern are available in obese subjects after biliopancreatic surgery. OBJECTIVE: To evaluate the modifications in LDL composition and LDL density after biliopancreatic surgery. SUBJECTS: 29 patients (17 type 2 diabetics (type 2) and 12 non-diabetics (ND)) with BMI <35, who failed previous attempts to decrease weight by diet, were studied before and 6 months after biliopancreatic diversion for morbid obesity. MEASUREMENTS: In all subjects, besides fasting circulating lipids, glucose and insulin, LDL and VLDL composition were determined and LDL density was evaluated as well. RESULTS: After surgery we observed a significant reduction of all circulating lipids, including apolipoprotein (Apo) B. The decrease was more marked for total cholesterol (-41%) than for triglycerides (-28%), without a significant difference between type 2 and ND. After surgery, LDL presented a marked decrease in the percentage of cholesterol (from 36 to 32%) with a marked increase in the percentage of triglycerides (from 13 to 18%), without appreciable modification of ApoB. After surgery, 1 patient changed from pattern B to A, while 2 patients previously pattern A became pattern B. Also a decrease in HDL and ApoAI was evident in all the subjects with an increase in the VLDL-1. CONCLUSIONS: Our data indicate that after biliopancreatic diversion, the plasma lipid profile improves along with improvement of plasma glucose and insulin sensitivity, but the LDLs become richer in triglycerides. It is possible that the greater atherogenicity of these LDLs is compensated by an improvement in the general metabolic condition.

Evaluation of serum leptin levels and thyroid function in morbidly obese patients treated with bariatric surgery.

Biliopancreatic diversion (BPD), a gastrectomy with a long ROUX en Y reconstruction, reduces intestinal absorption by delaying the mixing of food and biliopancreatic juices, and induces persistent weight loss in obese patients unresponsive to medical treatments. The levels of leptin (a plasma protein synthesised in human adipose tissue) are increased in obese subjects and significantly decrease after a major weight loss. A possible role of thyroid hormones in regulating adipose tissue metabolism in humans has been proposed, but it is not universally accepted and the relationship between thyroid function and leptin levels has not yet been clearly defined. We studied serum leptin, TSH, fT4 and fT3 levels in 38 obese patients (26 women and 12 men), before and 12 months after BPD. There was a significant post-surgical decrease in BMI and circulating leptin levels in all of the treated subjects, but thyroid function did not seem to be affected (TSH and fT4 levels were unchanged). However, fT3 levels significantly decreased after surgery. Our data suggest that BPD-induced malabsorption has no direct effect on thyroid function, but possibly reduces the peripheral conversion of thyroxine to T3. Further studies seem to be necessary to clarify the clinical relevance of these observations.