Nutrient re-routing and altered gut-islet cell crosstalk may explain early relief of severe postprandial hypoglycaemia after reversal of Roux-en-Y gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass is associated with an increased risk of postprandial hyperinsulinaemic hypoglycaemia, but the underlying pathophysiology remains poorly understood. We therefore examined the effect of re-routing of nutrient delivery on gut-islet cell crosstalk in a person with severe postprandial hypoglycaemia after Roux-en-Y gastric bypass. CASE REPORT: A person with severe postprandial hypoglycaemia, who underwent surgical reversal of Roux-en-Y gastric bypass, was studied before reversal and at 2 weeks and 3 months after reversal surgery using liquid mixed meal tests and hyperinsulinaemic-euglycaemic clamps. The nadir of postprandial plasma glucose rose from 2.8 mmol/l to 4.1 mmol/l at 2 weeks and to 4.4 mmol/l at 3 months after reversal. Concomitant insulin- and glucagon-like peptide-1 secretion (peak concentrations and area under the curve) clearly decreased after reversal, while concentrations of glucose-dependent insulinotropic polypeptide and ghrelin increased. Insulin clearance declined after reversal, whereas clamp-estimated peripheral insulin sensitivity was unchanged. The person remained without symptoms of hypoglycaemia, but had experienced significant weight gain at 15-month follow-up. DISCUSSION: Accelerated nutrient absorption may be a driving force behind postprandial hyperinsulinaemic hypoglycaemia after Roux-en-Y gastric bypass. Re-routing of nutrients by reversal of the Roux-en-Y gastric bypass diminished postprandial plasma glucose excursions, alleviated postprandial insulin and glucagon-like peptide-1 hypersecretion and eliminated postprandial hypoglycaemia, which emphasizes the importance of altered gut-islet cell crosstalk for glucose metabolism after Roux-en-Y gastric bypass.

Peptide YY and glucagon-like peptide-1 contribute to decreased food intake after Roux-en-Y gastric bypass surgery.

BACKGROUND/OBJECTIVES: Exaggerated postprandial secretion of glucagon-like peptide-1 (GLP-1) and peptide YY (PYY) may explain appetite reduction and weight loss after Roux-en-Y gastric bypass (RYGB), but causality has not been established. We hypothesized that food intake decreases after surgery through combined actions from GLP-1 and PYY. GLP-1 actions can be blocked using the GLP-1 receptor antagonist Exendin 9-39 (Ex-9), whereas PYY actions can be inhibited by the administration of a dipeptidyl peptidase-4 (DPP-4) inhibitor preventing the formation of PYY3-36. SUBJECTS/METHODS: Appetite-regulating gut hormones and appetite ratings during a standard mixed-meal test and effects on subsequent ad libitum food intake were evaluated in two studies: in study 1, nine patients with type 2 diabetes were examined prospectively before and 3 months after RYGB with and without Ex-9. In study 2, 12 RYGB-operated patients were examined in a randomized, placebo-controlled, crossover design on four experimental days with: (1) placebo, (2) Ex-9, (3) the DPP-4 inhibitor, sitagliptin, to reduce formation of PYY3-36 and (4) Ex-9/sitagliptin combined. RESULTS: In study 1, food intake decreased by 35% following RYGB compared with before surgery. Before surgery, GLP-1 receptor blockage increased food intake but no effect was seen postoperatively, whereas PYY secretion was markedly increased. In study 2, combined GLP-1 receptor blockage and DPP-4 inhibitor mediated lowering of PYY3-36 increased food intake by ~20% in RYGB patients, whereas neither GLP-1 receptor blockage nor DPP-4 inhibition alone affected food intake, perhaps because of concomitant marked increases in the unblocked hormone. CONCLUSIONS: Blockade of actions from only one of the two L-cell hormones, GLP-1 and PYY3-36, resulted in concomitant increased secretion of the other, probably explaining the absent effect on food intake on these experimental days. Combined blockade of GLP-1 and PYY actions increased food intake after RYGB, supporting that these hormones have a role in decreased food intake postoperatively.

Cystic duct closure by sealing with bipolar electrocoagulation.

BACKGROUND: Cystic duct leakage after cholecystectomy is not uncommon and is a potentially serious complication. The aim of this study was to assess a bipolar sealing system (LigaSure) for closure of the cystic duct. METHODS: The records from consecutive laparoscopic cholecystectomies performed in 2 hospitals with closure of the cystic duct with LigaSure after informed consent were recorded and complications and morbidity registered. The records were compared with those of patients undergoing laparoscopic cholecystectomy with closure of the cystic duct with clips during the same period. RESULTS: During the study period, 218 laparoscopic cholecystectomies were performed; 102 of these were performed with the LigaSure. One patient was excluded due to violation of the protocol. We experienced no cases of cystic duct leakage, but in one patient, bile leakage from the gallbladder bed was observed probably due to a small aberrant duct. CONCLUSION: The LigaSure system was safe and effective for closure and division of the cystic duct in laparoscopic cholecystectomy.

Disturbances in melatonin and core body temperature circadian rhythms after minimal invasive surgery.

BACKGROUND: Sleep disturbances, fatigue and reduced general well-being frequently occur after minimal invasive surgery. The circadian rhythms of melatonin and core body temperature are central to the regulation of normal sleep. The aim of this study was to assess changes in these circadian rhythms after laparoscopic cholecystectomy. METHODS: Twelve women were studied before and after laparoscopic cholecystectomy. The major urinary melatonin metabolite, 6-sulphatoxymelatonin (aMT6s), and the core body temperature were measured for 1 day before and 1 day after surgery. The basal and maximum secretion of aMT6s were determined, as well as the timing and amplitude of aMT6s and the temperature rhythm. The patients' rest-activity and calculated sleep parameters were assessed by actigraphy. RESULTS: A significant delay in the timing of aMT6s rhythm was observed after surgery [median (range) peak time of aMT6s: after surgery, 05:49 h (02:57-08:23 h); before surgery, 04:32 h (02:18-06:49 h); P< or = 0.05]. The amplitude of the aMT6s rhythm was also significantly decreased after surgery [after surgery, 7.1 ng aMT6s/mg creatinine (1-15.9 ng); before surgery, 13.2 ng aMT6s/mg creatinine (2.9-22.7 ng); P< or = 0.005]. There was almost a 12-h phase delay of the core body temperature rhythm after surgery [peak time: before surgery, 17:39 h (15:17-22:06 h); after surgery, 05:14 h (03:24-21:43 h); P< or = 0.01]. CONCLUSIONS: Following laparoscopic cholecystectomy, there was a delay in the timing of the aMT6s rhythm and a decreased evening decline in the temperature rhythm.

Biological tissue adhesive for mesh-application in pigs: an experimental study.

BACKGROUND: Tissue damage during herniotomy may attribute to postoperative complications including chronic pain, bleeding and infection. Thus the aim of this study was to evaluate a due and simple operative procedure with intraperitoneal application of mesh with glue in an experimental model prior to use in humans. METHOD: Laparoscopic insertion of a mesh was performed in three pigs. The meshes were fixed with a collagen glue. The pigs were sacrificed after 8 weeks and macroscopic and microscopic evaluation of the meshes, were performed. RESULTS: The intraperitoneal placed meshes did not migrate through the study period, and there was no sign of inflammation in surrounding tissue or adhesions around the meshes. CONCLUSIONS: If these findings can be applied to human inguinal herniotomy, this may lead to significant fewer complications including development of acute and chronic pain, formation of seroma and infection. Furthermore the operation technique is very simple.

Computed tomography scanning and recurrence after laparoscopic ventral hernia repair.

Laparoscopic ventral hernia repair is an advancing surgical method. It seems to have fewer recurrences than open surgery. However, with patients suspected of recurrence after laparoscopic hernia repair, it can be very difficult to determine whether or not there is recurrence by clinical examination alone. The purpose of this article is to show that computed tomography is a valuable diagnostic tool in excluding recurrence after laparoscopic ventral hernia repair. A total of 35 patients were included in a prospective study. They underwent laparoscopic ventral hernia repair, and all patients suspected of recurrence were computed tomography scanned. Four patients were suspected of recurrence. They all presented symptoms of swelling or pain or both. The computed tomography scanning did not show the presence of recurrence in any of the 4 cases. Computed tomography scanning can provide exact information about the content of swelling and whether there is recurrence or not. We conclude that computed tomography scanning is suitable as a valid imaging method in doubtful cases considering ventral hernia recurrence after laparoscopic ventral hernia repair.

Randomized clinical trial of virtual reality simulation for laparoscopic skills training.

BACKGROUND: This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy. METHODS: Sixteen surgical trainees performed a laparoscopic cholecystectomy on patients in the operating room (OR). The participants were then randomized to receive VR training (ten repetitions of all six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR)) or no training. Subsequently, all subjects performed a further laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotape, and assessed by two independent and blinded observers using predefined objective criteria. Time to complete the procedure, error score and economy of movement score were assessed during the laparoscopic procedure in the OR. RESULTS: No differences in baseline variables were found between the two groups. Surgeons who received VR training performed laparoscopic cholecystectomy significantly faster than the control group (P=0.021). Furthermore, those who had VR training showed significantly greater improvement in error (P=0.003) and economy of movement (P=0.003) scores. CONCLUSION: Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes.

Randomized clinical trial comparing an oral carbohydrate beverage with placebo before laparoscopic cholecystectomy.

BACKGROUND: Preoperative oral carbohydrate can attenuate postoperative insulin resistance and catabolism, and may have the potential to improve postoperative recovery. There are no data from randomized studies on postoperative clinical outcome after specific surgical procedures. This study evaluated the clinical effects of a preoperative carbohydrate beverage in patients undergoing laparoscopic cholecystectomy. METHODS: Ninety-four patients undergoing laparoscopic cholecystectomy were included in a randomized clinical trial. Patients were randomized to receive 800 ml of an iso-osmolar 12.5 per cent carbohydrate-rich beverage the evening before operation (100 g carbohydrate) and another 400 ml (50 g carbohydrate) 2 h before initiation of anaesthesia, or the same volume of a placebo beverage. The primary endpoint was general well-being the day after operation. Patients were evaluated from 5 days before to 5 days after operation. Daily scores of general well-being, fatigue, appetite and pain, computerized measurements of physical activity and sleep (actigraphy), and subjective sleep quality were recorded. Nausea and vomiting were assessed twice within the first 24 h after surgery. RESULTS: Data from 86 patients were available for statistical analysis, 43 in each treatment group. No significant intergroup differences in general well-being or any other outcome variable were found. CONCLUSION: A preoperative carbohydrate beverage did not improve clinical outcome after laparoscopic cholecystectomy.

Interobserver agreement in ultrasound examination of the biliary tract.

PURPOSE: To prospectively evaluate the interobserver agreement in US examination of the gallbladder and the biliary tract performed by an experienced and a novice radiologist. MATERIAL AND METHODS: Fifty consecutive patients underwent US examination because of clinically suspected gallstones. The examination was performed by a consultant and a trainee radiologist on the same day. The following outcome measures were registered: presence of gallstones, filling of the gallbladder, thickness of the gallbladder wall, splitting of the gallbladder wall, fluid around the gallbladder, diameter of the common bile duct (CBD), and presence of CBD stones. RESULTS: None of the radiologists observed CBD stones or fluid around the gallbladder. The CBD was clearly distinguished by both observers in all patients. There was good agreement in the conclusions of the two radiologists regarding the presence of gallbladder stones and substantial agreement regarding the filling of the gallbladder and splitting of the gallbladder wall. Significant difference existed in the measurements by the two radiologists regarding the thickness of the gallbladder wall and the diameter of the CBD. CONCLUSION: The novice radiologist's expertise in the primary diagnosis of uncomplicated gallstone disease was as good as the one provided by the experienced colleague. The significant interobserver difference in the measurements of the thickness of the gallbladder wall and the CBD diameter might indicate that assessment of these parameters requires extensive practise and the opinion of an experienced colleague must be sought in cases where complications are suspected.

[Gallbladder polyps]. / Galdeblaerepolypper.

Polyps in the gall bladder are detected in 4-5% of the population and most of them are benign. However, they can be premalignant and the prognosis for gall bladder carcinoma is still poor. As with other cancers, treatment at an early stage is therefore, considered essential to improve the prognosis. Because of the very low morbidity after laparoscopic cholecystectomy we recommend laparoscopic cholecystectomy when a polyp in the gall bladder is detected by ultrasonography. A wait and see attitude with repeated ultrasonography twice a year may be chosen, if there are contra-indications to laparoscopic cholecystectomy. If the lesion increases in size, cholecystectomy should be performed.

[Uncomplicated gallstone disease and pregnancy]. / Ukompliceret galdestenssygdom og graviditet.

Pregnancy is associated with an increased incidence of gallstones. However, most gallstones disappear spontaneously after pregnancy without having given any symptoms. New knowledge regarding the pathophysiology confirms changes in the motility of the gallbladder and the flow dynamics and lithogenicity of the bile. The studies have also shown, that these changes resolve completely after labour, which might explain the disappearance of most of the gallstones. These conditions support a conservative attitude towards treatment of gallstone disease during pregnancy. In case cholecystectomy is indicated, laparoscopic intervention seems safe during pregnancy and most optimal during the second trimester where the organogenesis of the fetus is completed and where the size of the uterus does not interfere with the operation technically. Laparoscopic cholecystectomy should under all circumstances be done in departments with routine in laparoscopic operations and with the possibility of gynaecological assistance, in case it is needed.

[Laparoscopic cholecystectomy in outpatient surgery]. / Laparoskopisk kolecystektomi i dagkirurgisk regi.

INTRODUCTION: The aim of the study was to describe the organisation of laparoscopic cholecystectomy in outpatient surgery and to discuss whether the method should be the future treatment of choice. MATERIAL AND METHODS: A retrospective descriptive study was carried out on 133 consecutive patients in the period 1 October 1999 to 30 September 2000. RESULTS: Seventy-seven per cent of the patients were discharged directly from the Department of Outpatient Surgery and 121 (97%) who underwent laparoscopy were discharged within 23 hours of the operation. The postoperative complication rate was 1.5% and the frequency of readmittance was 5%. DISCUSSION: Laparoscopic cholecystectomy is suitable for outpatient surgery and appears to be a recommendable setting for this operation. The method is safe and associated with few complications and readmittances.

[Diagnosis of common bile duct stones in symptomatic gallstone disease]. / Diagnosticering af choledochussten ved symptomgivende galdestenssygdom.

It is unclear which diagnostic procedure is optimal for the detection of common bile duct stones prior to laparoscopic cholecystectomy. It is routine to use blood tests for liver function and transabdominal ultrasound, and the best method is currently to continue evaluation with other methods when one or more blood tests for liver function are elevated and/or the diameter of the common bile duct is > or = 10 mm on transabdominal ultrasound. Magnetic resonance cholangiography, endoscopic ultrasound, laparoscopic ultrasound, intraoperative cholangiography and endoscopic retrograde cholangiography are all accurate in the detection of common bile duct stones. Intravenous cholangiography and computer tomography needs further evaluation before final recommendations can be made. Intraoperative cholangiography and endoscopic retrograde cholangiography have the best documentation available in the literature. Intraoperative cholangiography is easy, cheap and without significant complications, whereas endoscopic retrograde cholangiography has a high morbidity and mortality rate. Endoscopic retrograde cholangiography is therefore not suitable as a diagnostic test and should be abandoned as such in the future. Patients with cholangitis, jaundice and common bile duct stones visualised by transabdominal ultrasound have a high risk of common bile duct stones, and these patients can therefore undergo endoscopic retrograde cholangiography directly. Other patients should have a magnetic resonance cholangiography or endoscopic ultrasound preoperatively, or intraoperative cholangiography or laparoscopic ultrasound depending on local factors such as available equipment and surgical expertise.

[Treatment of common bile duct stones]. / Behandling af choledochussten.

Open single-stage treatment of gallstones and common bile duct stones (CBDS) has previously been standard procedure. Endoscopic stone extraction after a sphincterotomy has become a well-established therapeutic modality during the last twenty years and is now the standard procedure. The available options for management of patients with CBDS are reviewed. Although there is no evidence concerning the best treatment of CBDS, it is concluded, that a two-stage procedure with endoscopic CBDS extraction followed by cholecystectomy has no advantages over a single stage open or laparoscopic procedure. In the future the treatment of CBDS will be differentiated depending on size of the stone, the occurrence of complications to CBDS and the general health of the patient.

Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, double-blinded, placebo-controlled study.

UNLABELLED: Pain is the dominant complaint after laparoscopic cholecystectomy. No study has examined the combined effects of a somato-visceral blockade during laparoscopic cholecystectomy. Therefore, we investigated the effects of a somato-visceral local anesthetic blockade on pain and nausea in patients undergoing elective laparoscopic cholecystectomy. In addition, all patients received multi-modal prophylactic analgesic treatment. Fifty-eight patients were randomized to receive a total of 286 mg (66 mL) ropivacaine or 66 mL saline via periportal and intraperitoneal infiltration. During the first 3 postoperative h, the use of morphine and antiemetics was registered, and pain and nausea were rated hourly. Daily pain intensity, pain localization, and supplemental analgesic consumption were registered the first postoperative week. Ropivacaine reduced overall pain the first two hours and incisional pain for the first three postoperative hours (P < 0.01) but had no apparent effects on intraabdominal or shoulder pain. During the first 3 postoperative h, morphine requirements were lower (P < 0.05), and nausea was reduced in the ropivacaine group (P < 0.05). Throughout the first postoperative week, incisional pain dominated over other pain localizations in both groups (P < 0.01). We conclude that the somato-visceral local anesthetic blockade reduced overall pain during the first 2 postoperative h, and nausea, morphine requirements, and incisional pain were reduced during the first 3 postoperative h in patients receiving prophylactic multi-modal analgesic treatment. IMPLICATIONS: A combination of incisional and intraabdominal local anesthetic treatment reduced incisional pain but had no effect on deep intraabdominal pain or shoulder pain in patients receiving multimodal prophylactic analgesia after laparoscopic cholecystectomy. Incisional pain dominated during the first postoperative week. Incisional infiltration of local anesthetics is recommended in patients undergoing laparoscopic cholecystectomy.

[Abscess in the right flank--a late complication of laparoscopic cholecystectomy]. / Absces i højre flanke--senkomplikation til laparoskopisk kolecystektomi.

Laparoscopic cholecystectomy (LC) is the treatment of choice in cases of symptomatic gallstones. A 74-year-old female presented with a spontaneously perforated abscess in her right flank and passage through it of gallstones. Four years previously during LC the gallbladder perforated and 10-15 stones were lost intraperitoneally. In case of perforation of the gallbladder during LC it is essential to reduce loss of and remove all gallstones. In case of abdominal symptoms postoperatively, an intra-abdominal abscess must be suspected.

[Posterior rectotomy--a minimally invasive procedure?]. / Rectotomia posterior--en minimalt invasiv operation?

This study included twenty-five consecutive patients, 12 men and 13 women, treated with a posterior approach to the rectum because of diseases in the mid and lower third of the rectum. Surgical indication included rectovaginal fistula in four patients, villous adenoma in 13 patients, villous adenoma containing carcinoma in three patients, primary carcinoma in four old high-risk patients and recurrent cancer in one old high-risk patient. There were only a few minor postoperative surgical complications, one wound infection and one rectal bleeding from the place of the excision. The bleeding was treated transanally. Three patients developed pneumonia. No patients died as a complication of the procedure. The posterior approach provides excellent exposure for complete removal of tumour in the mid- and distal part of the rectum, and the results of this study indicated that the technique has a place in the management of various benign and selected malignant conditions in the mid and lower third of the rectum. The procedure is easy to perform, safe with only a few minor complications and well tolerated even in old high-risk patients.

[Open surgery of choledochus in Denmark]. / Aben choledochuskirurgi i Danmark.

For each of the years 1991-1994 400, 209, 170 and 133 open common bile duct stone extraction were performed in Denmark, corresponding to 35%, 17%, 12% and 5% respectively of patients diagnosed with common bile duct stone. There was only little variation between the 16 hospital counties. The expected decrease in open common bile duct surgery corresponds to the introduction of several non-invasive methods for the treatment of common bile duct stones. To achieve further reduction in open surgery, centralization of the treatment of common bile duct stones is necessary.