A series of infections due to Capnocytophaga spp in immunosuppressed and immunocompetent patients.

OBJECTIVE: To investigate the epidemiology, microbiology and outcome of infections caused by Capnocytophaga spp. at a single center. METHODS: We report on ten documented infectious episodes caused by Capnocytophaga observed between 1994 and 1999 at the Innsbruck University Hospital. RESULTS: In seven of ten patients, Capnocytophaga septicemia was diagnosed during periods of neutropenia. In contrast, the remaining three patients had normal white blood cell counts when acquiring Capnocytophaga septicemia (one) and pleural empyema (two). Blood cultures containing long, slender, Gram-negative rods, which grew slowly under anaerobic conditions and lacked susceptibility to metronidazole, were subcultivated in a CO2-enriched atmosphere (5%). Subcultivation yielded Capnocytophaga in all ten cases within 2-12 days. The patients were then placed on appropriate antibiotic therapy, with or without additional surgical intervention, and the organism was eradicated. CONCLUSION: Identification of Capnocytophaga facilitates appropriate, and in most cases effective, antimicrobial therapy.

Is a routine liquid contrast swallow following laparoscopic gastric banding mandatory?

BACKGROUND: The authors assess the value of liquid contrast medium swallow as a method to detect postoperative complications after laparoscopic adjustable gastric banding (LAGB) for the treatment of morbid obesity. METHODS: From January 1996 to January 2001, 350 morbidity obese patients (295 women, 55 men) underwent a LAGB operation. All data were prospectively collected in a computerized databank. All patients underwent a jopomidol swallow (JS) study in the early postoperative phase to exclude perforation of the esophagus or stomach, which is one of the most serious complications occurring after the LAGB operation. Furthermore, the JS was performed to confirm band position and to exclude early pouch dilatation. RESULTS: Out of the 350 LAGB operations, 6(1.8%) early pouch dilatations and 4(1.2%) stomach perforations occurred. All early pouch dilatations were recognized on postoperative JS and immediately repaired laparoscopically. Of the perforations, one was recognized intraoperatively, and the other three were diagnosed postoperatively, either by contrast media extravasation on the JS (two patients) or by computer tomography. CONCLUSION: Presently, all patients undergo routine postoperative JS, which exposes them to radiation, causes patient discomfort, and entails additional costs of approximately 100 US$ per patient. Of the last 250 patients in our series, there have not been any cases of early pouch dilatation and since 1998 only one case of perforation has occurred, which could be easily suspected clinically. Therefore, we believe that in experienced centers, it is not necessary to perform routine postoperative contrast media studies and recommend JS only in cases of complicated postoperative courses.

Laparoscopic gastric banding in older patients.

HYPOTHESIS: Older patients experience the same benefits from a laparoscopic gastric banding (LGB) operation as younger patients. DESIGN: A case series of 320 morbidly obese and superobese patients who underwent LGB within a 46-month period. SETTING: University Hospital Innsbruck, General Surgical Department, Innsbruck, Austria. PATIENTS: A consecutive sample of 320 patients who met the criteria for a bariatric procedure and were aged 18 years or older. Patients were divided into the following 2 age groups: younger patients (group A, 18-49 years) and older patients (group B, > or =50 years). INTERVENTION: Laparoscopic gastric banding with an adjustable gastric band. MAIN OUTCOME MEASURES: Clinicopathologic features, including weight loss, complications, length of hospital stay, and operative times, were reviewed retrospectively, and a multivariate analysis was carried out. RESULTS: Of 320 patients, we identified 68 older patients (21.5%, group B). The mean postoperative follow-up period was 12 months (range, 6-28 months). The average preoperative weight was 127.8 kg (body mass index [calculated as weight in kilograms divided by the square of height in meters], 44.29). The average total weight loss was 4.3 kg per month for the first 3 months, reaching an average total of 31.0 kg after 1 year. The excess weight loss after 12 months was 68%. Complications requiring reoperation occurred in 10.3% of patients. Ninety-seven percent of the patients reported an improvement in their comorbid conditions. CONCLUSIONS: Older patients receive the same benefits from LGB as younger patients, with an acceptable postoperative complication rate. Presently, our upper age limit is 70 years.

Pregnancies after adjustable gastric banding.

BACKGROUND: We evaluated outcome of pregnancies of morbidly obese women who are within the first 2 years after laparoscopic adjustable gastric banding. METHODS: 215 morbidly obese women of reproductive potential (age 18-45 years), who had agreed to remain on reliable contraceptives for 2 years after surgery, were retrospectively analyzed following bariatric surgery. RESULTS: 7 unexpected pregnancies were observed. 5 pregnancies were full-term (3 vaginal and 2 cesarean deliveries). The birth weights ranged from 2110 g to 3860 g. 2 women had first trimester miscarriages. All gastric bands were completely decompressed due to nausea and vomiting, resulting in further weight gain. 2 serious band complications were observed (1 intragastric band migration and 1 balloon defect), which required re-operation. CONCLUSIONS: Pregnancy in morbidly obese women soon after adjustable gastric banding may occur unexpectedly during a period of weight loss. Prophylactic fluid removal from the band eliminates the efficacy of the obesity treatment. Moreover, this cohort shows an increased incidence of spontaneous abortions and band-related complications.

A study of pain after laparoscopic gastric banding.

BACKGROUND: The introduction of the laparoscopic approach to bariatric surgery has brought similar advantages as those seen in general surgery. There have been no trials assessing postoperative pain after laparoscopic adjustable silicone gastric banding (LASGB). We compared prospectively postoperative pain and outcome in LASGB and laparoscopic cholecystectomy (LC), to determine if morbidly obese patients can expect the same benefits from a laparoscopic approach in gastric banding as those which are known for LC in non-obese and obese patients. METHODS: In a prospectively collected database of 80 patients undergoing LASGB, information including a survey assessing the postoperative pain, the amount of analgetic drugs used, operative reports, laboratory data, and follow-up data was collected. This was compared to an equal number of patients undergoing LC. Postoperatively, all patients received standardized pain medication of 150 mg tramadol per day. Pain was assessed twice on postoperative days 1-3 using a patient questionnaire. RESULTS: Patient characteristics and duration of hospital stay were similar in the two groups. Although there was no significant difference in type and intensity of pain experienced by the patients in either group, the gastric banding patients reported less postoperative pain overall than those in the LC group. CONCLUSION: The analyzed data show that LASGB offers the same advantages as other laparoscopic operations, in that it induces less pain and enables the patient to return quickly to normal activity and work. The advantage over the compared LC group may be due to higher patient motivation, but was not statistically significant.

Central liver hematomas caused by mountain-bike crashes.

BACKGROUND: Mountain biking, one of the most popular sports in recent years with more than 10 million riders, is implicated more and more in severe bike accidents with complicated injuries. In addition to head injuries, which are common and account for most of the fatalities, we have observed an increase in liver trauma over the years. METHOD: Approximately 19000 bike associated accidents were reported in 1998 in Austria. A total of 52 patients were admitted to our trauma ward between 1995 and 1997 with mountain-bike associated injuries. Of the 52, eight presented with subcapsular hematoma of the liver sustained by falling while riding. In all patients, nonoperative management was successful. These injuries were associated with a special form of bar-ends used on the mountain-bikes. After a broad response from the industry, facilitated by many articles in newspapers, life-style magazines, radio and television stations, this type of bar end has nearly vanished from the market. RESULTS: As a result, in 1998, only one case of liver injury was observed, and from 1999 to August 2000, no such injuries have been reported thus far.

Results and complications after adjustable gastric banding in a series of 250 patients.

BACKGROUND: Morbid obesity contributes to many health risks including physical, emotional, and social problems. The increasing prevalence of obesity is a major public health concern since obesity is associated with several chronic diseases. Morbid obesity is the biggest independent risk factor for early mortality. Various options for the surgical treatment of morbid obesity have been developed with varying results. METHODS: Between January 1996 and December 1999, we operated on a series of 250 patients (200 women and 50 men) at the General Surgical Department of the University Hospital in Innsbruck. The parameters that were evaluated included age, preoperative and postoperative body mass index (BMI), type of surgery, and intraoperative and postoperative complications. RESULTS: The mean follow-up period was 12 months (range 3 to 18). The average preoperative weight was 135.5 kg (BMI 46.69 kg/m(2)). The average total weight-loss was 5.5 kg per month, reaching an average total of 35 kg after one year. The excess weight loss (EWL) after 12 months was 72%. Complications requiring reoperation occurred in 8.8%. CONCLUSIONS: In the first year after laparoscopic adjustable gastric banding, weight reduction of the study population was excellent. Additionally, the complication rate was reasonable with no mortalities.

Injection port complications after gastric banding: incidence, management and prevention.

BACKGROUND: Laparoscopic adjustable gastric banding is advocated as a minimal invasive procedure with a low risk profile and high efficacy in the treatment of morbid obesity. Nevertheless, injection port complications are occasionally reported. The aim of this study was to assess port disconnections and port dislodgement with respect to two different implantation techniques. METHODS: Between January 1996 and October 1999 230 patients underwent laparoscopic gastric banding with the Swedish Adjustable Gastric Band (SAGB). In group 1 (118 patients), the injection port was implanted onto the sterno-xiphoid union. In group 2 (112 patients), an additional incision was made to suture the port onto the fascia of the lower third of the sternum. RESULTS: There is a significant reduction in port disconnection between group 1 (9.3 %) and group 2 (0 %). Port dislodgment was observed in one patient in each group. Reoperation was performed under local anesthesia in 11 patients, and general anesthesia was used for laparoscopic tube salvage in two patients. After reconnection, two patients experienced port infection. CONCLUSION: Correct implantation technique of the injection port of the SAGB onto the fascia of the lower third of the sternum reduces the risk for port complications. Technical notes are discussed.

Aberrant left hepatic artery in laparoscopic gastric banding.

BACKGROUND: The aberrant left hepatic artery (ALHA) is an anatomic variation which may be an obstacle in the laparoscopic gastric banding operation. Based on our experience, our mission was to answer the questions: How frequently is an ALHA encountered? Is division necessary? Are there any additional complications in cases where the ALHA is preserved? METHODS: In a prospectively collected database of 270 patients undergoing laparoscopic gastric banding in our unit, information including presence of an ALHA, clinical data, diagnostic work-up, operative reports, laboratory data, and follow-up data were collected. RESULTS: In 48 patients (17.7%) (39 women, 9 men, mean age 39.2 years) an ALHA was observed. Hiatal dissection was not impaired in any of these patients, and none required division of the ALHA. In all but two cases, the band was placed above the ALHA, offering additional stability to the band positioning. In 2 patients (4.1%), the artery was injured during dissection and was divided due to ongoing bleeding. Twenty-two (45.8%) of the ALHAs were of intermediate or large size. Neither pouch dilatation nor band slippage occurred in the above-mentioned group. The two patients with divided hepatic arteries had no postoperative symptoms related to impaired liver function. CONCLUSIONS: ALHA is not an uncommon finding during laparoscopic gastric banding and may be found in approximately 18% of patients. Division can nearly always be avoided and may be required only in selected cases due to bleeding. Patients do not experience clinical complications after division, although liver enzymes may be temporarily elevated, and no monitoring is necessary.

Capnocytophaga pleural empyema following laparoscopic Nissen fundoplication. A rare complication, a rare pathogen.

Empyema complicating laparoscopic fundoplication is exceedingly rare, as is Capnocytophaga infection in the immunocompetent host, with the exception of gingivitis. We report a 29-year-old healthy man who presented with Capnocytophaga empyema 10 days after uneventful elective, laparoscopic Nissen fundoplication for gastroesophageal reflux disease. The exact mechanism of this complication is not known, but hypotheses, including a mini-Boerrhave's syndrome, can be drawn based on knowledge of the operation, the involvement of Capnocytophaga sp., and a patient history that included severe gingivitis. Because of prompt operative evacuation of the empyema and expedient identification of Capnocytophaga in the empyema fluid, appropriate antibiotic therapy was initiated. The infection was adequately treated, and the patient recovered fully. To the best of our knowledge, this is the first report of such a complication.