Surgical treatment of morbid obesity with biliopancreatic diversion and gastric banding: report on an 8-year experience involving 235 cases.

STUDY AIM: Developments have recently been made in bariatric surgery outside the USA. The aim of this retrospective non-randomized study was to report on our experience regarding biliopancreatic diversion (BPD) and non-adjustable gastric banding (GB) in a population of 235 obese patients. PATIENTS AND METHODS: From March 1990 to March 1998, 235 obese patients were operated on, 142 by BDP and 93 by GB, via laparotomy after rigourous selection of the patient population. RESULTS: The mean duration of surgery was 2 h 50 minutes for BPD and 1 h for GB. One postoperative death occurred due to massive pulmonary embolism. Early major complications were frequent in the BPD group (n = 21) but rare in the GB group (n = 1). Mean duration of hospitalization was 16 days in the BPD group versus 9 days in the GB group. Mean percentage excess weight loss was 48% for the GB group and 60% for the BPD group after two years. Late mortality was limited to the BPD group (3.5%). Late complications were evenly distributed between the two groups, with a prevalence of malnutrition in the BPD group and outlet stenosis in the GB group. A high incidence of band removal was recorded related to this complication (17.2%). Incisional hernias were present in both groups. CONCLUSIONS: GB and BPD are techniques which can induce weight loss and bring about subsequent health benefits. Nevertheless, in a few patients further intervention or adaptation of the approach due to clinical failure or to a high complication rate is required. Additional research is needed regarding determination of the surgical treatment that is best adapted to the case in question, i.e., taking into consideration both the restrictive and malabsorbative aspects.

[Intestinal carcinoid. A propos of a case]. / Il carcinoide intestinale. A proposito di un caso.

In this paper the authors report a case of carcinoid neoplasm in a rare localization like sigmoid colon. They describe the clinical and biological aspects of this kind of tumors, with particular regard to the tumor site and its biochemical products. A rational and prompt clinical approach to this neoplasm is considered important for the good chance of long survivals, achievable in the case of early diagnosis.

Gastric Banding for Treatment of Morbid Obesity: Preliminary Results.

BACKGROUND: gastric banding (GB) has been used for treatment of morbid obesity. METHODS: a banding device, introduced by Broadbent and consisting of a self-blocking nylon strip covered with a silicone tube, was used in 13 patients who have completed 1-year follow-up. This device was used for its mechanical properties, biocompatibility, ease of insertion and low cost. RESULTS: at 1 year, mean excess weight loss was 51.6%, with all but one patient losing more than 25% of excess weight. Associated illnesses resolved. There were two complications (15%): one patient required band removal for self-induced vomiting and one patient required repair of an incisional hernia. CONCLUSIONS: GB has had good results thus far. Reported differences depend on materials, stoma diameter, pouch size, and developing techniques.

[Use of mechanical staplers in biliopancreatic diversion intervention]. / L'impiego delle suturatrici meccaniche nell'intervento di diversione biliopancreatica (BPD).

The use of mechanical staplers in general surgery and in particularity in biliopancreatic diversion (BPD) has led to a marked reduction in the duration of surgery, thus requiring shorter anesthesia times. In obese subjects this also serves to reduce the risks related to their particular clinical and metabolic conditions. The authors report their experience in 53 patients; in 26 cases automatic linear staplers were used to create the ileal-duodenal and gastric tomy only, whereas the entero-entero anastomosis and gastro-entero anastomosis were performed manually using a biliopancreatic diversion technique. In the remaining 27 cases the operation was performed exclusively using automatic staplers. The paper then examines the complications arising from the use of mechanical staplers, dividing them into early and late. Among the first were two episodes of GEA hemorrhage (7.4%) and an asymptomatic fistula again of the GEA (3.7%). The late complications only included two stenoses (7.4%) of the GEA, both resolved using endoscopic pneumatic dilation.

[Care of the patient after biliopancreatic diversion (BPD) surgery]. / L'assistenza al paziente operato di diversione biliopancreatica (BPD).

The authors report their experience in the care of severely obese patients undergoing biliopancreatic diversion (BPD) surgery. The success of this surgical technique not only depends on its correct application but also on correct postoperative management, both immediately and over time. After a short summary of the methods of management used immediately after surgery, the authors focus in greater detail on the most frequent complications in this type of surgery: these are divided into early and late. Among the former, the authors discuss thromboembolic disease, the most severe complications and bronchopneumonia disorders. The authors illustrate the methods of treating both as well as therapies for their prevention. The most frequent and potentially dangerous late complications are examined in detail: protein malnutrition, sideropenic anemia and diarrhea. Lastly, the authors underline the need for a constant rather than episodic approach to the problem of severe obesity since, in their opinion, only continuous and long term application ensures the best results with the fewest complications.

[Postoperative venous thromboembolism in bariatric surgery]. / Le tromboembolie venose post-chirurgiche in chirurgia bariatrica.

The authors discuss the problem of venous thromboembolism as a complication of bariatric surgery. They consider obese patients at risk for these complications, even if different opinions exist about this topic in the literature. They report their experience in bariatric surgery consisting of 53 patients submitted to biliopancreatic diversion. Antithrombotic prophylaxis consisted for every patient in elastic bandaging of the lower limbs, preoperative hemodilution, early post-operative mobilization, and subcutaneous heparin. Complications consisted in one popliteo-femoral deep venous thrombosis (DVT) (1.6%), and two pulmonary embolisms (PE) (3.2%) of which one caused patient's death; total morbidity for venous thromboembolism. These results compared with literature are similar with other series of bariatriac surgery and slightly higher than general surgery series. This difference is not however significant. Even in the absence of this significance, thromboembolism, as desumed from more than 2900 cases considered in the literature, remains the main cause of morbidity and mortality in the post-operative course of bariatric surgery patients, deserving particular attention in terms of prevention, also because of difficulty existing in early clinical diagnosis of DVT in obese people. Further studies intended to identify pathogenesis and risk factors of venous thromboembolism in obese people will allow a more correct prophylactic and therapeutic approach.

[Laparocele. A late complication of bariatric surgery]. / Il laparocele. Complicanza tardiva della chirurgia bariatrica.

In this paper the authors consider the problem of incisional hernias as late complications of bariatric surgery. After a description of relationships between obesity and incisional hernias they report their experience on this topic, consisting of 56 patients submitted to bilio-pancreatic diversion between March 1989 and September 1991, for surgical treatment of morbid obesity. Incisional hernias developed in 28% of cases. Analysis of some risk factors like infections, epidemiological patterns, materials and techniques used to suture the abdominal wall, has not allowed identification of significant associations with incisional hernias occurrence. Only early reinterventions (3 cases) have always determined a subsequent development of incisional hernias. The authors confirm the close relationship existing between obesity and incisional hernias. They suggest incisional hernia repair to be undertaken once weight loss has terminated and stabilized, and in the absence of other specific or aspecific morbid obesity surgery complications.

[Autotransfusion in bariatric surgery]. / L'autoemotrasfusione nella chirurgia bariatrica.

The authors, after some brief remarks on homologous blood transfusion discuss autotransfusion techniques, and haemodilution principles, they report their experience of autohemotransfusion with preoperative sampling in bariatric surgery, pointing out physiopathologic mechanisms and many advantages.

[Prophylactic cholecystectomy in bariatric surgery]. / Opportunità della colecistectomia profilattica in chirurgia bariatrica.

In this paper the authors discuss about prophylactic cholecystectomy in bariatric surgery. Having analyzed the mechanisms that increase bile lithogenicity after bariatric surgery, they evaluate advantages and disadvantages of prophylactic cholecystectomy. They present 53 obese patients submitted to biliopancreatic diversion and prophylactic cholecystectomy for surgical treatment of morbid obesity, because of the high incidence of pathological findings in the specimens and the absence of surgical complications related to cholecystectomy, the authors, in agreement with the literature, suggest routine cholecystectomy as an obvious adjunct to bariatric surgery. This attitude protects against the higher risk of subsequent cholecystectomy and against the misinterpretation of non-invasive diagnostic tests too, because of known limits of echography in obese people.

[Comparison of echo-Doppler and splenoportography in the hemodynamic evaluation of the portal system]. / Confronto tra eco-Doppler e splenoportografia nella valutazione emodinamica del circolo portale.

The Authors discuss the instrumental diagnosis of portal hypertension, comparing echo-Doppler and splenoportography by celiac artery catheterization, performed on 42 patients with cirrhosis. From the data obtained, there may be observed a clear correlation between angiographic and echographic criteria, correlated to the degree of illness. In particular echo-Doppler whether it possible, in a non-invasive way, to control the evolution of progressive haemodynamic resistance, and hepatic and splenic parenchyma, leaving to splenoportography the role to depict anatomic characteristics of portal circulation for a correct surgical program.

[Diagnostic "gold standard" in cerebrovascular insufficiency. Comparison of angiographic and ultrasonic imaging]. / "Gold standard" diagnostico nella ICV. Imaging angiografico e ultrasonico a confronto.

The Authors consider the complex diagnostic problems of cerebrovascular disorders, with particular concern to angiography and echography. After a complete analysis of different aspects of angiographic and echographic lesions, considering their experience, they identify chances and limits of the two methods, they draw the conclusion that each of the two techniques has a proper role, and only a correct correlation between them can depict correctly the pathologic lesions.

Biliopancreatic Diversion: early complications.

The experience and early complications in 66 morbidly obese patients who underwent biliopancreatic diversion are presented. There was one death, due to a pulmonary embolus (PE) at home on the 15th postoperative day. Postoperative complications occurred in nine patients, consisting of gastric hemorrhage (2), gastric outlet obstruction (2), non-lethal PE (1), deep vein thrombosis (1), wound dehiscence (1), and asymptomatic gastric leak (1). In addition, there were 12 superficial wound infections. Four patients required urgent reoperation for gastric hemorrhage (2), gastric outlet obstruction (1), and wound dehiscence (1). The high complication rate is believed to represent the early part of the learning curve. Some reports of the early complications following other bariatric operations are discussed.

[Femoral anastomotic pseudoaneurysms]. / Gli pseudoaneurismi anastomotici a sede femorale.

In this paper the Authors discuss about femoral anastomotic pseudoaneurysms. They throughly consider the etiopathogenesis of this late complication of arterial prothesic surgery, pointing out the different hypothesis currently discussed. Particularly from this analysis it can be concluded that the choice of appropriate prothesic grafts and the weakness of an eventually endarterectomized arterial wall are the principal determinants in causing pseudoaneurysms. Between the different therapeutic choices the opportunity of an interposition graft is underlined, except for (rare) cases when an extra-anatomic bypass must be preferred.

[Percutaneous angioplasty in the treatment of iliac artery stenosis]. / L'angioplastica percutanea (PTA) nel trattamento delle stenosi delle arterie iliache.

PTA represents a slightly invasive method for treatment of iliac arteries stenoses. The Authors present their experience about this topic and discuss current indications in the use of this technique. They believe that beyond the already defined indications, such as treatment of short stenoses, transluminal angioplasty can be employed for long stenoses too, eventually combined with limited surgical procedures. They stress the importance of combining traditional PTA with new percutaneous or intraoperative Argon Laser technology, that surely will contribute to broad its indications and to improve its results.

[Role of intraoperative phlebography in the therapeutic approach of varicocele]. / Il ruolo della flebografia intraoperatoria nella tattica terapeutica del varicocele.

Personal experience of intraoperative anterograde phlebography of the internal spermatic vein is reported. The use of this technique is suggested for controlling the result of internal spermatic vein ligature in cases of type I varicocele according to Coolsaet, diagnosed by preoperative retrograde phlebography. Early data make it possible to conclude that intraoperative anterograde phlebography is a valuable aid in reducing the frequency of recurrences.

[Proximal anastomosis in aorto-bifemoral bypass. Technical considerations]. / L'anastomosi prossimale nel by-pass aorto-bifemorale. Considerazioni tecniche.

Aorto-bifemoral bypass is the commonest way to correct stenotico-obstructive lesions of the aorto-iliac district. The problem of proximal anastomosis is examined by considering the advantages and disadvantages of the two types of anastomosis: end-to-end and end-to-side. On the basis of reported results and personal experience based on the use of end-to-side anastomosis, it is concluded that this is to be preferred over end-to-end, especially in view of the possibility offered by this procedure of maintaining the collateral circulations.

[Surgical treatment of thrombosis of the inferior vena cava]. / Il trattamento chirurgico delle trombosi della vena cava inferiore.

Personal experience of thromboses of the inferior vena cava is presented and pathogenetic and symptomatological aspects stressed. In addition, in relation to the results presented and reported data, it is concluded that the role of surgical therapy is fundamental to integrate the thrombolytic and anticoagulant treatment of these severe forms of deep venous thrombosis.

[Arterial hypertension after carotid endarterectomy]. / L'ipertensione arteriosa dopo intervento di endoarteriectomia carotidea.

Arterial hypertension as a consequence of carotid endarterectomy is a relatively frequent event and potentially dangerous because of the development of central postoperative neurological deficiency. The main pathogenetic theories are reviewed, with reference to hypotensive phenomena and preventive action also. Stress is laid on the importance of recognising potential risk factors, such as the use of anaesthetics which interfere with cerebral flow self-regulation mechanisms, diabetes and atherosclerosis.

[A case of biliary ileus in a subject who had already undergone cholecystectomy]. / Su di un caso di ileo biliare in soggetto già colecistectomizzato.

A rare case of biliary ileus in an already cholecystectomized subject is reported. Apart from the rarity of the case, the failure to evidence a bilio-digestive fistula intraoperatively is pointed out and a trans-choledochal migration mechanism for the gallstone is hypothesised. After a short review of the main complications connected with this serious form of intestinal occlusion, stress is laid on the advisability of carrying out, especially in emergency situations, simple entero-lithotomy, confining more invasive surgery, such as the repair of the biliodigestive fistula or cholecystectomy to cases in which recurrent biliary pathology is evident.