How to cope with insufficient pneumoperitoneum and exposure when performing laparoscopic gastric bypass surgery.

OBJECTIVE: Despite following international guidelines and conducting routine preoperative dietary counseling, every bariatric surgeon will encounter technical challenges in laparoscopic gastric bypass surgery. We present a series of patients in whom the bariatric procedure was stopped after encountering insufficient exposure during diagnostic laparoscopy. These patients were sent back for dietary counseling and underwent surgery after conservative weight loss. The data from this two-step procedure are analyzed and discussed. METHODS: This concept was applied and studied in 14 patients from a series of 620 bariatric procedures. Patients who underwent a primary laparoscopic gastric bypass (n = 593) were used as references. RESULTS: The patients in the study group were significantly heavier than those in the reference group (165 vs. 127 kg, p < 0.001), with 79 % having a BMI >50 kg/m(2). The patients lost a median of 11 kg after 2 months of conservative treatment, and the mean BMI decreased from 55.7 to 52.6 kg/m(2). All the patients in the study group underwent laparoscopic surgery for the second procedure with no need for conversion. The complication rate was not elevated in the study group. Overall hospital costs were higher for the study group compared with those for the primary laparoscopic bypass group (27,136 vs. 19,601 USD, p = 0.034). CONCLUSION: The primary laparoscopic procedure can be stopped in patients with insufficient exposure instead of having them undergo conversion to open surgery. These patients may undergo successful laparoscopic procedures after conservative weight loss with no increased risk and with all of the possible benefits of a laparoscopic approach. As a result of this study, we have established a fixed, preoperative lower limit of 10 % excess weight reduction before accepting superobese patients (BMI >50 kg/m(2)) for surgery at our hospital.

An atypical lateral hernia and concomitant inguinal and umbilical hernias in a patient with polycystic kidney disease and an intracranial aneurysm - a combined approach of clinical and radiological investigation, endoscopic hernia repair, and anatomical cadaver model documentation and a systematic review of the literature.

Atypical hernias are difficult to diagnose due to their rarity and often unspecific symptoms. In the literature there exist hints to peri-inguinal hernias, i.e. direct lateral hernia, but most of them are forms of Spigelian hernias. Since the majority were described during the first half of the past century or even earlier, only very few cases have been documented using modern diagnostic techniques. We report a unique case of a 51 year old patient presenting with an atypical inguinal hernia with concomitant inguinal and umbilical hernias in combination with cystic kidney disease and intracranial aneurysm. The atypical position of the hernia was assumed from clinical inspection, ultrasound and CT scan and verified during pre-peritoneoscopy. Using an anatomical cadaver dissection approach, we followed the unusual position of the hernia through the abdominal wall below the aponeurosis of the external oblique muscle. After a thorough literature search, we assume that the present hernia containing a hernial sac has not been documented before, especially not in such a multidisciplinary approach comprising radiological, surgical and anatomical localisation and endoscopic treatment in a patient with a clinical situation being aggravated by large cystic kidneys leading to dialysis-dependency. Rare hernias have been described as being often associated with concomitant inguinal or other hernias, a predisposition for the male gender and a pathogenic mechanism related to other soft tissue defects such as cystic kidney disease or cranial aneurysm. Thus, we consider this a unique case that has not been documented in this constellation previously, which may increase the awareness for these rare hernias.

An unusual case of mediastinal mass and bilateral nodules.

A 23-year-old woman presented with a mediastinal paraganglioma and multiple pulmonary chondromas following antral gastric resection for gastrointestinal stromal tumor. These tumors form the Carney triad, a rare disorder of unknown genetic background. First described in 1977, approximately 120 cases have been documented in the literature. The tumors do not harbor the specific c-kit or PDGFRA gene mutations often found in sporadic gastrointestinal stromal tumor. In most cases, gastric gastrointestinal stromal tumor is the first tumor to be detected, with secondary tumors appearing years later. Even if it is rare, Carney triad should be suspected in young patients with history of gastrointestinal stromal tumor.

Utility of routine versus selective upper gastrointestinal series to detect anastomotic leaks after laparoscopic gastric bypass.

BACKGROUND: In up to 4% of laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures, anastomotic leaks occur. Early detection of gastrointestinal leakage is important for successful treatment. Consequently, many centers advocate routine postoperative upper gastrointestinal (UGI) series. The aim of this study was to determine the utility of this practice after LRYGB. METHODS: Eight hundred four consecutive patients undergoing LRYGB from June 2000 to April 2010 were analyzed prospectively. The first 382 patients received routine UGI series between the third and fifth postoperative days (group A). Thereafter, the test was only performed when clinical findings (tachycardia, fever, and drainage content) were suspicious for a leak of the gastrointestinal anastomosis (group B; n = 422). RESULTS: Overall, nine of 804 (1.1%) patients suffered from leaks at the gastroenterostomy. In group A, four of 382 (1%) patients had a leak, but only two were detected by the routine UGI series. This corresponds to a sensitivity of 50%. In group B, the sensitivity was higher with 80%. Specificities were comparable with 97% and 91%, respectively. Routine UGI series cost only 1.6% of the overall costs of a non-complicated gastric bypass procedure. With this leak rate and sensitivity, US $86,800 would have to be spent on 200 routine UGI series to find one leak which is not justified. CONCLUSIONS: This study shows that routine UGI series have a low sensitivity for the detection of anastomotic leaks after LRYGB. In most cases, the diagnosis is initiated by clinical findings. Therefore, routine upper gastrointestinal series are of limited value for the diagnosis of a leak.

Treatment of ureteral complications after kidney transplantation with native ureteropyelostomy reduces the risk of pyelonephritis.

Urological complications contribute to morbidity and graft loss after kidney transplantation. Aim of this study was to assess the role of revisional surgery on patient outcome. From 1997 to 2007, 887 patients underwent kidney transplantation in our institution. Clinical data of patients with urological complications were analyzed. Ureteral complications were observed in 50 of 887 (5.6%) recipients, including ureteral necrosis (0.9%), stenosis (3.6%) and ureteral reflux with recurrent graft pyelonephritis (1.1%). Thirty-five patients underwent native ureteropyelostomy, and 14 patients had redo-ureterocystostomy. All patients treated for recurrent graft pyelonephritis had no further episodes. Overall, the rate of ureteral stenosis was significantly higher after secondary surgery, compared to the primary anastomosis (10% vs. 3.6%, p = 0.039). A significantly lower incidence of graft pyelonephritis was observed in patients after native ureteropyelostomy compared to patients treated with redo-ureterocystostomy (p = 0.019). In conclusion, reflux and recurrent graft pyelonephritis can be treated effectively by secondary surgery. The use of native ureteropyelostomy may offer protection from graft pyelonephritis after secondary surgery.

Reconstruction of the gastric passage by a side-to-side gastrogastrostomy after failed vertical-banded gastroplasty: a case report.

INTRODUCTION: Vertical-banded gastroplasty, a technique that is commonly performed in the treatment of morbid obesity, represents a nonadjustable restrictive procedure which reduces the volume of the upper stomach by a vertical stapler line. In addition, a textile or silicone band restricts food passage through the stomach. CASE PRESENTATION: A 71-year-old woman presented with a severe gastric stenosis 11 years after vertical gastroplasty. We describe a side-to-side gastrogastrostomy as a safe surgical procedure to restore the physiological gastric passage after failed vertical-banded gastroplasty. CONCLUSION: Occasionally, restrictive procedures for morbid obesity cannot be converted into an alternative bariatric procedure to maintain weight control. This report demonstrates that a side-to-side gastrogastrostomy is a feasible and safe procedure.

Prospective evaluation of vacuum-assisted closure in abdominal compartment syndrome and severe abdominal sepsis.

BACKGROUND: Open abdomen treatment because of severe abdominal sepsis and abdominal compartment syndrome remains a difficult task. Different surgical techniques are available and are often used according to the surgeon's personal experience. Recently, the abdominal vacuum-assisted closure (VAC) system has been introduced, providing a new possibility to treat an open abdomen. In this study, we evaluate the role of this treatment option. STUDY DESIGN: This prospective observational cohort study includes 37 consecutive patients who were temporarily treated with VAC for severe abdominal sepsis or abdominal compartment syndrome, or both. Patients with abdominal trauma were excluded from the study. Thirty-seven patients undergoing major elective laparotomy and primary abdominal closure served as control group. Primary end points were fascial closure rate, physicoemotional recovery, and appearance outcomes 1 year after closure. Secondary end points included mortality, duration of open abdomen, length of ICU stay, and hospitalization time. RESULTS: Abdomens were left open for 23 days (range 3 to 122 days) with 3.8 dressing changes (range 1 to 22) per patient. Abdominal closure was achieved in 70% (n = 26), with no marked relation to duration of open abdomen treatment (p > 0.05). After 3 months, patients with VAC treatment recovered to a physical and mental health status similar to patients in the control group (p > 0.05). This status remained stable until the end of the study. Aesthetic outcomes (according to the Vancouver Scar Scale) were considerably poorer in the VAC group compared with controls (p < 0.01). CONCLUSIONS: Treatment of laparostomy with VAC for abdominal sepsis and abdominal compartment syndrome results in a high rate of successful abdominal closure. In addition, patients recover more rapidly, although hypertrophic scars might interfere with body perception. We recommend abdominal VAC system as first option if open abdomen treatment is indicated.

Routine stenting reduces urologic complications as compared with stenting "on demand" in adult kidney transplantation.

OBJECTIVES: To examine the impact of the chosen surgical technique and of systematic versus "on-demand" placement of a primary stent on the incidence of urologic complications in adult kidney transplantation. METHODS: Data of 497 consecutive patients undergoing kidney transplantation at a single center were retrospectively analyzed with respect to urologic complications. Three different surgical strategies for the ureteroneocystostomy were compared: (1) transvesical anastomosis with stenting "on demand," (2) extravesical anastomosis with stenting "on demand," and (3) extravesical anastomosis with routine stenting. Nine parameters were evaluated by logistic regression for a possible contribution to the development of urologic complications. RESULTS: Routine placement of a stent significantly reduced the number of urologic complications compared with both transvesical or extravesical anastomoses with stenting "on demand" (20.8% in transvesical "on demand," 17.9% in extravesical "on demand," and 5.8% in extravesical "routine"). Logistic regression analysis revealed that routine stenting versus stenting "on demand" (P = 0.001) and living donor transplantation (P = 0.038) are two independent factors associated with a significantly lower incidence of urologic complications. Although routine stenting was not associated with an increased incidence of urinary tract infections, female gender was the only independent factor associated with this complication (P = 0.001). CONCLUSIONS: Routine stenting of the ureteroneocystostomy is superior to stenting "on demand" in adult kidney transplantation, suggesting that the intraoperative decision of whether to stent is insufficient to avoid urologic complications.

Three-year follow-up study of retrocolic versus antecolic laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Since 1994, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has gained popularity for the treatment of morbid obesity. In analogy to open surgery, the operation was initially performed in a retrocolic fashion. Later, an antecolic procedure was introduced. According to short-term studies, the antecolic technique is favorable. In this study, we compared the retrocolic vs the antecolic technique with 3 years of follow-up. We hypothesized that the antecolic technique is superior to the retrocolic in terms of operation time and morbidity. METHODS: 33 consecutive patients with retrocolic technique and 33 patients with antecolic technique of LRYGBP were compared, using a matched-pair analysis. Data were extracted from a prospectively collected database. The matching criteria were: BMI, age, gender and type of bypass (proximal or distal). The end-points of the study were: operation time, length of hospital stay, incidence of early and late complications, reoperation rates and weight loss in the follow-up over 36 months. RESULTS: In the retrocolic group, operation time was 219 min compared to 188 min in the antecolic group (P = 0.036). In the retrocolic group, 3 patients (9.1%) developed an internal hernia and 4 patients (12.1%) suffered from anastomotic strictures. In the antecolic group, 2 patients (6.1%) developed internal hernias and in 3 patients (9.1%) anastomotic strictures occurred. Median hospital stay in the retrocolic group was 8 days compared to 7 days in the antecolic group. In the antecolic group, the mean BMI dropped from 46 kg/m2 to 32 kg/m2 postoperatively after 36 months. This corresponds to an excess BMI loss of 66%. In the retrocolic group, we found a similar decrease in BMI from preoperative 45 kg/m2 to 34 kg/m2 after 36 months (P = 0.276). CONCLUSION: The results of our study demonstrate a reduction of operation time and hospital stay in the antecolic group compared to the retrocolic group. No differences between the two groups were found regarding morbidity and weight loss. Taken together, the antecolic seems to be superior to the retrocolic technique.

Suppression of transforming growth factor beta signalling aborts caerulein induced pancreatitis and eliminates restricted stimulation at high caerulein concentrations.

BACKGROUND: Transforming growth factors betas (TGF-betas) are implicated in pancreatic tissue repair but their role in acute pancreatitis is not known. To determine whether endogenous TGF-betas modulate the course of caerulein induced acute pancreatitis, caerulein was administered to wild-type (FVB-/-) and transgenic mice that are heterozygous (FVB+/-) for expression of a dominant negative type II TGF-beta receptor. METHODS: After 7 hourly supramaximal injections of caerulein, the pancreas was evaluated histologically and serum was assayed for amylase and lipase levels. Next, the effects of caerulein on amylase secretion were determined in mouse pancreatic acini, and cholecystokinin (CCK) receptor expression was assessed. RESULTS: The normal mouse pancreas was devoid of inflammatory cells whereas the pancreas from transgenic mice contained lymphocytic infiltrates. Caerulein injection in wild-type mice resulted in 6- and 36-fold increases in serum amylase and lipase levels, respectively, increased serum trypsinogen activation peptide (TAP) levels, gross oedema and a marked inflammatory response in the pancreas that consisted mainly of neutrophils and macrophages. By contrast, FVB+/- mice exhibited minimal alterations in response to caerulein with attenuated neutrophil-macrophage infiltrates. Moreover, acini from FVB+/- mice did not exhibit restricted stimulation at high caerulein concentrations, even though CCK receptor mRNA levels were not decreased. CONCLUSION: Our findings indicate that a functional TGF-beta signalling pathway may be required for caerulein to induce acute pancreatitis and for the CCK receptor to induce acinar cell damage at high ligand concentrations. Our results also support the concept that restricted stimulation at high caerulein concentrations contributes to the ability of caerulein to induce acute pancreatitis.

Acute gastrointestinal bleeding: detection of source and etiology with multi-detector-row CT.

This study was conducted to determine the ability of multi-detector-row computed tomography (CT) to identify the source and etiology of acute gastrointestinal bleeding. Eighteen patients with acute upper (n = 10) and lower (n = 8) gastrointestinal bleeding underwent 4-detector-row CT (n = 6), 16-detector-row CT (n = 11), and 64-slice CT (n = 1) with an arterial and portal venous phase of contrast enhancement. Unenhanced scans were performed in nine patients. CT scans were reviewed to determine conspicuity of bleeding source, underlying etiology, and for potential causes of false-negative prospective interpretations. Bleeding sources were prospectively identified with CT in 15 (83%) patients, and three (17%) bleeding sources were visualized in retrospect, allowing the characterization of all sources of bleeding with CT. Contrast extravasation was demonstrated with CT in all 11 patients with severe bleeding, but only in 1 of 7 patients with mild bleeding. The etiology could not be identified on unenhanced CT scans in any patient, whereas arterial-phase and portal venous-phase CT depicted etiology in 15 (83%) patients. Underlying etiology was correctly identified in all eight patients with mild GI bleeding. Multi-detector-row CT enables the identification of bleeding source and precise etiology in patients with acute gastrointestinal bleeding.

Perforated ulcer at the gastrojejunostomy: laparoscopic repair after Roux-en-Y gastric bypass.

A 44-year-old woman was admitted from the emergency department with severe acute upper abdominal pain. The patient had undergone a laparoscopic Roux-en-Y gastric bypass (RYGBP) operation 16 months previously. CT scan showed intraabdominal free air. At emergency laparoscopic reoperation, a perforated ulcer at the gastrojejunostomy was found. This late complication of RYGBP can be a rapidly progressing life-threatening situation, and requires prompt treatment. Closure and omental patch were successful laparoscopically.

[Benefits and risks of bariatric surgery]. / Adipositaschirurgie--Was nützt, was schadet?

The rapid increase of morbid obesity has become an important task in the Western world in recent years. Since conservative treatments have failed to prove sufficient efficacy, surgery has turned out to be the most powerful option in treating morbid obesity. In this paper, the different surgical techniques with their advantages and drawbacks are presented. In general, there are restrictive, malabsorptive and combinations of both procedures available. The adjustable gastric banding (Figure 1) represents a purely restrictive operation. It is useful for patients with a relatively low body mass index (BMI) and a good understanding and control of their eating habits. By contrast, the duodenal switch (Figure 2) stands for a mainly malabsorptive procedure that might be indicated in patients with a very high BMI. The Roux-en-Y gastric bypass (Figure 3) is the most widely used bariatric procedure worldwide. It combines restriction and malabsorption. Today, almost two thirds of all bariatric procedures are performed laparoscopically, which has further enhanced the use of surgery in the treatment of morbid obesity. In conclusion, the treatment of morbid obesity represents a significant challenge in the Western world, and bariatric surgery plays a paramount role in the fight against overweight.

New device for the introduction of a circular stapler in laparoscopic gastric bypass surgery.

BACKGROUND: In laparoscopic Roux-en-Y gastric bypass (LRYGBP) surgery, the anastomosis between the gastric pouch and the jejunum can be performed using a circular stapler, as described in the original publication by Wittgrove in 1994. The introduction of the circular stapler through the thick abdominal wall in morbidly obese patients can be challenging. To overcome the difficulties of this task, a new device was developed and its use is presented. METHOD: The new device has the shape of a trocar tip which can be mounted on the circular stapler, giving it the properties of a trocar. Therefore, easier introduction into the abdominal cavity is feasible. The use of the device was assessed analyzing the data of a prospective database, comparing patient groups operated without the device (n=301) and patients operated with the device (n=100). RESULTS: The groups were comparable in age, sex, BMI and number of previous abdominal operations. The wound infection rate at the site of stapler introduction decreased from 6.6% to 1% (P=0.035). The overall operating time, hospital stay and complication rate were unchanged. CONCLUSION: The new device proved to be useful in daily practice and enabled an easier stapler introduction with fewer wound infections.