[Internal hernias after bariatric surgery]. / Innere Hernien nach bariatrischer Chirurgie.

Hernias are among the most common long-term complications after bariatric surgery. Besides incisional hernias, which occur very often after conventional open bariatric surgery, internal hernias after bariatric surgery constitute a special challenge. The incidence of internal hernias after bariatric surgery is more common than for other upper gastrointestinal tract operations. Internal hernias are not limited to laparoscopic procedures but are also observed after conventional open gastric bypass surgery. As the incidence is significantly increased after laparoscopic interventions, there seems to be a close association with minimally invasive procedures. The clinical symptoms of internal hernias without complete obstruction are non-specific and the correct diagnosis is often not straightforward. In addition to the aspects of prevention of internal hernias in laparoscopic surgery, this article discusses the diagnosis and treatment, taking into account the various forms of internal hernia after bariatric operations.

[Laparoscopically assisted total pancreatectomy : feasible minimally invasive alternative to open resection]. / Laparoskopisch-assistierte totale Pankreatektomie : Mögliche minimalinvasive Alternative zur offenen Resektion.

BACKGROUND: Minimally invasive techniques are being used increasingly more in pancreatic surgery. Compared to resections of the pancreatic head and tail, total pancreatectomy is rarely performed. As no pancreatic anastomosis has to be made and open resection usually needs a wide laparotomy, a laparoscopically assisted technique seems desirable. AIM: The objective of this article is to report the initial results of laparoscopically assisted total pancreatectomy in three patients. MATERIAL AND METHODS: This series included two patients with a main duct type intraductal papillary mucinous neoplasm (IPMN) and one patient with pancreatic metastases from a renal carcinoma. RESULTS: All three resections were achieved laparoscopically. Reconstruction was performed through the retrieval incision. Operative time, blood loss, intermediate care and hospital stay were similar to a control group of open resections in seven patients. CONCLUSION: In this small group of selected patients laparoscopic total pancreatectomy is feasible when carried out in centers with high expertise in laparoscopy and pancreatic surgery.

[Freiburg index of patient satisfaction: interdisciplinary validation of a new psychometric questionnaire to describe treatment-related patient satisfaction]. / Freiburger Index für Patientenzufriedenheit: Interdisziplinäre Validierung eines psychometrischen Instrumentes zur Erfassung behandlungsbezogener Patientenzufriedenheit.

BACKGROUND: The recently introduced Freiburg index of patient satisfaction (FIPS) is a new questionnaire to assess treatment-related patient satisfaction after surgery and interventional procedures. The questionnaire had first been tested psychometrically in a mixed population of urology patients. The current study describes the results of an interdisciplinary validation. In addition, an English version is presented. METHODS: The questionnaire was used in two cohorts of cardiology (n = 120) and surgical (n = 127) patients. The evaluation included a comprehensive methodological and statistical evaluation including validation in comparison to the ZUF-8 questionnaire. RESULTS: The psychometric evaluation showed good results. The analyzed samples showed no missing values or ceiling effects. Furthermore, a high reliability (Cronbach's alpha 0.82), unidimensionality, sufficient distribution of values and validity (high correlation to the ZUF-8, r = 0.65, p < 0.001) of the questionnaire could be confirmed. CONCLUSIONS: The FIPS constitutes an interdisciplinary validated questionnaire to evaluate treatment-related patient satisfaction which can be used to objectify and compare results from clinical studies and quality in patient care. Colleagues of English-speaking countries are invited to participate in the validation of the hereby presented English version.

[The Freiburg Index of Patient Satisfaction: introduction and validation of a new questionnaire]. / Der Freiburger Index für Patientenzufriedenheit. Vorstellung eines neuen Instruments und seiner psychometrischen Eigenschaften.

BACKGROUND: In the era of evidence-based medicine health-related quality of life measurements are recognized as valuable indicative factors. Because there was no generally applicable questionnaire addressing patient satisfaction after interventional or surgical procedures, the Freiburg Index of Patient Satisfaction was developed and psychometrically evaluated. METHODS: A preliminary version was evaluated and optimized through structured interviews with 20 patients (qualitative pre-study). The final questionnaire was then applied to 257 urological patients and a comprehensive statistical analysis including validation to a matching questionnaire (ZUF-8, Kriz 2008) was performed. RESULTS: All psychometric qualities scored well. The examined sample showed no missing values and no ceiling effect as otherwise found frequently: the most positive answer categories accounted for 43.6 % of cases. Reliability (Cronbach's Alpha = 0.84, discriminatory power = 0.50) was high. Furthermore the results of a factor analysis proofed unidimensionality of the questionnaire. Validity was shown by a close correlation between FIPS and ZUF-8 scores (r = 0.747, p < .001). CONCLUSION: The Freiburg Index of Patient Satisfaction is a generally applicable questionnaire to evaluate treatment satisfaction after interventional or surgical procedures. The questionnaire can be used to objectify results and increase comparability of clinical studies and quality in health care.

Improvement of type 2 diabetes mellitus in obese and non-obese patients after the duodenal switch operation.

Introduction. Type 2 diabetes mellitus (T2DM) is one of the most important obesity-related comorbidities. This study was undertaken to characterise the effect of the biliopancreatic diversion with duodenal switch (BPD-DS) in morbidly obese and nonmorbidly obese diabetic patients. Methods. Outcome of 74 obese diabetic patients after BPD-DS and 16 non-obese diabetic patients after BPD or gastric bypass surgery was evaluated. Insulin usage, HbA(1c)-levels, and index of HOMA-IR (homeostasis model assessment of insulin resistence) were measured. Results. A substantial fraction of patients is free of insulin and shows an improved insulin sensitivity early after the operation, another fraction gets free of insulin in a 12-month period after the operation and a small fraction of long-term insulin users will not get free of insulin but nevertheless shows an improved metabolic status (less insulin needed, normal HbA(1c)-levels). Conclusion. BPD-DS leads to an improvement of T2DM in obese and non-obese patients. Nevertheless, more data is needed to clarify indications and mechanisms of action and to adjust our operation techniques to the needs of non-obese diabetic patients.

Video. Laparoscopic extirpation of a fork from the duodenum.

BACKGROUND: A 23-year-old woman who 2 weeks before visiting our institution swallowed a plastic fork while attempting to induce vomiting during a party presented with progressive abdominal pain. Various techniques for removing foreign bodies from the intestinal tract have been described. We present the laparoscopic retrieval of a 15-cm fork from the duodenal bulb. METHODS: The patient presented with leukocytosis and epigastric tenderness. An upper endoscopy revealed a plastic fork, tines up, perforating the duodenal bulb. The handle was irremovably lodged in the opposite part of the duodenum. Perforating objects and objects larger than 7 cm ought to be removed surgically to prevent esophageal perforation. The patient was placed in supine position with the surgeon standing between her legs. Four trocars, two 10-mm and two 5-mm, were used. We saw a slight swelling of the duodenum with few fibrin stripes and roughly 250 ml of white exudate. The fork tines were visible; there were no injuries to the liver. The tines were held with a clamp while the perforated intestinal wall was carefully dissected with a monopolar hug and later with an ACE harmonic scalpel due to bleeding. The fork was extracted in the proximal direction through the perforation injury. There was no severe necrosis and debridement was not necessary. The bowel was irrigated and continuously sutured with 3-0 PDS. Finally, the fork was retrieved through the 10-mm trocar incision. RESULTS: Operating time was 60 min and blood loss was roughly 100 ml. The patient's postoperative course was uneventful. One year after intervention, the patient is doing well. CONCLUSION: A fork may be swallowed, but usually does not spontaneously pass through the gastrointestinal tract. Early removal should be advised to avoid perforation and to minimize morbidity. Laparoscopic removal is a safe and feasible method of managing foreign bodies that are not removable endoscopically.

Influence of Sleeve Gastrectomy on NASH and Type 2 Diabetes Mellitus.

Background. Nonalcoholic fatty liver disease is present in up to 85% of adipose patients and may proceed to nonalcoholic steatohepatitis (NASH). With insulin resistance and obesity being the main risk factors for NASH, the effect of isolated sleeve gastrectomy (ISG) on these parameters was examined. Methods. 236 patients underwent ISG with intraoperative liver biopsy from December 2002 to September 2009. Besides demographic data, pre-operative weight/BMI, HbA1c, AST, ALT, triglycerides, HDL and LDL levels were determined. Results. A significant correlation of NASH with higher HbA1c, AST and ALT and lower levels for HDL was observed (P < .05, <.0001, <.0001, <.01, resp.). Overall BMI decreased from 45.0 ± 6.8 to 29.7 ± 6.5 and 31.6 ± 4.4 kg/m(2) at 1 and 3 years. An impaired weight loss was demonstrated for patients with NASH and patients with elevated HbA1c (plateau 28.08 kg/m(2) versus 29.79 kg/m(2) and 32.30 kg/m(2) versus 28.79 kg/m(2), resp.). Regarding NASH, a significant improvement of AST, ALT, triglyceride and HDL levels was shown (P < .0001 for all). A resolution of elevated HbA1c was observed in 21 of 23 patients. Summary. NASH patients showed a significant loss of body weight and amelioration of NASH status. ISG can be successfully performed in these patients and should be recommended for this subgroup.

Pitfalls and technical aspects during the research of intestinal anastomotic healing in rats.

BACKGROUND: Fundamental experimental research into intestinal anastomotic healing in rodent models will gain increasing interest in the future. METHODS: The aim of this study was to describe our 5-year experience with a standardized experimental setup of small and large bowel anastomoses in a rodent model and present a basic set of assessment tools investigating anastomotic healing. Anastomotic technique, perioperative complications such as anastomotic insufficiency (AI) and obstructive ileus were in the focus. RESULTS: During different studies with varying study patterns, 167 rat small bowel anastomoses and 120 colonic anastomoses were performed. Overall mortality was 3.6% in small bowel and 2.5% in colonic anastomoses, AI occurred in 2.9 and 4%, respectively. A postoperative obstructive ileus was seen in 3/167 small bowel anastomoses and none in the colonic group. CONCLUSION: When performing experimental intestinal anastomoses in a standardized operative setting and critically considering special perioperative issues, the incidence of relevant complications can be maintained at an adequately low level.

[Metabolic surgery and remission of type 2 diabetes]. / Metabolische Chirurgie und Remission des Diabetes mellitus Typ 2.

A new therapeutic field is developing from bariatric surgery. Gastrointestinal surgery does not only seem to be a very efficacious method for weight reduction but may also have the potential to reduce obesity-related metabolic disorders. Even if there is still a lack of prospective randomized trials evaluating the correct indications for metabolic surgery in patients with type 2 diabetes mellitus, there is the legitimate expectation that the surgical approach can be successful. This article provides an overview of the current state of bariatric surgery and gives a surgical perspective on the treatment of type 2 diabetes mellitus.

[Redo operations after bariatric and metabolic surgery]. / Reoperationen nach bariatrischer und metabolischer Chirurgie.

Because of the growing prevalence of morbid obesity, bariatric surgery is getting more and more important. According to the growing number of bariatric operations, the number of patients in need of revisionary surgery is also growing, mostly because of insufficient weight loss. This article gives an outline of indications, preoperative diagnostics and revisionary operations in bariatric surgery.

3D-MSCT gastric pouch volumetry in bariatric surgery-preliminary clinical results.

BACKGROUND: Insufficient weight loss or persistent abdominal complaints are reasons for revisionary operations in bariatric surgery. The selection of the secondary procedure is influenced by clinical and by patho-anatomical factors like the size of the gastric pouch. The purpose of this study was to evaluate multi-slice computed tomography (MSCT)-based volumetric assessment of gastric pouches, gastric sleeves, and anastomoses in patients after bariatric surgery. METHODS: Twenty-six patients after bariatric surgery received abdominal MSCT immediately after oral administration of an ionic contrast agent solution and intravenous administration of buthylscopalamine. Indications were insufficient weight loss after primary operation, persistent upper abdominal complaints, and decline of bariatric analysis and reporting outcomes system (BAROS) score. The gastric volumes, diameter of the gastrojejunostomy, and the proximal part of the Roux limb were measured on volume rendering images and freely angulated reformations. RESULTS: Evaluation of gastric volumes was successful in 25 examinations (96%). The diameters of gastrojejunostomy as well as the dimensions of the Roux limb were evaluable in all cases. After gastric bypass surgery, a pouch volume >30 ml was found in ten, a widening of the gastrojejunostomy in eight, and a dilated Roux limb in six cases. Two patients presented a combination of a wide anastomosis and a strongly dilated Roux limb. Patients after biliopancreatic diversion had gastric volumes between 210 and 840 ml. Other findings were a fistula, an intragastral stenosis, and internal hernias. CONCLUSIONS: MSCT allows crucial patho-anatomical measurements and provides helpful information for selecting the appropriate revisionary operation after bariatric surgery.