The Effect of Bariatric Surgery upon Diabetes Mellitus: A Proof of Concept by Using the Case of the Mid-Term Effect of Lap Adjustable Gastric Banding (LAGB) on Patients with Diabetes.

Obesity is a worldwide epidemic, with numbers on the rise in the world. Obesity is strongly correlated with increased morbidity and mortality. One of the major factors affecting this increase is comorbid diseases such as diabetes mellitus (DM), which is strongly associated with and dependent on the degree of obesity. Thus, it is not surprising that when efficient surgical treatments were found to battle obesity, researchers soon found them to be relevant and effective for battling DM as well. Laparoscopic Adjustable Gastric Banding (LAGB) is a common surgical treatment for morbid obesity. LAGB has the potential to improve control of the comorbidities of morbid obesity, primarily diabetes mellitus (DM). Our hypothesis was that patients treated with LAGB would have a long-term improvement in the control of DM and that due to its unique mechanism of action, this can lend us a better understanding of how to battle diabetes in an efficient and effective way. This was a cohort study based on patients who underwent LAGB surgery in our institution 4 to 7 years previously and had DM type 2 at the time of surgery. Data were collected from patient's charts and a telephone interview-based questionnaire including demographics, health status, and quality-of-life assessment (Bariatric Analysis and Reporting Outcome System [BAROS]). Seventy patients participated in the current study. The average follow-up time was 5.1 ± 0.9 years post-surgery. The average weight prior to surgery was 122.0 ± 20.2 kg, and on the day of the interview it was 87.0 ± 17.6 kg (p < 0.001). The average body mass index before surgery was 43.8 ± 5.1, and on the day of the interview it was 31.2 ± 4.8 (p < 0.001). On the day of the interview, 47.1% of the participants were cured of DM (not receiving treatment, whether dietary or pharmacologic). The sum of ranks for diabetes was lower after the surgery (p < 0.001), as was HTN and its treatment (p < 0.001). We have shown in this study that LAGB is an effective treatment for morbid obesity, as well as two comorbidities that come with it­DM type 2 and Hypertension (HTN)­in a longer period than previously shown, and with a unique look at the underlying mechanism of action of this procedure. There is a need for further studies to consolidate our findings and characterize which patients are more prone to enjoy these remarkable surgical benefits.

Laparoscopic adjustable gastric band removal and outcome of subsequent revisional bariatric procedures: A retrospective review of 214 consecutive patients.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) removal is required in cases of slippage, erosion, infection, intolerance, or failure in weight loss. The aim of the study was to follow up the patients who underwent band removal and analyze the outcome of subsequent revisional bariatric procedures. PATIENTS AND METHODS: A retrospective review of consecutive patients who underwent LAGB removal during 3.5 years. All patients underwent a phone interview in early 2015. Patients were divided to three groups following band removal: without additional surgery, laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en Y gastric bypass (LRYGB), and Redo LAGB(Re-LAGB). Outcome of different revisional procedures was compared according to causes and symptoms before band removal, patient satisfaction, weight loss, quality of life (QOL) questionnaire, and the bariatric analysis and reporting outcome system II (BAROSII) score. RESULTS: Overall 214 patients (73.8% females) with mean age of 41.9 years were enrolled in the study. The mean time between LAGB placement and removal was 81.0 months. Mean % estimated weight loss (%EWL) was 29.6 at time of band removal. There was no difference between groups in patient age, gender, BMI before LAGB, and most co-morbidities. Patients with 1-5 outpatient visits preferred additional surgery. Patients suffering from vomiting from 1 to 10 times per week preferred revision as LSG or LRYGB. Patients with lower BAROS score underwent LSG or LRYGB. Most of the patients with band intolerance underwent conversion to another bariatric procedure, while patients with band erosion and infected band preferred Re-LAGB. Most of the patients without band gained weight. There was a significant improvement in %EWL (39.9 vs 29.6), QOL (1.08 vs 0.07), and BAROS(2.82 vs-0.11) in patients who underwent additional bariatric surgery before and after band removal irrespective of surgery type. CONCLUSIONS: Patient selection for different revisional bariatric procedures after LAGB removal is a main point for surgery success. This results in high patient satisfaction, EWL, and QOL. All options (Re-LAGB, LSG, LRYGB) are feasible and safe.

Management of gastric perforations during laparoscopic gastric banding.

BACKGROUND: Gastric perforations are one of the intraoperative complications of laparoscopic gastric banding (LAGB). Delayed diagnosis can increase the mortality and morbidity rates. METHODS: Retrospective analysis of surgery outcome and long-term follow-up of the patients with gastric perforations during primary LAGB and revisional band procedures was performed. RESULTS: Twenty-four patients with gastric perforations were identified during 15 years of LAGB surgeries. Half of these had primary LAGB and half had revisional procedures (five emergent and seven elective). Gastric tear was found at surgery in 19 patients; the band was preserved and LAGB was completed in 18 of these. Five patients had delayed diagnosis and underwent re-exploration 24-72 h after surgery. During the surgery, 23 anterior, 8 posterior, 1 esophageal, and 1 small bowel tears were found. Laparoscopic repair was successful in 19 (83%) cases. The mean surgery time and mean hospital stay were 56.3 min and 7.8 days, respectively. Morbidity and mortality rates were 25 and 4.1%, respectively. Two patients underwent later band replacement following removal. Band erosion was observed in one patient. At least 17 patients had no complications during mean follow-up of 52.2 months. CONCLUSIONS: Band preservation is recommended following primary repair of gastric tear. Early intra- and postoperative diagnosis of gastric tear in LAGB is essential for successful management of this iatrogenic injury and decreases occurrence of complications.

Slit versus non-slit mesh placement in total extraperitoneal inguinal hernia repair.

BACKGROUND: The goal of the present research was to study patients who underwent laparoscopic total extraperitoneal repair using slit and non-slit mesh placement. METHODS: Patients who underwent laparoscopic inguinal hernia repair in our hospital between 2005 and 2009 were interviewed and examined. Surgery outcome, hernia recurrence, postoperative pain and time to return to normal physical activities, and surgery satisfaction were compared. RESULTS: During the study period 389 consecutive patients underwent laparoscopic groin hernia repair: 387 by the total extraperitoneal (TEP) approach and 2 by the TAPP approach. Six of the TEP patients were converted to TAPP. Eighty-seven patients in the TEP group had slit mesh placement and 300 had non-slit mesh placement. Mean follow-up was 36 months (range: 6-66 months). At follow-up, 387 patients responded to a request for interview and 277 were examined. The overall recurrence rate was 4.7%, the incidence of constant postoperative pain was 1.3%, the presence of permanent testicular pain was 2.8%, and patient satisfaction with the surgery was 94.5%. A significantly lower recurrence rate was found in the slit mesh group than in the non-slit group (0.6% versus 5.9%; p < 0.003). There was no difference in the length of time until return to normal activities, patient satisfaction, and postoperative pain between the groups. Surgery time and the occurrence of testicular pain were significantly greater in the anatomic group. CONCLUSIONS: Total extraperitoneal inguinal hernia repair with slit mesh placement is a safe technique with a very low recurrence rate and is superior to non-slit mesh positioning.

Abdominal cocoon as a rare cause of small bowel obstruction in an elderly man: report of a case and review of the literature.

Abdominal cocoon is a rare cause of intestinal obstruction usually diagnosed incidentally at laparotomy. The cause and pathogenesis of the condition have not been elucidated. It primarily affects adolescent girls living in tropical and subtropical regions. Several earlier cases have been reported in males. We describe an 82-year-old man presenting with small bowel obstruction without history of previous abdominal surgery. He was treated by warfarin following aortic valve replacement. Abdominal cocoon was detected at laparotomy. Excision of membrane and lysis of adhesions led to relief of obstruction. Abdominal cocoon is a rare pathology that may be found in all kinds of populations. It may be a rare form of small bowel obstruction diagnosed during surgery in elderly patients.

Laparoscopic appendectomy as an initial step in independent laparoscopic surgery by surgical residents.

BACKGROUND: Laparoscopic appendectomy (LA) can be used as a training model for the start of the independent experience of young residents. We tried to evaluate whether LA is a risk factor for patients when it is done by novice surgeons during the different steps of their training. MATERIALS AND METHODS: A retrospective study of all the patients who underwent LA in our department between 2000 and 2008 was conducted. The patients were operated on by novice surgeons, chief residents, and senior surgeons. Preoperative variables were compared, as well as surgical outcomes and complications. RESULTS: During the study period, 477 LA, were performed on 320 women and 157 men, with a mean age of 39 years. In 11 cases (2.3%), the operation was converted. No difference was found in preoperative patient status. There was no difference between groups in the rate of accurate preoperation diagnosis, in comparison with the pathologic report. The rates of conversion, postoperative complications, and negative appendectomies were similar between residents and seniors. These findings were also found in a subgroup analysis, in which we compared each group. CONCLUSIONS: There is no additional risk in a LA done by a resident, whether a chief or a novice. LA is a good model for training young surgeons in laparoscopic surgery: It enables the young surgeon to engage and lead a real case and does not imbue any risk upon the patient.

EAES recommendations on methodology of innovation management in endoscopic surgery.

BACKGROUND: Under the mandate of the European Association for Endoscopic Surgery (EAES) a guideline on methodology of innovation management in endoscopic surgery has been developed. The primary focus of this guideline is patient safety, efficacy, and effectiveness. METHODS: An international expert panel was invited to develop recommendations for the assessment and introduction of surgical innovations. A consensus development conference (CDC) took place in May 2009 using the method of a nominal group process (NGP). The recommendations were presented at the annual EAES congress in Prague, Czech Republic, on June 18th, 2009 for discussion and further input. After further Delphi processes between the experts, the final recommendations were agreed upon. RESULTS: The development and implementation of innovations in surgery are addressed in five sections: (1) definition of an innovation, (2) preclinical and (3) clinical scientific development, (4) scientific approval, and (5) implementation along with monitoring. Within the present guideline each of the sections and several steps are defined, and several recommendations based on available evidence have been agreed within each category. A comprehensive workflow of the different steps is given in an algorithm. In addition, issues of health technology assessment (HTA) serving to estimate efficiency followed by ethical directives are given. CONCLUSIONS: Innovations into clinical practice should be introduced with the highest possible grade of safety for the patient (nil nocere: do no harm). The recommendations can contribute to the attainment of this objective without preventing future promising diagnostic and therapeutic innovations in the field of surgery and allied techniques.

Bariatric emergencies for non-bariatric surgeons: complications of laparoscopic gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has gained popularity for treatment of morbid obesity worldwide. With the widespread use of LAGB, an increasing number of medical specialists are dealing with the potentially life-threatening complications of this procedure. METHODS: More than 6,000 LABGs were performed by our surgeons during the past 11 years, during which various complications of LAGB were observed, including band slippage, erosion, gastric pouch dilatation, port infection, and disconnection. Complicated cases requiring emergency surgical intervention were collected. We present and discuss the diagnostic and therapeutic possibilities of these complications. RESULTS: Fourteen cases were identified: six with acute band slippage, two with small bowel obstruction, and one each with band slippage and fetal intrauterine growth restriction during the 36th week of pregnancy, perforated gastric ulcer, upper gastrointestinal bleeding, connecting tube penetration into a stomach ulcer, connecting tube penetration into the colon, and port disconnection. All patients had gastrointestinal symptoms at admission. Band reposition was performed in four cases; eight patients required band removal for band contamination. The band was open and still in place in one case. Open and laparoscopic gastric resections for necrotic stomach were performed in two cases. Suture of perforated gastric ulcer was combined with cesarean section. Connection of disconnected port and suture of colonic and gastric penetrations and perforation of fundus were completed laparoscopically. Small bowel resection and enterotomy required an additional minimal laparotomic incision. No mortality was observed in our series. Four patients elected to have the LAGB reinserted at a later time. CONCLUSION: The increasing number of bariatric procedures has resulted in emergency physicians' knowledge of serious complications of LAGB that require urgent surgical intervention. Treatment algorithms require early diagnosis and a surgical approach to solving these conditions.

Gastric emptying of semisolids and pouch motility following laparoscopic adjustable gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has been popularized as an effective, safe, minimally invasive surgical technique for the treatment of morbid obesity. We performed a pilot study to evaluate gastric emptying of semisolid meals and antral motility following LAGB. METHODS: Gastric emptying half-time was compared in normal volunteers and morbidly obese patients before and 6-12 months after LAGB using sulfur colloid-labeled semisolid meals. RESULTS: There was no difference in mean age between groups. Women were prevalent in the group of obese patients. BMI was higher in patients before surgery (p < 0.001). Patients following LAGB demonstrated prolonged gastric pouch emptying (T1/2 = 36.6 +/- 9.8 min) compared to subjects without surgery (23.8 +/- 4.7 min) and healthy volunteers (22.8 +/- 6.8 min; p < 0.001). Similar gastric contractility was found all groups (3.3 +/- 0.4; p = 0.968). No cases of band slippage or pouch dilatation were observed during mean follow-up of 11.4 months. CONCLUSIONS: A standard normal gastric pouch emptying rate of semisolids in asymptomatic patients after LAGB was established. Postoperative prolongation of gastric emptying is a matter of mechanical delay without gastric pouch denervation. This study provides a first step of future functional evaluation of complications following this type of bariatric surgery.

Safety of laparoscopic appendectomy during pregnancy.

BACKGROUND: Use of laparoscopic appendectomy (LA) remains controversial during pregnancy because data regarding procedure safety are limited. The outcome of LA in pregnant women was evaluated and compared to results of open surgery. METHODS: Between January 1997 and December 2007, 42 pregnant women (mean age 24 years [range: 19-40 years]; range of gestation: 5-25 weeks) underwent appendectomy for suspected acute appendicitis: 23 laparoscopic (LA) and 19 open appendectomies (OA). Retrospective review of medical charts included preoperative information, surgery results, and outcome of the pregnancy. RESULTS: There was no difference between groups in surgery delay following arrival at the hospital. All procedures, except one case of Meckel's diverticulitis, were completed laparoscopically without need for conversion. Acute appendicitis was found in 19 cases and Meckel's diverticulitis in one case during LA (87%) and in 18 cases (95%) during OA. Complicated appendicitis was found in 7 (30%) pregnant women in the LA group and 1 (5%) in the OA group. Five women with normal preoperative abdominal ultrasonography had acute appendicitis (2 in the OA group and 3 in the LA group). The laparoscopic procedure was performed more often by senior surgeons (70% of cases), and OA was more commonly done by residents (47% of cases). There were no intraoperative or postoperative complications recorded. The length of postoperative hospital stay was slightly prolonged after LA-2.4 days versus 1.4 day after OA. There was one fetal loss in each group, 1 and 2 months after the operation. CONCLUSIONS: Laparoscopic appendectomy is safe and effective during pregnancy and is associated with good maternal and fetal outcome.

Value of laparoscopic appendectomy in the elderly patient.

BACKGROUND: Acute appendicitis (AA) in elderly patients (60 years of age and older) is a challenging problem associated with significant morbidity and mortality when perforation is present. We hypothesized that laparoscopic appendectomy (LA) would enable an earlier correct diagnosis and have advantages in elderly patients. METHODS: We performed a retrospective review of patients who underwent laparoscopic appendectomy for suspected AA. Data of elderly patients were compared to data of younger patients (18 to <60 years of age). RESULTS: Fifty-four LA were performed in elderly patients and 423 in younger patients. Patients over the age of 60 years had more co-morbidities and required more frequent use of anticoagulants. Preoperative imaging (ultrasound or computerized tomography) was significantly more frequent in elderly patients (36% versus 15%), and was associated with a higher rate of confirmation of acute appendicitis (78% versus 55%), which allowed a decrease in the rate of negative surgical explorations to 4.1% in elderly patients compared to 10.2% in younger patients. Complicated appendicitis and conversions were more frequent in the elderly patients. This resulted in prolonged operative time and longer hospital stay for this group. The overall complication rate was equivalent in the two groups, without differences in the occurrence either of infectious complications or of complications related to surgical site. There were no deaths following appendectomy in our series. CONCLUSIONS: Laparoscopic appendectomy is safe in the elderly population and is not associated with any increase in morbidity. The high incidence of complicated appendicitis in elderly patients affects operative time and length of hospital stay following laparoscopic appendectomy, and it can also lead to an increased rate of conversion to an open procedure. Use of preoperative abdominal computerized tomography scan is mandatory in elderly patients to provide an early diagnosis and to decrease unnecessary surgical exploration when acute appendicitis is suspected.

Laparoscopic diagnosis and treatment of postoperative complications.

BACKGROUND: There is no unequivocal attitude to a laparoscopy as to the means in the diagnosis and treatment of postoperative surgical complications. Our study sought to determine the role of laparoscopy in the management of suspected postoperative complications. METHODS: We performed a retrospective review of the patients who underwent laparoscopy for complications of previous surgery over a 6-year period. RESULTS: Sixty-four patients underwent laparoscopy for complications during the study period including 49 laparoscopies, 14 laparotomies, and 1 endoscopic procedure. The median delay between operations was 2 +/- 4.5 days. In 18 (28.1%) patients, laparoscopy did not find intra-abdominal pathology. The conversion to open surgery was necessary in 9 (14.1%) patients. Seven patients underwent more than 1 relaparoscopy. No cases of misdiagnosis were observed. Morbidity was 12.5%. There was no laparoscopy-related death. CONCLUSIONS: Laparoscopy is an effective tool for the management of postoperative complications after open and laparoscopic surgery. It avoids diagnostic delay and unnecessary laparotomy.

Presentation and management of port disconnection after laparoscopic adjustable gastric banding.

AIM: Laparoscopic adjustable gastric banding (LAGB) is a common and effective minimally invasive procedure in the treatment of morbid obesity. Port and connection tube complications are rarely reported. The aim of this study was to find presenting signs and predictors of tube disconnection from the access port that allow prompt diagnosis and appropriate treatment. PATIENTS AND METHODS: A retrospective chart review was performed on the 29 patients who underwent 31 laparoscopic reconnections of the connecting tube following LAGB during a 10-year period. RESULTS: Presenting signs were sudden lower-abdominal pain and free food passage following by weight gain and inability for band adjustment. Additional imaging was used to confirm diagnosis in the first three patients. Diagnostic laparoscopy for suspected acute appendicitis found tube disconnection from the port in one patient. Laparoscopic reconnection was successful in all patients. Access port exchange was done in 23 cases. Two patients had recurrent port disconnection. Band exchange was performed after second port reconnection. CONCLUSION: Sudden onset of flank or abdominal pain, free eating, weight gain, and inability to adjust the band are signs of port disconnection after LAGB. Education and information for medical staff and patients can help in early recognition of this complication and avoid unnecessary investigations.

Laparoscopic cholecystectomy for acute cholecystitis in the elderly: is it safe?

BACKGROUND: The purpose of this study was to evaluate the outcome of laparoscopic cholecystectomy (LC) in patients with acute cholecystitis aged 75 years and older. MATERIALS AND METHODS: A retrospective chart review was performed on the 1216 cholecystectomies performed in our department from 2000 to 2005. A total of 225 patients underwent attempted LC for acute cholecystitis, of whom 42 were more than 75 years old and 183 younger. RESULTS: There was no difference in mean duration of symptoms before admission and length of hospital stay before surgery (3.8 d in elderly vs. 3.1 in younger patients, and 2.8 vs. 2.3 d, respectively). In all, 21% of the elderly patients had American Society of Anesthesiologists score III and IV. Mean operative time and conversion rate to open surgery were similar in both groups. Postoperative stay was longer in elderly (3.9 vs. 2.8). The postoperative complications rate and mortality were significantly higher in the elderly group (31% vs. 15%, and 4.8% vs. 0.5%, respectively). CONCLUSIONS: LC in elderly patients suffering from acute cholecystitis is feasible and effective. It is associated with a higher rate of morbidity unrelated to the surgical site and mortality in elderly compared with younger patients. Stronger selection of elderly patients for surgery is needed.

Leukocyte scintigraphy SPECT/CT software fusion diagnosis of infected gastric band.

The prevalence of morbid obesity is increasing worldwide and presents a significant clinical problem. Laparoscopic adjustable gastric banding has been popularized as an effective, safe, minimally invasive surgical technique for the treatment of morbid obesity. Different diagnostic imaging modalities are crucial for follow-up of "banded" patients and detection of the different postoperative complications. We present a case report including detailed clinical, laboratory, radiological, and scintigraphic findings in a 50-year-old woman with an infected gastric band diagnosed by technetium 99m-hexamethyl propilenamine oxime-labeled leukocyte scintigraphy and discuss the value of integrated interpretation of anatomical and functional imaging modalities obtained by software fusion technique.

Early relaparoscopy for management of suspected postoperative complications.

BACKGROUND: Diagnosis of complications after laparoscopic surgery is difficult and sometimes late. METHODS: We compared the outcome of patients who had early (<48 h) relaparoscopy for suspected postoperative complication to those where relaparoscopy was delayed (>48 h). RESULTS: During the study period, 7726 patients underwent laparoscopic surgery on our service. Of these, 57 (0.7%) patients had relaparoscopy for suspected complication. The primary operations were elective in 48 patients and emergent in nine. Thirty-seven patients had early, 20 had delayed, secondary operations. The most common indication in the early group was excessive pain (46%) followed by peritoneal signs in 35%. In the delayed group, the most common indication was signs of systemic inflammatory response syndrome in 30% and peritoneal signs in 25%. Relaparoscopy was negative in 16 (28%) patients with no difference between groups. The identified complication was treated laparoscopically in 37(65%) patients, and the rest were converted. The patients in the delayed group had a significantly longer hospital stay (p < 0.003) and had a higher rate of complications (p < 0.05). They also had a higher mortality rate (10% vs. 2.7%), but the difference was not statistically significant. CONCLUSIONS: A policy of early relaparoscopy in patients with suspected complications enables timely management of identified complications with expedient resolution.

Jejunal obstruction caused by migrated gastric band.

We describe the rare complication of an eroded gastric band in the gastric cavity that passed through the pylorus and obstructed the proximal jejunum at the point allowed by the length of the connecting tube. At surgery, in addition to the expected finding, multiple necrotic pressure ulcerations in the jejunal wall were found in step ladder locations. Anyone who has adopted laparoscopic gastric banding as the modality for surgical treatment of morbid obesity should be familiar with this rare but potentially dangerous complication.

Evaluation of compensatory sweating after bilateral thoracoscopic sympathectomy for palmar hyperhidrosis.

The study is a retrospective review of 60 patients undergoing bilateral T2-T3 thoracoscopic sympathectomy for palmar hyperhidrosis in our department between 1997 and 2003. The study was based on a telephone questionnaire and medical chart review. Forty patients (67%) replied to the questionnaire and were included in the study. Postoperative complications, therapeutic results, patient satisfaction, and the severity of compensatory sweating (CS) were assessed. In all patients both palms were dry at the end of surgery. Postoperative complications included permanent unilateral Horner syndrome, wound infection, and residual pneumothorax resolving after thoracal drainage, in one patient each. CS with different severity occurred in 35 patients (87.5%). Six patients (15%) regretted undergoing the operation due to the extent and severity of the CS seriously affecting their quality of life. Thoracoscopic sympathectomy is a simple procedure with a high success rate. However, CS is a serious complication and a significant number of patients may regret undergoing the operation; a careful selection of patients and comprehensive explanation are advisable.

Complicated appendicitis: laparoscopic or conventional surgery?

BACKGROUND: The surgical treatment of complicated appendicitis remains controversial. The aim of this study was to evaluate the role of laparoscopic appendectomy in the treatment of complicated appendicitis in comparison with open surgery. METHODS: We reviewed the medical records of all patients who underwent an appendectomy for complicated appendicitis between January 2001 and August 2005. RESULTS: We identified 98 patients with complicated appendicitis. Forty-eight patients underwent open appendectomy, 42 laparoscopic appendectomy, and 8 initial laparoscopy with conversion to open surgery. Older patients, patients with comorbidities, and female patients were more likely to have been offered a laparoscopic appendectomy. Operating time, time to solid oral intake, and time of hospital stay were prolonged in the laparoscopic group but not significantly. There was no mortality observed in either group, and the complication rate was similar in both groups. CONCLUSIONS: Laparoscopic appendectomy is an acceptable procedure for complicated appendicitis, with the same rate of infectious complications as the conventional approach.