Reconstruction of the phreno-esophageal ligament (R-PEL) prevents the intrathoracic migration (ITM) after concomitant sleeve gastrectomy and hiatal hernia repair.

BACKGROUND: Laparoscopic Sleeve Gastrectomy (LSG) is the most attractive bariatric procedure, but the postoperative intrathoracic gastric migration (ITM) and "de novo" GERD are major concerns. The main objective of our study was to evaluate the efficiency of the concomitant HHR with or without partial reconstruction of phreno-esophageal ligament (R-PEL) to prevent ITM after LSG. The secondary objectives focused on procedure's metabolic and GERD-related outcomes. PATIENTS AND METHOD: Consecutive patients who underwent primary LSG and concomitant HHR were included in a single-center prospective study. According to the HHR surgical technique, two groups were analyzed and compared: Group A included patients receiving crura approximation only and Group B patients with R-PEL. The patients' evolution of co-morbidities, GERD symptoms, radiologic, and endoscopic details were prospectively analyzed. RESULTS: Two hundred seventy-three patients undergoing concurrent HHR and LSG were included in the study (Group A and B, 146 and 127 patients) The mean age and BMI were 42.6 ± 11.3 and 43.4 ± 6.8 kg/m2. The 12-month postoperative ITM was radiologically found in more than half of the patients in Group A, while in group B, the GEJ's position appeared normal in 91.3% of the patients, meaning that R-PEL reduced 7 times the rate of ITM. The percentage of no-improvement and "de novo" severe esophagitis (Los Angeles C) was 4 times higher in group A 3.4% vs. 0.8% with statistical significance, and correlated to ITM. The GERD symptoms were less frequent in Group B vs Group A, 21.3% vs 37%, with statistical significance. No Barrett's esophagus and no complication were recorded in any of the patients. CONCLUSION: Concurrent LSG and HHR by crura approximation only has a very high rate of ITM in the first postoperative year (over 50%). R-PEL is an innovative technique which proved to be very efficient in preventing the ITM after HHR.

Early Improvement in Glycemic Metabolism after Laparoscopic Sleeve Gastrectomy in Obese Patients - A Prospective Study.

BACKGROUND: according to W.H.O. in 2014 more than 600 million adults were obese, (more than doubled since 1980), and face a major risk for the onset of metabolic syndrome, including T2DM. Due to the poor control of glycemic imbalance for the conservative treatment of T2DM, the metabolic surgery was able to gain an important role in modern management of T2DM, with significant reported improvements or remissions for these patients. OBJECTIVE: to study the effects of laparoscopic sleeve gastrectomy (LSG) on glycemic metabolism in obese patients, with or without T2DM. METHODS: 60 consecutive patients were included in a prospective study and were submitted to laparoscopic sleeve gastrectomy in Ponderas Hospital between February - March 2013. BMI, waist circumference and glycemic parameters were studied at the moment of entering the study, 10 days after surgery and at 6 months follow up. RESULTS: the glycemic control was significantly improved starting with postoperative day 10. Statistically significant improvements were noticed after six months postoperatively in BMI values (p 0,0001), waist circumference (p 0,0001), glycemic levels (p 0,0001), insulin (p 0,0001), C-peptide (p 0,0001) and HOMA. CONCLUSIONS: a rapid induced improvement of glucose metabolism in both diabetic and non-diabetic patients occurs before a significant weight loss (POD 10). At 6 months, when associated with an important weight loss, both diabetic and non-diabetic patients present a furthermore improvement in glycemic metabolism, that enables us to consider that sleeve gastrectomy is an efficient method for a sustained improvement in the metabolic status of patients with obesity. These beneficial changes that can explain the remission of T2DM can also explain the prevention of T2DM after metabolic surgery.

Laparoscopic treatment of Spiegel hernia by total extraperitoneal (TEP) approach.

BACKGROUND: Spiegelian hernia is a rare type of ventral abdominal hernia. Surgical treatment is recommended due to the high risk of complications. Laparoscopic treatment is preferred to open repair, by means of intraperitoneal or extraperitoneal mesh placement, either by transperitoneal(TAPP) or by total extraperitoneal (TEP) approach. Total extraperitoneal approach is rarely reported in the literature. AIM: To evaluate the results of laparoscopic repair of Spiegelhernia by total extraperitoneal approach. MATERIAL AND METHOD: We prospectively studied the patients operated on for Spiegel hernia between October 2009 and March 2013 by laparoscopic TEP approach at Ponderas Hospital. Data regarding symptoms, sex, preoperative work-up,surgical technique, hospital stay and outcome of the procedure were analysed. Follow-up of the patients was achieved at 1week, 1 month, 6 months and yearly postoperatively and patients were evaluated for recurrence, chronic pain, mesh infection, time to reinsertion to normal activities and overall patient satisfaction score. RESULTS: We have treated 4 patients with Spiegel hernia by laparoscopic TEP repair, with mean age 55.25 years (range 50-64), sex ratio 1 (2 2); all patients were symptomatic, all cases had left sided hernias, the surgical intervention was elective in all cases. Mean hospital stay was 1.5 days (range1- 2 days). There was only one postoperative complication ina patient with asymptomatic seroma, with remission in 1 month. There were no recurrences, no mesh infection, no chronic pain or other morbidity at a mean follow-up of 25 months (range 12-53 months). The overall satisfaction score was maximal (5) in all cases. CONCLUSIONS: Spiegelian hernias are rare but surgery is mandatory because of the risk of complications like incarceration and strangulation. In the presented experience, laparoscopic total extraperitoneal approach proved to be an efficient technique,reproducible, with excellent results for Spiegel hernia treated electively.

Laparoscopic approach for rectosigmoidian resection in children.

Abdominoperineal approach for rectosigmoidian resection,first imagined and performed in 1948 by Orwar Swenson,was the surgical technique that opened the pathway in the treatment of congenital megacolon (1). B. Duhamel (1956) and F. Soave (1964) intended to correct the postoperative complications appeared after the Duhamel technique and proposed surgical procedures that keep the aganglionic rectum in transit (2,3). In 1994 K. Bax reproduces the Duhamel procedure using laparoscopic approach (4). K.Georgeson, in 1995, reproduced the Swenson technique for rectosigmoidian resection using minimal invasive surgery (5).Today, this approach represents the most frequently used procedure for the radical treatment of congenital megacolon.

Laparoscopic sleeve gastrectomy improves reproductive hormone levels in morbidly obese males -- a series of 28 cases.

BACKGROUND: Obese males frequently present with low androgen levels that may improve after weight loss achieved by bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) has been used often in the last decade as treatment for morbid obesity. The aim of this study was to evaluate modifications in the male reproductive hormone profile after LSG. PATIENTS AND METHODS: The prospective study included 28 males with body mass index (BMI) 35 kg m2 who underwent LSG.Total Testosterone (TT), Sex Hormone Binding Globulin(SHBG) and Luteinizing hormone (LH), together with biochemical and anthropometric data, were evaluated at baseline and after LSG. RESULTS: Baseline patients had a mean BMI of 50.10 (+-11.19)kg m2, SHBG 23.37 (+-17.47) nmol L, LH 3.83 (+-1.76)mUI ml and TT 8.31 (+-3.24) nmol L. After LSG, patients showed a mean BMI of 35.87 (+-7.02) kg m2 (p 0.001),SHBG 37.81 (+-18.95) nmol L (p 0.05), LH 4.76 (+-2.49)mUI ml (p 0.05), whereas mean TT was 12.7 (Â+-3.8) nmol L(p 0.001). The percentage of excess body weight loss (%EBL)was 43.07 (+-9.56) and metabolic syndrome prevalence decreased significantly from 75% to 25% (p 0.001). CONCLUSIONS: Beyond BMI loss, LSG significantly improved reproductive hormone levels in morbidly obese males.

Association of serum adiponectin and insulin-like growth factor I levels with parameters of cardiac remodeling in severely obese patients.

BACKGROUND: Obesity is associated with various changes in cardiac geometry and this process involves both hemodynamic and non-hemodynamic factors, among which adipocitokines and growth factors may play an important role. The aim of this study was to identify the extent and pattern of cardiac remodeling in a group of severely obese patients and analyze the relationship between adiponectin, IGFI and cardiac parameters reflecting obesity-associated structural changes. SUBJECTS AND METHODS: Our study included 344 patients (104 men) with severe obesity [mean body mass index (BMI)= 45.7 ± 8.5 kg/m(2)], extensively evaluated clinically and biologically (complete metabolic tests, serum adiponectin, and IGF-I measurements). Left ventricular (LV) mass index (LVMI), left atrium (LA) size, and LV geometry were determined by means of cardiac ultrasound. RESULTS: The most prevalent pattern of LV geometry was eccentric hypertrophy (28.7% of patients). In a gender-, age-, BMI-, diabetes- and hypertension-adjusted general linear model, patients with concentric or eccentric hypertrophy had significantly lower values of adiponectin than those with normal geometry (6.75 ± 0.41, 6.96 ± 0.53, vs 9.04 ± 0.42 mg/l, p<0.05). In multivariate analysis, independent determinants for LVMI were BMI (ß=0.364, p<0.001), systolic blood pressure (BP) (ß=0.187, p=0.004), age (ß=0.246, p<0.001), adiponectin (ß=-0.151, p=0.012), and IGF-I z-score (ß=0.134, p=0.025) while factors independently related to LA size were systolic BP (ß=0.218, p<0.001), BMI (ß=0.194, p<0.001), age (ß=0.273, p<0.001), gender (ß=-0.195, p<0.001), and adiponectin (ß=-0.180, p=0.005). CONCLUSIONS: In patients with severe obesity, IGF-I z score and adiponectin correlate with parameters of cardiac remodeling independently of anthropometric, hemodynamic or metabolic factors.

Laparoscopic sleeve gastrectomy reduces the predicted coronary heart disease risk and the vascular age in obese subjects.

BACKGROUND: Obesity is associated with high prevalence of coronary heart disease (CHD) and long term increased cardiovascular morbi-mortality. There are no data regarding the effect of laparoscopic sleeve gastrectomy (LSG) on long-term CHD - risk. It is known that "a man is as old as his arteries" and this concept is illustrated by Framingham coronary risk score, which can predict vascular age. PURPOSE: To assess the 10-year CHD risk in patients with obesity, preoperatively, and 6 and 12 months after LSG. METHODS: 47 consecutive obese subjects (44.7% males, mean age 39.8 years) scheduled for LSG were prospectively studied before and 6 and 12 months after surgery. The 10 years CHD risk and corresponding vascular age were calculated using Framingham risk score. RESULTS: The body mass index (BMI) decreased from 44.6 ± 10.6 kg m2 preoperatively to 32.2 ± 6.9 kg m2 and to 29.4 ± 5.4 kg m2 at 6 and 12 months follow-up (both p 0.05). Mean excessive weight loss (EWL) was 67.3 ± 23.7% and 78.3 ± 23.4% at 6 and 12 months postoperatively. At 6 and 12 months after LSG, there was a marked improvment of lipid profile(decrease of total cholesterol, LDL-cholesterol, triglycerides and increase of HDL-cholesterol) and a significant decrease in prevalence of diabetes mellitus, systemic hypertension and smoking. The 10-year CHD risk reduced from 10.1% preoperatively to 3.5% and to 2.2% at 6 and 12 months after surgery (both p 0.05). Patients' mean vascular age was 65.6 years preoperatively and decreased to 45.8 years 6 month spostoperatively (p 0.05) and to 40.7 years one year after LSG (p 0.05 vs. 6 months postoperatively, p=NS vs.chronological age). CONCLUSIONS: In obese subjects, CHD risk is significantly reduced early, beginning with 6 months after LSG and is diminished with 80% one year postoperatively. Despite the fact that not all patients had achieved the ideal weight yet,mean vascular age is similar to their chronological age one year after surgery.

Clinical importance of the determinant-based classification of acute pancreatitis severity.

PURPOSE: This classification should eliminate the confusion in terminology occurring over the last 20 years with direct implications in clinical practice. METHOD: The study was based on the web-based consultation of experts worldwide. 528 invitations were sent and 240 responses received from 49 countries from all continents. RESULTS: In an attempt to eliminate many confusions of the old classification, definitions that have built-in modern concepts of the disease have been issued, clinical evaluation of these severity has been improved and a standardized reporting data to objectively evaluate new treatments and to facilitate the communication of data between centers has been created. DISCUSSIONS: An ideal classification should reflect the whole area of clinical and paraclinical changes for one patient, at a given time. In the chosen classification, the main variable that characterizes the degree of severity is only the transitory or persistent organ dysfunction(s) failure(s). CONCLUSIONS: The most significant contribution to this update is redefining local complications based on their content,existence or non-existence of the wall, the place of their appearance and their evolution over time (local determinants).Systemic determinants take into account the presence of organ failures (transient or persistent). The presence of determinant factors has a cumulative effect.

Six months results of laparoscopic sleeve gastrectomy in treatment of obesity and its metabolic complications.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a popular bariatric surgical procedure, with proven results in achieving weight loss, however data regarding its effectiveness on metabolic syndrome (MetS) components are scarce. The aims of the present study were to assess the outcomes of LSG on weight loss and obesity associated metabolic complications at six months following intervention. PATIENTS AND METHODS: This was a retrospective study on 124 consecutive obese patients (29.8% men), who had undergone LSG between 01/01/2008 and 12/31/2010, in a highly specialized clinic. The dynamic of anthropometric and biochemical data between baseline and six months following LSG were evaluated. We also determined the change in MetS prevalence and used logistic regression to estimate predictors of MetS remission RESULTS: 6 months after LSG, the body mass index (BMI) decreased from 46.84 +/- 8.62 to 33.81 +/- 7.04 kg/m2 (p < 0.001). Mean excess BMI loss (EBL) was 65.24 +/- 25.16%. The best results on weight loss were observed in young patients, not affected by MetS, with lower initial BMI. Lipids profile suffered a significant improvement (HDL cholesterol increased, while LDL, total cholesterol, triglycerides decreased, p < 0.05 for each). HOMA-IR values decreased by 75.2%, from 5.24 +/- 4.49 to 1.30 +/- 1.22 (p < 0.001). MetS prevalence was reduced from 74.3% to 18.4% (p < 0.001). In multivariate analysis, % EBL remained the only significant predictor of MetS remission, the risk for lack of a MetS remission being practically 3 times higher in patients with EBL < 50%, compared to those with EBL > 50% (OR: 2.97, CI: 1.1-10.23, p < 0.05). CONCLUSIONS: As early as 6 months after LSG we recorded a significant weight loss and improvement in insulin resistance and lipids metabolism, as well as an impressive reduction in metabolic syndrome prevalence.

Noninvasive clinical model for the diagnosis of nonalcoholic steatohepatitis in overweight and morbidly obese patients undergoing bariatric surgery.

BACKGROUND: Liver biopsy, an invasive method, is the gold standard for differentiate nonalcoholic steatohepatitis (NASH) from other stages of fatty liver disease. A noninvasive test to diagnose NASH and disease severity before surgery and also for monitoring disease status after bariatric surgery (BS) will be an important medical challenge. AIM: To create a noninvasive biomarkers model for the diagnosis of NASH in overweight, obese and morbidly obese patients (MOP). PATIENTS AND METHODS: Sixty patients (mean BMI= 47.81kg/m2) were admitted after exclusion of other causes of liver disease. Liver biopsies were obtained at the time of the bariatric surgery or by percutaneous liver biopsy and graded using Kleiner score. Continuous variables were compared using Wilcoxon rank sum test and for prediction of NASH we used logistic regression. RESULTS: Logistic regression analysis showed that BMI, ALT, AST, alkaline phosphatase (ALP), HOMA-R, hs-CRP, M30, M65, leptine and adiponectine levels remained independent predictors for NASH (p less than 0.02). Using AUC analysis, we established the following cutoff levels being indicative of NASH: BMI e 47 kg/m2, ALT e 32 IU/mL, AST e 25 IU/mL, ALP e 85 IU/mL, HOMA-IR e 4, M65 e 389 U/L. Adiponectine less than 13.5 mg/L. A NASH-score, calculated as the sum of these 7 parameters, at a cutoff level of 4 points, can accurately predict NASH (sensitivity of 90%, specificity of 93.94% and AUC of 0.9576). CONCLUSIONS: We propose a noninvasive model for NASH diagnosis in MOP that should be validated prospectively. Using this noninvasive score, NASH would be predicted without the risks of liver biopsy.

[An experimental model of transgastric ooforectomy using a porcine model]. / Stabilirea modelului experimental de ooforectomie transgastrica pe model suin.

INTRODUCTION: Transabdominal routes for surgery entail general anaesthesia with its inherent risks and complications (prolonged hospital stay, abdominal incisions that may be difficult in obese patients). Minimally invasive procedures require shorter hospitalization, have shorter recovery periods, less postoperative discomfort, and lower morbidity and complications. The purpose of this study was to use a porcine model to determine the feasibility and the safety of organ resection (oophorectomy and tubectomy). MATERIALS AND METHODS: 10 Big White pigs between 25-30 kg underwent transgastric ooforectomy. The first 5 cases were performed in a hybrid procedure (laparoscopic-NOTES) in order to have a better control and supervise the maneuvers done by the mobile endoscope and to guide in the abdominal cavity. RESULTS: Adnexectomy was possible in all ten experiments. Full operative time (from starting endoscopy to complete gastrectomy closing) was 180 min to 270 min. The gastric defect closing was the most difficult manoever lasting from 10 min with OTSC clips to 100 using endoloops and clips. The animals have tolerated well the experiments and there have been no remarkable incidents during our 10 experments. In only one case a bleeding from gastotomy required electric coagulation. CONCLUSION: Transgastric ooforectomy in an experimental model is a procedure that requires advanced laparoscopical and endoscopical skills. Our early results are promissing. Its application in humans needs further confirmation of the method.

[The pig model for the laparoscopic antireflux surgery training]. / Modelul suin pentru antrenament în chirurgia laparoscopica anti reflux.

The laparoscopic treatment of the Gastroesophageal Reflux Disease (GERD) includes antireflux surgery (AR) procedure which may be performed in an optimal functional manner. To achieve this target adequate training is mandatory for the surgical team. In the "Sf. John" Laparoscopic Training Center (Bucharest, Romania) we have studied the advantages and disadvantages of a pig model for training in laparoscopic antireflux surgery. 16 pigs (20-25 kg) were included in this study. The results of this study included: 1. a complete description of the laparoscopic Nissen fundoplication in pigs and 2. the evaluation of the pig model for laparoscopic AR surgery. The use of pigs with anesthesia as a training model for laparoscopic AR surgery present certain advantages for the trainees: clear and humans similar anatomy, real surgical conditions (OR, equipment, instruments, lived animals).

[Laparoscopic training--the guarantee of a future in pediatric surgery]. / Trainingul laparoscopic--certitudinea unui viitor în chirurgia pediatrica.

Laparoscopy is considered today the highlight of modern surgery, the forerunner of the fascinating world of video and robotic surgery, both of them derived from the sophisticated areas of aeronautic industry. Remarkably, Romanian specialists keep up with the pace of worldwide technological developments, assimilating one by one each and every video endoscopic procedure. In the early 90s, the Romanian laparos-copic school was founded with the contribution of many important personalities; their activities and achievements have been an inspiration for the following generation of laparoscopic surgeons. In this last decade, the newest branch of laparoscopic surgery in our country, pediatric laparoscopy, managed to evolve from its "shy" beginnings to become an important method of improving the quality of surgical procedures, to the benefit of our "small patients". The purpose of this article is to encourage and promote minimally invasive video endoscopic surgery training, emphasizing its crucial role in the education and professional development of the next generation of pediatric surgeons, and not only. The modem concept of laparoscopic training includes experimental scientific practices, as well as the newest technical acquisitions such as virtual reality video-electronic simulation.

A Primary Retroperitoneal Diffuse Large B-Cell Lymphoma: A Challenging Diagnosis.

Although quite rare, retroperitoneum can harbour malignant limphomas. On the grounds that the anatomical location is uncommon and the symptoms are scarce, the diagnosis is usually late and challenging. Imaging methods such as magnetic resonance imaging, computed tomography (CT) and positron emission tomography-computed tomography (PET-CT), can characterize and locate the tumor while endoscopic ultrasound fine needle aspiration (EUS-FNA) may provide pathological confirmation. We present the clinical case of a fifty-five-year-old female that is admitted to our hospital with epigastric discomfort, nausea and vomiting. CT showed a homogenously enhancing mass lesion that encased the pancreas, in contact with the portal vein, inferior vena cava, invading splenomesenteric confluence. To investigate further, EUS-FNA was decided and it revealed lymphocyte proliferation suggestive for the diagnosis of lymphoma. Hereinafter, surgical intervention was performed and immunohistochemical analysis and sub classification of lymphoma was obtained. The final diagnosis was non-Hodgkin lymphoma, Diffuse Large B-Cell Lymphoma (DLBCL). Poly-chemotherapy with R-CHOP was initiated. At the end of the treatment fluorodeoxyglucose positron emission tomography (FDG-PET) was performed and no pathological findings were found. A brief review of literature is also provided.

[Laparoscopic hysterectomy]. / Histerectomia laparoscopica.

Our paper presents the experience gained in nearly 12 years by the General Surgery Clinic of "Sfantul Ioan" Hospital, Bucharest in the field of laparoscopic hysterectomy. The period of time is quite long compared to the evolving of mini-invasive techniques and also unequal towards the experience of the surgeons who perform these procedure. The total number of hysterectomies was 1491 from which 251 by laparoscopic approach, the rest being made by the classic methods (most of them by laparotomy and some by vaginal approach). In the statistic we have included 15 myomectomies, 4 cases of radical hysterectomy with pelvic lymphadenectomy and 4 cases of complete hysterectomy after partial procedures made by laparotomy. The indications were represented mostly by uterine fibroma (82.07%), but also by uterine prolapse (13.14%), uterine bleeding, cervix severe dysplasia, uterine and cervix neoplasia (stage I) or associated to ovariectomy related to breast cancer. The paper analyses the results looking at the incidents and accidents (hemorrhagic, ureteral, urinary bladder or rectal lesions) and also postoperative complications (we had three reinterventions, two by laparoscopy and one by laparotomy). We also recorded one death not directly as a consequence of surgery, but as a diagnosis error. Regarding the surgical technique we initially chose the laparoscopic assisted vaginal hysterectomy. Afterwards by gaining experience we started treating the uterine pedicle and now we settled for the integral laparoscopic procedure. In our opinion laparoscopic hysterectomy represents all the advantages of mini-invasive approach. The technological development, but essentially the experience gained by surgeons are the key factors in accepting and promulgating the technique.

[Hynes-Andersen pyeloplasty by mini-laparoscopy transperitoneal approach]. / Pieloplastie Hynes-Andersen pe cale minilaparoscopica transperitoneala.

Laparoscopy had significantly gained in the field of urologic surgery, almost all the surgical procedures in the retroperitoneal space being made, from the simple ones (renal cystectomy, varicocelectomy) to the ones requiring higher expertise (nephrectomy, adrenalectomy) by retro-peritoneoscopy and also transperitoneal. At the Surgery Department of "Sf. Ioan" Hospital, Bucharest, we approached initially the retroperitoneal pathology by lomboscopy, but afterwards we choose the transperitoneal approach because of the generous workspace and the clearer anatomical landmarks, regardless of the procedures (renal cystectomy, varicocelectomy, adrenalectomy, nephrectomy, pyelo-lithotomy, ureterolithotomy). In association with the Urology Department of "Sf. Ioan" Hospital we practiced two Hynes Andersen pyeloplasty for pyelo-ureteral junction stenosis by transperitoneal approach, using mini-laparoscopy tools. In one of the cases we also perform a basinetal lithotomy.