Ileosigmoid Knotting: Changing Trends Over 50 Years

Ileosigmoid knotting (ISK) is the wrapping of ileum and sigmoid colon around each other. The purpose is to evaluate the changes in incidence, treatment, and outcomes over several decades to the present. The clinical records of 78 patients over the last 50 years were reviewed retrospectively until June 1986, and prospectively thereafter, and the results of the first and last 25 years were compared. The incidence of ISK decreased during the reviewed 50-year period (p < 0.001). Although most of the diseased patient characteristics including age, gender, previous incidence, comorbidity, and shock rates were similar (p > 0.05 for each), the typical symptomatic period shortened (p < 0.05) over the last 25 years. Clinical symptoms and signs were also similar (p > 0.05), but the preoperative diagnostic accuracy rate increased (p < 0.001) due to the increased usage of CT and/or MRI (p < 0.001). Operative findings, including the type of ISK, extent of over-rotation, and bowel gangrene rates were also similar (p > 0.05 for each). The predominant surgical treatment was modified, as resection with primary anastomosis generally took the place of resection with stoma for both ileum (p < 0.01) and sigmoid colon (p < 0.005). Finally, the morbidity, mortality, and recurrence rates did not change (p > 0.05 for each), though the average hospitalization period shortened (p < 0.05). As a result, over time, we found a decrease in the incidence of ISK as well as some changes in the diagnostic and therapeutic strategies, although the clinical features and prognosis did not change.     

Sponge Rubber Revealed Two Years After Penetrating Injury: A Case Report

The present report illustrates a very rare case report of a foreign body granuloma of the foot associated with a 2-year period of a retained spongeous rubber foreign body after a penetrating injury. Because it appeared almost 2 years after the injury, the history of trauma was minimized, the foreign body had migrated from the plantar to the dorsal side of the foot, and the radiographic appearance resembled a malignant process, it was difficult to rule out the possibility of a malignant tumor. This case shows the weakness of magnetic resonance imaging in detecting spongeous rubber in the body. Also, a bone osteoblastic reaction to the foreign body has very rarely been noted. To the best of our knowledge, just 5 cases have been previously reported. Provided suspicion exists of previous trauma with an embedded foreign body, the differential diagnosis of a bone neoplasm should consider the possibility of a foreign body reaction. Biopsy proved to be the best diagnostic tool.     

Long-Term Follow-Up of Gastric Banding 10 Years and Beyond

Background

This investigation assessed the long-term outcome of patients with gastric banding implanted more than 10 years ago.

Methods

A total of 73 patients undergoing laparoscopic gastric banding between 1997 and 2003 were identified. Patients who had their band removed were converted to a laparoscopic gastric bypass procedure.

Results

The mean preoperative body mass index (BMI) was 44.4 (SD 5.3). The mean follow-up was 11.6 (SD 2.1) years. The reasons for reoperation were leakage (N?=?16, 21.9 %), slipping (N?=?15, 20.5 %), and insufficient weight loss (N?=?9, 12.3 %). The band was left in situ in 33 patients (45.2 %). The 5- and 10-year survival rates for the banding were 82.2 % (95 %CI 73.9–91.5 %) and 53.4 % (95 %CI 43.1–66.2 %). Best results were observed in male patients (10-year survival rate 76.5 %, 95 %CI 58.7–99.5 %, HR?=?0.44, P?=?0.043) and patients older than 50 years (10-year survival rate 63.8 %, 95 %CI 51.5–79.2 %, HR?=?0.41, P?=?0.006). Overall, the BMI was 31.0 (SD 6.3) at follow-up, excess weight loss was 68.1 % (SD 26.4), and the score for the Moorehead-Ardelt Questionnaire was 1.6 (SD 1.0). Similar results were obtained for patients with and without banding failure.

Conclusion

The present investigation provides evidence that gastric banding remains effective after more than 10 years in less than 50 % of initially operated patients. Older (>50 years) and male patients seemed to maintain the banding as long-time carriers with good results, and these patients subjectively profited from this method. Good results can be achieved if patients are followed thoroughly, and alternative surgical options for patients who fail may be offered with longstanding success.

     

Long-Term Improvements in Pulmonary Function 5 Years After Bariatric Surgery

Background

Obesity is associated with reduced pulmonary function. We evaluated pulmonary function and status of asthma and obstructive sleep apnoea syndrome (OSAS) before and 5 years after bariatric surgery.

Methods

Spirometry was performed at baseline and 5 years postoperatively. Information of asthma and OSAS were recorded. Of 113 patients included, 101 had undergone gastric bypass, 10 duodenal switch and 2 sleeve gastrectomy.

Results

Eighty (71 %) patients were women, mean preoperative age was 40 years and preoperative weight was 133 kg in women and 158 kg in men. Five years postoperatively, weight reduction was 31 % (42 kg; p?<?0.001) in women and 24 % (38 kg; p?<?0.001) in men. Forced expiratory volume in 1 s (FEV1) increased 4.1 % (116 ml; p?<?0.001) in women and 6.7 % (238 ml; p?=?0.003) in men. Forced vital capacity (FVC) increased 5.8 % (209 ml; p?<?0.001) in women and 7.6 % (349 ml; p?<?0.001) in men. Gender and weight loss were independently associated with the improvements in FEV1 and FVC. At follow-up, FEV1 had increased 36 % of the difference towards the estimated normal FEV1, and there was a corresponding 70 % recovery of FVC. These improvements occurred despite an expected decline in pulmonary function by age during the study period. Of the asthmatics and OSAS patients, 48 and 80 %, respectively, were without symptoms 5 years postoperatively.

Conclusions

Pulmonary function measured with spirometry was significantly improved 5 years after bariatric surgery, despite an expected age-related decline during this period. Symptoms of asthma and OSAS also improved.     

Endoscopic Evaluation of Laparoscopic Nissen Fundoplication: 89 % Success Rate 10 Years After Surgery

Background

The surgical outcome of fundoplication can be evaluated by means of esophagogastroduodenoscopy (EGDS). The literature reveals only one prior long-term follow-up series with endoscopic evaluation of the fundoplication wraps after laparoscopic Nissen fundoplication (LNF). The results achieved at a university clinic showed LNF to be more durable than open fundoplication (ONF). Previously, in our community-based hospital, the results of ONF were somewhat poorer than those achieved at a university clinic. The objective of the present study was to describe the long-term results of LNF in our hospital as regards surgical and symptomatic outcomes.

Methods

In 1997–1999, 107 LNFs were performed in our hospital. A questionnaire with symptom evaluation was mailed to all patients. The patients who agreed to participate were interviewed and underwent EGDS.

Results

Of the 107 patients, 64 (59.8 %) participated in the study (40 men, mean age 61.9 years, range 28–85 years). The mean follow-up time was 9.8 years. Seven endoscopic examinations (10.9 %) showed a defective fundic wrap; three of the patients had undergone reoperation. Fifty-eight (90.6 %) patients had no or minimal heartburn and 61 (95.3 %) had no or minimal regurgitation. Twenty-three (35.9 %) patients had moderate or severe dysphagia, and 43 (67.2 %) patients had moderate or severe flatulence. Fifty-seven (89.1 %) patients would have opted for surgery again.

Conclusions

This study contributes to the previous notion that LNF is associated with fewer surgical failures than ONF. Our results indicate that LNF can well be performed in a community-based hospital with acceptable long-term results.     

Outcomes of Laparoscopic Sleeve Gastrectomy in Patients Older than 60 Years

Background

Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown.

Methods

A retrospective review was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18?<?age?<?50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities.

Results

Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9?±?0.3 years). These were matched to 104 young patients, age 18–50 years (mean age, 35.7?±?0.8 years). Groups did not differ in male gender (44 vs. 43 %, p?=?0.9), preoperative BMI (42.6?±?0.7 vs. 42.6?±?0.6, p?=?0.97), and length of follow-up (17?±?2 vs. 22?±?1.4 months, p?=?0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65 %, p?<?0.001). Excess weight loss (EWL) was higher in the younger group (75?±?2.4 vs. 62?±?3 %, p?=?0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9 %, p?<?0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8 %, p?<?0.001). This included atrial fibrillation (9.5 %), urinary tract infection (7 %), trocar site hernia (4 %), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2 %, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80 %, p?=?0.13).

Conclusions

LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.     

Laparoscopic Roux-en-Y Gastric Bypass in Morbidly Obese Patients ≥55 Years Old

Background Advanced age is considered a relative contraindication to bariatric surgery at some institutions because of concerns about higher morbidity and less than optimal weight loss. The aim of our study was to evaluate the operative outcomes, length of stay, weight loss, and improvement of comorbidities in patients ≥55 years old who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery in our institution. Methods Retrospective data on 33 patients (26 women and 7 men) ≥55 years of age who underwent LRYGB from January 2003 to December 2006 were reviewed. Results Average patient age was 59 years (range 55–68 years), and the mean preoperative body mass index was 47 kg/m² (range 41.1–55.8 kg/m²). The median length of hospital stay was 3 days. There were no intraoperative or postoperative deaths. Early complications were one anastomotic leak, two upper gastrointestinal bleedings, and two readmissions for intractable vomiting. Late complications included four anastomotic strictures and one small bowel obstruction. Patients were followed for a mean 13 months (range 3–24 months). The mean excess body weight (EBW) loss was 13.5 kg (23%), 23.3 kg (39.8%), 33.3 kg (58.1%), 39.8 kg (66.8%), 40.1 kg (69.5%), and 40.8 kg (75.3%) at 1, 3, 6, 9, 12 and 24 months, respectively. Diabetes mellitus improved in 19 (100%) patients and completely resolved in 10 (53%). Hypertension improved in 18 (64%) patients, completely resolved in 9 (32%) and was unchanged in 10 (36%). Conclusions LRYGB is safe and effective in morbidly obese patients ≥55 years of age.     

Factors Related to Weight Loss up to 4 Years after Bariatric Surgery

Background  

Gastric bypass is the bariatric surgery most frequently performed in the world. It is responsible for sustainable weight loss, resolution of comorbidities, and improvement of quality of life. However, weight loss is not homogeneous, at times being insufficient in some patients. Our objective was to assess which factors were important in influencing this differentiated weight loss over a period of 4 years after surgery.     

Weight Loss Outcome After Roux-en-Y Gastric Bypass: 10 Years of Follow-up

Background

By submitting obese people to surgical treatment, we hope they lose weight and stay slim. Long-term monitoring is essential to assess effectiveness of surgery. This study aims to evaluate weight loss over 10 years in an obese population undergoing banded Roux-en-Y gastric bypass (B-RYGBP).

Methods

The surgery was performed in 211 obese between May 1999 and December 2000. This prospective study evaluated excess weight loss (%EWL) and body mass index (BMI) during the period. We considered surgical treatment failure if %EWL was less than 50 %.

Results

We followed 54.9 % of the population (116 patients). Patients' %EWL was 67.6?±?14.9 % 1 year after surgery, 72.6?±?14.9 % after 2 years, 69.7?±?15.1 % after 5 years, 66.8?±?7.6 % after 8 years, and 67.1?±?11.9 % after 10 years postoperatively. Surgical treatment failure occurred in 16 patients (14.6 %) over 10 years.

Conclusions

B-RYGBP is a good technique to promote and maintain weight loss 10 years after surgery with low failure rate.     

Nipple-Sparing Mastectomy in 99 Patients With a Mean Follow-up of 5 Years

Background

The safety and practicality of nipple-sparing mastectomy (NSM) are controversial.

Methods

Review of a large breast center’s experience identified 99 women who underwent intended NSM with subareolar biopsy and breast reconstruction for primary breast cancer. Outcome was assessed by biopsy status, postoperative nipple necrosis or removal, cancer recurrence, and cancer-specific death.

Results

NSM was attempted for invasive cancer (64 breasts, 24 with positive lymph nodes), noninvasive cancer (35 breasts), and/or contralateral prophylaxis (50 breasts). Twenty-two nipples (14%) were removed because of positive subareolar biopsy results (frozen or permanent section). Seven patients underwent a pre-NSM surgical delay procedure because of increased risk for nipple necrosis. Reconstruction used transverse rectus abdominis myocutaneous flaps (56 breasts), latissimus flaps with expander (35 breasts), or expander alone (58 breasts). Of 127 retained nipples, 8 (6%) became necrotic and 2 others (2%) were removed at patient request. There was no nipple necrosis when NSM was performed after a surgical delay procedure. At a mean follow-up of 60.2 months, all 3 patients with recurrence had biopsy-proven subareolar disease and had undergone nipple removal at original mastectomy. There were no deaths.

Conclusions

Five-year recurrence rate is low when NSM margins (frozen section and permanent) are negative. Nipple necrosis can be minimized by incisions that maximize perfusion of surrounding skin and by avoiding long flaps. A premastectomy surgical delay procedure improves nipple survival in high-risk patients. NSM can be performed safely with all types of breast reconstruction.